An uncomfortable truth: Is Emergency Medicine a failed paradigm? St.Emlyn’s

When I was asked to join a debate at SMACC on whether emergency was a failed paradigm I was instantly agreeable. I love Emergency Medicine, I love the breadth of what we do and I think I have a pretty good gig here in Virchester where I can practice at a reasonably high level and with great support for our ED critical care activites. I thought this would be an easy topic to talk to and defend.

That’s when I heard that I’d be up against Scott Weingart who is a rather fabulous speaker with an intellect to match. You’ve no doubt listened to him on the EMCRIT podcast1, seen his lectures on line, heard him at a conference, or if you’re lucky like me you’ll have had time to just enjoy a beer and have a chat. I’d happily say that Scott is a great guy and here at St.Emlyn’s we’ve a huge amount of time for him.

That said, the idea of debating a topic with him left me with some trepidation and I’ll explain how we approached this later on, but before that, let’s get to the topic.

Is EM a failed paradigm?

It’s a great question and one that deserves airing at a conference like SMACC2. Traditionally emergency medicine has often prided itself on being a broad speciality. We see everyone and everything from cradle to grave and all in between. We consider ourselves specialists in undifferentiated care, but also apply other terms like resuscitationist or some other neoligism tagged to a part of our practice. In truth although we have a vision of what an emergency physician is it’s a personal one. It’s dictated by our local service, our training and our interests and thus the concept of a one size fits all emergency physician is a myth. Our services usually develop around what our patients and our system require and we as workers within those systems develop around the needs of the service.

There is no standard EM system and there is no standard EM Clinician. We are essentially products of the environments we work in, a point Scott makes early on in his talk.

Scott lays out his vision in the PRO debate as a world where specialisation is an inevitable consequence of our speciality growing and establishing itself and I have a huge amount of sympathy with this view. If I look at how the other Prof C, @FCarleyOphth, (Ed – technically now a Sofa of Professors) works as an Ophthalmologist then she doesn’t. Fiona stopped being an Ophthalmologist about 10 years ago really, she is now corneal and ocular surface surgeon. She doesn’t do stuff at the back of the eye, she is a super-specialist, and that’s typical of pretty much all other specialities. Surgery, Cardiology, Medicine, Gastro no longer exist in many places as they subdivide into organs, systems, settings or technologies.

One could argue that emergency medicine is simply in a phase of developing in a similar direction. From our beginnings as generalists we are clearly seeing the emergence, divergence and fragmentation of the speciality as tribes of paediatricians, geriatricians and yes, perhaps even those of us identifying as resuscitationists, go from interested parties, to enthusiasts, to collegiates, to specialists, to breakaway identities requiring different training and accreditation programs. There is nothing new in the fragmentation of specialities, and there is nothing new in the problems associated with this evolution.

We will still be required to train as generalists, at least at the start, as for a speciality such as EM it would be unwise and counterproductive to sub-specialise early. For those who end up working outside the ivory towers that Scott and I inhabit there will always be the need for future generalists too. Not everyone in EM will have 26 senior colleagues (as we do in Virchester).

Sub-specialisation risks becoming a victim of it’s own success. It’s great to have an interest and to take a lead role around one aspect of care but if a sub-speciality becomes exclusive to the point of degrading the contributions of non-specialists they may find themselves painted into a corner where only a small number of people on a rota are considered able to deal with certain patient groups. Arguably we’ve seen this in paediatric emergency medicine already in some parts of the world, the impact on staffing, rosters and sustainability are rarely considered in the first flush of specialist enthusiasm.

So there is certainly something true about the demise of the generalist.

Scott also talks about the scope of EM practice and he’s right that the way that we’ve changed our priorities around the sick and not sick patients. In the UK that’s something that will chime with many an emergency physicians who typically have to try and sort the sick patients from those who are using the ED because a more convenient and accessible alternative is not available. This dilutes the experience and expertise of our workforce around the management of the sickest patients. He’s right of course and there are lots of places in the UK where this happens. The ED docs get pushed to the minors and the moderately unwell, in the pursuit of time based targets, whilst the sickest and most seriously injured patients are farmed off to in-patient specialities.

I would hate to work in a place like that, and yet I know they exist. In Virchester, at consultant level at least, we have an excellent balance. The team works hard to ensure that we have the presence and skills in the resus room to maintain the vision of emergency medicine that we aspired to when we signed up to do emergency medicine and which we still hold true today. Sadly, it’s not the case everywhere and not even the case for everyone who carries the professional label of emergency physician. It is perhaps an uncomfortable truth that in many emergency departments the emergency physicians are not the resuscitationists that many aspired to be when they chose this path.

In reality I understand and agree with much of what Scott has to say.

EM is not a failed paradigm

So, whilst I do agree with much of what Scott says there is of course an alternative perspective and my pitch against Scott’s argument was fairly simple. Emergency medicine and emergency physicians are indeed a function of the system that we work in. As other groups have become more and more specialised there is a need for those of us who are still trained as generalists (currently at least) to be part of the system. The demand amongst our populations is clearly there and EM has been demonstrated be effective. We need clinicians who can work with an undifferentiated population in a range of settings and who have been trained from a generalist background. More than that we need a workforce that is adaptable to a changing healthcare economy.

I would also argue that leading the resus room does not mean that you need to physically do everything. You do need to know how and why things work so that you can manage the resuscitation. For example some of my fab colleagues in Virchester don’t intubate routinely but they know how, when and why and can spot trouble when it’s about to happen. Similarly when I’m running a trauma I don’t even wear gloves as I’m not going to be touching the patient. Leadership in the resus room is not doing everything yourself, it’s more about facilitating others, though in order to do that you do need to know what it is they are doing!

This debate closely linked to my talk on the future of emergency medicine, and in particular the changes to the politics of emergency medicine in the UK. In that talk, and again now I state that I want EM to remain a broad based speciality, it is our real strength, but in doing so we need to maintain our breadth of practice that extends into the resus room. We should not let managers, systems or specialists make us unwelcome in our own house.

Click on the link below to watch the presentation from SMACC Dublin.

Preparing for a debate.

I’ve done a few of these cage fight or debate sessions at conferences and I think it’s important that we take them with a pinch of salt. Typically you get a topic that you have a view on and on which you can construct an argument. What’s required in a debate though is a degree of polarisation of views and as such one often ends up being a little more radical on stage than in real life.

The plan is always to try and get into the head of the other person and to imagine what they might say and how they might construct their argument. In this case Scott has a strong case which I largely agree with from a personal perspective. As an individual I do have a focus on the critical care side of our speciality, like many of my colleagues in Virchester we do deliver advanced critical care in our resus room and we lead it with the support of our speciality colleagues. It’s a great place to work in that regard and one of the reasons that we continue to attract like minded and incredibly competent colleagues. So there was a degree of insight into what Scott would say, but how to reply? Head to head he has the best arguments and rationale on many points and so the only thing to do was to find an alternative approach to the question and that was to take an epidemiological, more global perspective. As the St.Emlyn’s team we talked this through (always get help for different perspectives) and thought this the best counter-argument that we could use.

We also know that the SMACC team have used the debate sessions to get the audience to think for themselves and to get engaged in the process and that requires a degree of entertainment. Also, to try and win an argument on a subject like this, one that touches our very worth as emergency clinicians, it’s as much about the emotional response as the facts and so we needed an appeal to the heart as well as the brain. Hence the fake faculty, the award and the conversation on stage with Natalie. Finally, the idea of finding an envelope below the chairs as a way of joining the spoof faculty was for fun and was our memorable moment for the talk. In truth it was a complete act of plagiarism from Haney Mallemat’s talk at SMACC where he delivered one of the most fantastically well designed talks I’d ever seen at that time. It worked superbly for him then and I hope it worked in Dublin.

The bottom line.

On the day of the debate and again today some seven months later I still don’t know who won the debate and in truth it does not matter. Personally I fear the fragmentation of the speciality into divisions typified by patient type (e.g. paeds, geris), but I also see the differentiation between departments and individuals who strive to maintain and deliver critical care skills in the resus room, and those who don’t.

In Virchester I think we are as close to ED critical care as any other department in the UK but I know that this is not the case everywhere. Thus it is an uncomfortable truth that much of what Scott said may well be right unless we take control, train, practice and excel in all aspects of EM, and that includes the resus room.

vb

S

Before you go please don’t forget to…

1.
EMCRIT. EMCRIT. http://emcrit.org/. Published 2017. Accessed January 20, 2017.
2.
DasSMACC. DASSMACC. http://www.smacc.net.au/. Published 2017. Accessed January 20, 2017.

1 Comment

  1. Matt Wong

    As an emergency physician in North America, I can empathize with a lot of what Scott, and you are saying. Some of the rhetoric, particular Scott’s half, is surely embellished for the sake of the debate. But I do not think that the current state of affairs is anywhere as bad as he makes it seem.

    Nor are the issues that Scott raises isolated to emergency medicine. Most doctors tell themselves a slightly more dramatic macroscopic story about their job that doesn’t microscopically line up with their day-to-day realities. It is true, that in my heart of hearts I consider myself a resuscitator of critically ill, undifferentiated patients; though quite honestly I spend more time doing rectal and gyn exams than I do intubating and placing central lines. And likewise, most intensivists probably consider themselves akin to cowboy physiologists who are heroically saving the sickest of the sick, when in reality their day-to-day life probably involves a lot of goals of care discussions, placement issues for patients with long term illnesses and nowhere else to go, and managing acute on chronic illnesses that are ultimately irrecoverable. Most likely, similar job-title versus reality mismatches are ringing in the heads of every physician and nurse in every hospital in world. Yeah, it’s dis-illusioning, but it’s our reality, and I don’t find it disheartening. Medicine, and emergency medicine in particularly, is a job with an important and near divine sense of purpose, which is always mired by the difficulties of reality. A secular versus sacred divide.

    I don’t think that is a problem, however. Nor do I think that emergency medicine is a failed paradigm. The soul of the emergency physician is still in resuscitation. But like all other aspects of healthcare, we have to have a business model that overlaps with the shared mental model of what our job is actually supposed to be.

    Reply

Thanks so much for following. Viva la #FOAMed

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