(with apologies to Barbara Streisand)
Dr. Jim Antinori
Emergency Medicine is now a well-established and well-respected specialty within the House of Medicine. It has many residency programs, and is a popular career choice for medical students. In our state, several emergency physicians have served as president of the Utah Medical Association (UMA), and many have served as chiefs of staff of Utah hospitals. Emergency physicians are well represented in UMA leadership positions, and an emergency physician (Steven Stack) has been elected as President of the American Medical Association. The US public, as well as most physicians regardless of specialty, could not imagine the healthcare system functioning without emergency medicine or without well-trained, experienced emergency physicians.
But it was not always so. Let me tell you some stories from the “early days” of our specialty in Utah.
The American College of Emergency Physicians was founded in 1968, by physicians who had trained in other specialties but who had the foresight to realize that a key element in the US health care system was “missing”. (Thus the logo of ACEP – a grid with one square missing.) Shortly after the founding of ACEP, certain hospitals along the Wasatch Front began the then-radical practice of hiring physicians to work full-time in their emergency “rooms”. This was not 24/7/365 coverage. These emergency medicine pioneers in Utah usually were on duty “only” 12 hours a day, 5 days a week. The rest of the coverage, plus weekend and night coverage was still provided by hospital staff members who had traditional private practices. They were required by their medical staff bylaws to be on-call to the hospital ED, not just for admissions and not just for their area of specialty. They were called in to see anything the triage nurse (who often staffed the ED alone) felt had to be seen right away, rather than being referred to a physician’s office. Fortunately for those physicians and for patients, ED volumes at that time were usually low.
But health care was changing. The VietNam war had proved the medical value of early treatment of the sick and injured. Medical practice was also evolving, from mostly “general practice” to a majority of physicians receiving specialty training. Those physicians increasingly wanted to only see patients with problems in their specialty, preferably as consults in the hospital or in their office. Doctors on a hospital medical staff, then as now, didn’t like interrupting their day or waking up in the middle of the night to see unscheduled patients.
The pioneers of emergency medicine in Utah – including Mike Romney, Jess Wallace, Charlie Caton, Peter Midgley and others – decided to form the Utah Chapter of ACEP in the early 1970’s. In those early years, the Board of the Utah Chapter met perhaps 2 or 3 times a year, with one representative from each of the Wasatch Front hospital ED’s attending (if we were lucky). Total Chapter membership was fewer than 40 physicians. There was no emergency medicine residency at the University of Utah – that would take many more years to become reality.
Unfortunately, in those days the rest of the House of Medicine considered emergency physicians to be second-class citizens, if in fact they considered us at all. When Dick Wallen from St. Mark’s Hospital was president of the Utah Chapter in the early 1980s and I was secretary-treasurer, we were called in front of the Utah Medical Association (UMA) Board of Trustees to explain and justify why the emergency physicians in Price were billing so much for their services. I was still early enough in my career to be greatly intimidated by the Medical Eminences. Fortunately, Dr. Wallen was not.
He sat patiently while they berated us and emergency medicine, and asked how “we” could charge such high rates (in their opinion) for “our” services. After letting them talk for almost 30 minutes, Dick told them in no uncertain terms that Utah ACEP did not determine what any of our members could or would charge, just like any other specialty society. And if they were so concerned, why were they questioning Utah ACEP, rather than the physicians involved? The answer, although they did not say so, was that the physicians in Price were not UMA members, and “we” were the easy target. He also told them, in a very diplomatic way, that emergency physicians would no longer tolerate being treated like the unwanted stepchildren of the medical profession. Then we got up and left. They were stunned.
In my opinion this was an important, if little known, inflexion point in the history of emergency medicine in Utah. After that meeting, organized medicine in the state started to take emergency physicians (slightly) more seriously. And the nascent emergency medicine community realized the importance of becoming more involved in the UMA, as well as in our respective hospital medical staffs. But we still had battles to fight.
In the mid 1990’s, there was a prominent member of the UMA who decided that the organization needed to do an investigation of “unnecessary” emergency department visits, to see how much those “unnecessary” visits were costing the healthcare system. I happened to be at UMA headquarters at that time, and overheard the plan. I asked him (in front of many others) if it was possible that somewhere, sometime there might be cardiac surgery performed which could be considered “unnecessary”. He agreed that it was possible. I pointed out that since one “unnecessary” cardiac surgery would cost the healthcare system many times as much as one “unnecessary” emergency department visit, wouldn’t the UMA’s time and resources be better spent investigating unnecessary cardiac surgery? He immediately got the message. The idea was dropped.
There were many other challenges along the way. They were overcome to make emergency medicine not just tolerated, but an essential part of the health care system in Utah and nationally. Our specialty will continue to have more and different challenges to address, now and in the future. But I have no doubt that the current and upcoming group of dedicated, residency-trained, board certified emergency medicine specialists will be up to the task.