I’m not old enough, in emergency medicine years, to identify with the struggle of those calling for the end of the term “ER.” The argument was about the “R” vs. the “D”: “It’s not a room!” It’s a department!” was the war cry. Then perceptions changed, battles were won, and along came the very popular TV show, “ER.” The war hawks quieted down. After all, who could argue with the limelight into which our profession was cast? Now a new battle is underway. This fight is not about credibility or legitimacy, but sustainability and identity. It’s about the “E.”
The “E” can no longer stand for “emergency” at least in a literal sense. Only a minority of time and resource are used to take care of emergencies. Rather, the “E” should now stand for everything. Instead of the classic “emergency room” we now have an “everything department.” We can care for your poison ivy or your pulmonary embolism, your chronic migraine headache or your acute myocardial infarction, and most things in between. We can be a one-stop shopping department for a lot of folks, and to paraphrase Jeff Spicoli (Fast Times at Ridgemont High, 1982), we’ve got an awesome set of tools, we can fix it! The “room for emergencies” has indeed become a “department for everything.”
Going further, the”E” isn’t just everything; it’s everyone. We don’t turn anyone away and consequently, the ER should now be the “Everything, for Everyone, Department.” The government gets a lot of the credit for this via EMTALA. No insurance? No problem. No ID or passport? No problem. Many folks have no alternative source of timely care, true, and providers and administrators alike don’t really want to turn away business – I mean patients. Bring in the poorly managed chronically ill, the low acuity, the work note shoppers, the convenient care seekers, as well as the emergencies. We’ll take them all.
And, of course, “E” could also stand for every time. After all, we’re never closed either; “The Everything, for Everyone, Every time Department.” We’ve always been open nights, weekends, and holidays, as most homes are. Though tempted at times, we don’t close the doors at 5:00 or midnight or on Christmas day. Perhaps we should have a little more “tough love” philosophy in our medical home.
Are emergency departments, as part of the power struggles between hospitals, in remodeling their facilities, concentrating on patient satisfaction, and offering an increasing array of services, crowding out other, more appropriate, venues of care? Are these other venues really stepping up to help cure the problems in American health care delivery? Are people being pushed into the ED or being pulled into the ED? Does anyone have any idea of where the emergency department, in today’s health care market, fits in? If so, are those people willing to put their money where their mouth is? Are they willing to pay for it? Are we, the emergency medicine community, here entirely by default, necessity, or perhaps by a bit of covert advertised-wait-times marketing?
Emergency medicine, it seems to me, has a serious identity crisis. Are we emergency specialists or everything generalists? Which do we want to be and perhaps, more importantly, which will we be required to be? How will we train our residents? Should we be teaching more primary care? What should we be taking care of? Who should we be taking care of? When should we be taking care of them?
Though the answers to these questions are important, it’s more important to determine who will be answering them; politicians, executives, lobbyists, or physicians – particularly emergency physicians? This is a systems problem. We need a unified, clear, common sense answer to the question of “what is emergency medicine?” from emergency physicians.
I’m curious to see where we’ll be in 25 years, particularly with health care reform on the verge of causing some seismic shifts in at least financing, if not delivery. Perhaps, the system will push us out of the department and back into a room. Or perhaps, in the vernacular of our surgical colleagues and considering the growing focus on customer satisfaction, we’ll now start to call it the “Emergency Suite” (and, by the way, that’s a nice flat screen HDTV in room 23). And who would argue, with the usual cast of characters and dramatic moments that at times we seem to be practicing in an “Emergency Theater”? Surely, we haven’t become the “Everything, for Everyone, Every Time Department with Suites and a Theater.”
Or have we?
David Schlueter is an emergency physician.
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