President's Message (A Trip in a Time Machine)
I recently took a trip in a time machine. It took me back into the 1970’s. Maybe not literally, but I did go to a place where my hosts told me, frankly, that the state of emergency medicine is just like it was across the entire nation in the `70s. And the story they told me serves as a warning for all but the oldest of our colleagues.

Let me set the stage. The city is large and exotic. It is populated by numerous cultures, each with its characteristic food, music and arts. The metropolitan area is among the largest in the nation. The weather attracts many people, and this city is situated in one of the most populous states.

Yet conditions there create a nearly perfect storm, stunting the advancement of emergency medicine and putting much of the population of the region at risk of inferior care. Here’s the skinny:

Start with the contract holders. The region is rotten with them. My hosts told me they couldn’t name a single private group in the area. Hospital administrators in the area do not even seem to understand that their emergency departments (EDs) can function without the involvement of a staffing company.

These same administrators do not understand the importance of a functional ED. There is little expectation that an average patient be seen and treated expeditiously. One board certified doc told me that a (non-board certified) co-worker told him to stop seeing patients so fast; it was making others look bad. Emergency departments are, apparently, looked upon as simply a conduit for admissions, with little expectation that quality care is either necessary or provided.

Working conditions are correspondingly bad. Income for the doctors in the region is well below average. The doctors I spoke with just accept this as part of the price they must pay to live and work in a highly desirable area. I was told that they expect to be fired from one hospital and hired at another on a periodic basis. One told me he had not spent more than a few years at any single hospital.

While I was visiting, one of my hosts was scrambling to provide coverage for one of his partners who was summarily fired at the insistence of a surgeon, who wielded a great deal of power and took exception to something the partner had done. “What had he done?” I asked. “He dared to practice modern medicine,” was the response.

If the hospitals or the general public placed some importance on having board certified and properly qualified doctors working in their EDs, then perhaps there might be a modicum of protection for the physicians. But apparently there is no such emphasis. Being a popular region, there is no shortage of other docs willing to staff the EDs in the area. They travel in from hundreds of miles away. Further, the state medical board has shown no concern for board certification or appropriate training. Given the apparent lack of emphasis on quality care, anyone is welcome to come down and fill vacant positions.

Perhaps one factor in this mess is the relative lack of qualified emergency docs. Other states of comparable size have more EM residencies and graduate more residents each year. Further, one of the training programs in the state is run by one of the big contract groups, which has an established track history of employing non-trained and non-boarded docs. Surely this is not helping the state of EM in that area.

But things are looking up. I met a number of young EM residents training at one of the local hospitals, and they seemed as enthusiastic and qualified as any I have met (note: shame on the local university hospital which has failed, apparently repeatedly, to establish an EM training program). Perhaps the growing number of properly trained and certified EM physicians will raise expectations at the local hospitals. Perhaps area citizens will begin to ask “How come big, high quality hospitals elsewhere in the country have their EDs staffed entirely by board certified docs, but not around here.”

Maybe some bright hospital administrator will recognize that high quality care begins in the emergency department. That half or more of his patients come in through the ED and that what happens there can make a big difference both to hospital operations and to the bottom line. That helping establish an independent EM group is the best way to bypass the money sucking contract holder and thus support a group of high quality physicians.

Perhaps someday the hospitals in this city will learn that good ED care brings rewards. Once that light bulb turns on, they will have taken the first step toward quality acute care. Heck, right now they are thirty or forty years behind the rest of the nation; they have to smarten up sometime. Don’t they?