Emergency Medicine: What Are We Smoking? by Jim Ducharme, M.D.
Monday, July 13, 2009 
Jim Ducharme MD CM FRCPI had the chance to read a commentary from A. Seefeld in AEM this year. He is an EM resident, and like most residents had little idea what he was getting into when he started his residency. What I think scares me more is that most residency programs don’t know what residents are getting into. Allow me to explain. When was the last time someone actually measured what it is we do? How many know what the distribution of illness is that exists in our practice? Is that distribution represented in the same ratio in our training? For example, 20-22% of our patients present with their primary complaint being pain originating from a chronic painful condition, yet we spend NO time teaching residents about chronic pain. We, like the ostrich, bury our heads in the academic sand and say that is not part of emergency medicine. That is like an athlete saying that his team is better than its record indicates – when in fact you are exactly equal to what your record indicates. We insist instead that we all know how to try to resuscitate dead people – otherwise known as ACLS – when in fact that represents less than 0.01% of our patients. If we do not define who we see, and do not train our learners about the patients they will actually see (rather than training them about who they hope to see), will we not all be frustrated and continue to misunderstand our specialty? How do we ever answer Dr. Seefeld who wishes to have the word “emergency figuratively placed back on the sign in front of our EDs” when we have yet to define properly what it is we do? Even today we allow others to define what we should NOT do: stroke centres, straight-to-cath-lab policies for EMS etc. But that is for another discussion….
Reader Comments (2)
Jim,
You are right - we need to understand what we actually do for ourselves before we can explain to others. I think that this starts with a realistc examination of our casemix. In most big western-world style EDs, the break-up of cases would be something like this: up to 10% true resuscitation cases (including major trauma), up to 20-30% low-complexity acute care (fractures, wounds, miscarriage, renal colic etc etc), and the remaining 60 - 70% a combination of cases needing :work-up" or intellectual input. Some of these need acute care (asthma, heart failure, CPOD exacerbations, cholecystitis), but a significant number need either well-patient risk-management rule-outs (chest pain, PE, febrile child etc) or the complex elderly with multiple medical problems and marginal coping (an increasing proportion of our work).
So, what is "emergency medicine" practice? It is not just resuscitation and trauma management. The majority of it is problem-assessment, risk-management and problem-solving. Why did this person come today, and what do they need from me? Could this relatively well-looking person have ectopic pregnancy, PE, acute coronary syndrome, swine flu? Is this rash meningococcaemia? Is this episode of dizziness anything sinister? Is this an acute abdomen? Does this person need hospital admission or are they safe at home or with community follow-up. These critical decisions, made in a time-dependent manner with multiple unsceduled presentations, and with minimal information, respresent our specialty. It is an intellectual skill, a cognitive skill - not a technical one. Anyone can be trained to do procedures, but no-one else in the medical community knows how to do what we do. Imagine your local cardiologist running ED for a day - the beds would fill instantly because nobody could go home while their risk of adverse events was anything above zero. The orthopaedic surgeon would admit nobody but they would all re-present on your next shift. The geriatrician would still be there a day later sorting out all the details...
Until we understand and value to cognitive aspects of our work, how can we expect anyone else to do so?
P.S. Lovely photo, Jim. You never seem to age!!