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Mumford, MD, speaking with regard to the a d m i n i s t r a tion of medical schools, said, There is no doubt that the fundamental trouble is with our governing boards. They are business and professional men who are important in their community. They are chosen governors because they are important people. They know nothing at first hand about the conduct of great or small university matters. Our best medical schools are run too exclusively for the race horses. The average man doesn't get enough mental stimulation or practical advice. I see the results constantly .in my younger consultants and then there is the protest throughout the land. What is the matter with the practice of medicine? Remember, this was w r i t t e n 63 years ago. Sounds almost like a m e m b e r of A C E P t a l k i n g to a U A / E M S member. The same author really starts to focus on the problem. The question of providing competent and humane physicians to take care of the sick is becoming increasingly urgent and the trouble lies with the high grade medical schools and hospitals. These institutions are dominated by men largely unfamiliar with the problems of practice, their leading idea being to train both students and physicians to an expert knowledge of medicine, but they emphasize theory rather than practice. They realize their shortcomings but justify their course by saying young men will get all of their bedside practice when they become hospital interns. They call themselves consultants and keep hours and appointments so irregular that practice cannot find them. When the chief shepherds have for a generation so neglected and mistreated their flocks, what can one expect? A s you can see medicine was already i n deep, d a r k trouble 63 years ago, at least according to a distinguished Boston practitioner. Why am I t a k i n g the time to r u n this past history by you? Well, I t h i n k it is g e r m a n e - - g e r m a n e to us i n U A / E M S w h e n we q u e s t i o n o u r role as a c a d e m i c types in the field and future of emergency medicine. The t r a d i t i o n a l specialist, at least i n the u n i v e r s i t y setting, will probably never give up his interest in emergency medicine - - he is dealing with e m e r g e n t problems on a day-to-day basis with his hospitalized p a t i e n t s and he is i n s t r u c t i n g medical s t u d e n t s a n d house staff i n d e a l i n g with these very same problems. The t r a d i t i o n a l specialist's i n t e r e s t i n his own branch of medicine is i n part generated by the types of e m e r g e n t problems t h a t area of medicine encompasses. The t a c h y a r r h y t h m i a in the failing elderly h e a r t challenges a cardiologist's intellect and skill, the p a t i e n t with multiple t r a u m a t i c injuries taxes and s t i m u l a t e s the surgeon whose research interest may focus on the role of lysosomal enzymes in h y p o v o l e m i c shock, a n d the p s y c h i a t r i s t r u n n i n g a n acute service will stop his daily therapy session with a depressed postmenopausal w o m a n to be challenged by a t h r e a t e n i n g , suicidal, drug-addicted t e e n a g e g u i t a r i s t . The t r a d i t i o n a l specialists will not give up these interests w i t h i n their own areas of e:¢pertise - - nor should they. The academic, t r a d i t i o n a l specialist also has the duty and obligation to do more t h a n crawl along the frontiers of science with a h a n d lens: he is responsible for research as it applies to his p a r t i c u l a r area of interest - - basic research, and i m m e d i a t e l y applicable clinical research. With rare exceptions, double-blind, randomized, prospective studies c a n n o t be carried out i n a c o m m u n i t y setting.

Page 904 Volume 5 Number 11

I n general, most academic, t r a d i t i o n a l specialists have done their work well, b u t they have failed i n their teach. ing, research, administrative, service and organizational, functions w h e n it comes to o u t p a t i e n t emergency medi, cine. They h a v e neglected, f o r g o t t e n about, avoided, walked around, evaded and repressed the single largest source of most p a t i e n t s admitted to the hospital acutely - - the emergency department. Are they blind? No. Are they unconcerned? No. Are they u n a w a r e ? Sometimes. But they have had house staff r u n n i n g interference for them, placing three stitches in a minor laceration, giving a n a s t h m a t i c a b r o n c h o d i l a t o r , s t r a p p i n g a sprained ankle, a n d i n v e s t i g a t i n g the p a t i e n t w i t h acute chest pain. The academician has lagged behind i n his u n d e r s t a n d. ing of the emergency d e p a r t m e n t explosion: the patient on rush, the episodic elective care, the expectation' of a 24-hour, well-staffed facility. Remember, it was only in 1970 that a group of physicians, concerned with the lack of emphasis being placed on or a t t e n t i o n b e i n g directed to e m e r g e n c y m e d i c i n e i n u n i v e r s i t y t e a c h i n g centers, formed this organization. Practice-based physicians, two years earlier, had formed the A m e r i c a n College of Emergency Physicians. Are these organizations at cross purposes? No. They can h a p p i l y coexist. UA/EMS is the. academically based, teaching, research, and service component i n the univer. s i t y s e t t i n g . A C E P is p r i m a r i l y s e r v i c e - o r i e n t e d , community-based and i n t e r e s t e d in certifying the compe. tence of those already i n practice or about to go into practice. Our o r g a n i z a t i o n h a s b e e n h o m e to traditional specialists who have had the foresight to poke and prod the u n i v e r s i t y into recognizing emergency medicine as a special, distinct, o u t p a t i e n t area. As this organization reviews its objectives, as its Long Range P l a n n i n g Committee deliberates about our future, I t h i n k you will find some t r a d i t i o n a l specialists l e a v i n g the ranks, b u t I predict a growth i n m e m b e r s h i p - - a growth made up of those people who are responsible for university-based t r a i n i n g programs in emergency medicine and those individuals i n these t r a i n i n g programs. At this point, and almost as a n aside, I would like to add t h a t all emergency m e d i c i n e r e s i d e n c y t r a i n i n g p r o g r a m s s h o u l d be university-based or affiliated, a n d related to educational goals and manpower needs - - not to the service needs of the practicing emergency p h y s i c i a n who establishes a program u n d e r the guise of replicating more of his own kind. STEM, the Society for Teachers of Emergency Medicine, will find t h a t UA/EMS, with a slight change in the c h a r a c t e r of its m e m b e r s h i p roles, does represent academic emergency medicine and hence the need for yet a n o t h e r o r g a n i z a t i o n m a y be obviated. O u r founding fathers, interested i n the future of emergency medicine, b u t choosing to r e m a i n t r a d i t i o n a l specialists, m a y well s u b m i t letters of resignation, b u t this m a y only serve to s t r e n g t h e n the common i n t e r e s t a n d cause t h a t they founded. Let me r e m i n d all of you t h a t our constitutional objeC' tives are still valid. Our priorities i n achieving these ob' jectives m u s t be revised from t i m e to time and our consti'

November 1976 J ~ P

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