f
Editorialsl The American College of Emergency Physicians in the Bicentennial Year
E a c h of these types still exists. F r o m these two colonies have developed several t h o u s a n d e m e r g e n c y d e p a r t m e n t s of today a n d some 15,000 p h y s i c i a n s p r a c t i c i n g emergency medicine.
IN THE SAME MANNER t h a t the U n i t e d S t a t e s is looking back over its history and the role of the founding fathers, the A m e r i c a n College of E m e r g e n c y P h y s i c i a n s (ACEP) must give much of the credit for its p r e s e n t s t a t u s to the efforts of its founders.
Like this g r e a t n a t i o n which was a m e l t i n g pot for the world, e m e r g e n c y m e d i c i n e said "send me your downtrodden, overworked physicians" and, at first, the specialty was t h o u g h t to consist of ~'old r e t i r e d GPs," as we were told a t one o r g a n i z a t i o n a l meeting. It soon became a p p a r e n t , however, t h a t this specialty was going to require youth and vigor.
The D e c l a r a t i o n of Independence, although d a t e d J u l y 4, 1776, was a c t u a l l y published on J u l y 2. It h a d been drafted by five men, n a m e l y B e n j a m i n F r a n k l i n , Robert .Livingston, J o h n Adams, T h o m a s Jefferson a n d Roger Sherman of Connecticut. S h e r m a n h a d a h a b i t of p i c k i n g his teeth d u r i n g the d r a f t i n g sessions and this so a g g r a rated B e n j a m i n F r a n k l i n t h a t he t h r e a t e n e d to "play my harmonica" unless S h e r m a n quit. It is i n t e r e s t i n g to note that S h e r m a n was a lawyer. The a r t i c l e s of incorporation of A C E P were d r a w n up in 1968 by a group of M i c h i g a n physicians in response to a local p r o b l e m in t h e i r area. These men, then, m i g h t be considered d r a f t e r s of t h e A C E P d e c l a r a t i o n of independence and should be listed for history. They are J o h n G. Wiegenstein, MD, J o h n T. Rogers, MD, George C. F i n k , MD, Robert Leichtman, MD, R i c h a r d Lingenfelter, MD, Eugene C. Nakfoor, MD, J o h n A. Rupke, MD, and Robert J. Rathburn, MD. Symbolically, perhaps, an o r g a n i z a t i o n a l m e e t i n g was called in W a s h i n g t o n , DC, N o v e m b e r of 1968 by R e i n a l d Leidelmeyer, MD. He h a d w r i t t e n to a n u m b e r of physiclans w h o m he k n e w to be in e m e r g e n c y practice and 26 of these a t t e n d e d the meeting. It was at t h a t t i m e the Michigan incorporators graciously offered t h e A m e r i c a n College of E m e r g e n c y P h y s i c i a n s a s t h e basis for a nati0nal organization. A f t e r this m e e t i n g the B o a r d of Directors included the previously listed incorporators and Reinald L e i d e l m e y e r , MD, J a m e s D. Mills, MD, H a r r i s B. Graves, MD, W i l l i a m T. Haeck, MD, R. R. H a n n a s , Jr, ~ID, J o h n v a n de Leuv, MD, and Donald M_ Wenger, ~ID. This board c o n s t i t u t e d the first official body of the national e x t e n s i o n of t h e ACEP. Dr. W i e g e n s t e i n was elected t h e first c h a i r m a n . If, t h e n , Dr. W i e g e n s t e i n m i g h t be c o n s i d e r e d . o u r George W a s h i n g t o n , p e r h a p s Dr. Mills would be considered our T h o m a s Jefferson and Dr. H a n n a s our Theodore ,Roosevelt. C e r t a i n l y , Dr. Rupke is well t h o u g h t of as our William J e n n i n g s Bryan. Our "colonies" were begun in 1961 by the A l e x a n d r i a [t0spital in V i r g i n i a and the Pontiac G e n e r a l H o s p i t a l in ~ichigan w h e n t h e y i n d e p e n d e n t l y e s t a b l i s h e d two types 0f contract, full-time e m e r g e n c y d e p a r t m e n t coverage. I~~his editorial is based on an address to the Southeast Emergen~YCongress on May 4, 1976.
~ ] ~ ) Octobgr 1976
A profile of t h e College m e m b e r s h i p i n d i c a t e d t h a t / over 25% of the c u r r e n t A C E P m e m b e r s h i p was 35 y e a r s of age or younger. Less t h a n 12% was 60 years or older. Of the new applications received, more t h a n 50% was u n d e r the age of 35. Lest one believe t h a t y o u t h m e a n s inexperience, rem e m b e r t h a t the M a r q u i s de Lafayette, the general in c h a r g e of F r a n c e ' s p a r t i c i p a t i o n in o u r r e v o l u t i o n a r y struggle, was only 19 y e a r s old. T h a t A l e x a n d e r H a m i l ton was only 30 y e a r s old d u r i n g the t i m e of the constitutional debates. Hamilton (though not fashionably t h o u g h t of today) was described by H. L. M e n k e n as having shown a '~steady w i l l i n g n e s s to believe t h a t his oppon e n t is as w i l l i n g a m a n as h i m s e l f - and m a y be right." Indeed, this is an a t t i t u d e we m a y well consider in our efforts today. It is, perhaps, the effect of this m e l t i n g pot, however, t h a t h a s allowed the College to become effective w i t h other o r g a n i z a t i o n s so rapidly. A m o n g our m e m b e r s are surgeons, o b s t e t r i c i a n s , f a m i l y p h y s i c i a n s , i n t e r n i s t s , psychiatrists, p e d i a t r i c i a n s , and so on, all able to r e l a t e between the A C E P and o t h e r specialty groups. The previously m e n t i o n e d s t u d y 1 r e v e a l e d t h a t a p p r o x i m a t e l y 45% of the m e m b e r s were board eligible or certified in a n o t h e r specialty. A p p r o x i m a t e l y 15% of the m e m b e r s were surgeons, a p p r o x i m a t e l y 15% were family physicians, and a p p r o x i m a t e l y 11% were internists. C h r i s t o p h e r Columbus, as you well know, was not sent on his voyage to seek t h e new world. Indeed, he convinced Queen I s a b e l l a of Spain t h a t he could find the W e s t Indies and reopen the t r a d e in spices t h a t had been closed by the Turks. All of this for such a simple t h i n g as pepper. However, p r i o r i t i e s do change. A n d A C E P ' s p r i o r i t i e s c h a n g e from t i m e to t i m e . P e r h a p s we will look back on some of our e a r l y efforts a n d w o n d e r how we could h a v e s p e n t so much t i m e s e a r c h i n g for pepper. But each goal m u s t be evaluated. T h e old c o l o n i a l s l e a r n e d t h a t t h e r e is no l i v e l i e r s t i m u l u s to brotherhood t h a n physical danger. ACEP's brotherhood s t i m u l u s now is the effort to identify ourselves with true specialists in the house of medicine. A l e a r n e d j u d g e once said "Justice is a splendid
Volume 5 Number 10 Page 809
t h i n g b u t you m u s t not expect justice from this life." You and I know t h a t emergency medicine is a true specialty b u t we j u s t c a n n o t expect t h a t everyone else will so recognize it.
Progress Toward Specialty Status A great deal of effort has already gone into the steps necessary for emergency medicine to become a p r i m a r y specialty. F i r s t of all, ACEP became a recognized national scientific medical society in 1973. Secondly, emergency medicine became a p e r m a n e n t scientific section of the A m e r i c a n Medical Association (AMA) in December Of 1975. The first m e m b e r s have been appointed to t h a t scientific section and they m i g h t be considered our "minu t e m e n " i n the forefront of our efforts to demonstrate the quality of emergency medicine. Those physicians are Dr. H a n n a s , Ronald L. Krome, MD, Dr. Wiegenstein, George Podgorny, MD, and Carl Jelenko, III, MD. Thirdly, a n application was sent i n March of 1976, to the A m e r i c a n Board of Medical Specialties (ABMS) asking t h a t emergency medicine be designated a p r i m a r y specialty. T h a t application contained a large a m o u n t of i n f o r m a t i o n assembled in a n expert m a n n e r by ACEP staff. This application has been referred to the Liaison Committee on Specialty Boards composed of representatives of the ABMS a n d the AMA Council on Medical Education. We hope w i t h i n six m o n t h s after referral to the Liaison Committee, a r e c o m m e n d a t i o n for approval or disapproval will be given to its p a r e n t bodies.* A n aff i r m a t i v e vote of two t h i r d s of the m e m b e r s of both ABMS a n d the AMA Council on Medical E d u c a t i o n is necessary for approval. In the e v e n t of a n e g a t i v e response, a h e a r i n g before the Liaison Committee m a y be requested by the College. A new application m a y be submitted b u t it would not be considered for at least 12 months from the date of the final decision on the original application. I n the m e a n t i m e , the A m e r i c a n Board of E m e r g e n c y Medicine (ABEM) has been formed and will soon be incorporated.t Twelve physicians, r e p r e s e n t i n g ACEP, the U n i v e r s i t y Association for Emergency Medical Services (UA/EMS) and the AMA Section on E m e r g e n c y Medicine have been n a m e d to t h a t Board. For the history of the College, those physicians should be listed. R e p r e s e n t i n g A C E P are Dr. W i e g e n s t e i n , Dr. Podgorny, Dr. Mills, Peter Rosen, MD, J a m e s J. Dineen, MD, and Dr. H a n n a s . R e p r e s e n t i n g UA/EMS are Robert H.. Dailey, MD, Allen P. Klippel, MD, David K. W a g n e r , MD, a n d Gall V. Anderson, MD. R e p r e s e n t i n g the Section on E m e r g e n c y Medicine are Dr. Krome and Dr. Jelenko.
*On June 9, 1976 the Liaison Committee on Specialty Boards requested additional background information. This has been prov]ded and a request to appear before the Liaison Committee and ABMS prior to formal action has been made. tSince this address was given, ABEM has been incorporated, has held its first organizational meeting, and approved eligibility requirements. See September JACEP, p 724. SFor a complete report on the progress of the certification examination see "The Emergency Medicine Specialty Certification Examination." JACEP July, 1976_
Page 810 Volume 5 Number 10
It is i m p o r t a n t to r e m e m b e r t h a t ABEM is a n a~, tonomous organization a n d will establish its own rttle~, and regulations r e l a t i n g to certification_ It is expecte~ t h a t t h e m e c h a n i s m s u g g e s t e d by t h e C o m m i t t e e 0R Board E s t a b l i s h m e n t will be accepted by ABEM, b u t it i~ obviously not mandatory.* Work continues on the certification e x a m i n a t i o n aad~ great deal of time and effort has been provided by the Certification Task Force. Since you will hear a complet~ report on the e x a m i n a t i o n itself tomorrow I will not # further except to say t h a t the t i m e t a b l e is being kept a~d the e x a m i n a t i o n should be ready late i n 1977.$ It is my own opinion t h a t we m u s t continue the certifi. cation process regardless of the decision of ABMS and the Council on Medical Education. There are, of course, several reasons why emergenc1 medicine should be a specialty with its own certificati0~ examination. 1) E m e r g e n c y m e d i c i n e r e s i d e n c y p r o g r a m s are i~. creasing in n u m b e r . It is vital t h a t essentials for these programs be established a n d t h a t official residency re. view be performed. The s t a n d a r d s for residency prograr, t i n e m e r g e n c y m e d i c i n e were a p p r o v e d by the AMA House of Delegates in 1975 for the use of the Liaison Residency E n d o r s e m e n t Committee, consisting of repre. s e n t a t i v e s from A C E P a n d UA/EMS. This same docu. m e n t was referred to the Liaison Committee for Grad. uate Medical Education (LCGME) for its use in devel. o p i n g e s s e n t i a l s for r e s i d e n c y r e v i e w by t h e AMA However, to the best of our knowledge n o t h i n g has been done to further the approval of those essentials. A resolu. tion was presented to ABMS, March 26, by the American Board of F a m i l y Practice u r g i n g t h a t the LCGME study and recommend methods t h a t facilitate, expedite and i•. prove the process of residency approval. The resolution was approved t h a t day a n d is c e r t a i n l y a necessary re. quest. 2) C e r t i f i c a t i o n s e r v e s to m a i n t a i n h i g h , unifor~ standards a n d protects the public from unqualified pra¢. titioners. 3) N a t i o n a l c e r t i f i c a t i o n w o u l d p r o v i d e i m p r o v d mobility for the emergency physician by identifying hi6 professionalism. 4) The unrecognized status of emergency medicine i~ a n obstacle to the d e l i n i a t i o n of privileges by the Joini Committee on Accreditation of Hospitals. 5) Certification would expedite medical staff appoint ments. 6) Lastly, b u t far from least, we are the largest a~ last group of physicians i n a specialty area without the p r o v i s i o n of c e r t i f i c a t i o n . C e r t i f i c a t i o n is definite]l' needed to protect us from i n c u r s i o n of g o v e r n m e n t a l reg' ulations. But, if we are forced to do all this i n d e p e n d e n t l y fr0~ the A m e r i c a n Medical Association, t h e n it m u s t be do~e i n a m a n n e r above criticism. I can assure you t h a t this is the i n t e n t a n d t h a t it will be so accomplished.
October 1976 J ~
DueS and A s s e s s m e n t
REFERENCES
The Boston Tea P a r t y was a raid by fake i n d i a n s on ships of t h e E a s t I n d i a c o m p a n y . The m a s q u e r a d e r s d u m p e d 300 chests of t e a in the Boston H a r b o r because of the 3 pence a pound tax. There was some concern t h a t we m i g h t h a v e our own L a n s i n g Tea P a r t y if the A C E P m e m b e r s were not convinced of the v a l i d i t y of the reasons for the 1975 increase in dues a n d the v o l u n t a r y a s s e s s m e n t to s u p p o r t the development of the certification e x a m i n a t i o n . However, m e m b e r s h i p now s t a n d s at 7,636 m e m b e r s , an increase of 33% over the previous 12-month period. Of some 131 n a t i o n a l scientific medical societies, A C E P now s t a n d s n u m b e r 12 in m e m b e r s h i p . We hope to r e a c h 8,000 m e m b e r s w i t h i n the next one or two months.* The response to t h e a s s e s s m e n t to fund the developm e n t of the certifying e x a m i n a t i o n has been gratifying. A l t h o u g h the a s s e s s m e n t s t a t e m e n t s have only been out since March, n e a r l y 23% of the m e m b e r s h i p has a l r e a d y contributed. And, of those contributing, a p p r o x i m a t e l y 60% h a v e r e t u r n e d t h e full a m o u n t d u e . t T h i s c a n only reflect the u n d e r s t a n d i n g and e n t h u s i a s m of t h e m e m b e r s h i p t o w a r d s the need for certification. C o n s e n t of the G o v e r n e d
P e r h a p s the single most i n f l a m m a t o r y line in the Decl a r a t i o n of I n d e p e n d e n c e is t h a t g o v e r n m e n t s d e r i v e their j u s t powers from consent of the governed. W h e n the people in power can n e i t h e r keep the consent of the governed, nor respond to the dissent of the governed, t h e r e m u s t be an explosion. The s p e a k e r of t h e Council of ACEP, M a r k M. Lindsey, MD, a n d the vice-speaker, J e r r y R. H u g h e s , MD, have recognized this principle and are a t t e m p t i n g to educate, inform a n d organize the Council into the l e g i s l a t i v e body it should be. I urge all of you to follow t h e i r guidance, to elect k n o w l e d g e a b l e councillors and to keep y o u r s e l f informed of the affairs of t h e College. N e v e r forget - - i t w a s not politicians t h a t m a d e t h i s country great, b u t i t was t h a t m a g n i f i c e n t group, commonly called '~the people." Accordingly, it h a s been t h e t r e m e n d o u s devotion of the m e m b e r s of A C E P t h a t h a s w r o u g h t w h a t we see today. Organizations, like people and nations, go t h r o u g h a cycle of e a r l y g r o w t h w i t h e n t h u s i a s m a n d vigor, followed by m a t u r i t y w i t h reflection and finally senescence with little hope. U n l i k e the h u m a n body, however, organizations a n d n a t i o n s m a y be r e j u v e n a t e d by the infusion of new blood a n d the i n s t i l l a t i o n of new ideas. I have no a r g u m e n t w i t h m a t u r i t y , b u t we m u s t n e v e r let A C E P become slow, a n d u n r e s p o n s i v e . We m u s t c o n t i n u e to persevere so t h a t , at some t r i c e n t e n n i a l c e l e b r a t i o n in the future, our m e m b e r s can look back a n d say, "They did well." Harris B. Graves, MD President * As of July 31, 1976, ACEP membership was 8,000. t As of July 31, 1976, 35% had contributed.
J~P
October 1976
1. Fahrney PM: ACEP membership: a~statistical analysis. J A C E P[ 3:297-301, 1974.
To Each His Own - And More Power to Him A T THE PEAK OF THE ENERGY shortage several winters past, I was given a special opportunity. I was w a t c h i n g a television news b r o a d c a s t d i s p l a y i n g the life style of an electrician's family living through the bitter Maine w i n t e r w i t h e n e r g y to burn. The father h a d built his own hydroelectric energy p l a n t on a s t r e a m on his property. It was producing generous a m o u n t s of free electric power, power exceeding t h e family's wildest demands. S i t t i n g before the TV in the 70 degree b a l m of a South~rn C a l i f o r n i a winter, I watched interviews with local Maine r e s i d e n t s w o r r i e d about automobile fuel shortages, n a t u r a l gas shortages, and the u n a v a i l a b i l i t y of low cost, a l t e r n a t i v e energy source. They felt they had lost control over t h e i r lives and were bitter_ I was s t i m u l a t e d a n d a trifle awed by the accomplishm e n t of the resourceful Maine man. He had insured a v i r t u a l l y endless, free supply of a precious commodity, w i t h o u t b r a v a d o and w i t h o u t i n t e r f e r i n g in any w a y with the needs of others. I n s p i r e d by his example, at the local l i b r a r y I sought out a book on power generation. For a week or two, while s i t t i n g p a t i e n t l y in t h e hour-long lines at the gas stations, I r e a d about w i n d power, wood power, m e t h a n e power, solar power, and w a t e r power, c l u t t e r i n g m y m i n d w i t h d e t a i l s of h e a d r a c e s , t u r b i n e s , a n d o v e r s h o t waterwheels. The little I know of these a r c a n e m a t t e r s was recalled in a flash upon r e a d i n g the article by Morton C. Morris, MD, in the S e p t e m b e r issue of JACEP. In "On-the-Scene E m e r g e n c y Care by t h e P r i m a r y Physician," Dr. Morris writes about his experiences. He calls h i m s e l f a p r i m a r y care p h y s i c i a n and he m a y be found among the faculty in F a m i l y Practice at the P e o r i a School of Medicine of the U n i v e r s i t y of Illinois. Dr. Morris gave a n o t h e r g r e a t o p p o r t u n i t y . R e s t i n g here in the bosom of a g r e a t institution, surrounded by sophisticated e q u i p m e n t and s u p e r b l y t r a i n e d personnel, served w i t h stabilized p a t i e n t s by competent p a r a m e d i c s who b l a n k e t the u r b a n environs w i t h the m a n t l e of advanced life-support, the exciting opportunities afforded by our specialty are u n a p p r e c i a t e d . Dr. Morris reveals t h e m as he recounts his activities. He responds p r o m p t l y to emergencies in a r u r a l area, a r r i v i n g in less t h a n t e n m i n u t e s following a call. He solves t h e problem of providing a knowledgeable, capable, d i s c r i m i n a t i n g , m e d i c a l l y t r a i n e d i n d i v i d u a l to render e m e r g e n c y e v a l u a t i o n a n d t r e a t m e n t by s u p p l y i n g himself. He solves the problem of delays and confusion in c o m m u n i c a t i o n d u r i n g t h e e m e r g e n c y by giving confidence to those who m i g h t call h i m for help - - patients, t h e i r families, a m b u l a n c e a t t e n d a n t s , and public safety
Volume 5 Number 10 Page 811
Editorialsl The American College of Emergency Physicians in the Bicentennial Year
E a c h of these types still exists. F r o m these two colonies have developed several t h o u s a n d e m e r g e n c y d e p a r t m e n t s of today a n d some 15,000 p h y s i c i a n s p r a c t i c i n g emergency medicine.
IN THE SAME MANNER t h a t the U n i t e d S t a t e s is looking back over its history and the role of the founding fathers, the A m e r i c a n College of E m e r g e n c y P h y s i c i a n s (ACEP) must give much of the credit for its p r e s e n t s t a t u s to the efforts of its founders.
Like this g r e a t n a t i o n which was a m e l t i n g pot for the world, e m e r g e n c y m e d i c i n e said "send me your downtrodden, overworked physicians" and, at first, the specialty was t h o u g h t to consist of ~'old r e t i r e d GPs," as we were told a t one o r g a n i z a t i o n a l meeting. It soon became a p p a r e n t , however, t h a t this specialty was going to require youth and vigor.
The D e c l a r a t i o n of Independence, although d a t e d J u l y 4, 1776, was a c t u a l l y published on J u l y 2. It h a d been drafted by five men, n a m e l y B e n j a m i n F r a n k l i n , Robert .Livingston, J o h n Adams, T h o m a s Jefferson a n d Roger Sherman of Connecticut. S h e r m a n h a d a h a b i t of p i c k i n g his teeth d u r i n g the d r a f t i n g sessions and this so a g g r a rated B e n j a m i n F r a n k l i n t h a t he t h r e a t e n e d to "play my harmonica" unless S h e r m a n quit. It is i n t e r e s t i n g to note that S h e r m a n was a lawyer. The a r t i c l e s of incorporation of A C E P were d r a w n up in 1968 by a group of M i c h i g a n physicians in response to a local p r o b l e m in t h e i r area. These men, then, m i g h t be considered d r a f t e r s of t h e A C E P d e c l a r a t i o n of independence and should be listed for history. They are J o h n G. Wiegenstein, MD, J o h n T. Rogers, MD, George C. F i n k , MD, Robert Leichtman, MD, R i c h a r d Lingenfelter, MD, Eugene C. Nakfoor, MD, J o h n A. Rupke, MD, and Robert J. Rathburn, MD. Symbolically, perhaps, an o r g a n i z a t i o n a l m e e t i n g was called in W a s h i n g t o n , DC, N o v e m b e r of 1968 by R e i n a l d Leidelmeyer, MD. He h a d w r i t t e n to a n u m b e r of physiclans w h o m he k n e w to be in e m e r g e n c y practice and 26 of these a t t e n d e d the meeting. It was at t h a t t i m e the Michigan incorporators graciously offered t h e A m e r i c a n College of E m e r g e n c y P h y s i c i a n s a s t h e basis for a nati0nal organization. A f t e r this m e e t i n g the B o a r d of Directors included the previously listed incorporators and Reinald L e i d e l m e y e r , MD, J a m e s D. Mills, MD, H a r r i s B. Graves, MD, W i l l i a m T. Haeck, MD, R. R. H a n n a s , Jr, ~ID, J o h n v a n de Leuv, MD, and Donald M_ Wenger, ~ID. This board c o n s t i t u t e d the first official body of the national e x t e n s i o n of t h e ACEP. Dr. W i e g e n s t e i n was elected t h e first c h a i r m a n . If, t h e n , Dr. W i e g e n s t e i n m i g h t be c o n s i d e r e d . o u r George W a s h i n g t o n , p e r h a p s Dr. Mills would be considered our T h o m a s Jefferson and Dr. H a n n a s our Theodore ,Roosevelt. C e r t a i n l y , Dr. Rupke is well t h o u g h t of as our William J e n n i n g s Bryan. Our "colonies" were begun in 1961 by the A l e x a n d r i a [t0spital in V i r g i n i a and the Pontiac G e n e r a l H o s p i t a l in ~ichigan w h e n t h e y i n d e p e n d e n t l y e s t a b l i s h e d two types 0f contract, full-time e m e r g e n c y d e p a r t m e n t coverage. I~~his editorial is based on an address to the Southeast Emergen~YCongress on May 4, 1976.
~ ] ~ ) Octobgr 1976
A profile of t h e College m e m b e r s h i p i n d i c a t e d t h a t / over 25% of the c u r r e n t A C E P m e m b e r s h i p was 35 y e a r s of age or younger. Less t h a n 12% was 60 years or older. Of the new applications received, more t h a n 50% was u n d e r the age of 35. Lest one believe t h a t y o u t h m e a n s inexperience, rem e m b e r t h a t the M a r q u i s de Lafayette, the general in c h a r g e of F r a n c e ' s p a r t i c i p a t i o n in o u r r e v o l u t i o n a r y struggle, was only 19 y e a r s old. T h a t A l e x a n d e r H a m i l ton was only 30 y e a r s old d u r i n g the t i m e of the constitutional debates. Hamilton (though not fashionably t h o u g h t of today) was described by H. L. M e n k e n as having shown a '~steady w i l l i n g n e s s to believe t h a t his oppon e n t is as w i l l i n g a m a n as h i m s e l f - and m a y be right." Indeed, this is an a t t i t u d e we m a y well consider in our efforts today. It is, perhaps, the effect of this m e l t i n g pot, however, t h a t h a s allowed the College to become effective w i t h other o r g a n i z a t i o n s so rapidly. A m o n g our m e m b e r s are surgeons, o b s t e t r i c i a n s , f a m i l y p h y s i c i a n s , i n t e r n i s t s , psychiatrists, p e d i a t r i c i a n s , and so on, all able to r e l a t e between the A C E P and o t h e r specialty groups. The previously m e n t i o n e d s t u d y 1 r e v e a l e d t h a t a p p r o x i m a t e l y 45% of the m e m b e r s were board eligible or certified in a n o t h e r specialty. A p p r o x i m a t e l y 15% of the m e m b e r s were surgeons, a p p r o x i m a t e l y 15% were family physicians, and a p p r o x i m a t e l y 11% were internists. C h r i s t o p h e r Columbus, as you well know, was not sent on his voyage to seek t h e new world. Indeed, he convinced Queen I s a b e l l a of Spain t h a t he could find the W e s t Indies and reopen the t r a d e in spices t h a t had been closed by the Turks. All of this for such a simple t h i n g as pepper. However, p r i o r i t i e s do change. A n d A C E P ' s p r i o r i t i e s c h a n g e from t i m e to t i m e . P e r h a p s we will look back on some of our e a r l y efforts a n d w o n d e r how we could h a v e s p e n t so much t i m e s e a r c h i n g for pepper. But each goal m u s t be evaluated. T h e old c o l o n i a l s l e a r n e d t h a t t h e r e is no l i v e l i e r s t i m u l u s to brotherhood t h a n physical danger. ACEP's brotherhood s t i m u l u s now is the effort to identify ourselves with true specialists in the house of medicine. A l e a r n e d j u d g e once said "Justice is a splendid
Volume 5 Number 10 Page 809
t h i n g b u t you m u s t not expect justice from this life." You and I know t h a t emergency medicine is a true specialty b u t we j u s t c a n n o t expect t h a t everyone else will so recognize it.
Progress Toward Specialty Status A great deal of effort has already gone into the steps necessary for emergency medicine to become a p r i m a r y specialty. F i r s t of all, ACEP became a recognized national scientific medical society in 1973. Secondly, emergency medicine became a p e r m a n e n t scientific section of the A m e r i c a n Medical Association (AMA) in December Of 1975. The first m e m b e r s have been appointed to t h a t scientific section and they m i g h t be considered our "minu t e m e n " i n the forefront of our efforts to demonstrate the quality of emergency medicine. Those physicians are Dr. H a n n a s , Ronald L. Krome, MD, Dr. Wiegenstein, George Podgorny, MD, and Carl Jelenko, III, MD. Thirdly, a n application was sent i n March of 1976, to the A m e r i c a n Board of Medical Specialties (ABMS) asking t h a t emergency medicine be designated a p r i m a r y specialty. T h a t application contained a large a m o u n t of i n f o r m a t i o n assembled in a n expert m a n n e r by ACEP staff. This application has been referred to the Liaison Committee on Specialty Boards composed of representatives of the ABMS a n d the AMA Council on Medical Education. We hope w i t h i n six m o n t h s after referral to the Liaison Committee, a r e c o m m e n d a t i o n for approval or disapproval will be given to its p a r e n t bodies.* A n aff i r m a t i v e vote of two t h i r d s of the m e m b e r s of both ABMS a n d the AMA Council on Medical E d u c a t i o n is necessary for approval. In the e v e n t of a n e g a t i v e response, a h e a r i n g before the Liaison Committee m a y be requested by the College. A new application m a y be submitted b u t it would not be considered for at least 12 months from the date of the final decision on the original application. I n the m e a n t i m e , the A m e r i c a n Board of E m e r g e n c y Medicine (ABEM) has been formed and will soon be incorporated.t Twelve physicians, r e p r e s e n t i n g ACEP, the U n i v e r s i t y Association for Emergency Medical Services (UA/EMS) and the AMA Section on E m e r g e n c y Medicine have been n a m e d to t h a t Board. For the history of the College, those physicians should be listed. R e p r e s e n t i n g A C E P are Dr. W i e g e n s t e i n , Dr. Podgorny, Dr. Mills, Peter Rosen, MD, J a m e s J. Dineen, MD, and Dr. H a n n a s . R e p r e s e n t i n g UA/EMS are Robert H.. Dailey, MD, Allen P. Klippel, MD, David K. W a g n e r , MD, a n d Gall V. Anderson, MD. R e p r e s e n t i n g the Section on E m e r g e n c y Medicine are Dr. Krome and Dr. Jelenko.
*On June 9, 1976 the Liaison Committee on Specialty Boards requested additional background information. This has been prov]ded and a request to appear before the Liaison Committee and ABMS prior to formal action has been made. tSince this address was given, ABEM has been incorporated, has held its first organizational meeting, and approved eligibility requirements. See September JACEP, p 724. SFor a complete report on the progress of the certification examination see "The Emergency Medicine Specialty Certification Examination." JACEP July, 1976_
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It is i m p o r t a n t to r e m e m b e r t h a t ABEM is a n a~, tonomous organization a n d will establish its own rttle~, and regulations r e l a t i n g to certification_ It is expecte~ t h a t t h e m e c h a n i s m s u g g e s t e d by t h e C o m m i t t e e 0R Board E s t a b l i s h m e n t will be accepted by ABEM, b u t it i~ obviously not mandatory.* Work continues on the certification e x a m i n a t i o n aad~ great deal of time and effort has been provided by the Certification Task Force. Since you will hear a complet~ report on the e x a m i n a t i o n itself tomorrow I will not # further except to say t h a t the t i m e t a b l e is being kept a~d the e x a m i n a t i o n should be ready late i n 1977.$ It is my own opinion t h a t we m u s t continue the certifi. cation process regardless of the decision of ABMS and the Council on Medical Education. There are, of course, several reasons why emergenc1 medicine should be a specialty with its own certificati0~ examination. 1) E m e r g e n c y m e d i c i n e r e s i d e n c y p r o g r a m s are i~. creasing in n u m b e r . It is vital t h a t essentials for these programs be established a n d t h a t official residency re. view be performed. The s t a n d a r d s for residency prograr, t i n e m e r g e n c y m e d i c i n e were a p p r o v e d by the AMA House of Delegates in 1975 for the use of the Liaison Residency E n d o r s e m e n t Committee, consisting of repre. s e n t a t i v e s from A C E P a n d UA/EMS. This same docu. m e n t was referred to the Liaison Committee for Grad. uate Medical Education (LCGME) for its use in devel. o p i n g e s s e n t i a l s for r e s i d e n c y r e v i e w by t h e AMA However, to the best of our knowledge n o t h i n g has been done to further the approval of those essentials. A resolu. tion was presented to ABMS, March 26, by the American Board of F a m i l y Practice u r g i n g t h a t the LCGME study and recommend methods t h a t facilitate, expedite and i•. prove the process of residency approval. The resolution was approved t h a t day a n d is c e r t a i n l y a necessary re. quest. 2) C e r t i f i c a t i o n s e r v e s to m a i n t a i n h i g h , unifor~ standards a n d protects the public from unqualified pra¢. titioners. 3) N a t i o n a l c e r t i f i c a t i o n w o u l d p r o v i d e i m p r o v d mobility for the emergency physician by identifying hi6 professionalism. 4) The unrecognized status of emergency medicine i~ a n obstacle to the d e l i n i a t i o n of privileges by the Joini Committee on Accreditation of Hospitals. 5) Certification would expedite medical staff appoint ments. 6) Lastly, b u t far from least, we are the largest a~ last group of physicians i n a specialty area without the p r o v i s i o n of c e r t i f i c a t i o n . C e r t i f i c a t i o n is definite]l' needed to protect us from i n c u r s i o n of g o v e r n m e n t a l reg' ulations. But, if we are forced to do all this i n d e p e n d e n t l y fr0~ the A m e r i c a n Medical Association, t h e n it m u s t be do~e i n a m a n n e r above criticism. I can assure you t h a t this is the i n t e n t a n d t h a t it will be so accomplished.
October 1976 J ~
DueS and A s s e s s m e n t
REFERENCES
The Boston Tea P a r t y was a raid by fake i n d i a n s on ships of t h e E a s t I n d i a c o m p a n y . The m a s q u e r a d e r s d u m p e d 300 chests of t e a in the Boston H a r b o r because of the 3 pence a pound tax. There was some concern t h a t we m i g h t h a v e our own L a n s i n g Tea P a r t y if the A C E P m e m b e r s were not convinced of the v a l i d i t y of the reasons for the 1975 increase in dues a n d the v o l u n t a r y a s s e s s m e n t to s u p p o r t the development of the certification e x a m i n a t i o n . However, m e m b e r s h i p now s t a n d s at 7,636 m e m b e r s , an increase of 33% over the previous 12-month period. Of some 131 n a t i o n a l scientific medical societies, A C E P now s t a n d s n u m b e r 12 in m e m b e r s h i p . We hope to r e a c h 8,000 m e m b e r s w i t h i n the next one or two months.* The response to t h e a s s e s s m e n t to fund the developm e n t of the certifying e x a m i n a t i o n has been gratifying. A l t h o u g h the a s s e s s m e n t s t a t e m e n t s have only been out since March, n e a r l y 23% of the m e m b e r s h i p has a l r e a d y contributed. And, of those contributing, a p p r o x i m a t e l y 60% h a v e r e t u r n e d t h e full a m o u n t d u e . t T h i s c a n only reflect the u n d e r s t a n d i n g and e n t h u s i a s m of t h e m e m b e r s h i p t o w a r d s the need for certification. C o n s e n t of the G o v e r n e d
P e r h a p s the single most i n f l a m m a t o r y line in the Decl a r a t i o n of I n d e p e n d e n c e is t h a t g o v e r n m e n t s d e r i v e their j u s t powers from consent of the governed. W h e n the people in power can n e i t h e r keep the consent of the governed, nor respond to the dissent of the governed, t h e r e m u s t be an explosion. The s p e a k e r of t h e Council of ACEP, M a r k M. Lindsey, MD, a n d the vice-speaker, J e r r y R. H u g h e s , MD, have recognized this principle and are a t t e m p t i n g to educate, inform a n d organize the Council into the l e g i s l a t i v e body it should be. I urge all of you to follow t h e i r guidance, to elect k n o w l e d g e a b l e councillors and to keep y o u r s e l f informed of the affairs of t h e College. N e v e r forget - - i t w a s not politicians t h a t m a d e t h i s country great, b u t i t was t h a t m a g n i f i c e n t group, commonly called '~the people." Accordingly, it h a s been t h e t r e m e n d o u s devotion of the m e m b e r s of A C E P t h a t h a s w r o u g h t w h a t we see today. Organizations, like people and nations, go t h r o u g h a cycle of e a r l y g r o w t h w i t h e n t h u s i a s m a n d vigor, followed by m a t u r i t y w i t h reflection and finally senescence with little hope. U n l i k e the h u m a n body, however, organizations a n d n a t i o n s m a y be r e j u v e n a t e d by the infusion of new blood a n d the i n s t i l l a t i o n of new ideas. I have no a r g u m e n t w i t h m a t u r i t y , b u t we m u s t n e v e r let A C E P become slow, a n d u n r e s p o n s i v e . We m u s t c o n t i n u e to persevere so t h a t , at some t r i c e n t e n n i a l c e l e b r a t i o n in the future, our m e m b e r s can look back a n d say, "They did well." Harris B. Graves, MD President * As of July 31, 1976, ACEP membership was 8,000. t As of July 31, 1976, 35% had contributed.
J~P
October 1976
1. Fahrney PM: ACEP membership: a~statistical analysis. J A C E P[ 3:297-301, 1974.
To Each His Own - And More Power to Him A T THE PEAK OF THE ENERGY shortage several winters past, I was given a special opportunity. I was w a t c h i n g a television news b r o a d c a s t d i s p l a y i n g the life style of an electrician's family living through the bitter Maine w i n t e r w i t h e n e r g y to burn. The father h a d built his own hydroelectric energy p l a n t on a s t r e a m on his property. It was producing generous a m o u n t s of free electric power, power exceeding t h e family's wildest demands. S i t t i n g before the TV in the 70 degree b a l m of a South~rn C a l i f o r n i a winter, I watched interviews with local Maine r e s i d e n t s w o r r i e d about automobile fuel shortages, n a t u r a l gas shortages, and the u n a v a i l a b i l i t y of low cost, a l t e r n a t i v e energy source. They felt they had lost control over t h e i r lives and were bitter_ I was s t i m u l a t e d a n d a trifle awed by the accomplishm e n t of the resourceful Maine man. He had insured a v i r t u a l l y endless, free supply of a precious commodity, w i t h o u t b r a v a d o and w i t h o u t i n t e r f e r i n g in any w a y with the needs of others. I n s p i r e d by his example, at the local l i b r a r y I sought out a book on power generation. For a week or two, while s i t t i n g p a t i e n t l y in t h e hour-long lines at the gas stations, I r e a d about w i n d power, wood power, m e t h a n e power, solar power, and w a t e r power, c l u t t e r i n g m y m i n d w i t h d e t a i l s of h e a d r a c e s , t u r b i n e s , a n d o v e r s h o t waterwheels. The little I know of these a r c a n e m a t t e r s was recalled in a flash upon r e a d i n g the article by Morton C. Morris, MD, in the S e p t e m b e r issue of JACEP. In "On-the-Scene E m e r g e n c y Care by t h e P r i m a r y Physician," Dr. Morris writes about his experiences. He calls h i m s e l f a p r i m a r y care p h y s i c i a n and he m a y be found among the faculty in F a m i l y Practice at the P e o r i a School of Medicine of the U n i v e r s i t y of Illinois. Dr. Morris gave a n o t h e r g r e a t o p p o r t u n i t y . R e s t i n g here in the bosom of a g r e a t institution, surrounded by sophisticated e q u i p m e n t and s u p e r b l y t r a i n e d personnel, served w i t h stabilized p a t i e n t s by competent p a r a m e d i c s who b l a n k e t the u r b a n environs w i t h the m a n t l e of advanced life-support, the exciting opportunities afforded by our specialty are u n a p p r e c i a t e d . Dr. Morris reveals t h e m as he recounts his activities. He responds p r o m p t l y to emergencies in a r u r a l area, a r r i v i n g in less t h a n t e n m i n u t e s following a call. He solves t h e problem of providing a knowledgeable, capable, d i s c r i m i n a t i n g , m e d i c a l l y t r a i n e d i n d i v i d u a l to render e m e r g e n c y e v a l u a t i o n a n d t r e a t m e n t by s u p p l y i n g himself. He solves the problem of delays and confusion in c o m m u n i c a t i o n d u r i n g t h e e m e r g e n c y by giving confidence to those who m i g h t call h i m for help - - patients, t h e i r families, a m b u l a n c e a t t e n d a n t s , and public safety
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