"The Future of Emergency Medicine" Inaugural address to the First Canadian EM Residents Workshop

Resident Issues

CJEM 2000;2(4):262-264

When Jason Frank asked me to speak tonight I was deeply honoured. I know that every single one of my many equally deserving colleagues would have been equally honoured. In my personal view an integral part of honour is truth. In seeking to demonstrate how profoundly moved I was by this invitation, I have decided to share some "truths" with you. I am going to take the liberty of sharing with you a side of me that is often seen by those who are close to me, but is more rarely seen by those such as those of you in the audience that I have not yet had the pleasure to meet.

You have asked me to speak about the future of emergency medicine. If you had occasion to attend the recent ICEM in Boston, you know that one of our colleagues from the UK was accorded the honour of delivering a keynote plenary on the same subject. He chose to start his commentary with a historical review of emergency medicine. My view is that the future of emergency medicine is here in this room at this very moment, and it is my contention that, in part, the course the future will take is rooted in your past experiences, particularly as they relate to your choice of medicine, and particularly emergency medicine, as a career.

My past starts as a child of the age of 10 who suffers a significant penetrating eye injury, and thus comes into contact with the emergency medical system for the first time in his life. It was only as an adult that I began to recognize the importance that that experience, and the consequent multiple hospitalizations, would have on my ethos as a physician. Certainly, that experience taught me the importance of compassion, of empathy, and a great deal about the impact of hospitalization, injury and illness, particularly, on the young. I suggest that you, and equally importantly, your patients, would be well served by you remembering your experiences as consumers. As Harper Lee eloquently wrote in To Kill A Mocking Bird, "you never really know what it's like to be someone 'til you put on their shoes and walk around in them for a while."

A several year period of witnessing my mother and father who were, at best, lower-middle income earners, slowly but surely paying down accumulated hospital bills in $5 and $10 increments, helped form my values with regards to socialized health care systems and their importance to Canadian society. Remember always how easy it is for those of us blessed with opportunity and wealth to make blanket judgements about privatization of health care.

If we shift to the present we could focus on issues such as funding cutbacks and the consequent ED overcrowding, limitation of licensure, or staffing problems in emergency departments in small and rural hospitals.

However, you have asked me to focus on the future. It is my premise that while in some of your minds the future may be rooted in issues such as new and sophisticated technology, or new and evolving illnesses and therapies, the future is not, in fact, in any way to be defined by these issues or other parochial concerns such as limited licensure or charging tuition for residency programs.

The future, in fact, will be defined by you, the individuals sitting in this room. Not only your personal future but the future of health care and emergency medicine will be shaped by your humanism, for it is that which will make the public your ally and your supporting political constituency. In helping you prepare for this considerable burden, I wish to share some of my experiences as a consumer, as a parent, and as a child.

Several years ago, my daughter, who was then about 11, fell on Easter Sunday and sustained a fracture of her ankle. I took her to the emergency department, and in the course of looking at her lying on the stretcher with a swollen and obviously fractured ankle, the same fears and apprehension that every parent would have in that circumstance began to flash through my mind, if anything, heightened because of my experience as a physician. I began to fear non-union, surgical intervention with osteomyelitis, amputation, and as my imagination grew even wilder, tears began to well up in my eyes and pour down my cheeks. At that point my daughter looked up at me and said, with all the naïve innocence of youth, "You are not really crying. You are just faking it, so I'll feel better." Not only did that experience lead me to say for the first and thus far only time in my life "wait until you have your children of your own," but it also led me to realize the emotional stress and strain all parents experience when taking a child to the emergency department.

Of note, as we were leaving the department, her nurse, a close colleague of mine asked: "How did you like the service?" It dawned on me how rarely we ask our "real" patients that question. And how rarely we really care about the answer. I also pointed out to her that, as the department chief attending with his child, if I didn't like the service, it would be a damning condemnation!

Perhaps, more telling is the recent experience I had when my son fell while skiing and fractured his tibia. He made the diagnosis on his own, before the arrival of the ski patrol. They astutely confirmed his diagnosis, which was then relayed, appropriately, to the ambulance attendants who transported him to hospital. By the time he arrived in the emergency department, in excess of an hour had elapsed. The registration process was a rather tedious one, and necessitated that my son, who is 14, be separated from me in a strange environment for approximately 30 to 40 minutes. At the end of that time he was in tears with pain. It dawned on me that, notwithstanding the fact the diagnosis was obvious, confirmed by 3 separate independent observers and relayed to experienced emergency department providers, no one had thought about the importance of treating his pain. How often do we make that mistake?

I had always felt I was an "expert" in breaking bad news. Several years ago, my father passed away at the end of an extended illness. By sheer coincidence, the very first patient I saw on my first day back at work was also an older gentleman, who presented with an obvious massive intracerebral hemorrhage. Over the course of the morning I spent a great deal of time interacting with his family. They informed me that they respected my opinion and judgement, but that they had been through several medical crises over the years with their father, and were reluctant, at face value, to accept my opinion that his death was imminent and that life support should be withdrawn. In contradistinction to my generally applied approach of "pushing" the family to cease life support, I agreed to continue venting him in the ED. As the morning unfolded, the gentleman gradually deteriorated and eventually died. As clinical events occurred, I made frequent contact with the family to ask if there were any questions, and to ensure they were receiving all the appropriate supports.

After their father passed away, the family took me aside and pointedly mentioned to me that, notwithstanding their personal loss, they felt this encounter with the health care system was qualitatively a far superior one to any other encounter they had had. They thanked me for my help in making their tragedy as bearable as it was. They then asked me why, in my opinion, this encounter was so different. Notwithstanding my arrogance respecting my skills in dealing with issues of death and dying, it was the first time in my career that I'd ever received such feedback from a patient's family.

I realized that notwithstanding my previous estimate of my expertise, having recently gone through what this family just experienced had brought a whole new perspective to my ability to deliver care as an emergency physician. I remind you that although each of us thinks we "know what other people are feeling," we really don't. Even if we have had similar experiences, for each of us the experience is hugely different.

Having then talked about my view of the importance of perspective and context, the question is, What other challenges will face you in the future?

I suggest that some, but by no means all, of the challenges are as follows.

1. Be a mensch. For those of you who are not fluent in the Yiddish language, being a mensch means being a man -- not in the gender sense, but rather in the sense of being a real human being with real feelings and real sensitivities. Several years ago a resident in the University of Toronto program mentioned, during the course of rounds I was delivering, that he felt he was being "abused" by patients who arrived in the ED at 3 o'clock in the morning with relatively trivial health care problems.

   I pointed out that we are complete strangers to individuals who present to the emergency department. Notwithstanding the fact that patients have no ability to determine if they are dealing with Dr. Schweitzer or Dr. Hannibal Lecter, they confide the most intimate details of their private lives to us, and they undress completely and allow us to poke and prod the most intimate parts of their anatomy. Ultimately, they place their complete faith in our diagnostic process, acumen, knowledge and judgement.

   Therefore, I ask you: "Who is it, in fact, that is the individual at risk in such a relationship?" Be patient -- not doctor -- focussed.

2. Stay humble. Each of us has ingrained in us the attitude that we know, or should know, all the answers to all the questions. The best advice I can give you is to learn to say "I don't know." Sometimes "I don't know" means that you don't know but it is important to find out urgently and, therefore, you will admit the patient to hospital. Sometimes "I don't know" means "I don't know, but there are questions that remain unresolved" and you will need to send patients for further investigations on an ambulatory basis. Occasionally, the problem may have been present for years and non-progressive -- in which case, the fact that you don't know is probably immaterial. The important thing is to be able to say to the patient that you don't know and say it with both honesty and humility. They will accept this truth and respect you for your integrity.
3. Accept that you will make mistakes. Each of your teachers has made a mistake, some of them errors of omission, some of commission. Some of these mistakes have resulted in minor morbidity and others have resulted in mortality. The simple fact of the matter is, however, that each of us has made mistakes and each of you will make mistakes too. The challenge to you is to make mistakes that are honest errors. Errors owing to a lack of knowledge of some exotic or rare illness or presentation can and will happen to all of us. Errors that come from malice, or refusal to use or apply the knowledge that you have, or unwillingness to advocate for the patient in the face of a reluctant or marginally competent colleague are, in my view, the only inexcusable ones.
4. Accept the eccentricities and human failings of the people around you. In the end it is your interactions and your personal relationships with them that will make your career worthwhile. As I draw closer to the end of my career, I realize increasingly the great memories I carry with me are not the clever diagnoses or technically demanding procedures, but the endless array of fine people I have met.
5. Avoid burnout. Realise that your job is but a job, but it is not who you are. Who you are is defined by the kind of lover, parent and person that you are. Read a book, see a play, travel, have a hobby, stay fit and love your family. The enhanced quality of care you will bring to your career as a consequence more than compensates for the lost income, or the cost of tickets.
6. Realize that your job is to be the patient's advocate -- not the hospital's or the government's.
   
7. Finally, I share with you my belief that we are blessed to be members of the greatest profession in the world. Notwithstanding the opinion of many of our colleagues who would actively dissuade their children from embarking on a career in medicine, I feel it is a rare and unique opportunity to have a job that affords you the opportunity to make a real difference in real lives every day.

In conclusion, I want to tell you why I am optimistic about the future. When I look at your eyes I see the fire I felt in mine. I see the intensity, the commitment, and the resolve all wrapped in the athletic exterior of youth. It sounds horribly "parentalistic" to say it, but the difference in our ages allows me to know some of what will happen in your lives over the next several years. I talk not only of your professional growth, but of your personal growth.

In truth -- I don't really know a damn about the future of emergency medicine, but I am confident that it is secure in your hands. And I am, in all honesty, deeply jealous of all that you will experience in the next 25 years.

In conclusion, I take this opportunity to thank you sincerely for the honour that you have bestowed upon me in asking me to speak here this evening. It is an experience I shall remember dearly always.