An American Form of Practice: Societal Contexts for the Rise of Emergency Medicine

Abstract

Perhaps the key term in the name “American College of Emergency Physicians” is American. That emergency medicine as we now know it arose largely in the United States is no accident: as pioneers in the field recall, emergency medicine responded to specific needs that appeared at the crossroads of American patient care practices and public health infrastructure in the mid-20th century. Its rise is an implicit commentary on the distinctive strengths, contradictions, and blind spots of both American society and American medicine. In the 40 years since emergency medicine became an organized specialty, its practitioners and institutions have decisively answered most of the objections initially raised by the field's opponents. “Every specialty that acted as an obstructionist at a national level,” says Ronald L. Krome, MD, professor emeritus of emergency medicine at Wayne State University School of Medicine, “had a little axe to grind.” Some internists and surgeons worried that emergency physicians would siphon away significant proportions of their caseload or take over certain procedures. Neither occurred on any notable scale. Others attributed the demand for emergency care to a transient national shortage of primary care physicians and speculated that emergency medicine would decline with improved primary care; to the contrary, visits to emergency departments (EDs) have risen steadily despite an increase in primary care physicians, and the same pattern holds in countries that have long outperformed the US in providing primary care. Some academic physicians decried the absence of an established emergency medicine research base–a kind of “Catch 22,” as the recognition as a legitimate field was needed to attract researchers, Dr. Krome points out. That objection became moot as emergency medicine attained specialty status and academic emergency medicine became one of its robust branches. Only one of the opponents' concerns has proved accurate, says Brian J. Zink, MD, chair of emergency medicine at Rhode Island Hospital, recipient of ACEP's 2008 Award for Outstanding Contribution in Education, and author of the specialty's first comprehensive history.1Zink B.J. Anyone, Anything, Anytime: A History of Emergency medicine. Mosby/Elsevier, Philadelphia2006Google Scholar Emergency medicine became a talent drain from other specialties attracting the best medical students from more traditional career paths. It took decades of experience for many opponents to be replaced by specialty leaders who had grown up with emergency medicine and recognized its validity. Many academic internists and surgeons gradually “lost the skills to be able to deal with undifferentiated problems… . They really didn't know how to deal with things they didn't know,” says Lewis Goldfrank, MD, professor and chairman of emergency medicine at Bellevue Hospital Center. “They stopped feeling at ease, they dissociated themselves further and further, and in many ways their specialties deteriorated dramatically because they didn't want to cooperate.” With emergency medicine embracing the challenges of diagnostic uncertainty under pressure, and with emergency medicine residencies spreading from the University of Cincinnati's initial program to leading medical schools nationwide, Dr. Zink adds, “we're getting the best and the brightest of medical school graduates. The specialty is very strong.” That strength is a relatively recent, historically specific phenomenon. American emergency medicine is both a success story and a cautionary tale, an example of visionary improvisation in the face of difficult conditions. The specialty might easily have evolved in a different form if not for certain decisions and personalities. Understanding its current state requires a look at the broader influences that made its development necessary or even inevitable. Emergency medicine appeared when the rapidly expanding needs of patients began to reveal the alarming inadequacies of the existing health care system. Then as today, the specialty served as a critical social safety net for a nation reluctant to acknowledge that it needed one. Emergency medicine is now healthy enough in the US that it is hard to picture the day when it was viewed as the house of medicine's rusty back door. “It has always puzzled me as to why emergency care was the last area of medicine to develop as a specialty,” says Peter Rosen, MD, director of education in emergency medicine at Boston's Beth Israel/Deaconess Medical Center and senior lecturer at Harvard Medical School. “If you think about it, it should have been almost the first.” Yet physicians who have observed the specialty's origins recall an environment where only those with limited professional options worked in emergency rooms. Dr. Goldfrank describes the typical emergency staff of the 1950s as “moonlighting people of all sorts, or people who failed in other specialties who dropped in to work there and make money, or unsupervised interns.” House staff and graduates of international medical programs constituted much of the work force in some areas; for example, “New York could have gone another hundred years” with no emergency medicine residents, says Dr. Zink. “Even though the care was crappy, they could still throw bodies down there. They had plenty of bodies.” Facilities were primitive, says Dr. Goldfrank, sometimes old outpatient spaces or offices, with little thought given to connections between function and design. Equipment was often what Dr. Krome calls “the operating room's rejects,” including malfunctioning clamps and resterilized sharps. (“We had a guy in our hospital,” he recalls, whose “sole task was to sharpen needles.”) Emergency room duty in some hospitals was a punishment for poorly performing nurses or a mandatory, low-prestige rotation for physicians from any specialty, regardless of relevance to the cases seen, in order to obtain staff privileges. Patient outcomes under such conditions, Dr. Krome says, were such that “people got sick [and] went to the emergency room, believing that they went to be in the arms of Jesus.” This loose group of facilities and desperate personnel grew into a specialty that is the envy of much of the world. American emergency medicine gradually developed practices and standards that, to say the least, embody the antithesis of the fatalism Dr. Krome witnessed. Leading American emergency physicians now travel widely as the consultants of choice for nations hoping to improve their emergency medicine systems. The causes behind this evolutionary process are numerous and intertwined. “This is the only specialty,” Dr. Krome notes, “that grew out of a service demand.” What might be called supply side factors in this process involved the medical resources and priorities of hospitals, academic institutions, and public officials. The demand side includes changes in patients' demographics, living habits, epidemiologic patterns, resources, and expectations. The crisis in the quality of trauma care and other aspects of emergency medicine noted by commentators like Robert H. Kennedy, MD,2Kennedy R.H. Our fashionable killer: the oration on trauma.Bull Am Coll Surg. 1955; 40: 73-82PubMed Google Scholar and Ernest Shortliffe, MD,3Shortliffe E.C. Hamilton T.S. Noroian E.H. The emergency room and the changing pattern of medical care.N Engl J Med. 1958; 258: 20-25Crossref PubMed Scopus (57) Google Scholar, 4Shortliffe E.C. Emergency rooms … weakest link in hospital care?.Hospitals. 1960; 34: 32-34PubMed Google Scholar in the 1950s and early 1960s indicates a segment of the medical system that was caught in the pincers between these 2 sets of forces. Even before emergency physicians began identifying themselves as a distinct professional community, institutional responses to this crisis had mass media visibility, as when Time magazine noted a “boom in emergency rooms” as early as 1963.5AnonymousBoom in emergency rooms Time, Aug. 16, 1963.http://www.time.com/time/printout/0,8816,894579,00.htmlDate: 2008Google Scholar America's physician supply, Dr. Zink says, has never had the kind of “national medical control system … [that can] incentivize people toward the types of care needed,” as some other nations have. Nevertheless, that workforce responds to major governmental actions, however unpredictably. Expanded federal research sponsorship and technological advances after World War II helped make specialist care a more attractive career path than general practice, leaving the nation proportionately short of primary care physicians in the face of growth in both absolute population and the underserved urban and impoverished segments of that population. The Education Council for Foreign Medical Graduates exam, a 1958 innovation, reduced the flow of minimally trained immigrant physicians, a source of cheap and often underqualified emergency room labor. Dr. Zink emphasizes the Hill-Burton Act of 1946, the repeatedly renewed legislation that provided ample federal investment in hospital construction and renovation through the 1950s and 1960s,6For more discussion of the Hill-Burton Act, Dr. Zink recommends Stevens R, American Medicine and the Public Interest: A History of Specialization (Berkeley: U of California, 1998, rev. ed.); Stevens R, In Sickness and in Wealth: American Hospitals in the Twentieth Century (NY: Basic Books, 1989), and Starr P, The Social Transformation of American Medicine (NY: Basic Books, 1982).Google Scholar as a strong catalyst for 2 national tendencies that contributed to an expansion of emergency medicine: the move from homes to hospitals as the dominant setting for care and the refusal to construct a national health care system providing universal coverage. Since the New Deal, Dr. Zink says, congressional Republicans had blocked health plans out of fear of anything even remotely resembling socialism or social democracy. “There was a lot of push even in the ‘50s for a Medicare/Medicaid type of help for poor people,” Dr. Zink notes, “but Congress always resisted. Where they put the money was into building hospitals, because that could make everyone feel good: ‘We’re not going to pay for people to get medical care, but we're going to build tons of hospitals.’ That's really where the money went: billions of dollars over a long period… . In this country our choice was to go toward technology and infrastructure rather than viewing medicine as a social service.”7Starr, The Social Transformation of American Medicine, p. 350.Google Scholar Another factor on the physician/institutional side was changes in technical knowledge derived from wartime experience. Military medical innovations in Korea and particularly in Vietnam, Drs. Zink and Krome both point out, offered examples of successful transportation, resuscitation, and intervention for trauma patients who would have had little chance a few decades earlier. Emergency medical services (EMS) and emergency medicine both benefited from increasingly aggressive approaches to resuscitative care. The federal EMS Systems Act of 1973 (Public Law 93-154), initially a simple ambulance funding proposal, grew with input from trauma surgeons and a then-fledgling ACEP into a substantial measure supporting planning, research, and education for EMS personnel. Though administrative complications limited actual expenditures under this law, it was the only major new social program to receive support during a period of widespread federal spending cuts, implying that improved emergency services had come to outweigh fiscal parsimony in political calculations, even during the second Nixon term and the Ford administration. The demand side included dramatic changes in many patients' resources, including but not limited to the proliferation of employment-based health insurance after World War II. Dr. Zink attributes the eventual passing of Medicare/Medicaid legislation to the alliance of President Lyndon Johnson and Rep. Wilbur Mills (D-Ark.), whose reversal of position in 1964–as House Ways and Means chairman, he had helped defeat the Kennedy administration's original Medicare proposal–finally overcame the entrenched opposition of the AMA,8Skidmore M.J. Ronald Reagan and “Operation Coffeecup”: a hidden episode in American political history.J Amer Culture. 1989; 12: 89-96Crossref PubMed Google Scholar Republicans, and conservative Democrats. Several effects on emergency care ensued from public sector acceptance of the principle that citizens, at least those of certain ages or income brackets, have a legitimate claim on public assistance with health care costs. One effect was simply to spur a dramatic expansion in access to the medical system as a whole. Dr. Goldfrank recalls a “massive influx after the Civil Rights movement, after Medicare and Medicaid in the ‘60s opened the doors.” As Dr. Krome says, Medicare and Medicaid “enabled people in those days to have a choice of what hospital or emergency room they wanted to go to,” often choosing private hospitals over the public facilities that had previously been their only option (and directing large amounts of the newly available public funds to private institutions).9Ziegler E. Emergency Doctor. Ivy/Ballantine, NY1987Google Scholar Medicare/Medicaid also exerted indirect effects on emergency medicine by fueling sharp increases in caseloads for primary care physicians, much of which overflowed into emergency care as patients realized they could bypass overbooked primary care offices and obtain care with less delay. Popular views of the medical profession in general were in flux during the early days of emergency medicine. Dr. Zink recounts the effects of polio vaccination and antibiotics: before such advances, in the minds of much of the populace, “hospitals were more the place you went to die.” After the 1950s, people began to realize that by going to a hospital, they could get more than a diagnosis, perhaps even a cure. Some degree of background influence may also be attributed to certain cultural features of the 1960s: space age technological enthusiasm, blended with attitudinal shifts toward individual pursuits and away from stoic acceptance of adversity, plausibly created a more optimistic, interventionist atmosphere conducive to greater senses of entitlement by patients and, as Dr. Zink's history cautiously hints, an openness to new forms of practice on the part of some physicians. As a growing population with rising expectations overwhelmed a shrinking primary care sector amid expansion in hospitals' physical plant, increasing reliance on emergency medicine became both the unavoidable outcome and the default institutional response. Changes within that population also affected emergency medicine disproportionately. Increases in urban poverty, violence, mental illness, and substance abuse brought urgent problems increasingly to EDs. “If you look at the emergency room as the conscience of a community,” says Dr. Krome, “things happen [there] and were picked up before they were seen generally. We saw substance abuse before it became a popular ‘in’ thing to write about … [and] I can remember, as old as I am, when the incidence of knife wounds in Detroit was exceeded by gunshot wounds.” Every emergency physician's experience offers insights on the specialty's unique sensitivity to disparities in wealth and privilege. Years before Emergency Medical Treatment and Labor Act (EMTALA) regulations were in place, patient dumping was common. Peter Rosen, MD, speaks of his days as a surgical resident in Oakland, working at one of only 2 local hospitals with an ED in a city whose shipbuilding industry had attracted a large African-American population with wartime jobs, then laid many of these workers off en masse after the Korean war and “overnight created a big indigent class.” Other hospitals, he recalls, routinely diverted emergency patients to county facilities. Similar conditions occurred in other locations nationwide, and with “people dying in the streets because there was no care,” in his words, cities responded by passing proto-EMTALA-style ordinances requiring any licensed hospital to accept patients regardless of ability to pay. “Imagine what that would do to the supermarkets,” Dr. Rosen comments. “That's what it did to the hospitals. That's how the University of Chicago, which had turned patients away, changed from 9,000 visits [per year] to 52,000 in less than a decade… . When I first got to Chicago, some of the first memos that I issued [said] ‘You will not transfer gunshot wounds to Cook County Hospital.’ I didn't understand why I had to write them, but that was the practice, and it had a lot to do with who could pay for the care. So demand plus public relations plus forced response basically drove the development of a specialty that should have been one of the first ones to form.” Changes in the built environment and transportation modes fed both the demand for emergency care and the capacity for delivering it. Road construction and the promotion of larger, faster cars, unsurprisingly, brought alarming increases in vehicular blunt trauma, particularly in the 1950s and 1960s, before crash testing, seatbelts, headrests, improved brakes, road lighting, crosswalks, airbags, anti-drunk-driving campaigns, and other safety measures became standard means of mitigating highway slaughter. Dr. Goldfrank cites William Haddon, Jr., MD, the first head of the National Highway Traffic Safety Administration, as a pioneer in promoting the recognition that accident prevention was both possible and necessary. At the same time, mobility increased the health care system's potential ability to respond to the same problems. The ambulance, with its French Revolution-era battlefield origins, was for many years essentially a hearse-equivalent that might deliver a patient to a morgue as easily as to a hospital. Better training for EMS personnel after the 1973 act allowed for vast improvements in remote care, sometimes putting hospital standards to shame. As Dr. Goldfrank recalls, “we often saw that the care was done better in the ambulance than in many big hospitals across the country.” Dr. Goldfrank's own efforts to foster both a public service ethic and a vigorous research component (particularly in toxicology), first at Montefiore and Morrisania in the South Bronx, then at Bellevue, included strategic use of the news media to draw public and regulatory attention to clinical inadequacies. “You can't count on the government to deliver on that, and you can't count on the leader of the hospital,” he says. “You have to be able to push them.” Dr. Goldfrank collaborated extensively with author Edward Ziegler on a nonfiction profile9Ziegler E. Emergency Doctor. Ivy/Ballantine, NY1987Google Scholar; Dr. Krome, too, has recently published his clinical recollections.10Krome R. The Floater's Log. PublishAmerica, Frederick, Md2007Google Scholar Both are strong believers in the power of public opinion to drive regulatory reforms, motivate personnel to improve standards, and (in the case of Bellevue) maintain a community service mission despite the competing claims of academic research and other priorities. Dr. Goldfrank spoke for this article shortly after a recent visit to Ghana to assess the state of that nation's emergency medicine system and offer recommendations. What he saw there rang a bell with great personal resonance. “It could have been the South Bronx in the 1970s: just total chaos,” he says. “There weren't the resources, there wasn't the space, there wasn't the philosophy. So you create it.” Across the world, he has helped new EDs understand how to organize triage, oversee inexperienced physicians, and analyze the social problems that bring needy crowds to the door. The American model of emergency medicine, he believes, has much to offer developing nations, despite the shortcomings in other aspects of American social service such as preventive care. The distinctive aspect that marks America's EDs as global leaders in emergency medicine appears to be that they offer an organized response to the ambiguities of their overwhelming caseload. If the rise of emergency medicine to unusual prominence in the US reflects elements of national character as well as particular events and trends, Dr. Krome attributes it to American patients' extraordinary demand for top-rank treatment and American physicians' independent streak. “We don't want anybody else telling us how to practice. Not the insurance companies, not legal people, not even to some extent our organizations. We want to practice the way we want to practice.” Economics has been a key variable in gaining institutional respect, emergency medicine veterans agree. Hospital administrators, Dr. Krome says, began to realize in the 1970s that “the ED was not a loss leader. It could be a money maker” by contributing admissions and stimulating the use of laboratories, imaging facilities, and intensive care units. “Somebody once said that his emergency room contributed at least 65% of the income of the hospital in which he worked…Now you've got their attention.” Dr. Rosen, too, counts the “loss leader” myth among 3 widespread misconceptions he would like to see debunked, along with the assumptions that adequate primary care would cut the need for EDs and that ED crowding is due to non-emergent primary care visits. (“It's the patient who can't get admitted to the inpatient service,” he says, along with “the patient who's sent over from the nursing home, who shouldn't be there in the first place.”) Realistic accounting that included credit for funds generated by EDs through services, Dr. Rosen believes, would show that emergency medicine is a net profit center. “One other point,” he adds: “not only do we fill hospital beds, we fill them appropriately.”