SPECIAL CONTRIBUTION Presidential Address
Emergency Medicine: Winning the Revolution! [Anzinger RE: Emergency medicine: Winning the revolution! Ann Emerg Med January i990;19:90-94.] Emergency physicians are a special group of people. First, w e share a c o m m o n purpose and second, w e m a k e exciting things happen. I'd like to address s o m e current college issues that influence our purpose and share w i t h you m y vision of the future of e m e r g e n c y medicine. E m e r g e n c y m e d i c i n e b e g a n as a r e s p o n s e to p u b l i c n e e d . In t h e mid-1960s, e m e r g e n c y care in this c o u n t r y was described in crisis terms. Patients w a n t e d expert care 24 hours a day, 365 days a year, on demand. The A m e r i c a n College of Emergency Physicians was founded to respond to that demand. The A m e r i c a n Board of Emergency M e d i c i n e was the first board to be approved, only after public hearings. T h e i r c o m m o n purpose was to care for all a c u t e l y ill and injured on a t i m e l y basis. For the first time, there was a specialty devoted to the p a t i e n t from the t i m e of onset of acute illness or injury up to and through disposition in an e m e r g e n c y department. T h e p r e m i s e was that the quality of medical care should n o t vary w i t h the t i m e of day, the day of the week, or holidays. It should vary n e i t h e r w i t h the rapidity of onset nor w i t h the ability to pay. It is t i m e to add that it should n o t vary w i t h geographic location. This was t h e legacy of our founders and it is still the focus of our daily efforts - the p a t i e n t in crisis. EDs are, in m y view, one of society's great levelers - places where the ills and accidents of the day can be reversed, at least partially, no m a t t e r w h o you are. Perhaps this springs from m y V i e t n a m experience where it was a t r e m e n d o u s morale factor to our c o m b a t a n t s t h a t 30 m i n u t e s after injury y o u could be on an operating table. Today, emergency physicians w i t h their skills and knowledge on the line stand ready, s o m e t i m e s in hostile environments, s o m e t i m e s w i t h marginal rest, to a t t e m p t to reverse w h a t e v e r m a l a d y is brought through the door. Some have said t h a t the v i s i o n of ACEP blurred after we achieved the i m p o r t a n t m i l e s t o n e of board certification status. But I believe that the quality of care of the patient has always been our p r e m i e r focus - the rest of our activities are subservient to that goal. So there is the palpable comm o n a l i t y and a sense of values supporting it that have always m a d e m e feel that ACEP meetings were celebrations of friendships, of c o m m i t m e n t , and of life. But w i t h i n the house of e m e r g e n c y m e d i c i n e w i t h c o m m o n core values, there are m a n y different c o m p e t i n g interests. This is good there is strength in diversity. In the early days of emergency medicine, in the 1970s, I w o r k e d for a group t h a t flew around Illinois staffing EDs. A t last count I've w o r k e d in s o m e 20 different EDs, s o m e t h i n g t h a t w i t h today's credentialling rules m i g h t be difficult to do. M y perspective was that no two of t h e m were the same. It is understandable to me, therefore, that interests m a y vary, based on one's practice setting and personal goals. I a m delighted to be addressing y o u at a t i m e w h e n the Board has approved a section policy and y o u confront the issue of voting privileges of sections on this floor. You should give voice and vote to those particular interests within the College. ACEP m u s t c o n t i n u e to be the voice of all
19:1 January 1990
Annals of Emergency Medicine
Robert K Anzinger, MD, FACEP American College of Emergency Physicians Dallas, Texas Presented as the Presidential Address to the Council of the American College of Emergency Physicians in Washington, DC, September 1989. Address for reprints: American College of Emergency Physicians, PO Box 619911, Dallas, Texas 75261-9911.
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e m e r g e n c y p h y s i c i a n s . T h i s College, t h r o u g h its leadership, will m a k e every effort to provide a comfortable and d y n a m i c h o m e for all its m a n y constituencies. T h e specialty of e m e r g e n c y m e d i c i n e is a specialty in breadth, and ACEP, to be truly representative, m u s t give voice to its broad interests. To those w h o have felt in the past that ACEP was not sufficiently c o m m i t t e d to your area of i n t e r e s t . . . I say try us again. To those w h o have formed other related organizations to pursue your interests . . . I say m a k e y o u r voice heard in this Council, in this College. ACEP, t h r o u g h its policy on sections, has t a k e n a first step to unify, in a fede r a t i o n , t h e i n t e r e s t s of e m e r g e n c y p h y s i c i a n s . I h a v e asked the M e m b e r s h i p C o m m i t t e e this c o m i n g year to address w h a t a fully developed section c o m p l e m e n t might look like. Our c o m m o n purpose m u s t also be the c e m e n t of our c h a p t e r / n a t i o n a l r e l a t i o n s h i p . In 1982, John N a i s b i t t , in M e g a t r e n d s , n o t e d t e n d o m i n a n t trends, one of w h i c h was a decentralization of A m e r i c a n structures. Surely this has profound i m p l i c a t i o n s for any n a t i o n a l organization. Strong chapters are vital to the success of emergency medicine for several reasons: at the local level, chapters are perceived to b e ACEP; problems do not arise d e n o v o m Dallas. T h e y come from the m e m b e r s often through their chapter offices; increasingly, solutions to local p r o b l e m s will have i m p l i c a t i o n s for other localities, states, and for the n a t i o n a l organization; and leadership d e v e l o p m e n t has historically flowed from the states to the n a t i o n a l organization. The C h a p t e r Advisory Panel m e t this past M a y and has forwarded to the Board policy s t a t e m e n t s recognizing the i m p o r t a n c e of nondues revenue for the states, the need for an effective c o m m u n i c a t i o n network, and the need for an issues-prioritization system. We w o u l d be well served to t h i n k of issues wherever they arise, not as state or national issues, but as e m e r g e n c y m e d i c i n e issues. W h e t h e r it is overcrOwding in N e w York; M e d i c a i d d i v e r s i o n m Maryland; M e d i c a i d initiatives in Oregon; tort reform in Florida, Michigan, and Texas; hospital closures in California or in the rural heartland; or legislative initiatives w i t h sin taxes to pay for indigent care and t r a u m a - the curr e n t l o c a t i o n of the p r o b l e m and the initiatives m a y be localized, b u t these are surely e m e r g e n c y m e d i c i n e issues for us all. We have a t r e m e n d o u s potential for collaboration bet w e e n our n a t i o n a l and state organizations. It m a k e s little difference w h e r e p r o b l e m s arise as long as we w o r k tog e t h e r for t h e best s o l u t i o n s . It m a k e s l i t t l e difference w h o comes up w i t h the best answer as long as that a n s w e r is shared. T h e n a t i o n a l organization must, however, serve as a clearinghouse for issues so that policy f o r m u l a t i o n is consistent and viable nationally. Clearly, the w h o l e will be greater t h a n t h e s u m of the parts! There's a great deal of concern in some states regarding their o w n e c o n o m i c viability. I a m s y m p a t h e t i c w i t h that concern. Last year, this C o u n c i l passed a resolution that asked ACEP to help states develop sources of n o n d u e s revenue. This C o u n c i l has before it a resolution on revenuesharing from n a t i o n a l meetings. I have asked the C h a p t e r A d v i s o r y Panel, a s a specific o b j e c t i v e this year, to develop a m e t h o d for negotiating joint ventures b e t w e e n the natiOnal organizations and the states. Such m e t h o d o l o g y must, at a m i n i m u m , be legal, m u t u a l l y beneficial to the 148/91
national organization and state chapters, and fair to all. W h a t e v e r the o u t c o m e of t h e debate on the p a r t i c u l a r issue before you, I a m confident that the Board and staff are c o m m i t t e d to a r e i n v i g o r a t e d c h a p t e r / n a t i o n a l r e l a t i o n ship. N e x t m o n t h , as an e x a m p l e , we w i l l be p a r t i c i p a t i n g w i t h the N e w York chapter in a cooperative v e n t u r e to highlight to the m e d i a the p r o b l e m of overcrowding in the nation's EDs. We will c o n t i n u e to look for m u t u a l l y beneficial joint ventures t h r o u g h o u t the year. C o m m o n a l i t y of purpose is at the very heart of the defin i t i o n of fellowship. I have read every letter w r i t t e n objecting to the fellowship criteria established over the past year and have found several c o m m o n t h e m e s : We should n o t have changed the rules in the m i d d l e of the game; w e should have had a grace period. We should have applied the criteria to all fellows. We should have criteria to include s o m e o n e w h o (only) w a n t s to practice good clinical e m e r g e n c y m e d i c i n e and should not favor particularly politicians, researchers, or educators as a specialty providing p r i m a r y care services. To go back to our c o m m o n purpose w h a t was our original goal? H i s t o r i c a l l y , a p h y s i c i a n w i t h i n t e r e s t in e m e r g e n c y m e d i c i n e , m a i n t e n a n c e of t h e CME requirement, and p a y m e n t of dues allowed ACEP membership. Passing the w r i t t e n and oral board e x a m i n a t i o n in emergency m e d i c i n e m a k e s one a d i p l o m a t of the A m e r i c a n Board of Emergency Medicine. Again, before this Council is the question, in addition to having passed the boards, w h a t criteria does ACEP w i s h to set to call one a fellow? Webster's dictionary defines fellow as an equal in rank, power, or Character a peer: and an i n c o r p o r a t e d m e m b e r of a college or collegiate foundation. There are several points on this that I'd like to make. It has generated more negative m a i l than any other issue m ACEP's recent history. The m e m b e r views this change as coming not from the Council or the Board or even from the president, but from the College. Original criteria for f e l l o w s h i p were inclusive, requiring o n l y three years of m e m b e r s h i p after passing t h e boards; the set of criteria adopted by the Council last year is viewed by m a n y as exclusive and elitist. Whatever criteria are decided here in the next two days, t h e y should certainly encompass those who share our c o m m o n p u r p o s e providing excellent care to the patient m crisis. O u r c o m m o n purpose springs from our shared core values. One of those values shared around this r o o m ts the f u n d a m e n t a l goodness and w o r t h of our fellow man. We don't believe that we are perfect, and at t i m e s it is exciting the different ways we are imperfect. But deep down, there's an u n d e r s t a n d i n g of the h u m a n p r e d i c a m e n t and the aspirations c o m m o n to us all - life, liberty, the p u r s u i t of happiness . . . and yes, the pursuit of health. H o w else does one explain the willingness, no. the excitement, we feel going to give care to perfect strangers on a daily basis! Absorbing the moans, tears, insults, the sleep d e p r i v a t i o n . To go on and a l l e v i a t e the pain, t h e shortness of breath, the d e v a s t a t i o n of loss. H o w else does one explain the willingness and e x c i t e m e n t reported by m e m b e r s of the Casualty Surgeons A s s o c i a t i o n and ACEP relative to the earthquake in Armenia. There, in hostile surroundings, t h e y reached out to refugees of a devastating disaster to do w h a t could be done to alleviate suffer-
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ing. T h e y did not send to k n o w for w h o m the bell tolled . . . they k n e w . . , t h e y w e n t there. I a m excited by w h a t I sense in ACEP as a n e w l y found i m p o r t a n c e of e m e r g e n c y m e d i c i n e in t h e i n t e r n a t i o n a l arena, of its potential as a peacemaker, of its p o t e n t i a l to f a v o r a b l y i m p a c t m o r b i d i t y and m o r t a l i t y , e s p e c i a l l y in m a s s c a s u a l t y disasters, and m a y b e even its p o t e n t i a l ; through education, to become an exported service. I said at the o u t s e t that our special c h e m i s t r y of an ACEP gathering came from two things: our c o m m o n purpose and the feeling that s o m e t h i n g exciting is about to happen. Somet h i n g exciting is about to happen - at this m e e t i n g and over the n e x t year. Looking back over our brief history, I cannot r e m e m b e r a t i m e w h e n things were "stable." In our m i n d s t h e issues were a t t a c h e d to " s u r v i v a l , " ours and the patients'. O u r history chronicles our efforts to improve educational programs, c o n t i n u a l l y improve our journal, enter into the house of medicine, advance the distrib u t i o n and quality of EMS, establish a creditable research wing, achieve board status, w o r k for l i a b i l i t y reform ... . . . and n o w we m e e t in Washington, DC, in w h a t Congress has dubbed " T h e Year o f the Physician," Congress' i n t e n t tO do for physicians w h a t D R G s did for hospitals. W e ' v e k n o w n we were to be judged by the quality of the c l i n i c a l care of p a t i e n t s , o u r c o n t r i b u t i o n s to m e d i c a l knowledge, and our general c o m p o r t m e n t . To us, survival was the issue, and as W i n s t o n Churchill said: " T h e r e is n o t h i n g so exhilarating as being shot at and m i s s e d . " W h a t is the sense of e x c i t e m e n t at an ACEP meeting? For me, it is that n e w ideas will be born - n e w solutions to old p r o b l e m s , n e w i n f o r m a t i o n - w h e t h e r at t h i s Council meeting, from the a n i m a t e d conversations I see in the hallways, from the c o m m i t t e e m e e t i n g s , tO the scientific meetings, the forum, the Board m e e t i n g - all that s t i m u l a t e s n e w thought and leaves you invigorated to go h o m e to do the very best you can. Today, of course, there is a r e v o l u t i o n in h e a l t h care. T h e e x c i t i n g t h i n g a b o u t a r e v o l u t i o n is t h a t b a t t l e s fought and w o n will significantly change the face of medicine for years to come, the pace is faster, the stakes are higher. A n d ACEP is in the t h i c k of it, trying to steer the issues so that w h e n all is said and done, the practice of emergency m e d i c i n e will be better for our patients and our members. For the t u r m o i l we have passed t h r o u g h and c o n t i n u e in, we owe it to ourselves and to our p a t i e n t s to have an end product vastly i m p r o v e d from where we started. To fight the good fightl I m u s t believe that a better o u t c o m e is possible! Revolution. The word itself strikes fear in our hearts, a reaction to the speed w i t h w h i c h change takes place. The revolution in m e d i c i n e today is part of a larger information/technological revolution, only accelerated by t h e imperatives of the budget deficit. Like other revolutions, the industrial, the computer, the i n f o r m a t i o n revolutions, We s h o u l d k n o w t h a t things w i l l be forever different. O u r c o m m i t m e n t is to m a k e t h e m better. Today the issues are access, costs, and quality. ACCESS T h e r e are 37 m i l l i o n u n i n s u r e d a n d m i l l i o n s i n a d e quately insured, one third of w h o m are children. Emergency p h y s i c i a n s are c o m m i t t e d e t h i c a l l y and m o r a l l y and, m o r e recently, legally to the care of these patients. 19:1 January 1990
It should be a great source of pride to y o u t h a t we have n o t abandoned these citizens. But w e m u s t do more and w e cannot do it alone. Hospitals are closing, EDs are closing, EDs are f u n c t i o n a l l y closed due to overcrowding, and a m b u l a n c e s are diverted, c r e a t i n g d i s r u p t i o n w i t h i n t h e prehospital system. We are s i m u l t a n e o u s l y m a n d a t e d by law to see all p a t i e n t s and chastised for providing "inapp r o p r i a t e " services to patients in EDs. ACEP will c o n t i n u e to w o r k w i t h Congress on the dil e m m a s surrounding indigent care. We will support pri~ m a r y care for i n d i g e n t p a t i e n t s in other settings. We w i l l w o r k for m a n d a t e d benefits and other i n n o v a t i v e funding for indigent patients. We m u s t continue to educate our legislators that w e are, in m a n y cases, the physician of last resort, the safety n e t for the delivery s y s t e m , that w e deserve appropriate c o m p e n s a t i o n for providing that care. It Should also be a great source of pride that y o u r care of t h e s e p a t i e n t s has a l l o w e d this c o u n t r y to e x p e r i m e n t w i t h different delivery modes in the m i d s t of a revolution. In the early 70s David Rutstein, in Blueprint for Medical Care, wrote, "above all i n the i n t r o d u c t i o n of a n e w s y s t e m of a m b u l a t o r y care, w e m u s t be sure that no patient is h a r m e d in the changeover process. The s m o o t h l y operating e m e r g e n c y care program that w o u l d assure the effective t r e a t m e n t Of life-threatening medical and surgical events w o u l d m a k e it possible to take a m o r e thoughtful, unhurried and thorough~going approach to the design and i m p l e m e n t a t i o n of an efficient a m b u l a t o r y program in a c o m p l e t e m e d i c a l care s y s t e m . " Surely, the a m b u l a t o r y r e v o l u t i o n is n o t over, as w e have m o r e and more care given in the a m b u l a t o r y setting, freestanding a m b u l a t o r y care centers, nursing homes, h o m e h e a l t h care, and selfcare venues: ACEP stands c o m m i t t e d to working w i t h legislatures to assure c o n t i n u e d access in a responsible fashion. In 1989, there were 3,900 freestanding a m b u l a t o r y care centers seeing 50 m i l l i o n patients. It is projected t h a t in 1991 there will be 5,000 freestanding a m b u l a t o r y care centers seeing 85 m i l l i o n patients. To some considerable extent, I believe their practice represents t h e a m b u l a t o r y or private practice of e m e r g e n c y m e d i c i n e . We m u s t c o n t i n u e to p l a n our future, recognizing that a reconfigured medical practice will increasingly be a m b u l a t o r y based. COSTS T h e driving force in the restructuring of medical care today is the n e e d to lower costs. T h e current focus is on p h y s i c i a n r e i m b u r s e m e n t w i t h its 17% increase b e t w e e n 1980 and 1987. I b e l i e v e t r a i n e d e m e r g e n c y p h y s i c i a n s using the appropriate n u m b e r of tests - not too many, n o t too few - diagnosing the illness the first t i m e the patient presents to the ED, and appropriately a d m i t t i n g or referring for follow-up care represents one of the m o s t effective, efficient, and p o t e n t i a l l y cost-saving i n v e s t m e n t s for the m e d i c a l care delivery system. However, there are other things that w e can do to att e m p t to control costs for our patients. In 1983, the ACEP cost c o n t a i n m e n t project, developed in conjunction w i t h T h e Kellogg Foundation, defined a scientific m e t h o d for cost r e d u c t i o n , and w h e n w e d d e d to s t a n d a r d s developm e n t and o u t c o m e s m e a s u r e m e n t , can continue to be an effective m e c h a n i s m for lowering costs. The standards dev e l o p m e n t process itself incorporates cost-effective m e c h anisms. O u t c o m e s research will provide answers to cost-
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effective diagnostic and treatment efforts. Professional liability reform could significantly alter the cost of care in this country and m u s t be pursued. P r e m i u m costs are but a portion of the total costs, with an estimated $15 billion being spent by physicians practicing defensive medicine. There are exciting initiatives in this arena. In Massachusetts, the ACEP chapter has initiated a quality assurance program based on dictated records and computerized QA review and presented a proposal tO the state insurance c o m m i s s i o n e r for a 28% reduction in malpractice prem i u m s . T h e Texas c h a p t e r has a state initiative t h a t would provide a state risk pool for the first $100,000 loss for emergency physicians providing indigent care. The Michigan chapter has an initiative to increase the standard to "willful and w a n t o n " for emergency patients without an established physician relationship. Additionally, ACEP is a sponsor and supporter of the A M A Liability Project, which offers an administrative system to replace the current tort system. It is becoming apparent, even to the Congress, that one cannot have a fix for the physician i n c o m e side of the equation and let the professional liability expense remain free-floating. This year I have appointed a Public Health Issues Task Force for several reasons. First, an ounce of prevention is still worth a pound of cure. With each escalation of the cost of medical care, the cost benefit ratio of prevention becomes more and more attractive. In the arena of injury, for instance, each year we lose 150,000 Americans with 450,000 becoming totally and permanently disabled, costing $75 to $100 billion yearly in direct and indirect costs. We are currently investing only 2¢ of the research dollar for trauma. Almost half of the fatally injured have blood alcohol concentrations of .10 or more. Who among us can be i m m u n e to the terrible toll taken by firearms in this country? Four hundred sixty-four were shot to death in one week; more than 30,000 a year. Guns in two years take more lives than the Vietnam War, with handguns accounting for three quarters of these deaths. For every death, there are at least five nonfatal firearms injuries, and one study at San Francisco General showed that 86.56% of the cost incurred was paid by public funds! Second, the Council resolutions year after year propose significant public health initiatives to prevent illness and injury. Third, the media has focused a great deal of attention on prevention. As costs of medical care escalate, I believe the public, Congress, and the media will increasingly ask what we have done to prevent the illness and injury we are n o w seeing. I have, therefore, asked the committee to develop a fiveyear plan to analyze the impact of the lack of preventative strategies on emergency medicine in terms of dollars and volume of patients; analyze from the literature k n o w n effective strategies for reduction of illness and injury; and recommend to the Board those policies and strategies to effect change in the patterns of illness and injury seen in EDs. To further control costs, I believe that we, as emergency physicians, m u s t work to control the total price of our service - the facility, professional component, supplies, ancillaries, and consultants. To do justice to our patients, we m u s t k n o w and control total costs to the consumer. We have made emergency medicine our practice - we m u s t make it our business. Furthermore, as a major entry 150/93
point into the care system, it is m a n d a t o r y that we as emergency physicians appreciate and influence the societal implications of government policy decisions. We have an i m m e n s e vested interest in anticipating the societal impacts of government policy decisions, and we serve as an on-line, early warning system that planning has gone awry and needs revision. It is refreshing and exciting to me to see one of our own, John Kitzhaber, emergency physician, president of the Oregon senate, struggling with the allocation of finite resources to effect the greatest good for the least cost - truly a staggering triage decision. QUALITY I am excited about the prospects of the impending vote on primary board status for emergency medicine. Primary board status represents another step down the road of specialty maturation, allowing the development of needed subspecialty areas. It allows us to reflect on the careful deliberation and the w i s d o m of our leadership and this Council, who supported emergency medicine initially as a conjoint board. It affirms that w h e n our focus is right, our vision clear, and we are patient and persistent, progress will be made. Primary board status will formally recognize the functional peer standing we have enjoyed with our colleagues in other specialties. I cannot help but think that primary board status will improve the quality of our practice and the quality of our relationships. With the increasing costs of medical care and attempts at controlling those costs, there is an increasing concern about the unevenness in the quality of care. Consumers, third parties, the government, and business are looking for measures of that quality. ACEP is actively involved in formulating clinical policies for chest pain, blunt abdominal trauma, adult seizures, and the febrile child. The relationship between clinical policies, reimbursement, risk management, quality assurance and resource allocation should not be underestimated - nor should we have any illusions - we will develop our own policies or someone else will. In working on the Harvard RBRVS, the only code I found no other specialty performs was prehospital care. Our quality of care will depend on the number, health, and well-being of emergency physicians. We continue to study the m a n y and changing variables impacting on manpower needs. We have completed a preliminary staffing ratio study and will look for further funding for a more complex modeling study. There are, at present, four articles in development that will be submitted to Annals elaborating on our manpower needs and focusing on further study. We also are conducting an attrition study to measure emergency physician turnover. I have reappointed the Wellness Committee to support our m o s t valuable resource, the e m e r g e n c y physician. That committee will study the impact of career developm e n t on physician wellness. The Academic Affairs Committee is completing materials to assist those starting residency programs, and they will examine ways to expand residency programs and identify part-time faculty. In the area of research, the Emergency Medicine Foundation generated $240,000 in funding for research, and additional f u n d i n g f r o m five large e m e r g e n c y p h y s i c i a n groups has been obtained to fund a director of grants-fundraising to assure further progress in keeping emergency medicine at the cutting edge. Our continuing medical ed-
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ucation programs address the needs of this membership, and this year we will explore new technologies to reduce costs, assure accessibility, and improve quality of programs. The EMS C o m m i t t e e continues to serve as a coalition for discussion and action on issues facing the EMS industry. As we continue to work on clinical policies, we m u s t prioritize and develop clinical standards for prehospital care. This year, we will work to define ACEP's role in multicenter research trials in EMS. We m u s t scientifically prove the value of our in-field interventions. I believe that as a college we m u s t establish EMS standards that include a definite response time parameter. ACEP has published The Principles of EMS, already in its second printing, and has completed an EMS medical director's text. These are but a few of the exciting areas that will receive our attention in the next year. I ' m sure this week, this year, new ideas will be born. My vision for the College is a d y n a m i c federation of emergency medicine issues, interests, subspecialties , and chapters. We will con-
19:1 January 1990
tinue to provide cohesion for the medical care delivery system. We will continue on the front lines of access for the patient. Our skills in relating to other organizations with overlapping interests will improve and mature. Paym e n t reform will preserve our specialty. G o v e r n m e n t s will recognize us as an innovative partner in problem solving. The sophistication and expense of noninvasive imaging and laboratory testing plus the needed orchestration of treatment resources will make us the premier physicians for the unclassified severely ill or injured patient. Our departments will be sought after for educational experiences. Our research and management contributions will gain in significance. Why? Because we are well positioned in this revolution to impact our destiny. And because great, sometimes heroic, individual efforts come together here in the American College of Emergency Physicians. With your persistence, y o u r c o m m i t m e n t , and your vision, the College will not only survive the current revolution, we will prevail.
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Emergency Medicine: Winning the Revolution! [Anzinger RE: Emergency medicine: Winning the revolution! Ann Emerg Med January i990;19:90-94.] Emergency physicians are a special group of people. First, w e share a c o m m o n purpose and second, w e m a k e exciting things happen. I'd like to address s o m e current college issues that influence our purpose and share w i t h you m y vision of the future of e m e r g e n c y medicine. E m e r g e n c y m e d i c i n e b e g a n as a r e s p o n s e to p u b l i c n e e d . In t h e mid-1960s, e m e r g e n c y care in this c o u n t r y was described in crisis terms. Patients w a n t e d expert care 24 hours a day, 365 days a year, on demand. The A m e r i c a n College of Emergency Physicians was founded to respond to that demand. The A m e r i c a n Board of Emergency M e d i c i n e was the first board to be approved, only after public hearings. T h e i r c o m m o n purpose was to care for all a c u t e l y ill and injured on a t i m e l y basis. For the first time, there was a specialty devoted to the p a t i e n t from the t i m e of onset of acute illness or injury up to and through disposition in an e m e r g e n c y department. T h e p r e m i s e was that the quality of medical care should n o t vary w i t h the t i m e of day, the day of the week, or holidays. It should vary n e i t h e r w i t h the rapidity of onset nor w i t h the ability to pay. It is t i m e to add that it should n o t vary w i t h geographic location. This was t h e legacy of our founders and it is still the focus of our daily efforts - the p a t i e n t in crisis. EDs are, in m y view, one of society's great levelers - places where the ills and accidents of the day can be reversed, at least partially, no m a t t e r w h o you are. Perhaps this springs from m y V i e t n a m experience where it was a t r e m e n d o u s morale factor to our c o m b a t a n t s t h a t 30 m i n u t e s after injury y o u could be on an operating table. Today, emergency physicians w i t h their skills and knowledge on the line stand ready, s o m e t i m e s in hostile environments, s o m e t i m e s w i t h marginal rest, to a t t e m p t to reverse w h a t e v e r m a l a d y is brought through the door. Some have said t h a t the v i s i o n of ACEP blurred after we achieved the i m p o r t a n t m i l e s t o n e of board certification status. But I believe that the quality of care of the patient has always been our p r e m i e r focus - the rest of our activities are subservient to that goal. So there is the palpable comm o n a l i t y and a sense of values supporting it that have always m a d e m e feel that ACEP meetings were celebrations of friendships, of c o m m i t m e n t , and of life. But w i t h i n the house of e m e r g e n c y m e d i c i n e w i t h c o m m o n core values, there are m a n y different c o m p e t i n g interests. This is good there is strength in diversity. In the early days of emergency medicine, in the 1970s, I w o r k e d for a group t h a t flew around Illinois staffing EDs. A t last count I've w o r k e d in s o m e 20 different EDs, s o m e t h i n g t h a t w i t h today's credentialling rules m i g h t be difficult to do. M y perspective was that no two of t h e m were the same. It is understandable to me, therefore, that interests m a y vary, based on one's practice setting and personal goals. I a m delighted to be addressing y o u at a t i m e w h e n the Board has approved a section policy and y o u confront the issue of voting privileges of sections on this floor. You should give voice and vote to those particular interests within the College. ACEP m u s t c o n t i n u e to be the voice of all
19:1 January 1990
Annals of Emergency Medicine
Robert K Anzinger, MD, FACEP American College of Emergency Physicians Dallas, Texas Presented as the Presidential Address to the Council of the American College of Emergency Physicians in Washington, DC, September 1989. Address for reprints: American College of Emergency Physicians, PO Box 619911, Dallas, Texas 75261-9911.
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e m e r g e n c y p h y s i c i a n s . T h i s College, t h r o u g h its leadership, will m a k e every effort to provide a comfortable and d y n a m i c h o m e for all its m a n y constituencies. T h e specialty of e m e r g e n c y m e d i c i n e is a specialty in breadth, and ACEP, to be truly representative, m u s t give voice to its broad interests. To those w h o have felt in the past that ACEP was not sufficiently c o m m i t t e d to your area of i n t e r e s t . . . I say try us again. To those w h o have formed other related organizations to pursue your interests . . . I say m a k e y o u r voice heard in this Council, in this College. ACEP, t h r o u g h its policy on sections, has t a k e n a first step to unify, in a fede r a t i o n , t h e i n t e r e s t s of e m e r g e n c y p h y s i c i a n s . I h a v e asked the M e m b e r s h i p C o m m i t t e e this c o m i n g year to address w h a t a fully developed section c o m p l e m e n t might look like. Our c o m m o n purpose m u s t also be the c e m e n t of our c h a p t e r / n a t i o n a l r e l a t i o n s h i p . In 1982, John N a i s b i t t , in M e g a t r e n d s , n o t e d t e n d o m i n a n t trends, one of w h i c h was a decentralization of A m e r i c a n structures. Surely this has profound i m p l i c a t i o n s for any n a t i o n a l organization. Strong chapters are vital to the success of emergency medicine for several reasons: at the local level, chapters are perceived to b e ACEP; problems do not arise d e n o v o m Dallas. T h e y come from the m e m b e r s often through their chapter offices; increasingly, solutions to local p r o b l e m s will have i m p l i c a t i o n s for other localities, states, and for the n a t i o n a l organization; and leadership d e v e l o p m e n t has historically flowed from the states to the n a t i o n a l organization. The C h a p t e r Advisory Panel m e t this past M a y and has forwarded to the Board policy s t a t e m e n t s recognizing the i m p o r t a n c e of nondues revenue for the states, the need for an effective c o m m u n i c a t i o n network, and the need for an issues-prioritization system. We w o u l d be well served to t h i n k of issues wherever they arise, not as state or national issues, but as e m e r g e n c y m e d i c i n e issues. W h e t h e r it is overcrOwding in N e w York; M e d i c a i d d i v e r s i o n m Maryland; M e d i c a i d initiatives in Oregon; tort reform in Florida, Michigan, and Texas; hospital closures in California or in the rural heartland; or legislative initiatives w i t h sin taxes to pay for indigent care and t r a u m a - the curr e n t l o c a t i o n of the p r o b l e m and the initiatives m a y be localized, b u t these are surely e m e r g e n c y m e d i c i n e issues for us all. We have a t r e m e n d o u s potential for collaboration bet w e e n our n a t i o n a l and state organizations. It m a k e s little difference w h e r e p r o b l e m s arise as long as we w o r k tog e t h e r for t h e best s o l u t i o n s . It m a k e s l i t t l e difference w h o comes up w i t h the best answer as long as that a n s w e r is shared. T h e n a t i o n a l organization must, however, serve as a clearinghouse for issues so that policy f o r m u l a t i o n is consistent and viable nationally. Clearly, the w h o l e will be greater t h a n t h e s u m of the parts! There's a great deal of concern in some states regarding their o w n e c o n o m i c viability. I a m s y m p a t h e t i c w i t h that concern. Last year, this C o u n c i l passed a resolution that asked ACEP to help states develop sources of n o n d u e s revenue. This C o u n c i l has before it a resolution on revenuesharing from n a t i o n a l meetings. I have asked the C h a p t e r A d v i s o r y Panel, a s a specific o b j e c t i v e this year, to develop a m e t h o d for negotiating joint ventures b e t w e e n the natiOnal organizations and the states. Such m e t h o d o l o g y must, at a m i n i m u m , be legal, m u t u a l l y beneficial to the 148/91
national organization and state chapters, and fair to all. W h a t e v e r the o u t c o m e of t h e debate on the p a r t i c u l a r issue before you, I a m confident that the Board and staff are c o m m i t t e d to a r e i n v i g o r a t e d c h a p t e r / n a t i o n a l r e l a t i o n ship. N e x t m o n t h , as an e x a m p l e , we w i l l be p a r t i c i p a t i n g w i t h the N e w York chapter in a cooperative v e n t u r e to highlight to the m e d i a the p r o b l e m of overcrowding in the nation's EDs. We will c o n t i n u e to look for m u t u a l l y beneficial joint ventures t h r o u g h o u t the year. C o m m o n a l i t y of purpose is at the very heart of the defin i t i o n of fellowship. I have read every letter w r i t t e n objecting to the fellowship criteria established over the past year and have found several c o m m o n t h e m e s : We should n o t have changed the rules in the m i d d l e of the game; w e should have had a grace period. We should have applied the criteria to all fellows. We should have criteria to include s o m e o n e w h o (only) w a n t s to practice good clinical e m e r g e n c y m e d i c i n e and should not favor particularly politicians, researchers, or educators as a specialty providing p r i m a r y care services. To go back to our c o m m o n purpose w h a t was our original goal? H i s t o r i c a l l y , a p h y s i c i a n w i t h i n t e r e s t in e m e r g e n c y m e d i c i n e , m a i n t e n a n c e of t h e CME requirement, and p a y m e n t of dues allowed ACEP membership. Passing the w r i t t e n and oral board e x a m i n a t i o n in emergency m e d i c i n e m a k e s one a d i p l o m a t of the A m e r i c a n Board of Emergency Medicine. Again, before this Council is the question, in addition to having passed the boards, w h a t criteria does ACEP w i s h to set to call one a fellow? Webster's dictionary defines fellow as an equal in rank, power, or Character a peer: and an i n c o r p o r a t e d m e m b e r of a college or collegiate foundation. There are several points on this that I'd like to make. It has generated more negative m a i l than any other issue m ACEP's recent history. The m e m b e r views this change as coming not from the Council or the Board or even from the president, but from the College. Original criteria for f e l l o w s h i p were inclusive, requiring o n l y three years of m e m b e r s h i p after passing t h e boards; the set of criteria adopted by the Council last year is viewed by m a n y as exclusive and elitist. Whatever criteria are decided here in the next two days, t h e y should certainly encompass those who share our c o m m o n p u r p o s e providing excellent care to the patient m crisis. O u r c o m m o n purpose springs from our shared core values. One of those values shared around this r o o m ts the f u n d a m e n t a l goodness and w o r t h of our fellow man. We don't believe that we are perfect, and at t i m e s it is exciting the different ways we are imperfect. But deep down, there's an u n d e r s t a n d i n g of the h u m a n p r e d i c a m e n t and the aspirations c o m m o n to us all - life, liberty, the p u r s u i t of happiness . . . and yes, the pursuit of health. H o w else does one explain the willingness, no. the excitement, we feel going to give care to perfect strangers on a daily basis! Absorbing the moans, tears, insults, the sleep d e p r i v a t i o n . To go on and a l l e v i a t e the pain, t h e shortness of breath, the d e v a s t a t i o n of loss. H o w else does one explain the willingness and e x c i t e m e n t reported by m e m b e r s of the Casualty Surgeons A s s o c i a t i o n and ACEP relative to the earthquake in Armenia. There, in hostile surroundings, t h e y reached out to refugees of a devastating disaster to do w h a t could be done to alleviate suffer-
Annals of Emergency Medicine
19:1 January 1990
ing. T h e y did not send to k n o w for w h o m the bell tolled . . . they k n e w . . , t h e y w e n t there. I a m excited by w h a t I sense in ACEP as a n e w l y found i m p o r t a n c e of e m e r g e n c y m e d i c i n e in t h e i n t e r n a t i o n a l arena, of its potential as a peacemaker, of its p o t e n t i a l to f a v o r a b l y i m p a c t m o r b i d i t y and m o r t a l i t y , e s p e c i a l l y in m a s s c a s u a l t y disasters, and m a y b e even its p o t e n t i a l ; through education, to become an exported service. I said at the o u t s e t that our special c h e m i s t r y of an ACEP gathering came from two things: our c o m m o n purpose and the feeling that s o m e t h i n g exciting is about to happen. Somet h i n g exciting is about to happen - at this m e e t i n g and over the n e x t year. Looking back over our brief history, I cannot r e m e m b e r a t i m e w h e n things were "stable." In our m i n d s t h e issues were a t t a c h e d to " s u r v i v a l , " ours and the patients'. O u r history chronicles our efforts to improve educational programs, c o n t i n u a l l y improve our journal, enter into the house of medicine, advance the distrib u t i o n and quality of EMS, establish a creditable research wing, achieve board status, w o r k for l i a b i l i t y reform ... . . . and n o w we m e e t in Washington, DC, in w h a t Congress has dubbed " T h e Year o f the Physician," Congress' i n t e n t tO do for physicians w h a t D R G s did for hospitals. W e ' v e k n o w n we were to be judged by the quality of the c l i n i c a l care of p a t i e n t s , o u r c o n t r i b u t i o n s to m e d i c a l knowledge, and our general c o m p o r t m e n t . To us, survival was the issue, and as W i n s t o n Churchill said: " T h e r e is n o t h i n g so exhilarating as being shot at and m i s s e d . " W h a t is the sense of e x c i t e m e n t at an ACEP meeting? For me, it is that n e w ideas will be born - n e w solutions to old p r o b l e m s , n e w i n f o r m a t i o n - w h e t h e r at t h i s Council meeting, from the a n i m a t e d conversations I see in the hallways, from the c o m m i t t e e m e e t i n g s , tO the scientific meetings, the forum, the Board m e e t i n g - all that s t i m u l a t e s n e w thought and leaves you invigorated to go h o m e to do the very best you can. Today, of course, there is a r e v o l u t i o n in h e a l t h care. T h e e x c i t i n g t h i n g a b o u t a r e v o l u t i o n is t h a t b a t t l e s fought and w o n will significantly change the face of medicine for years to come, the pace is faster, the stakes are higher. A n d ACEP is in the t h i c k of it, trying to steer the issues so that w h e n all is said and done, the practice of emergency m e d i c i n e will be better for our patients and our members. For the t u r m o i l we have passed t h r o u g h and c o n t i n u e in, we owe it to ourselves and to our p a t i e n t s to have an end product vastly i m p r o v e d from where we started. To fight the good fightl I m u s t believe that a better o u t c o m e is possible! Revolution. The word itself strikes fear in our hearts, a reaction to the speed w i t h w h i c h change takes place. The revolution in m e d i c i n e today is part of a larger information/technological revolution, only accelerated by t h e imperatives of the budget deficit. Like other revolutions, the industrial, the computer, the i n f o r m a t i o n revolutions, We s h o u l d k n o w t h a t things w i l l be forever different. O u r c o m m i t m e n t is to m a k e t h e m better. Today the issues are access, costs, and quality. ACCESS T h e r e are 37 m i l l i o n u n i n s u r e d a n d m i l l i o n s i n a d e quately insured, one third of w h o m are children. Emergency p h y s i c i a n s are c o m m i t t e d e t h i c a l l y and m o r a l l y and, m o r e recently, legally to the care of these patients. 19:1 January 1990
It should be a great source of pride to y o u t h a t we have n o t abandoned these citizens. But w e m u s t do more and w e cannot do it alone. Hospitals are closing, EDs are closing, EDs are f u n c t i o n a l l y closed due to overcrowding, and a m b u l a n c e s are diverted, c r e a t i n g d i s r u p t i o n w i t h i n t h e prehospital system. We are s i m u l t a n e o u s l y m a n d a t e d by law to see all p a t i e n t s and chastised for providing "inapp r o p r i a t e " services to patients in EDs. ACEP will c o n t i n u e to w o r k w i t h Congress on the dil e m m a s surrounding indigent care. We will support pri~ m a r y care for i n d i g e n t p a t i e n t s in other settings. We w i l l w o r k for m a n d a t e d benefits and other i n n o v a t i v e funding for indigent patients. We m u s t continue to educate our legislators that w e are, in m a n y cases, the physician of last resort, the safety n e t for the delivery s y s t e m , that w e deserve appropriate c o m p e n s a t i o n for providing that care. It Should also be a great source of pride that y o u r care of t h e s e p a t i e n t s has a l l o w e d this c o u n t r y to e x p e r i m e n t w i t h different delivery modes in the m i d s t of a revolution. In the early 70s David Rutstein, in Blueprint for Medical Care, wrote, "above all i n the i n t r o d u c t i o n of a n e w s y s t e m of a m b u l a t o r y care, w e m u s t be sure that no patient is h a r m e d in the changeover process. The s m o o t h l y operating e m e r g e n c y care program that w o u l d assure the effective t r e a t m e n t Of life-threatening medical and surgical events w o u l d m a k e it possible to take a m o r e thoughtful, unhurried and thorough~going approach to the design and i m p l e m e n t a t i o n of an efficient a m b u l a t o r y program in a c o m p l e t e m e d i c a l care s y s t e m . " Surely, the a m b u l a t o r y r e v o l u t i o n is n o t over, as w e have m o r e and more care given in the a m b u l a t o r y setting, freestanding a m b u l a t o r y care centers, nursing homes, h o m e h e a l t h care, and selfcare venues: ACEP stands c o m m i t t e d to working w i t h legislatures to assure c o n t i n u e d access in a responsible fashion. In 1989, there were 3,900 freestanding a m b u l a t o r y care centers seeing 50 m i l l i o n patients. It is projected t h a t in 1991 there will be 5,000 freestanding a m b u l a t o r y care centers seeing 85 m i l l i o n patients. To some considerable extent, I believe their practice represents t h e a m b u l a t o r y or private practice of e m e r g e n c y m e d i c i n e . We m u s t c o n t i n u e to p l a n our future, recognizing that a reconfigured medical practice will increasingly be a m b u l a t o r y based. COSTS T h e driving force in the restructuring of medical care today is the n e e d to lower costs. T h e current focus is on p h y s i c i a n r e i m b u r s e m e n t w i t h its 17% increase b e t w e e n 1980 and 1987. I b e l i e v e t r a i n e d e m e r g e n c y p h y s i c i a n s using the appropriate n u m b e r of tests - not too many, n o t too few - diagnosing the illness the first t i m e the patient presents to the ED, and appropriately a d m i t t i n g or referring for follow-up care represents one of the m o s t effective, efficient, and p o t e n t i a l l y cost-saving i n v e s t m e n t s for the m e d i c a l care delivery system. However, there are other things that w e can do to att e m p t to control costs for our patients. In 1983, the ACEP cost c o n t a i n m e n t project, developed in conjunction w i t h T h e Kellogg Foundation, defined a scientific m e t h o d for cost r e d u c t i o n , and w h e n w e d d e d to s t a n d a r d s developm e n t and o u t c o m e s m e a s u r e m e n t , can continue to be an effective m e c h a n i s m for lowering costs. The standards dev e l o p m e n t process itself incorporates cost-effective m e c h anisms. O u t c o m e s research will provide answers to cost-
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effective diagnostic and treatment efforts. Professional liability reform could significantly alter the cost of care in this country and m u s t be pursued. P r e m i u m costs are but a portion of the total costs, with an estimated $15 billion being spent by physicians practicing defensive medicine. There are exciting initiatives in this arena. In Massachusetts, the ACEP chapter has initiated a quality assurance program based on dictated records and computerized QA review and presented a proposal tO the state insurance c o m m i s s i o n e r for a 28% reduction in malpractice prem i u m s . T h e Texas c h a p t e r has a state initiative t h a t would provide a state risk pool for the first $100,000 loss for emergency physicians providing indigent care. The Michigan chapter has an initiative to increase the standard to "willful and w a n t o n " for emergency patients without an established physician relationship. Additionally, ACEP is a sponsor and supporter of the A M A Liability Project, which offers an administrative system to replace the current tort system. It is becoming apparent, even to the Congress, that one cannot have a fix for the physician i n c o m e side of the equation and let the professional liability expense remain free-floating. This year I have appointed a Public Health Issues Task Force for several reasons. First, an ounce of prevention is still worth a pound of cure. With each escalation of the cost of medical care, the cost benefit ratio of prevention becomes more and more attractive. In the arena of injury, for instance, each year we lose 150,000 Americans with 450,000 becoming totally and permanently disabled, costing $75 to $100 billion yearly in direct and indirect costs. We are currently investing only 2¢ of the research dollar for trauma. Almost half of the fatally injured have blood alcohol concentrations of .10 or more. Who among us can be i m m u n e to the terrible toll taken by firearms in this country? Four hundred sixty-four were shot to death in one week; more than 30,000 a year. Guns in two years take more lives than the Vietnam War, with handguns accounting for three quarters of these deaths. For every death, there are at least five nonfatal firearms injuries, and one study at San Francisco General showed that 86.56% of the cost incurred was paid by public funds! Second, the Council resolutions year after year propose significant public health initiatives to prevent illness and injury. Third, the media has focused a great deal of attention on prevention. As costs of medical care escalate, I believe the public, Congress, and the media will increasingly ask what we have done to prevent the illness and injury we are n o w seeing. I have, therefore, asked the committee to develop a fiveyear plan to analyze the impact of the lack of preventative strategies on emergency medicine in terms of dollars and volume of patients; analyze from the literature k n o w n effective strategies for reduction of illness and injury; and recommend to the Board those policies and strategies to effect change in the patterns of illness and injury seen in EDs. To further control costs, I believe that we, as emergency physicians, m u s t work to control the total price of our service - the facility, professional component, supplies, ancillaries, and consultants. To do justice to our patients, we m u s t k n o w and control total costs to the consumer. We have made emergency medicine our practice - we m u s t make it our business. Furthermore, as a major entry 150/93
point into the care system, it is m a n d a t o r y that we as emergency physicians appreciate and influence the societal implications of government policy decisions. We have an i m m e n s e vested interest in anticipating the societal impacts of government policy decisions, and we serve as an on-line, early warning system that planning has gone awry and needs revision. It is refreshing and exciting to me to see one of our own, John Kitzhaber, emergency physician, president of the Oregon senate, struggling with the allocation of finite resources to effect the greatest good for the least cost - truly a staggering triage decision. QUALITY I am excited about the prospects of the impending vote on primary board status for emergency medicine. Primary board status represents another step down the road of specialty maturation, allowing the development of needed subspecialty areas. It allows us to reflect on the careful deliberation and the w i s d o m of our leadership and this Council, who supported emergency medicine initially as a conjoint board. It affirms that w h e n our focus is right, our vision clear, and we are patient and persistent, progress will be made. Primary board status will formally recognize the functional peer standing we have enjoyed with our colleagues in other specialties. I cannot help but think that primary board status will improve the quality of our practice and the quality of our relationships. With the increasing costs of medical care and attempts at controlling those costs, there is an increasing concern about the unevenness in the quality of care. Consumers, third parties, the government, and business are looking for measures of that quality. ACEP is actively involved in formulating clinical policies for chest pain, blunt abdominal trauma, adult seizures, and the febrile child. The relationship between clinical policies, reimbursement, risk management, quality assurance and resource allocation should not be underestimated - nor should we have any illusions - we will develop our own policies or someone else will. In working on the Harvard RBRVS, the only code I found no other specialty performs was prehospital care. Our quality of care will depend on the number, health, and well-being of emergency physicians. We continue to study the m a n y and changing variables impacting on manpower needs. We have completed a preliminary staffing ratio study and will look for further funding for a more complex modeling study. There are, at present, four articles in development that will be submitted to Annals elaborating on our manpower needs and focusing on further study. We also are conducting an attrition study to measure emergency physician turnover. I have reappointed the Wellness Committee to support our m o s t valuable resource, the e m e r g e n c y physician. That committee will study the impact of career developm e n t on physician wellness. The Academic Affairs Committee is completing materials to assist those starting residency programs, and they will examine ways to expand residency programs and identify part-time faculty. In the area of research, the Emergency Medicine Foundation generated $240,000 in funding for research, and additional f u n d i n g f r o m five large e m e r g e n c y p h y s i c i a n groups has been obtained to fund a director of grants-fundraising to assure further progress in keeping emergency medicine at the cutting edge. Our continuing medical ed-
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ucation programs address the needs of this membership, and this year we will explore new technologies to reduce costs, assure accessibility, and improve quality of programs. The EMS C o m m i t t e e continues to serve as a coalition for discussion and action on issues facing the EMS industry. As we continue to work on clinical policies, we m u s t prioritize and develop clinical standards for prehospital care. This year, we will work to define ACEP's role in multicenter research trials in EMS. We m u s t scientifically prove the value of our in-field interventions. I believe that as a college we m u s t establish EMS standards that include a definite response time parameter. ACEP has published The Principles of EMS, already in its second printing, and has completed an EMS medical director's text. These are but a few of the exciting areas that will receive our attention in the next year. I ' m sure this week, this year, new ideas will be born. My vision for the College is a d y n a m i c federation of emergency medicine issues, interests, subspecialties , and chapters. We will con-
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tinue to provide cohesion for the medical care delivery system. We will continue on the front lines of access for the patient. Our skills in relating to other organizations with overlapping interests will improve and mature. Paym e n t reform will preserve our specialty. G o v e r n m e n t s will recognize us as an innovative partner in problem solving. The sophistication and expense of noninvasive imaging and laboratory testing plus the needed orchestration of treatment resources will make us the premier physicians for the unclassified severely ill or injured patient. Our departments will be sought after for educational experiences. Our research and management contributions will gain in significance. Why? Because we are well positioned in this revolution to impact our destiny. And because great, sometimes heroic, individual efforts come together here in the American College of Emergency Physicians. With your persistence, y o u r c o m m i t m e n t , and your vision, the College will not only survive the current revolution, we will prevail.
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