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Mumford, MD, speaking with regard to the adminis t ra- t ion of medical schools, said,

There is no doubt that the fundamental trouble is with our governing boards. They are business and professional men who are important in their community. They are chosen governors because they are important people. They know nothing at first hand about the conduct of great or small university matters. Our best medical schools are run too exclusively for the race horses. The average man doesn't get enough mental stimulation or practical advice. I see the results constantly .in my younger consultants and then there is the protest throughout the land. What is the matter with the practice of medicine?

Remember, this was wr i t ten 63 years ago. Sounds al- most l ike a m e m b e r of ACEP t a l k i n g to a UA/EMS member.

The same author really starts to focus on the problem.

The question of providing competent and humane physicians to take care of the sick is becoming increasingly urgent and the trouble lies with the high grade medical schools and hospitals. These institutions are dominated by men largely unfamiliar with the problems of practice, their leading idea being to train both students and physicians to an expert knowledge of medi- cine, but they emphasize theory rather than practice. They realize their shortcomings but justify their course by saying young men will get all of their bedside practice when they be- come hospital interns. They call themselves consultants and keep hours and appointments so irregular that practice cannot find them. When the chief shepherds have for a generation so neglected and mistreated their flocks, what can one expect?

A s you can see medicine was already in deep, dark trouble 63 years ago, at least according to a dis t inguished Boston practit ioner.

Why am I t ak ing the t ime to r un this past history by you? Well, I th ink it is germane - - germane to us in U A / E M S w h e n we q u e s t i o n our role as a cademic types in the field and future of emergency medicine. The t radi t ional specialist, at least in the univers i ty setting, will probably never give up his interest in emergency medicine - - he is deal ing with emergent problems on a day-to-day basis with his hospitalized pat ients and he is ins t ruc t ing medical s tudents and house staff in deal ing w i t h these ve ry s ame p rob lems . The t r a d i t i o n a l specialist 's in teres t in his own branch of medicine is in par t generated by the types of emergent problems tha t area of medicine encompasses. The t achyar rhy thmia in the fail ing elderly hear t challenges a cardiologist's intel- lect and skill, the pa t ient with mult iple t raumat ic in- jur ies taxes and s t imulates the surgeon whose research interest may focus on the role of lysosomal enzymes in hypovolemic shock, and the psych ia t r i s t r u n n i n g an acute service will stop his daily therapy session with a depressed postmenopausal woman to be challenged by a th rea ten ing , suicidal, drug-addicted teenage gui tar is t . The t radi t ional specialists will not give up these interests wi th in their own areas of e:¢pertise - - nor should they.

The academic, t radi t ional specialist also has the duty and obligation to do more t han crawl along the frontiers of science with a hand lens: he is responsible for research as it applies to his par t icular area of interest - - basic research, and immedia te ly applicable clinical research. With rare exceptions, double-blind, randomized, prospec- tive studies cannot be carried out in a communi ty set- ting.

Page 904 Volume 5 Number 11

In general, most academic, t radi t ional specialists have done their work well, bu t they have failed in their teach. ing, research, administrat ive, service and organizational, functions when it comes to outpa t ien t emergency medi, cine. They have neglected, forgot ten about, avoided, walked around, evaded and repressed the single largest source of most pat ients admit ted to the hospital acutely - - the emergency department. Are they blind? No. Are they unconcerned? No. Are they unaware? Sometimes. But they have had house staff r u n n i n g interference for them, placing three stitches in a minor laceration, giving an a s thma t i c a bronchodi la tor , s t r app ing a sprained ankle , and inves t iga t ing the pa t i en t wi th acute chest pain.

The academician has lagged behind in his unders tan d. ing of the emergency depar tment explosion: the patient on rush, the episodic elective care, the expectation' of a 24-hour, well-staffed facility. Remember, it was only in 1970 that a group of physicians, concerned with the lack of emphasis being placed on or a t tent ion being directed to e me r ge nc y medic ine in u n i v e r s i t y t e a c h i n g centers, formed this organization. Practice-based physicians, two years earlier, had formed the American College of Emer- gency Physicians.

Are these organizations at cross purposes? No. They can happi ly coexist. UA/EMS is the. academically based, teaching, research, and service component in the univer. s i ty s e t t i ng . A C E P is p r i m a r i l y service-or iented , community-based and interested in certifying the compe. tence of those already in practice or about to go into prac- tice. Our o rgan i za t i on has been home to tradit ional specialists who have had the foresight to poke and prod the univers i ty into recognizing emergency medicine as a special, distinct, outpat ient area. As this organization re- views its objectives, as its Long Range P l ann ing Commit- tee deliberates about our future, I th ink you will find some t radi t ional specialists l eav ing the ranks, but I pre- dict a growth in membership - - a growth made up of those people who are responsible for university-based t r a in ing programs in emergency medicine and those in- dividuals in these t r a in ing programs. At this point, and almost as an aside, I would like to add that all emergency m e d i c i n e r e s i d e n c y t r a i n i n g p r o g r a m s shou ld be universi ty-based or affiliated, and related to educational goals and manpower needs - - not to the service needs of the practicing emergency p h y s i c i a n who establishes a program under the guise of repl icat ing more of his own kind. STEM, the Society for Teachers of Emergency Med- icine, will find that UA/EMS, with a slight change in the c h a r a c t e r of i ts m e m b e r s h i p roles , does represent academic emergency medicine and hence the need for yet another o rgan iza t ion may be obviated. Our founding fathers, interested in the future of emergency medicine, bu t choosing to r ema in t radi t ional specialists, may well submi t letters of resignation, bu t this may only serve to s t r e n g t h e n the common in t e re s t and cause t ha t they founded.

Let me remind all of you tha t our const i tut ional objeC' t ives are still valid. Our priorities in achieving these ob' jectives mus t be revised from t ime to t ime and our consti'

November 1976 J ~ P

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