This post is based on one of the most interesting articles I have ever read in EM. The article written by Dr. Peter Rosen in 1979 and published in The Journal of the American College of Emergency Physicians (later become Annals of Emergency Medicine) is a landmark piece. It defines the specialty with so much precision that even contemporary authors find very little discrepancy of what Dr. Rosen wrote and the state of EM in present time.
There is a very clear opinion of what Dr. Rosen believed the unique biology of EM should be. He explains the birth of EM, which was not validated by other specialties in the house of medicine. It was more a reaction from multiple factors, which included financial incentives, growth of urban centers, need of a doctor in a geographic region, and the decreased numbers of physicians house calls.
One of my favorite sections in the article is when he writes “Defining The Specialty.” He states that the responsibilities of the emergency physician (EP) entails differentiating the sick from the non-sick patient, handling multiple patients at the same time, and instituting life/limb saving interventions. He uses the analogy of a climber who for whatever reason has fallen from a precipice and the job of the EP is to get the climber to a much safer place as possible, assuming 100% safety is not attainable.
Interesting enough, he also states that prehospital care should also be managed by the EP. This is an aspect of EM in which EPs are more directly involved. In Dr. Rosen’s opinion, the hardest task of an EP is sending home a patient with a potentially life-threatening diagnosis when the patient presents with nonspecific signs or symptoms.
- I have worked with some amazing clinicians, and their diagnostic skills are impressively accurate. They arrive at the correct diagnosis with very little information due to the patient’s altered mental status, his/her being a poor historian, or even how atypical the disease is presenting.
In the essay, he states that stabilization takes priority over diagnosis. This contrasts medical school teachings where the emphasis of education is on primary care. Consequently, the priority is to take a history, do a physical exam, and then treat the patient– in that order.
- This statement reminds me of a web search that I did last year on how to think like an EP. I came across Dr. Reuben Strayer’s (@emupdates) 30-minute video “How to Think Like an Emergency Physician” delineating how an EP should go about seeing patients in the ED. I think this is what Dr. Rosen envisioned the specialty should focus on. Treat the patient first when indicated, and then do a history and physical.
The hardest thing to teach residents, according to Dr. Rosen, is to “assume the worst even if statistically improbable”. I believe that Dr. Amal Mattu (@amalmattu) refers to this as a “healthy paranoia”. This means that we still need to rule out life threatening diagnoses for seemingly non-emergent patients. We must also have enough knowledge of NON-life threatening diagnoses in order to address these in the ED, if possible. If we feel confident that the patient has no life threatening diagnoses and can be discharged the patient home, then we should ensure appropriate follow up.
In tomorrow’s post (part 2), we will look at how Dr. Rosen categorized ED patient visits and his views on EM administration and research.
- Rosen P. The biology of emergency medicine. JACEP. 1979 Jul;8(7):280-3. Pubmed.
- Peter Rosen’s lecture at UCLA. All L.A. Conference May 5, 2011: Reflections on 40 Years of Emergency Medicine. (Need to download actual video)
- Zink BJ. The Biology of Emergency Medicine: what have 30 years meant for Rosen’s original concepts? Acad Emerg Med. 2011 Mar;18(3): 301-4. Pubmed .