EM Mindset: John P. Marshall – The Twin Challenges of EM Practice

Author: John P Marshall, MD (@john_p_marshall – Chairman, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY) // Edited by: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER)

Emergency Medical care, in the United States and many other countries, is a right.  A patient in need has a right to treatment.  While there are many models for how emergency care is funded or reimbursed, and much debate about the relative merits of these models, the common theme is that life is valuable.  The systems of care that work to preserve life in the injured or ill, the interlaced nets of emergency care, are of deeply significant value to society.

The practice of Emergency Medicine, by contrast, is a privilege.  It is a privilege to be allowed to attend to the dying, to comfort those in their most difficult circumstances, to be the place people turn when they are in trouble.  It is a privilege to be given the responsibility for society’s healthcare safety net.  To be the group of people who are up all night and prepared to attend to the sick or injured, regardless of circumstance.   To be the people others turn to in their time of need.

There are many physicians, likely the majority, who don’t see Emergency Medicine practice as a privilege to be desired.  While the thought of helping an ill patient appeals to physicians in general, most find the emergency department to be too overwhelming a work environment for a lifelong clinical practice.  The requirement to reliably perform complex tasks in unpredictable, high-stakes circumstances is not a responsibility that appeals to many.  Emergency Medicine requires decision making in the setting of incomplete information, inadequate resources, and a paucity of time.  It is practice of action to the novice.  To the experienced, however, it is a more measured practice of balancing action and inaction.  It takes years to develop the clinical acumen necessary to consistently recognize the subtle signs of physiologic compromise, to learn to act early in a measured fashion, as dictated by the patient’s individual physiology, to choose the right action most every time.  It takes even longer to develop the confidence to not act too early, to not act too aggressively, to watch and to wait, to choose the right action at the right time.

If you are interested in reading the rest of this and other EM Mindset pieces, please see “An Emergency Medicine Mindset,” a collection evaluating the thought process of emergency physicians. This book is available as ebook and print on Amazon.