—Ronald A. (“Ron”) Hellstern, MD,
FACEP(E), Colleyville, Texas

Emergency Medicine has its own language and culture. People who don’t practice emergency medicine think it’s just internal medicine in the ER. They picture us having the same leisures they have in how they manage patients, ie, linearly managing patients with known diagnoses. They will never learn our culture or language because they don’t necessarily even recognize that there is a difference. Like most people, they don’t go looking for things they don’t know are in existence. As such, we will always be misunderstood, I fear.

I have seen positive changes in the way we are perceived over my 20 years of practice, but there is still a way to go. I explain it as thus: Our job is to manage a community resource, the emergency department. Manage is the key word. Everybody else in medicine has the job of managing the patient’s illness. We do that to the extent possible in the background of managing a community resource, but we are never relieved of our duty to first manage a community resource. We co-manage several patients at a time, providing safety for the downstream docs to do their work with major and unexpected medical conditions identified, treated, or ruled out…and, like, 5 minutes ago.

We speak a language that nobody else in medicine speaks. Like anybody in that situation, we often can only shake our heads “yes” and move on.

—William Franklin, DO, FACEP
Bakersfield, California

While I do agree with Dr. Klauer that it appears emergency medicine was unjustifiably singled out in this study, I would like to add a few observations from over 35 years of practicing emergency medicine.

It is an ideal situation if the ED physician is able to arrive at a diagnosis in an efficient and timely manner. Unfortunately, the human machine is not always willing to cooperate and in many cases a definitive diagnosis simply cannot be achieved in the ED within a reasonable timeframe. The next issue for the ED physician becomes “Do I admit or do I refer?” A physician who has listened to the patient’s story—and I don’t mean asked six or seven preconceived “Yes/No” history template questions that “best fit” (but don’t EXACTLY fit) the patient’s chief complaint—has done a focused physical examination—not just the now-ubiquitous “stethoscope tap” chest exam or “momentary palm touch” abdominal exam—formulated a differential diagnosis that is followed, has ordered appropriate lab and imaging tests based on his/her assessment of the patient, reviewed all tests results, and addressed any unexpected results is going to be much more secure in deciding whether a patient with an undiagnosed condition needs emergency admission or simply follow-up with their own physician or a referral to a specialist.