The Oxford English Dictionary defines dissent as, “the expression or holding of opinions at variance with those previously, commonly, or officially held.”

Emergency medicine, perhaps more than any other medical specialty, is a specialty borne of dissent. I believe younger emergency physicians need to know this history. Reasoned dissent was a crucial tool in the formation of emergency medicine, and it continues to improve our practice environment today.

How Dissent Can Change the World

From a global perspective, those who dissent have improved nations. Consider Dr. Martin Luther King Jr., who is honored not for “put-ting up” silently with our society’s flaws but for his leadership in the Civil Rights movement, which implemented thoughtful, non-violent dissent against laws and barriers that precluded the full benefits of citizenship from being enjoyed by all Americans. Also, consider the legacy of the late Supreme Court Justice Ruth Bader Ginsburg. She regularly implemented dissent in her writings and decisions during her long and illustrious career on the bench.

In considering these legacies, it is also ap-propriate to review the influence dissent has emergency medicine as a specialty.

1. The Founding of ACEP

The founding of the American College of Emergency Physicians can be considered an act of dissent. ACEP was founded 11 years before the American Board of Medical Specialties (ABMS) granted emergency medicine official specialty status in 1979. Physicians, linked by a dissenting vision that “emergency room medicine” could indeed become a career choice, met in Arlington, Virginia, in November 1968. At the time, emergency medicine had no identifiable special body of knowledge and was widely considered a place for doctors who had challenges with other practices. ACEP’s founders had an initial goal of sharing ideas to improve business practices and foster new educational programs.

At that meeting, Dr. R. R. Hannas took dis-sent a step further. He articulated a unique vision for emergency medicine to become a full-fledged medical and academic special-ty, which our nation demonstrably needed. Did you know that in 1966, two years before ACEP was founded, the National Academy of Sciences disseminated a white paper titled Accidental Death and Disability: The Neglected Disease of Modern Society?.¹ This work highlighted broad deficiencies in America’s emergency care systems. Dr. Hannas’ new vision provided a road map to illustrate a path for remediating many of those deficiencies.

2. Dr. Bruce Janiak, the World’s First Emergency Medicine Resident

Nearly simultaneously, the world’s first emergency medicine resident, Dr. Bruce Janiak, began training in 1969 at the University of Cincinnati. At that time, there was no such thing as an academic emergency department or an emergency medicine residency program. Dr. Janiak rotated on various relevant services as he developed his own personalized curriculum, such as it was, on the fly. He spent two years training for a specialty for which there would not be an official certifying board until 1979.

Dr. Janiak was so confident in his dissenting vision that while in his residency, he said if he were a betting man, he “wouldn’t bet against me.” This statement was noted with-in the exhibits commemorating ACEP’s 50th anniversary, displayed at the 2018 ACEP Scientific Assembly in San Diego. Time has certainly proven Dr. Janiak to be right.

3. Laboring in Dissent

Organized dissent by many explains how emergency medicine became an official specialty within ABMS. ABMS voted in September 1977 (100 to five) to reject emergency medicine’s application for specialty board status. Not content to accept failure, numerous visionary founders of our specialty, such as Drs. John Wiegenstein, George Podgorny, David Wagner and Ron Krome, led the efforts to labor effectively in dissent. Two years later in September 1979, through their considerable and persuasive efforts, emergency medicine became an approved specialty by ABMS in an almost unanimous vote. It is difficult to capture in a brief paragraph the ex-tensive persuasive efforts required to effect this change. These leaders dissented from the overwhelming opinion of the ABMS, as expressed in 1977. They dissented so effectively that they changed minds and hearts and made emergency medicine an official ABMS-recognized specialty in 1979.

Further, we all have heard of Dr. Peter Rosen, a founder of our specialty. I will paraphrase an incident involving Dr. Rosen, as reported by Dr. Brian Zink in his book, Anyone, Anything, Anytime: A History of Emergency Medicine. Dr. Zink interviewed Dr. Rosen in Jackson, Wyoming, in 2003 as he collected the history of our specialty “from the horses’ mouths,” as it were.

In 1977, Dr. Rosen was leading the emergency department at the University of Chica-go, and he had the occasion to meet with his new dean. The dean, Daniel C. Tosteson, was an anatomist and not a physician. The dean opined in meeting with Dr. Rosen that he did not understand why emergency medicine should exist because there is no “biology” of emergency medicine. (We don’t claim an organ system in the manner of nephrologists with the renal system or cardiologists with the cardiovascular system.) The dean noted that if he were to have a heart attack, for example, he wanted to receive the care of a cardiologist. Dr. Rosen asked this dean how he might know he was having a heart attack. The dean replied that he’d expect to be having chest pain. Dr. Rosen replied by asking what the dean would expect to occur if the symptoms were mainly nausea. Dr. Rosen was quoted by Dr. Zink as saying, regarding the reaction of Dr. Tosteson, “It was the first time it had ever occurred to him that maybe you couldn’t run an emergency department with 47 different specialties. … I got so pissed at him that … I went out and wrote a paper.” Now, that’s effective dissent, when you look your dean in the eye and use his own words to explain why his opinion of our specialty is so wrong!

4. IV Opiate Analgesia Administration

Consider how we now employ opiate analgesia for patients with abdominal pain. When I finished residency in 1989, such a practice by emergency physicians was considered wildly inappropriate. Merciful IV opiate analgesia could be administered only after a surgeon (typically one who was often a surgical resi-dent with less experience than the emergency department attending) had operated on or first seen and laid hands on the patient. The dogma of Dr. Zachary Cope, which had persisted since the early decades of the 20th century, was rejected once emergency medicine researchers dissented with data in peer-reviewed publications. If you wish to read more about how Dr. Cope and his dogma regarding analgesia became a historical footnote, peruse the on-line tool The NNT at www.thennt.com/nnt/opiate-analgesia-acute-abdominal-pain/. It summarizes the body of research that led to our modern view regarding use of analgesia for patients with acute abdominal pain.

5. Overturning “Pain as the Fifth Vital Sign”

More recently, emergency physicians have been among those speaking out against the Pain as the Fifth Vital Sign (PATFVS) initiative. The Joint Commission for Accreditation of Hospital Organizations, now known as The Joint Commission, initiated PATFVS in 2000. Of course, pain is a symptom and not a sign, so the entire initiative was flawed from the outset. Emergency physicians have been among many within the medical field to call out the folly. Joint Commission was only supported by a letter to the editor in the New England Journal of Medicine stating that opiates, such as oxycodone and hydrocodone, were not potentially addicting.²

Emergency medicine researchers are among those who have demonstrated how the opiate crisis has followed increased prescribing of opiates, a practice that was arguably augmented by concomitant patient satisfaction initiatives. Fortunately, The Joint Commission finally heeded dissent from ACEP and others and overturned its advocacy for PATFVS. Efforts within The Joint Commission to change its standards began in 2016 and were finally officially revised by 2018.³

Dissent Fosters Growth and Improvement

These examples demonstrate how reasoned dissent has led to positive changes. I hope they can inspire some of you to dissent thoughtfully and constructively from the status quo when it becomes necessary. As you do, realize that you are the latest in a long line of emergency physicians who are not content to put up and shut up when you know that changes are needed to improve the safety or efficacy of the systems that deliver lifesaving care to our patients.

When we engage in dissent in the interest of more effective emergency department care, we not only foster team building and improved patient care environments, we add our names to the long, honorable and growing register of change agents who have utilized constructive dissent to advance our specialty. Sometimes, those in leadership require time to become convinced of the merits of our suggestions, but persistent reasoned dissent is part of the fabric of an aware and caring emergency physician.

Dr. Gaddis is a former professor of emergency medicine at Washington University School of Medicine in St. Louis, MO.

References

1. National Academy of Sciences (US) and National Research Council (US) Committee on Trauma; National Academy of Sciences (US) and National Research Council (US) Committee on Shock. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington (DC): National Academies Press (US). 1966. https://www.ncbi.nlm.nih.gov/books/NBK222962/?report=classic
2. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980;302(2):123
3. Baker DW. The Joint Commission’s pain stan-dards: origins and evolution. 2017 May. https://www.jointcommission.org/-/media/tjc/documents/resources/pain-management/pain_std_history_web_ version_05122017pdf.pdf.