Many of the problems currently facing the U.S. health care system are similar to what emergency medicine pioneers faced in the 1960s – increasing ED visits, lack of access to primary care, a high number of uninsured patients. That correlation was evident this summer when ACEP and others celebrated the 50th anniversary of the Alexandria Plan – the model for current emergency care.
In America back in 1961, change was in the air. President Dwight D. Eisenhower had just handed over the reins to the much younger John F. Kennedy, and across the Potomac River change was also brewing at Alexandria Hospital. There, the president-elect of the medical staff, a respected general practitioner named James Mills Jr., had been handed a perplexing problem.
The Alexandria Hospital ED was reeling from a nearly 300% increase in patient visits from 1950 to 1960 – up to 18,000 per year. Complaints and wait times were rising. Staffing the ED was a big problem, as consigned medical staff objected to working in the ED, housestaff (primarily foreign medical graduates) had declined by 50%, and a plan to use Georgetown University medical students to cover the night shifts had failed.1
Dr. Mills had worked shifts in the ED and he liked the pace and variety, and was committed to helping the poor, as demonstrated by his numerous volunteer activities. Dr. Mills was also finding his general practice less than satisfying. His idea for solving the problem in the Alexandria Hospital ED came to him early one morning.
“One night I came home after 1 a.m. from working a day that had started that morning at 7,” he noted in a 1965 Reader’s Digest article. “I remember thinking that as a chronically tired and overworked GP, I wasn’t being fair to myself, my family or my patients. It came to me that in emergency service, with regular hours, I would be able to practice much better medicine. If I could get three other good men to join me, we’d have a team that could provide top-notch treatment.”2
Dr. Mills did find three good men to help him: John McDade, M.D.; C.A. Loughridge, M.D.; and William Weaver, M.D. These four general practitioners all gave up their private practices and entered into a contract with Alexandria Hospital to establish a new, revolutionary type of practice that was unheard of in the 1960s.
They were each on duty for 5 straight days in a 450-square-foot basement ED with four stretchers, working 12-hour shifts that went from noon to midnight or the reverse. They then had 5 straight days without shifts, which was unheard of for a 1960s physician. By charging $5 per visit and collecting a hospital subsidy for indigent care, they were able to be as financially successful as they had been in their private practices. As Dr. McDade noted, the Alexandria emergency physicians had three main constituencies they wanted to “take care of – patients, the hospital, and the medical staff. We were going to give them all the same top-door service. That was the whole purpose when we went into it.”3
It was a fabulous success. All three constituencies came to embrace the new emergency practice – ED visits at Alexandria Hospital doubled in the next 5 years. The Alexandria Plan garnered a great deal of attention from the world of medicine, the public, the media, and physicians who wanted to replicate what the Alexandria team had done.
Within 5 years, Alexandria-type plans had sprung up across the country. By 1968, emergency physicians had organized to create the American College of Emergency Physicians with the Alexandria physicians playing a key role. Dr. Mills became the second ACEP President and a founding member of the American Board of Emergency Medicine. Dr. McDade was an early ACEP leader and a strong advocate and organizer for the development of emergency medical services (EMS).
On June 24, 2011, a diverse group commemorated the Alexandria Plan’s golden anniversary at the “new” Inova Alexandria Hospital. Representatives from the hospital, ACEP, Society for Academic Emergency Medicine, Association of Academic Chairs of Emergency Medicine, Council of Residency Directors in Emergency Medicine, American Board of Emergency Medicine, Emergency Medicine Residents’ Association, and Emergency Nurses Association organized and funded the event.
The program featured a historical review of the Alexandria Plan, and speeches and commentary from elected officials, emergency physician and nurse leaders, and the presentation of certificates from the state of Virginia and the city of Alexandria.
A video featuring Jane Pinkus, a nurse who worked in the ED with the Alexandria pioneers, and Vince Whitmore, a paramedic, provided first-hand accounts of what it was like to usher in a new model of emergency practice. Perhaps the most special moment was the introduction of C.A. (Babe) Loughridge, M.D., one of the founding four physicians, who was in attendance. Although he came in a wheelchair due to recent illness, Dr. Loughridge stood and acknowledged the applause with a broad smile.
A video of the entire ceremony is available online at www.acep.org.
Fifty years later, as we reflect on what the Alexandria Plan accomplished, we confront similar issues in a very different environment of care. Our charge now, in a challenging new era of health care reform, is to be as innovative, persevering, and visionary as the four physicians and their ED and EMS colleagues who created the Alexandria Plan.
- Zink, BJ. Anyone, anything, anytime – a history of emergency medicine. 2006, Mosby Elsevier; Philadelphia, pp. 30-32.
- Maisel, AQ. Emergency service: medicine’s newest specialty, Reader’s Digest 86(518):96-100, 1965.
- Zink, BJ. Anyone, anything, anytime – a history of emergency medicine. 2006, Mosby Elsevier; Philadelphia, pp. 35-36.
Dr. Zink is Professor and Chair of the Department of Emergency Medicine at The Alpert Medical School of Brown University.