KK: When they can’t figure us out, we have two ways to look at it. It does provide great opportunity for us to shape their understanding and create, perhaps, a larger scope for emergency medicine. But if they don’t understand EM, they might also interpret this in another direction, as many have already done: that the emergency department is an expensive place to receive care and people shouldn’t go there, clearly a preposterous assumption about our specialty.

EG: But one of the biggest challenges we have, Kevin, is the old pit-doctor mentality from 20 years ago that I do not want to understand how these changes may impact my practice and my livelihood, that I’m going to work my shift, I’m going to go home, I’m going to take care of my family, I’m going to educate my kids and whatever, and I’m not going to get involved. The biggest threat is that’s a doctor who thinks all of this stuff is a lot of white noise and somebody else is going to do it for him or her. We all can make a difference, and we should consider how we all stand on the shoulders of the giants of emergency medicine who carved this specialty out of solid rock—they all stepped up time and time again, and we all need to follow their leadership and example.

KK: We’re going to do it collectively and collaboratively, but we all have to be involved; at the least, we have to be informed. Do you remember that book from several years ago, Who Moved My Cheese? Well, they’re moving our cheese. We have to evolve and move with it. If we don’t change the way we think and the way we practice, this specialty will be at real risk. I have a question for each of you, based on a comment that Ed made about utilization. How many tests does it take to diagnose a hip fracture? Most emergency physicians when they initially respond will say one: a hip X-ray. How does that look to CMS and third-party payers? How many tests and how many dollars does it take to diagnose a hip fracture? Well, it’s the cost of a hip X-ray, an IV, a PT, PPT, an INR, a CBC, a BMP, type and screen, a urinalysis, maybe a Foley catheter, a chest X-ray, an ECG, and anything else the admitting physician may want for medical clearance. It appears when they take care of a hip fracture payment mainly from medical clearance, the cardiologist and anesthesiologist spend no money except for their consultation. They are so efficient. But for the emergency physician, it takes a whole lot more to diagnose a hip fracture when you look at all the tests we order.