Foreword by Jeremy Samuel Faust, MD, MS, FACEP
Peter Rosen, MD, a giant in the field of emergency medicine, died on Nov. 11, 2019, in Tucson, Arizona, from complications of long-standing cardiac and renal disease. He was 84 years old. Dr. Rosen’s professional life and legacy were defined by a decades-long campaign to legitimize emergency medicine as a discipline, a field of study, and a vital academic specialty. In these efforts, he was largely successful. He was the author of hundreds of academic articles, he founded the Journal of Emergency Medicine, and he was the first emergency physician elected to the Institute of Medicine of the National Academy of Sciences. He founded two prestigious emergency medicine residency programs and taught at several others in a career that spanned six decades. The recipient of droves of awards and accolades as a medical educator, he will perhaps best be remembered as the founding editor of the first definitive textbook for the field of emergency medicine, Rosen’s Emergency Medicine: Concepts and Clinical Practice, known today simply as “Rosen’s.”
His landmark 1979 essay, “The Biology of Emergency Medicine,” largely defined the landscape of a field still in its infancy, laying out the dueling responsibilities of the well-trained emergency physician: the identification and treatment of life- and limb-threatening conditions on one hand, and the cognitive discipline of confidently reassuring and discharging the well on the other. He argued convincingly that the unique skills of the emergency physician could not be adequately performed by physicians from other specialties, who typically had expertise in only one particular facet of emergency medicine.
Dr. Rosen mentored hundreds of emergency physicians and had many more thousands of admirers. Equal parts intellectual and indelicate, he furnished his colleagues and disciples with a lifetime of memorable quotations, both amusing and poignant. His insights, quips, and bon mots are often repeated, passed down from one generation to the next, making him a kind of modern-day Osler.
I have asked Dr. Richard Wolfe to provide some personal recollections.
Dr. Faust is ACEP Now Medical Editor in Chief.
Peter Rosen died on the evening of Nov. 11, 2019, slipping off quietly, his wife and best friend, Ann, at his side, as she had been throughout their 60-year marriage.
Medically, his death came as no surprise. He had long suffered from coronary artery disease and ischemic cardiomyopathy. In the last year of his life, he was on dialysis, had become frail, and used a wheelchair to get around. But until the end, his mind remained brilliant, incisive, and iconoclastic. To all of us who knew him, his death still feels untimely.
Peter Rosen was larger than life, extraordinary in vision, language, and character. His work inspired, guided, and shaped our specialty through lectures and writing, and more directly as a mentor to countless students, residents, and practicing physicians who carry on his passion and vision for emergency medicine. His productivity—books, articles, editorials, lectures, and national leadership—defined the specialty of our field as we know it, and many justly consider him to have been the “father of emergency medicine.” His appointment as the first emergency physician to the Institute of Medicine of the National Academy of Sciences was an appropriate recognition of a life devoted to our specialty.
I knew Peter—as he always insisted on being called, never “Dr. Rosen” except with patients—my entire life. He was my uncle and became a father figure to me. Later, he was my mentor, as a student and during residency, and finally a colleague.
I am lucky to have visited Peter a week before his passing. Over steaks and Diet Cokes, we shared stories about the early days of emergency medicine. We worried over threats to our specialty: ED crowding and the commoditization of our physician colleagues by large corporate groups. He cared deeply for emergency medicine and felt that his mission was not over. At the time of his death, he had recently decided to record podcasts that would have covered the history of emergency medicine and also tried to help guide its future.
Peter Rosen was born to Jewish parents on Aug. 3, 1935, in Brooklyn, New York, where he was raised. He described tearing through the Italian neighborhoods on his bike, armed with a bicycle chain to fight off kids in from other neighborhoods, and lying on the subway tracks while the trains rolled over as a dare with his friends. Perhaps fittingly, he was a devoted fan of the Brooklyn Dodgers. He was particularly fond of Nathan’s hot dogs in Coney Island and steaks at Peter Luger’s.
Peter obtained his B.A. at the age of 20 at the University of Chicago. He was accepted into medical school—on his second attempt, he always pointed out with his usual modesty—at Washington University in St. Louis. After graduating in 1960, he returned to Chicago for an internship in surgery. He completed surgical training at Highland County Hospital in Oakland, California, perhaps the youngest surgeon in the country to graduate that year.
The Vietnam War was raging, and he was drafted into the Army. But as an attending surgeon with the U.S. forces in Germany, he was not enamored by Army rules or its hierarchy. “Captain Rosen’s” sense of humor and rebellious nature were frequently at odds with military expectations. One evening in particular, in annoyance over some banality, he picked up a “hot mic” and announced to the entire base, “Now hear this! The Army sucks. That is all.” As a result of this, he was relegated to a small first-aid station where his “punishment” was to play tennis and chess, thereby reinforcing a life-long strategy of breaking rules he deemed wrong.
After an honorable discharge, he, his wife, and three sons moved to Thermopolis, Wyoming, where he joined a surgical practice (a fourth son was later born there). From 1968 to 1971, he was the only board-certified surgeon in the state. The demand for his skills, combined with his exceptional work ethic, resulted in exceedingly long hours, often causing him to forgo adequate sleep. He would drive back and forth over hundreds of miles from town to town, surgery to surgery.
On the road one night, he developed substernal chest pain. At 35 years old, he was having a myocardial infarction from coronary artery spasm that would end his career as a surgeon and help launch a new academic specialty.
A Career Shift
He later told me that he survived stunningly poor care in a local emergency department. At the time, care was provided in emergency rooms staffed by physicians without formal training. Emergency care was viewed by hospitals as a necessary evil, assigned in academic centers to the most junior house staff, usually without supervision.
Peter’s experience with the death of his father from poor emergency treatment and his own as a patient helped form his vision and conviction that patients in their most vulnerable stage of disease need the most-, not the least-, trained doctors.
After his recovery, he was told to cease surgical practice and find a less stressful occupation. He considered basic science, but the dean at the University of Chicago instead found him a restful, nonstressful position as the director of the division of emergency medicine. When he took the job, he imagined he would simply continue to practice as a surgeon and that emergency medicine would be an administrative duty. However, the responsibilities to his patients and his department soon led to adversarial relations with other specialties, including the chair of surgery, to whom he reported.
Peter perceived that there was a different way to think when managing emergency patients and a different set of responsibilities. As few others had at that time, he saw the need for a new specialty and began to advocate for it. Despite years neglecting emergency patients writ large, physicians from other disciplines who frequently staffed emergency rooms were suddenly threatened by the loss of turf and income that the shift of emergency care to these new-fangled “emergency physicians” seemed to represent.
Peter was joining a movement still in its early stages. He served as a member of the American Board of Emergency Medicine’s original Board of Directors (from 1976 to 1986), which created the certification process in place today. Only a few years earlier, James Mills had written about one of the first EM practices, the “Alexandria Plan.” Community practitioners were just beginning to identify as emergency physicians. The nation’s first EM residency had recently been inaugurated in Cincinnati.
What was lacking, however, was a vision of emergency medicine as an academic specialty with a core fund of knowledge, a biology, and an organizational structure like the traditional specialties had.
Peter Rosen had become a visionary advocate for the specialty of emergency medicine at the perfect time.
Transforming Emergency Care
From his position, he began his lifelong mission of transforming emergency care in this country. He started a residency in Chicago and then another one in Denver, when he moved there in 1977 to become director of the department at what was then Denver General Hospital (today Denver Health Medical Center).
Sensing the need for a formalized curriculum, he spearheaded the first textbook written by and for emergency physicians, Rosen’s Emergency Medicine: Concepts and Clinical Practice. At the helm of this large undertaking, Peter in essence defined the parameters and the body of knowledge of our specialty. The book is now in its ninth edition, and the 10th is well under way.
After Denver, he built the residency in San Diego and guided the development of the academic departments at the Harvard-affiliated hospitals. He also served as faculty at the University of Arizona in Tucson, completing his career as the senior mentor for three vibrant academic departments.
In 1979, he wrote an influential paper published in the Journal of the American College of Emergency Physicians (today known as the Annals of Emergency Medicine) outlining “the biology” of emergency medicine and defining ownership of an area of basic science that would define emergency medicine. He founded the Journal of Emergency Medicine to further enrich and support academic work in the new specialty.
Despite his academic and educational achievements, however, Peter’s first loyalty was always to the patient.
Peter was also interested in some of the legal implications of practicing emergency medicine and believed that our legal tort system had, in part, triggered the creation of our specialty by compelling hospitals to staff emergency departments with trained providers. In 1990, he wrote about the importance of being a plaintiff expert witness, saying that “physicians who work as an expert for just the defense may appear to a jury to be less objective than physicians who are willing to testify that another physician was negligent.” He believed that impartial experts evaluating cases for plaintiffs’ attorneys would invisibly stop many lawsuits before they were ever filed. But he also felt that validating legitimate claims by injured patients was important as well. “The last guarantee of fairness in the system is to have available the testimony of honest physicians,” he said. “In the long run, this will prove the strongest defense against nonobjective partisan testimony proffered only to further the financial gain of the dishonest expert.” In pursuit of this, he testified for patients and physicians for 40 years and earned a reputation of uncompromising honesty. However, Peter’s testimony against another physician in a case several years ago was criticized, turning his long-held beliefs into a surprisingly public issue. While he was officially censured by ACEP, Peter always maintained that his testimony had been medically justified and that he was simply acting upon the beliefs that he had voiced and practiced for years.
Peter is now gone. And yet he will live on in each of us—those who knew him and those who did not—for as long as emergency physicians value our responsibilities as specialists and fight to protect them and our patients.
Peter would ask and expect us to care and protect our vulnerable patients, to expand and transfer our knowledge to the next generation of specialists, and to demand excellence in all of these endeavors. And he would do so with the same rigor, affection, and humor for which he was so widely admired during his long and productive life. This is how we will honor the prodigious legacy of Peter Rosen, MD, 1935–2019.
Dr. Wolfe is chief of emergency medicine at Beth Israel Deaconess Medical Center in Boston.