House Divided

In the prophetic words of Abraham Lincoln in addressing the antebellum Nation, " A house divided against itself cannot stand. " As physicians, we too live in a house divided. We factionalize along lines of specialty, practice size, practice location, ethnicity, etc. As emergency physicians, we are among the most egregious in splintering the House of Medicine. We have subdivided our small young specialty and then wonder, while we bicker amongst ourselves, how sly attacks by trial attorneys, managed care corporations, and hospital associations are so effective in eroding reimbursement and diminishing access to care. When addressing the Nation, Lincoln prognosticated that when a crisis is finally reached, the " house " will cease to be divided. Is that crisis not upon us now? How many more emergency departments must close? How long must wait times grow? How many hospitals should an ambulance have to pass to find a hospital not on diversion? It is time to come together, not only within our own specialty, but within the larger House of Medicine. We must not isolate ourselves from our physician colleagues or we risk losing our message when the California Medical Association (CMA) or American Medical Association speaks to our elected officials. This risk was partially realized this October when the CMA convened its annual House of Delegates, the most important legislative and policy steering session of the year. Among the many contentious issues discussed was Proposition 86, the tobacco tax, a Band-aid solution aimed at helping fund emergency care in order to stem the flurry of emergency department closures. Although the CMA initially supported this proposition, the House of Delegates expressed concerns about legislative provision that theoretically might exempt hospitals from antitrust laws for pooling on-call physician resources in order to expand emergency services. These good-faith concerns about a theoretical unintended outcome overwhelmed the debate. The primary issues at hand for emergency physicians and patients – the imminent closure of emergency departments, increased ambulance diversions, longer wait times, and further erosion of surge capacity – were scarcely mentioned. Why were these issues not raised? Why did the CMA back down from its initial strong support, choosing instead to table the issue and not allow its name to be added to the " Support " column in the voter ballot? The answer is plain. The CMA expresses the will of the entire House of Medicine. As of November 2006, only …