Reflections on a Graduation By Neal E. Flomenbaum, MD, Editor-in-Chief

Graduating from residency training is always a significant milestone. But some graduations are more significant than others. Last month, one such special graduation took place at New York Presbyterian Hospital in New York City.

The first graduation of our emergency medicine residency represented the culmination of many years of efforts to take advantage of opportunities created by the merger of two distinguished university hospitals—New York Cornell and Columbia Presbyterian. But most importantly, this particular emergency medicine residency can trace its origins to the events of September 11, 2001.

When I think of that day, of the 10 patients with 80% to 100% third-degree burns brought to our emergency department from the World Trade Center and of the hundreds of attending physicians, residents, and students who lined the corridors ready to care for anyone who might arrive, I can’t help thinking of the one group that was missing—emergency medicine residents. On that day, the resolve of our institution to start the emergency medicine program was solidified, and 12 months later the ACGME residency review committee provisionally approved the program. We started interviewing applicants, and the first 10 residents began their training a few months after that, in July 2003. Last month, four years later, they graduated.

For these new attending emergency physicians and others across the country, I would like to share some thoughts from this graduation.

Emergency medicine is about time and timing. The limited time we have to resuscitate a patient whose heart has stopped or the time we have to intervene after serious trauma. The timing that brings together the right people and the right resources to rapidly diagnose and effectively treat an acutely ill patient. We might prefer curing our patients immediately in our emergency departments, but we can also buy time for a patient to allow our colleagues from other specialties to deal with the problem in the operating room or intensive care unit.

Never place any consideration before patient care. Too often medical education is cited as one such consideration, specifically the practice of allowing junior residents or medical students to perform procedures in order to learn how to do them properly or to demonstrate their proficiency. There is a world of difference, however, between allowing this to be done at the appropriate time and place with an attending physician at the bedside and allowing it to be done when the attending is somewhere else.

Never pass up a tip from a jockey. Who knows the horse better? I learned this many years ago from my mentor during my internal medicine training, but it is just as applicable to the emergency department. According to Jerome Groopman, MD, author of “How Doctors Think,” the average physician allows a patient just 18 seconds to describe a medical complaint before interrupting with questions. Particularly in the case of patients who have chronic conditions, including acute or recurrent exacerbations of chronic conditions, isn’t it reasonable to expect them to know their illnesses better than we do? Let them talk.

Finally, I found my thoughts drifting to another graduation taking place about 50 miles north of ours, at the United States Military Academy at West Point, where virtually all the new graduates could expect to be heading for combat duty to help protect our way of life. Graduating emergency medicine residents in this post-9/11 era are also frontline responders to senseless, catastrophic aberrations that claim innocent lives. Every patient who is resuscitated and every life that is saved as a result of their training will become further proof that our basic values regarding the preservation of human life will continue to prevail in the end.

Emerg Med 39(7):6, 2007