Identity in emergency medicine: Who are we and what are we doing?

Identity and its relevance to the past, present and future of Emergency Medicine may not be the highest priority for emergency physicians balancing their clinical, administrative, and personal time while reading this article. However, pause to consider your sense of self-worth. Identity is who we are and what we do. It is the basis of our actions, expectations, and achievements. As emergency physician Clare Skinner confidently observes of herself … ‘Emergency Medicine is central to my identity’.1 Conversely, if the purpose of an emergency physician is difficult to define, and the definition of Emergency Medicine is elusive, do we lose our individual and collective identity? The contemporary philosopher Akeel Bilgrami provides a lens through which to view identity parameters by applying a traditional European dualist philosophy.2 Our subjective or internal identity is how we view ourselves as having desires, values, or beliefs that we endorse and try to achieve as individuals. The flip side of this coin, how others view us, is our objective or external identity. Bilgrami's approach extends to professional identity. For an emergency physician, their internal identity may include ethical values or firmly held beliefs such as autonomy, justice, and the unique primacy of the doctor–patient relationship. Their objective external identity may include being a FACEM, a diligent Consultant in the Emergency Department of a particular hospital, or a respected medical educator. This model also provides a form of psychological economy as strong identity achievement can be a great source of dignity, resilience and self-respect, as well as solidarity and belonging when shared with others who are the same or similar.2 These models are embedded in our culture as medical education at both undergraduate and postgraduate levels fosters the acquisition of professional identity in parallel with Millar's Pyramid of knowledge, performance, competence, and action.3 Professional identity was a simple equation for the first Australian Emergency Physicians. We were the newly recognised specialists who worked in the Emergency Department. We were there to save lives, set new standards, and fix a broken system.4 At the time, the emergency physician's primary relationship was with the patient as a scientifically driven reliever of suffering, therapist, diagnostician, resuscitator, and ethical advocate. The identity of emergency physicians was undeniable, and they achieved the respect of their patients, their peers, and, most importantly, themselves. By the time of my first junior Consultant appointment in 1995, patients who previously had their care delivered by junior doctors in facilities unfit for purpose were attended by doctors who had been trained as specialists to deliver appropriate, timely care and diagnostic services. Emergency physicians' relationship with patients became supported by facilities and technology specifically designed to deliver acute care. Triage systems were designed to prioritise care for individuals with the greatest risk and the most to gain. Systems of care developed that placed the individual patient as the central and primary focus of acute healthcare and became coordinated and streamlined with acute inpatient systems in Trauma, Cardiac Care, Interventional Radiology, Sepsis, and Stroke. As we entered the 21st Century, community expectation was also driving systems of care with broad application of safety and quality standards, clinical governance, and institutional risk management. These justice-driven utilitarian models aim to deliver the best care to the most people. Emergency physicians began to move into managing systems of care rather than individual patients, changing the focus of their primary relationship and the field of Emergency Medicine from individual patients to the community and institutions. For the emergency physician who has been educated to believe that their primary relationship is with the patient, justice-driven utilitarian system management can be conflictual and ethically difficult to negotiate because supply, demand, and resource availability create predictable operational limits within health systems. Although risks to patients can be limited by the use of evidence-based algorithmic decision-making applying safety standards, the hard fact remains that all health systems have predictable, inevitable, identifiable, and measurable morbidity and mortality risks. The emergency physician who once saved lives, set new standards, and fixed a broken system has now become the manager of a new system that can measure and quantify patient harm. The operational utility of Triage in creating queues in overcrowded emergency departments is a prime example, as prolonged delay will always carry a morbidity or mortality risk for some patients in every Triage category. Emergency physicians, who previously cared for patients in a traditional doctor–patient relationship, are now pivotal in delivering systems of acute healthcare that aim to deliver pathways to the best outcome, for the lowest cost, for the most number. The inevitable harm arising from these systems challenges the internal identity values of many of us. At the same time, our patients have high expectations. However, circumstances such as the increasing imbalance between demand and supply, socio-economic stress, and overcrowding in public health systems appear to mean that they have less influence and choice, so patients are in a situation of high expectations, with relatively little choice in a system that prioritises minimum standards and carries an inherent risk. This represents a further identity challenge for emergency physicians who value their relationship with individual patients. In settings where achievements fail to meet what we expect of ourselves and/or where there is a conflict between internal and external perceptions of identity, the psychological economy of identity can also work against the individual's dignity, resilience, and self-respect and undermine any sense of solidarity or belonging. Smith's recent editorial of Emergency Medicine Australia observes the ‘unsustainable position’ of emergency physicians who have been trained to manage undifferentiated patients but find themselves in departments gridlocked by overcrowding with the task of risk-managing system flow while screening queues of triaged unassessed patients for risks of deterioration.5 Viewed through the lens of the psychological economy of identity, this illustrates that our professional identity is undermined by the systems and institutions we have embraced. The effect on our colleagues in this ‘unsustainable position’ is a loss of dignity, self-respect, resilience, and belonging. So what of Emergency Medicine, as declared sick but treatable?5 As the speciality searches for inspiration from the NHS,6 swings between sub-specialisation and generalisation,7 considers narrow scopes and broader world views,8 and begins to accept that it is vital to both individual and health system decision-making,1 it would seem that Emergency Medicine is also in the nexus its own identity crisis. Both our present and future seems to be so much more than ‘a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury’ and ‘an understanding of the development of prehospital and in-hospital emergency medical systems and the skills necessary for this development’.9 Emergency physicians who have been trained to define their identity based on values that no longer seem to apply to the jobs they are being asked to perform are likely to have low self-worth and feel they don't belong. Emergency Medicine has developed such scope and relevance to the current and future health system that old definitions and boundaries no longer apply. The tragically amusing hyperbole that we don't know who we are and we don't know what we're doing is worthy of consideration. Defining our future individual and collective identity is surely the first step on the path back to self-respect, dignity, resilience, and belonging. None declared.