UK Emergency Medicine's midlife crisis. St.Emlyn's. #RCEMCPD16 • St Emlyn's

UK Emergency medicine was arguably founded by a group of emergency physicians on the 12th October 1967 (this, amazingly, also happens to be Cliff Reid’s birthday). The first president was Maurice Ellis who envisaged a future for specialists in what was then known as Casualty departments. His impact was clearly huge and we are now approaching our 50th anniversary. We have a Royal Warrant and any suggestion that we are a ‘new’ or immature speciality must surely now be quashed.

I too am approaching my 50th birthday and it’s an interesting time. The speciality, like me, is approaching middle age and that presents its problems. Middle age can be a difficult time for many of us and so it’s perhaps interesting to think about how EM has evolved by decade since its inception.

The early days of the 60’s

Although we were founded in the 60’s we won’t remember much of those early years as a toddler. The world was busy flying to the moon, finding love, peace and having a rather excellent summer of love.

The children of the 70’s

The 70’s saw emergency medicine find its feet. A baby struggling initially to walk and survive as we established what we were trying to do, what we were trying to be, and in many ways learning from those around us, amalgamating skills, techniques, learning much. Assimilating what we could and moulding ourselves in the image of our teachers and colleagues.

The teenage years in the 80’s

The 80’s were our teenage years when, although still young, we were full of aspiration and ambition. A cohort of truly fantastic leaders in our speciality fought to establish themselves. There were risks but as teenagers they were prepared to take them and win and lose but to emerge unscathed into the 90’s and beyond.

The hip and cool 90’s

The 90’s, the first era that I can personally remember was cool. EM was still felt to be a young, innovative speciality. The consultants were younger, fitter, cooler and doing exciting things. I had a whole host of amazing people to look up to as role models. They were dynamic, risky, decisive and we want to be like them. At the same time pre-hospital care (which started way before really) started to become established and we saw an increasing amount of research and academic work, and the establishment of emergency physicians at the core of resuscitation and emergency education and delivery. Organisations that transformed emergency care such as the Advanced Life Support Group were founded and championed by emergency medicine and its friends. These were exciting times and I’m sure that many of my generation will remember this time as that which inspired us to be where we are today. Towards the end of the decade we had our children. Paediatric EM and Pre-Hospital EM developed and we were rightly proud of them. Some emergency physicians even went off to look after them full time.

Consolidating in the noughties and beyond

The noughties are our recent past. We are now established and no longer striving to prove our worth. Everyone knows we are essential components of the healthcare system. We do a great job and serve an amazingly important purpose. We’ve built amazing links with other organisations and established ourselves physically, geographically and intellectually as a speciality. A succession of amazing leaders have led us to the Royal Warrant and the ultimate external validation as the Royal College of Emergency Medicine. Our views are sought on a range of issues and it would be rash and unwise for any organisation to dictate emergency care without our involvement (they do still do it, I’m just saying it’s stupid when they do). Our children are growing up and striking out in their own way. They sometimes seem to want to break away, forming their own identities and getting into relationships with other specialities (notably general paediatrics and anaesthesia) and although that’s always tricky as a parent they are using that space to develop and grow well.

So what next?

As we approach our 5^th decade where are we now in our life cycle?

It may be that we are approaching a bit of mid life crisis. We’ve achieved so much and done such a great deal to get where we are and yet it might seem that we are in the midst of a difficult and challenging time.

In fact if we look at some data from the UK Office of National Statistics, we can see that at this age we are perhaps at our lowest ebb. People in their late 40’s and early 50’s are, in terms of happiness, at the nadir. They are less happy than 90 year-olds and more anxious than at any other age despite their trappings of comparative wealth and success.

It might be a little bit of stretch to compare our fabulous speciality with human experience, there are clearly differences, but stay with me here for a second. There are analogies.

The explanations for the ONS statistics are interesting, correlation does not equal causation but it has been mooted that these middle years are difficult owing to the number of life stressors, rather than any specific psychological or physical/hormonal cause. In middle age work is peaking, responsibility is high combined with the potential for future uncertainty and the requirements to manage up (ageing parents) and downwards (children). EM may be in a similar position. Current external pressures from service volume, reconfiguration and some insane political policies around junior and consultant employment contracts are making people feel uncertain and worried. It’s a stretch but perhaps we are in the midst of a mid-life event.

If we keep that analogy going then it begs the question as to what a mid-life crisis response might look like for our UK emergency physician?

What does an EM mid-life crisis look like?

Well they, could go off and have an affair. By this I mean they could be enticed away from their path by the allure of something that appears to be younger, more attractive, more fun; a way of reliving the heady youth and uncertainty that attracted us to the speciality. Alternatively, they may be forced out by unreasonable behaviour from the other party (take note Mr Hunt).

Yes – we could go to #AusCaNz where everything appears to be perfect and wonderful. Now, I’m not sure that this is a great analogy and it’s clear that, like many middle-aged (predominantly) men, the attraction to go and do something dramatic is there. I can see why it’s an attractive idea, but it’s also true that it damages what’s left behind and inevitably leaves some feeling betrayed (Ed – bit controversial that…..).

I don’t know whether the grass is really greener on the other side of the world. I can understand people who move jobs (abroad or locally) to achieve something new and interesting. However, it all rather depends on the motivation for change. In general those seeking to escape fundamental problems of unhappiness tend to take those feelings with them. In contrast a move to something that meets an unmet need tends to be successful (the move towards vs move away way of viewing decisions). Psychologically the towards usually works, simply escaping doesn’t.

We could acquire more stuff. Work harder. Take on extra jobs, earn more money, but all the data around happiness suggests that once you reach a certain point you don’t get happier. The amount varies because it varies depending on culture and circumstance but in the UK over £50k seems about right. As emergency physicians we all earn above the happiness threshold. Acquiring stuff is not going to make you happy. Getting an extra 20% of income won’t make you 20% happier.

The could acquire a nice car, or bike, or in the case of our pre-hospital colleagues a helicopter. It looks great and for a time will make them happy, but the simple acquisition of the objects and trophies whilst creating a brief thrill rarely lasts, that is unless you do something with it. As Cliff Reid said, you might look at the lovely Ferrari in the car park owned by the ENT surgeon. Owning it is not making them happy. However, breaking into it, hotwiring it and taking it through the car park at speed and pulling donuts will. Basically experience trumps acquisition every time.

The bottom line is that it’s tough at the moment and all too easy to forget what it is that we are trying to achieve and what must have been in the minds of those who set our speciality up in the 1960’s.

We will inevitably spend a significant part of our life in work. The nature of our speciality is that we will always need to nurture and develop the relationships, skills and abilities that allow us to do our job. It’s clearly important for us to be happy in our work if we are to be happy overall and thus we need to consider what we can do to allow us to do that.

So where do we go from here?

But there is good news. The ONS stats suggest that it gets better from here. As time passes the stresses and uncertainties reduce and our view of the world and psychological health improves. As a speciality we’ve already achieved so much, but there is more to do, more to achieve and I hope better times ahead for us individually and as an organisation.

Don’t worry, keep the faith and remember that this is a great job with great people. Times are tough for lots of people at this age, but it gets better. Let’s hope it gets better for our speciality in the same way that it seemingly does for the population.

Oh, and for those of you who went off on a crazy affair down under. It’s OK. We forgive you and when you’ve got it out of your system we’d love to have you back.

@EMManchester

NB: This is clearly a little tongue in cheek in preparation for a talk I’m giving at #RCEMCPD16. The real history of emergency medicine is far more complex and much more interesting. If you want to know more then please read the book by Henry Guly.