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The Future of Emergency Medicine Jonathon M. Sullivan MD, PhD Wayne State University Detroit Receiving Hospital.

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2 The Future of Emergency Medicine Jonathon M. Sullivan MD, PhD Wayne State University Detroit Receiving Hospital

3 Purpose of this Lecture Put away your pencils, class Put away your pencils, class This wont be on the test This wont be on the test Raina Burke wouldnt stop bugging me Raina Burke wouldnt stop bugging me Sullydog just wants to have fun Sullydog just wants to have fun Some of us might actually learn something Some of us might actually learn something

4 Outline Science fiction vs. futurism Science fiction vs. futurism How futurism (doesnt) work How futurism (doesnt) work Identifying trends: Identifying trends: Technological trends Technological trends Sociological and demographic trends Sociological and demographic trends Economic and political trends Economic and political trends Global trends (megatrends) Global trends (megatrends) Summary (how I failed to predict the future) Summary (how I failed to predict the future)

5 Science Fiction vs. Futurism

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8 The difference between fiction and reality? Fiction has to make sense. The difference between fiction and reality? Fiction has to make sense. –Stephen King

9 Futurism Historical antecedents Historical antecedents 19 th century Comte's discussion of the metapatterns of social change 19 th century Comte's discussion of the metapatterns of social change Early 20 th century systems science in academia, Early 20 th century systems science in academia, National economic and political planning: National economic and political planning: France France Soviet Union and Eastern bloc countries. Soviet Union and Eastern bloc countries. Emerged as an academic discipline after WWII Emerged as an academic discipline after WWII

10 Futurism Two broad approaches: Two broad approaches: American: Quaterly Report/Bottom Line mentality American: Quaterly Report/Bottom Line mentality applied projects applied projects quantitative tools quantitative tools systems analysis systems analysis analysis of complex, large scale systems and the interactions within those systems. analysis of complex, large scale systems and the interactions within those systems. Identification of units, processes and structures game theory analysis and modelingsignficant $$$ apps Identification of units, processes and structures game theory analysis and modelingsignficant $$$ apps European: What about our Great-Grandkids? mentality European: What about our Great-Grandkids? mentality more speculative and interested in long-term future of humanity, planetary systems, etc more speculative and interested in long-term future of humanity, planetary systems, etc Increasing crossover Increasing crossover

11 Futurism

12 Futurism An increasingly dismal science An increasingly dismal science Wild cards (Asimovs Mule) Wild cards (Asimovs Mule) Butterfly effects (chaos theory) Butterfly effects (chaos theory) Uncooperative markets Uncooperative markets Uncooperative societies and electorates Uncooperative societies and electorates Self-organizing systems Self-organizing systems Singularities – point at which f(x) = ; also describes historical or technological discontinuities: Singularities – point at which f(x) = ; also describes historical or technological discontinuities: Advent of agriculture Advent of agriculture Printing press Printing press Internet Internet War, Famine, Plague, Bush War, Famine, Plague, Bush The odd asteroid The odd asteroid

13 Futurism Anticipatory thinking (futures) Anticipatory thinking (futures) Causal layered analysis (CLA) Causal layered analysis (CLA) Environmental scanning Environmental scanning Scenario method Scenario method Delphi method Delphi method Future history Future history Monitoring Monitoring Backcasting (eco-history) Backcasting (eco-history) Back-view mirror analysis Back-view mirror analysis Cross-impact analysis Cross-impact analysis Futures workshops Futures workshops Failure mode and effects analysis Failure mode and effects analysis Futures biographies Futures biographies Futures wheel Futures wheel Relevance tree Relevance tree Simulation and modelling Simulation and modelling Social network analysis Social network analysis Systems engineering Systems engineering Thinklets Thinklets Visioning Visioning Trend analysis Trend analysis Morphological analysis Morphological analysis Technology forecasting Technology forecasting If you cant dazzle em with prophecy….

14 Futurism The Delphi Method The Delphi Method An explicit approach developed by the Rand corporation for Defense/Strategic planning An explicit approach developed by the Rand corporation for Defense/Strategic planning Utilizes panels or pools of experts Utilizes panels or pools of experts Highly rigid methodology and information flow Highly rigid methodology and information flow Lousy track record Lousy track record

15 Identify opposing trends and extrapolate Extreme Scenario 1 Extreme Scenario Extreme Scenario x Extreme Scenario 1 Extreme Scenario x p p t, p p p

16 And Voila! A Stunningly Accurate Prediction Emerges!

17 Id like to thank the Nobel Academy… You want fries wit dat? My Wife The Match Identify opposing trends and extrapolate p p t, p p p

18 Trend ?

19 Enough CYA, Dog Step One In This Fools Errand: Step One In This Fools Errand: Identify Trends: Identify Trends: Technological trends Technological trends Sociological and demographic trends Sociological and demographic trends Economic and political trends Economic and political trends Global trends (megatrends) Global trends (megatrends)

20 Technological Trends Information Technologies Information Technologies Artificial Life, Genetic Algorithms, Cellular Automata Artificial Life, Genetic Algorithms, Cellular Automata Molecular biology, proteomics, computational protein folding Molecular biology, proteomics, computational protein folding Artificial organs Artificial organs Medical imaging Medical imaging Materials science and nanotechnology Materials science and nanotechnology Drug delivery technologies for deep organ and organ- spec txs Drug delivery technologies for deep organ and organ- spec txs Point-of-care testing Point-of-care testing Resuscitative adjunts Resuscitative adjunts

21 Technological Trends: IT More than just data storage and collection More than just data storage and collection Increasing penetration into EM is manifest Increasing penetration into EM is manifest Pros: efficiency, safety, info availability Pros: efficiency, safety, info availability Cons: info overload, privacy concerns, infrastructure vulnerability Cons: info overload, privacy concerns, infrastructure vulnerability Important sub-trends: Important sub-trends: Decreasing processor size Decreasing processor size Moores law Moores law Wireless networks Wireless networks HIPAA considerations, security issues HIPAA considerations, security issues Neural networks, diagnostic algorithms Neural networks, diagnostic algorithms

22 Technological Trends: IT Question: does more information = better care? Question: does more information = better care? Available evidence casts grave doubt on such a presumption Available evidence casts grave doubt on such a presumption Swan-Ganz Catheters Swan-Ganz Catheters Question: does increased information increase the resolution of the retrospectoscope? Question: does increased information increase the resolution of the retrospectoscope?

23 Tech Trends: IT Information vs. Exformation As disorder in a system increases: As disorder in a system increases: The entropy of the system The entropy of the system increases increases the amount of information encoded in the system the amount of information encoded in the system increases increases

24 Tech Trends: IT Information vs. Exformation Work Information Entropy Work Value Added

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26 Tech Trends: IT Accelerating Acceleration Kurzweil: Kurzweil: Human technological progress tends to accelerate over the course of history Human technological progress tends to accelerate over the course of history IT accelerates the rate of acceleration of technological progress IT accelerates the rate of acceleration of technological progress Have we passed the singularity? Have we passed the singularity? 20 years ago, could we have predicted: 20 years ago, could we have predicted: Internet porn, PDAs, MyYahoo!, the Y2K scare, CIS, genetic algorithms? Internet porn, PDAs, MyYahoo!, the Y2K scare, CIS, genetic algorithms? 10 or so years ago we actually DID predict: 10 or so years ago we actually DID predict: The Internet would make everything perfect forever The Internet would make everything perfect forever , dial-ups and Yahoo! would free China and N. Korea , dial-ups and Yahoo! would free China and N. Korea Less paperwork for everybody! Yipee! Less paperwork for everybody! Yipee! A sudden return to neolithic civilization at midnight, A sudden return to neolithic civilization at midnight, (Cruz told me he was dissappointed when it didnt happen) (Cruz told me he was dissappointed when it didnt happen) A better informed public and more honest politicians A better informed public and more honest politicians The Internet was going to change EVERYTHING! The Internet was going to change EVERYTHING! Network evolution: emergent and unpredictable Network evolution: emergent and unpredictable

27 Trends: IT Oppos. Trend Overwhelming (Info Overload), low E/I Decreased Efficiency Used to enforce rigid protocols Spawns non-pt-care busywork Cart > Horse Privacy at Risk Pulls physician FROM bedside Promotes balkanized healthcare I am Dr. Borg. Your files will deleted within 29 minutes. I may contain malicious programs. If you wish to continue, hit pay. Streamlined information, hi E/I Maximizes efficiency Promotes innovation and flexibiity Minimizes non-pt-care responsibilities Transparent IT Maximizes privacy Pulls physician TO the bedside Integrates healthcare systems Hmm…650 delinquent charts, an expiring license and a transfer from Providence. There. All done. Back to patient care!

28 Trends: Bioimaging Ultrasound Ultrasound More compact: every doc with a unit More compact: every doc with a unit enhanced resolution enhanced resolution contrast materials contrast materials expanded utilization by EPs expanded utilization by EPs Continued evolution of computed tomography Continued evolution of computed tomography MRI MRI Magnetic resonance spectroscopymore info about chemical and physical properties of a region than MRI Magnetic resonance spectroscopymore info about chemical and physical properties of a region than MRI Multinuclear imagingtweak nuclei other than H Multinuclear imagingtweak nuclei other than H Internal imaging Internal imaging

29 Tech Trends: Bioimaging The M2A capsule endoscope The M2A capsule endoscope miniature video camera, light source, batteries and a radio transmitter. miniature video camera, light source, batteries and a radio transmitter. Video images transmitted by radio telemetry Video images transmitted by radio telemetry 50,000 images / seven-hour procedure. 50,000 images / seven-hour procedure. Data recorder: walkman-like device worn by the patient Data recorder: walkman-like device worn by the patient Computer workstation imaging software Computer workstation imaging software

30 Tech Trends Neural networks and pattern recognition Neural networks and pattern recognition Currently used to look for Osama bin Laden at the JFK airport Currently used to look for Osama bin Laden at the JFK airport Systems require mimimum processing power to learn complex patterns Systems require mimimum processing power to learn complex patterns Never miss a pneumonia on CXR again Never miss a pneumonia on CXR again

31 Tech Trends: TMS Uses electromagnetic induction to set up currents in neuronal populations Uses electromagnetic induction to set up currents in neuronal populations Already being used in neuropsychiatry and brain research Already being used in neuropsychiatry and brain research This one could be a singularity This one could be a singularity

32 Tech Trends: Point-of-Care Testing

33 We got blind diabetics out there taking their own blood sugar, but JCAHO says Im not certified to do it. - Rick Bukata

34 Tech Trends: Biomolecular Medicine Comprises several fields: Comprises several fields: Genomics, proteomics, computational protein folding, molecular genetics, molecular immunology, computational protein folding, etc. Genomics, proteomics, computational protein folding, molecular genetics, molecular immunology, computational protein folding, etc. Short-term effects on EM probably moderate, compared to disciplines like oncology, hematology and rheumatology Short-term effects on EM probably moderate, compared to disciplines like oncology, hematology and rheumatology Long term effects are critical: Long term effects are critical: Molecular adjuncts to resuscitation Molecular adjuncts to resuscitation Molecular/genetic diagnostics Molecular/genetic diagnostics Rapid protein repair Rapid protein repair Early prevention of cell-death triggers Early prevention of cell-death triggers

35 Tech Trends: Drug Delivery Organ/tissue-specific delivery systems Organ/tissue-specific delivery systems Ability to deliver engineered or recombinant proteins to tissues will be key Ability to deliver engineered or recombinant proteins to tissues will be key Targeted tissue delivery will be a major step forward Targeted tissue delivery will be a major step forward innovations in interventional radiology innovations in interventional radiology Computational protein folding Computational protein folding recombinant proteins, eg, active group + targeting domain recombinant proteins, eg, active group + targeting domain engineered virions engineered virions nanotechnology nanotechnology engineered microorganisms engineered microorganisms antisense RNA technologies antisense RNA technologies micelles, microspheres micelles, microspheres

36 Tech Trends: Materials Science New materials technologies will have implications for all areas of medicine: New materials technologies will have implications for all areas of medicine: Prosthetic limbs, organs and joints Prosthetic limbs, organs and joints Drug development and delivery systems Drug development and delivery systems Medical imaging Medical imaging Emerging technologies: Emerging technologies: Superconducting materials, esp ceramics Superconducting materials, esp ceramics Composites Composites Self-assembling layers/vapor deposition Self-assembling layers/vapor deposition Nanolithography and nanomatrices Nanolithography and nanomatrices

37 Who is this Man? Dr. K. Eric Drexler

38 Tech Trends: Nanotechnology Youre going to feel a little prick now… Note: This is NOT a nanomachine! Note: You should NEVER say this to a patient.

39 Tech Trends: Nanotechnology Engineering at the molecular and atomic level Engineering at the molecular and atomic level Progress is explosive: Progress is explosive: nanomaterials: nanotubes, buckyballs, nanocomposites nanomaterials: nanotubes, buckyballs, nanocomposites elementary nanocircuits elementary nanocircuits nanophotonics and nanolasers nanophotonics and nanolasers nanolithography nanolithography Preliminary work with ATPase-driven nanomotors hacked out of natural casettes Preliminary work with ATPase-driven nanomotors hacked out of natural casettes Holy grails: kinematic replicators, rod logic, molecular-level quantum processors Holy grails: kinematic replicators, rod logic, molecular-level quantum processors

40 Tech Trends: Nanotechnology Nanogears operating at room temp. Han and Globus, et al, NASA.

41 Tech Trends: Nanotechnology Carbon nanotube deposits carbon on a diamond matrix.

42 Tech Trends: Nanotechnology Carbon Nanotube Microarray for Chip Cooling (JPL)

43 Tech Trends: Nanotechnology

44 An example of an artificial microstructure created with carbon nanotube nanolithography

45 Tech Trends: Materials Science and Nanotechnology National Nanotechnology Initiative National Nanotechnology Initiative Instituted during the Clinton Admin Instituted during the Clinton Admin Bush increased funding to $3.63 B Bush increased funding to $3.63 B Incorporates dozens of Federal agencies, including HHS and NIH Incorporates dozens of Federal agencies, including HHS and NIH Already moving rapidly into the commercial sector Already moving rapidly into the commercial sector hydrogen sensors hydrogen sensors chip manufacture chip manufacture manufacture of night vision and solar-power technologies manufacture of night vision and solar-power technologies textiles textiles

46 Tech Trends: Nanotechnology

47 Implications for Emergency Medicine: Implications for Emergency Medicine: Drug delivery Drug delivery Antibiotics, antivirals Antibiotics, antivirals tissue stabilization and repair tissue stabilization and repair Diagnostics and imaging Diagnostics and imaging Microtelemetry Microtelemetry Thrombolysis Thrombolysis cell surgery cell surgery gene excision and repair gene excision and repair Artificial tissues and organs Artificial tissues and organs

48 Tech Trends: Nanotechnology Challenges: Challenges: New technologies always mandate new skill sets New technologies always mandate new skill sets Some nanotechnologies will be biohazards; handling and regulation Some nanotechnologies will be biohazards; handling and regulation adverse reactions to nanomachines adverse reactions to nanomachines potential for abuse: neo-protists, microexplosives, Gray Goo scenario potential for abuse: neo-protists, microexplosives, Gray Goo scenario

49 Tech Trends: Artificial Organs Continued progress with mechanical organs and tissues, especially pumps (hearts), tubes (vascular, ducts), joints, bone and muscle. Continued progress with mechanical organs and tissues, especially pumps (hearts), tubes (vascular, ducts), joints, bone and muscle. New materials and processes New materials and processes A new generation of artificial tissues and organs, representing a confluence of several technologies A new generation of artificial tissues and organs, representing a confluence of several technologies

50 Tech Trends: Artificial Organs Biodegradable Tissue Scaffold (see nanolithography) Inoculate with tissue-specific cultured cells or stem cells Ya got ya kidney, there. Here Be Dragons

51 Tech Trends: Resuscitative Adjuncts Synthetic oxygen carriers Synthetic oxygen carriers Hypothermia Hypothermia Reperfusion cocktails Reperfusion cocktails Cardiac, cerebral, renal, spinal cord, muscle Cardiac, cerebral, renal, spinal cord, muscle caspase and calpain inhibitors caspase and calpain inhibitors insulin, growth factors insulin, growth factors mitochondrial stabilizers mitochondrial stabilizers free radical scavengers free radical scavengers thrombolytics post-arrest? thrombolytics post-arrest? Refinement of the EGDT approach Refinement of the EGDT approach

52 Tech Trends: AL, GAs, CAs Hows this for sci-fi…. Hows this for sci-fi…. You will use artificial life forms to plan for staffing and maximize ED patient flowthrough. You will use artificial life forms to plan for staffing and maximize ED patient flowthrough.

53 Tech Trends: AL, GAs, CAs Genetic Algorithms Genetic Algorithms a form of Artificial Life that uses principles of natural selection and fitness to evolve solutions to complex problems a form of Artificial Life that uses principles of natural selection and fitness to evolve solutions to complex problems Already being used to optimize just in time shipping strategies, flight plans, traffic volumes, etc. Already being used to optimize just in time shipping strategies, flight plans, traffic volumes, etc.

54 Social and Demographic Trends Your patients getting older: Your patients getting older:

55 Social and Demographic Trends Your patients getting older: Your patients getting older:

56 Social and Demographic Trends Your patients getting more complex: Your patients getting more complex:

57 Social and Demographic Trends Your patient is smarter (maybe) Your patient is smarter (maybe) Patients have more access to medical information Patients have more access to medical information Less trusting of doctors Less trusting of doctors More likely to ask questions More likely to ask questions We treat them like customers, they act like customers We treat them like customers, they act like customers

58 Social and Demographic Trends Your patient speaks Urdu. Hows your Urdu? Your patient speaks Urdu. Hows your Urdu? Actually, he/she probably speaks Actually, he/she probably speaks Spanish Spanish Chinese Chinese French French German German Tagalog Tagalog Vietnamese Vietnamese Italian Italian Korean Korean Russian Russian Polish Polish Notwithstanding all the rhetoric, America will become increasingly polyglot in the next century. Notwithstanding all the rhetoric, America will become increasingly polyglot in the next century. More important is the issue of cultural diversity. More important is the issue of cultural diversity.

59 Social and Demographic Trends Your Patient Does Tai Chi and smokes Tigoba Root Your Patient Does Tai Chi and smokes Tigoba Root New Age Freaks from Royal Oak will rock your world New Age Freaks from Royal Oak will rock your world Use of alternative medicine is increasing: Use of alternative medicine is increasing: in 2002, 36% of Americans had used some form of alternative therapy in the past 12 months (NIH data) in 2002, 36% of Americans had used some form of alternative therapy in the past 12 months (NIH data) Many issues of safety, efficacy and regulation remain unresolved Many issues of safety, efficacy and regulation remain unresolved Increased immigration affects this trend Increased immigration affects this trend

60 Apocalypse is boring. -Bruce Sterling

61 Economic and Business Trends: Apocalypse Now 114 million ED visits annually 114 million ED visits annually more than 1 for every 3 people in the United States more than 1 for every 3 people in the United States 16 million per ambulance. 16 million per ambulance. EDs have become preferred setting for many patients EDs have become preferred setting for many patients Seen as an djunct to community physicians ("go to the ED for some labs") Seen as an djunct to community physicians ("go to the ED for some labs") (recent growth in ED use driven by patients with private healthinsurance) (recent growth in ED use driven by patients with private healthinsurance)

62 Economic and Business Trends: Apocalypse Now Between 1993 and 2003: Between 1993 and 2003: population grew 12 percent population grew 12 percent hospital admissions increased 13 percent hospital admissions increased 13 percent ED visits rose 26 percent ED visits rose 26 percent During the SAME PERIOD: During the SAME PERIOD: United States lost 703 hospitals United States lost 703 hospitals 198,000 hospital beds 198,000 hospital beds 425 hospital Eds 425 hospital Eds "mainly in response to cost-cutting measures and lower reimbursements by managed care, Medicare, and other payors. (Institute of Medicine) "mainly in response to cost-cutting measures and lower reimbursements by managed care, Medicare, and other payors. (Institute of Medicine)

63 Economic and BusinessTrends Apocalypse Now

64 Economic and Business Trends: Apocalypse Now EDs are the principal sources of care for 45 million uninsured Americans. EDs are the principal sources of care for 45 million uninsured Americans. Hospitals have little financial incentive to prevent ED overcrowding. Hospitals have little financial incentive to prevent ED overcrowding. "The ED often serves as primary care provider, a role for which it is not optimally designed. "The ED often serves as primary care provider, a role for which it is not optimally designed. Increasing unavailability/reluctance of consultants Increasing unavailability/reluctance of consultants

65 Economic and Business Trends: Apocalypse Now Overloaded EDs Overloaded EDs Waits of hours or days for inpatient beds. Waits of hours or days for inpatient beds. Ambulance diversion daily problem in many cities. Ambulance diversion daily problem in many cities. EMS fragmented and disorganized EMS fragmented and disorganized 45 million uninsured Americans. 45 million uninsured Americans. System is ill prepared to handle large-scale emergencies System is ill prepared to handle large-scale emergencies natural disaster (more common) natural disaster (more common) Influenza pandemic (more likely) Influenza pandemic (more likely) Acts of terrorism (imminent) Acts of terrorism (imminent)

66 Economic and Business Trends

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72 Overall United States health care performance ranked 37th (WHO) Overall United States health care performance ranked 37th (WHO) Far below the average of developed nations. Far below the average of developed nations. Health care level ranked 72nd in the world by WHO Health care level ranked 72nd in the world by WHO worse than China worse than China comparable to Iraq. comparable to Iraq. Euro Itchy and Scratchy: Euro Itchy and Scratchy: Have far fewer uninsured Have far fewer uninsured Get more bang for their health care buck Get more bang for their health care buck Have comparable waiting times and rationing Have comparable waiting times and rationing Achieve comparable patient satisfaction Achieve comparable patient satisfaction Take it up the butthole on taxes, but dont seem to mind Take it up the butthole on taxes, but dont seem to mind

73 Universal Coverage: the Worst Possible System Would require new taxes and at least some increase in Federal bureaucracy Would require new taxes and at least some increase in Federal bureaucracy People who hate it: People who hate it: Doctors Doctors HMOs, insurance cos HMOs, insurance cos Big Pharma Big Pharma Conservatives Conservatives in power in power Libertarians Libertarians Trial Lawyers Trial Lawyers The public The public Current trends in American healthcare are unsustainable Current trends in American healthcare are unsustainable Other systems have huge problems, but still work better than ours Other systems have huge problems, but still work better than ours People who want it: People who want it: Doctors Progressives & Libs Hate America Employers The public Oppos. Trend

74 EM takes up more slack for a sick healthcare system More uninsured Few social support systems Lack of regionalization and nationalization Highest bidder technologies crafted to make money, not sense EM becomes MORE DIVERSIFIED and LESS FOCUSED Im doing a fellowship in Emergency Podiatric Acupunture! EM loses its academic momentum Increasing loss of hospitals and academic centers makes EM a red- headed stepchild EM seen as an economic drain on govts, med schools and hospitals EM not well integrated in local and national disaster/antiterro planning EM integrated into a comprehensive national healthcare strategy EM integrated into a comprehensive national healthcare strategy Innovated technologies selected and deployed to maximze patient care and departmental readiness Innovated technologies selected and deployed to maximze patient care and departmental readiness EM becomes MORE FOCUSED and LESS DIVERSIFIED EM becomes MORE FOCUSED and LESS DIVERSIFIED Its called EMERGENCY MEDICINE EMs academic momentum continues EMs academic momentum continues More academic chairs More NIH funding More translational research New areas of investigation Stabilization of hospitals and medical centers stabilizes the standing of Eds Stabilization of hospitals and medical centers stabilizes the standing of Eds EM seen as crucial to the success of local, regional and national health care systems, both operationally and financially EM seen as crucial to the success of local, regional and national health care systems, both operationally and financially EM a keystone element in disaster planning EM a keystone element in disaster planning Oppos. Trend

75 What are your predictions, Sullydog? You havent been listening.

76 Okay, fine. Predictions the next y Predictions the next y Technological innovation will proceed apace Technological innovation will proceed apace significant deployment of nanotech, TMS, AI, neural nets, etc. significant deployment of nanotech, TMS, AI, neural nets, etc. Biotech from Singapore Biotech from Singapore Emergency Medicine will continue its current academic trajectory Emergency Medicine will continue its current academic trajectory Resuscitology, heart failure, stroke, sepsis Resuscitology, heart failure, stroke, sepsis Systems analysis, GAs, IT Systems analysis, GAs, IT Physician wellness Physician wellness Creation of new National Institute for acute/emergency/trauma medicine (as recommended by IOM) Creation of new National Institute for acute/emergency/trauma medicine (as recommended by IOM)

77 Okay, fine Predictions for next y Predictions for next y IT will streamline our workflow and help put us at the bedside IT will streamline our workflow and help put us at the bedside Increasing deployment of neural nets and AI- like systems to improve diagnosis and tx and reduce errors Increasing deployment of neural nets and AI- like systems to improve diagnosis and tx and reduce errors Continued refinement and evolution of CQI Continued refinement and evolution of CQI Appearance of more explicit multidisciplinary team approach to EM Appearance of more explicit multidisciplinary team approach to EM

78 Okay, fine Predictions Predictions EDs will continue to pick up the slack while America gets her s**t together EDs will continue to pick up the slack while America gets her s**t together EPs and EDs will continue to do more primary care EPs and EDs will continue to do more primary care Bad for Emergency Medicine Bad for Emergency Medicine Bad for Primary Care Bad for Primary Care Bad for patients Bad for patients Public health mandates (funded vs unfunded)? Public health mandates (funded vs unfunded)? Overcrowding will continue for the foreseeable future Overcrowding will continue for the foreseeable future

79 Okay, fine Increasing regionalization and nationalization of health care systems Increasing regionalization and nationalization of health care systems Driven less by public health concerns than disaster / terror preparedness Driven less by public health concerns than disaster / terror preparedness What is the role of EM in govt surveillance of the public? What is the role of EM in govt surveillance of the public? Gradual integration of hospital systems and IT networks (this will be rough and slow going) Gradual integration of hospital systems and IT networks (this will be rough and slow going) Gradual evolution of single payer system(s) Gradual evolution of single payer system(s) Probably 50 of em, regulated by Feds (carrot-stick) Probably 50 of em, regulated by Feds (carrot-stick) Hospitals, pharmaceutical co.s, PGs, etc, continue to be operated on entrpeneurial models Hospitals, pharmaceutical co.s, PGs, etc, continue to be operated on entrpeneurial models

80 CONGRATULATIONS TO THE CLASS OF 2006!


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