the college — today and tomorrow

SPECIAL CONTRIBUTION American College of Emergency Physicians

The C o l l e g e - Today and Tomorrow

[Krentz MJ: The College - - Today and tomorrow. Ann Emerg Med January 1988;17:89-92.]

I N T R O D U C T I O N I would l ike to take you back for a momen t to the year 1974. January.

Wintertime in Portland, Oregon. A downtown communi ty hospital. It is 2:00 in the morning, and on duty in the emergency room - - it is an emergency room, not a depar tment - - is a straight surgical intern, barely six months out of medical school. He is the only physician there.

Suddenly the sound of sirens, the sight of flashing red lights. The doors burst open. An elderly gent leman is brought in on a stretcher. It is immedi- ately apparent to the intern that the man is in severe respiratory distress - - he is too blue even for the cold night air. He has received no treatment; he is probably going to die.

Anxiously walking next to the stretcher is the patient 's son, whom the intern immed ia t e ly recognizes as an a t tending surgeon on the hospi ta l ' s medical staff. The surgeon is obviously in a panic. He says his father has heart disease, mutters something about pulmonary edema, and curses because the cardiologist has not yet arrived.

The intern is having a panic a t tack of his own, as he realizes that one of his own mentors mus t ent rus t to h im the life of a parent. He fumbles through his rudimentary medical data base. Somehow the appropriate words pass his lips, the proper critical actions are performed. The man lives. The surgeon regains composure and thanks the intern. The cardiologist finally arrives, ignores the intern, and immedia te ly transfers the already stabilized patient to the coronary care unit.

With the crisis past, the young intern menta l ly and emot ional ly reviews what has just transpired. His previous panic and concern give way to relief and intense satisfaction. He did not realize it then, but at that m o m e n t a career in emergency medicine was born.

This is not a unique story. Each of us could describe a similar scenario. The details are different. Some tell of second careers, others of having com- pleted emergency medicine residencies. But all would culminate here, in this room, at the annual Council meet ing of the Amer ican College of Emergency Physicians. It is that same former surgical intern who tomorrow will humbly accept office as the 17th president of this College.

Additional stories could be told by each of our nearly 12,000 members; those 12,000 physicians, regardless of background or histories, are today the American College of Emergency Physicians.

Webster defines a college as, "a group of persons engaged in a common pursuit, having common interests or a common duty or role." Our "college" consists of those 12,000 dedicated emergency physicians; their common interest is to care for over 80 mil l ion emergency visits in the next year. We are here to represent the "common pursuits" of that body. Obviously, then, in a tangible sense, the College is more than the president, or the 13 members of the Board of Directors, or even the 140 councillors. Our business, in the next two days and throughout the next year, is the business of all emergency physicians.

Michael J Krentz, MD, FACEP American College of Emergency Physicians Dallas, Texas

Presented as the Presidential Address to the Council of the American College of Emergency Physicians in San Francisco, November 1987.

Address for reprints: American College of Emergency Physicians, PO Box 619911, Dallas, Texas 75261-9911.

17:1 January 1988 Annals of Emergency Medicine 89/147

SPECIAL CONTRIBUTION Krentz

GOALS A N D OBJECTIVES It is in that light and with a sense of our history that I

share with you the major goals and objectives of the College for this year.

When I made the transition from a neurosurgical training program to a career as a full-time emergency physician, i t involved no th ing more complex than get t ing m y name placed on the emergency department schedule. I could not do that in today's environment. In fact, as an emergency department director today I would not even consider some- one with such limited preparation. That is as it should be. The mission of this College has always been to improve the quality of emergency medical care~ and we have succeeded, largely by improving the min imum qualifications for emergency physicians.

Academic affairs, the continued production of qualified emergency physicians in sufficient numbers to meet the demand for their services, must be the first goal of the Col- lege. This year it is of major importance as we face a unique situation, the decline of the practice eligibility track for the board examination in emergency medicine. There are probably more than 15,000 physicians who practice emergency medicine in this country. Of those, only slightly more than 5,000 are board certified in emergency medicine. In the absence of the practice eligibility track, the only source of new emergency physicians qualified to sit for the boards is residency programs. Yet they are turning out only about 400 new graduates each year.

This College, in concert with other academically oriented emergency medicine organizations, must have as a major priority the continued viability and growth of superb residency programs in emergency medicine~ We will devote significant efforts to meet head on the serious shortage of qualified emergency physicians.

We have appointed a task force on manpower in emergency medicine to assist the College in finding ways to address this critical issue. The Board will later consider the prelimi- nary recommendations of that task force.

On November 20th, 1987, the College will formally testify before the Council on Graduate Medical Education. The unique manpower needs of our sldecialty will be presented, as will the need for improved funding of graduate medical education in emergency medicine.

Moreover, the Government Affairs Commit tee of ACEP will continue to monitor the Washington environment for opportunities to positively impact funding for emergency medicine residencies. Where appropriate, we will seek out the expertise available f rom our own Academic Affairs Committee, as well as from other organizations, including the University Association for Emergency Medicine, Soci- ety of Teachers of Emergency Medicine, and the Emergency Medicine Residents Association.

We will also continue to persist in our efforts to enhance the quality emergency patient care through research. Last year the Emergency Medicine Foundation funded resident and fellow research awards of $120,000; $45,000 of this came from individual,contributions. ACEP contributes all the administrative costs to the foundation; every penny contributed to EMF directly supports these fellowships. We will increase our efforts to solicit corporate contributions. Finally, ACEP's Research Commit tee will seek out other new horizons for the College in this area.

We will maintain a close liaison with other organizations, most notably STEM and UAEM, who share with us a major

interest in academic affairs in emergency medicine. As always, ACEP is prepared to support these organizations and to participate in any innovative organizational discussions promoting the interests of academics in emergency medicine. Our participation is not for the sake of control, but as a vitally interested party dedicated to the common goals of the enhancement of emergency care and assurance of the future growth of our specialty.

Let us look at some other concerns of our 12,000 members. At this very moment, for example, there are a number of our colleagues providing both on- and off-line medical direction for emergency medical services. EMS is a singular aspect of medical practice that is, and ought to be, uniquely within the province of emergency medicine. It.is particu- larly gratifying to me to tell you that no longer is it neces- sary for anyone to proclaim that ACEP should be the leader in EMS. ACEP is the leader in EMS today, and EMS will continue to be a major College priority. In the coming year we will augment the major achievements already made.

As a result of the vision of ACEP's EMS Committee, a new coalition exists, a coalition under ACEP's leadership that has united major national EMS organizations around mutual objectives. This past summer, that coalition had an impact on the development and revision of the latest national EMS legislation, including SID.

In the next year, ACEP will facilitate, through this same coalition, the development of a new statement of direction for the EMS industry. For the first t ime since the historic "White Paper" of the 1960s, the EMS industry will, under ACEP's leadership, seize the opportunity to take a coordinated look at itself and to begin shaping the future of EMS for years to come. This is an exciting prospect, one which could lead to even more comprehensive EMS legislative ini- tiatives, spearheaded by ACEP.

ACEP is a leading participant in the ASTM process for the development of national voluntary standards in EMS. ACEP funds eight of its members and staff to attend each semiannual ASTM meeting. Several ACEP representatives hold leadership roles within ASTM, including two as members of the executive subcommittee. We are confident that ACEP will have a positive impact on the deliberations and products of this body. The end result will be to enhance prehospital care throughout the nation.

As yet another reflection of ACEP's leadership in prehospital care and our commitment to EMS education, the College will be involved in two major EMS educational efforts this year. A text and course for EMS medical directors is well into the development process. ACEP is under contract with a major publishing company to develop a new national textbook for basic EMTs. At long last, the Bible of basic prehospital care will be one developed and published under the leadership of emergency medicine.

Accidental death and injury continue to take a huge toll on our society. ACEP will continue to realize its rightful major role in the development of t rauma care systems. Through the collaborative leadership of our own Trauma, EMS, and Government Affairs committees, we have suc- cessfully integrated the concept of t rauma systems into federal trauma legislation. Also, as a result of our liaison's active role in the Center for Injury Control, ACEP will, in January 1988, cosponsor wi th the CDC, Depar tment of Transportation, and American College of Surgeons, a national invitational conference on trauma registries.

Even more exciting, we will continue progress toward de-

148/90 Annals of Emergency Medicine 17:1 January 1988

velopment of a joint s ta tement on t rauma care wi th the American College of Surgeons. In marked contrast to the painful "Turf" battles of years ago, the national specialty so- cieties r ep resen t ing surgeons and emergency phys i c i ans now have wi thin their grasp a joint s ta tement that will em- phasize cooperation and mutua l i ty toward a common goal: optimal care for vic t ims of mul t i sys tem trauma.

Earthquakes, airplane accidents, hazardous materials inci- dents, and the like occur with alarming frequency. As an additional aspect of our EMS effort, we will accelerate our activity in the realm of disaster medical services. The Task Force on Disasters has become a full commit tee , a reflection of the enhanced role that emergency medic ine and ACEP should play in this area. The commit tee will carry forward several recommendat ions made by the prior task force. It will focus pr imari ly on networking between members interested in EMS and on forming relationships wi th other involved groups outside ACEP

The active involvement of our individual members in lo- cal, reg ional , and s t a t e EMS s y s t e m s also c o n s t i t u t e s ACEP's proper leadership role. It will continue to be ACEP's goal not only to realize that leadership role on a nat ional scale, but also to facilitate the same pursuit for our members at o ther levels, r ~'hus, as e v e r y emergency physic ian recognizes and fulfills his responsibil i ty for EMS, ACEP will proudly hold its place as the leader of that unique aspect of health care delivery, emergency medical services. The ulti- mate beneficiaries, then, are the people of this great nation.

Consider now the emergency physic ian who is at this moment caring for one of America 's most precious citizens, an ill or injured child. ACEP shares the concerns of our pe- diatrician colleagues that chi ldren mus t have predictable and ready access to emergency care in all circumstances. We are actively part icipating in reviewing federal legislation that addresses that very issue, and we have established for- mal dialogue with the American Academy of Pediatrics. Ad- ditionally, I have reconst i tuted the former Task Force on In- fant and Childhood Emergencies into a standing commit tee on pediatric emergency medicine.

Besides the implementa t ion of the advanced pediatric life support course, the objectives of that commi t t ee for the coming year include further definit ion of the unique needs of the ill or injured child and the pursuit of ways that the College can have a positive impact on the care provided. Thus, ACEP wil l cont inue to do its part to ensure the health and well-being of the future. Reflect for a minu te on our colleagues who are right now caring for mi l l ions of Americans in emergency facilities throughout the land. Re- gardless of their training, they all need ongoing education to hone their skills and keep abreast of the exploding tech- nology of modem medicine. To meet that need, ACEP will continue to provide stellar educational programs, most notably the Scientific Assembly, Winter Symposium, and all the CREMS. As before, we have under taken a detailed process to ensure that we are offering t imely and needed cours- es that reflect not only the current state of the art in emergency medical practice, but also cont inue to feature the basic principles of our core curriculum. That curr iculum itself has been and will be in te rmi t ten t ly revised. We are cur- rently considering what the nature of the CREMS should be as recertification in emergency medicine becomes a reality.

As an extension of a trend first recognized several years ago, emergency physicians continue to expand the scope of their practices into areas where definite needs exist. ACEP

will continue to facilitate the efforts of these new pioneers of emergency medic ine through the support of i ts Tox- icology, Critical Care, and Occupational Medicine committees. Each of these is charged with defining the need for and art iculat ing the role of emergency physicians.

Let us now turn our thoughts from the clinical practice of emergency medicine to survival, ours and our patients. As the health care re imbursement environment undergoes major change, the emergency depar tment often becomes the only source of access to acute medical care for a growing segment of our population. There are serious implications. We are the only medical specialty that wil l ingly accepts all comers, and are under federal mandate n o t to refuse service or to transfer patients; yet at the same t ime we are under payor pressure not to be fairly reimbursed. What effects do these new re imbursement concepts have on our abil i ty to care for our patients?

MANAGED CARE AND REIMBURSEMENT Managed care. I often get the feeling in m y own practice

that some of these patients present to emergency facilities with l i t t le signs tat tooed on their foreheads: "Property of XYZ HMO. Do not touch wi thout prior authorizat ion." The fact is that some so-called managed care plans don ' t manage care at all . They manage r e i m b u r s e m e n t . "Care" of ten seems to be a secondary consideration. In this scenario, the emergency physician, who is the responsible manager of care in the emergency facility, finds himself in the role of pat ient advocate, f requent ly at odds wi th a "gatekeeper" who has a definite financial incentive to deny reimbursement for properly delivered emergency care.

It is only the p a t i e n t or his legal guardian who rightfully gives "permission to treat," not the payor. When an individual perceives the need for emergency care and comes, or is brought, to an emergency facility, a doctor-patient rela- t ionship is established with an emergency physician. That is a t ime-honored contract into which no third par ty should intervene to the detr iment of emergency care provision. On the other hand, emergency physicians m u s t assume more responsibil i ty for controll ing the cost of that care. We mus t be able to demonstrate that emergency care is not inher- ently cost-wasteful.

The need for emergency physic ians to unders tand and deal effectively wi th managed care sys tems has become critical, not just for the sake of fair compensation, but more importantly, to assure proper access to the emergency medical system for patients who require it. To begin to address that need, the ACEP Board recently adopted a posi t ion paper on managed care. It is only a beginning. In the next year, the Practice Management Commi t t ee will be working as- s iduously to develop materials to assist our members in un- derstanding, interacting with, and educating managed care plans, their physicians, and patients. There is much work to be done here, and it m u s t be a priority.

The effects of the current re imbursement scenario on the practice of emergency medicine and on the access of the public to that practice are even more complex with respect to the role of government, specifically through the Medicare program. As Congress struggles wi th the impossible task of balancing the federal budget, more and more reductions of Medicare benefits will occur. The strategy, of course, is to effect cost savings through reduced payments to providers, both hospi ta ls and physicians. But, as we in emergency medicine have already seen, the undesirable side effect is



reduced access for the elderly to a level of medical care that they have considered "usual and cus tomary" throughout their lives. Thus, much like the lot of our nation's indigent, we see more and more elderly patients coming to emergency facilities, their only ready entr4 to the heal th care system. When they do come they are often cri t ically ill, due to the delay in seeking care as a result of payor-forced financial disincentives.

From the emergency physic ian 's perspective, the situa- t ion is even more complex, because many of our colleagues are trapped by ridiculously low fee profiles, dinosaurs from the pre-TEFRA days when hospitals billed for emergency physician services wi th no rhyme or reason. Absurd incon- sistencies are rampant from state to state and carrier to carrier. In addition, even though ACEP won a major victory in Congress several years ago with the definition of bona fide emergency, we now find that many carriers can and do sim- ply ignore it when applying reductions for so-called non- emergency visits. And there is even a more bizarre carrier strategy adorning - - a strategy t h a t would downcode anyone who has ever visited an emergency facility to an "established patient for all subsequent visits." One thing is clear - - the federal goal is to reduce payments to physicians, and it mat ters l i t t le how it is done or who might fall by the wayside in the process.

We face a unique situation. On one hand the legi t imate demand for our services is increasing as this nation's 31 mil- l ion elderly turn to emergency facil i t ies as thei r best re- maining immedia te access to heal th care. Yet in many in- s tances emergency phys i c i ans are no t g ran ted p a y m e n t parity wi th other specialists. What is needed here is exten- sive reform in the Medicare payment system. That is pre- cisely what the government is in the process of doing, even if for vastly different reasons. ACEP will be there in many ways. Our pr imary goal is to ensure cont inued access to needed emergency care. At the same t ime we believe that cur ren t r e i m b u r s e m e n t i nequ i t i e s m u s t be cor rec ted if emergency physicians are to be able to continue to provide that care.

Our legislative and regulatory policy staff in Dallas and our Washington office staff have devoted untold hours, not to ment ion blood, sweat, and tears, to this effort; they will cont inue to do so. Our Physic ian Payment Reform Task Force will continue to work overt ime to a t tempt to solve the puzzles constant ly thrown at us by Congress and the federal administrat ion.

"Wins" in this game are difficult to achieve, and even more difficult to recognize. The kind of instant results we are used to in our practices just don ' t occur in a Washington envi ronment general ly host i le to physicians. In fact, the "winners" may be those who somehow manage to hold onto their current position. Thus, it becomes a struggle not only for advancement , but also, perhaps more realist ically ' for damage control. That is somet imes difficult for us to accept.

We have made considerable progress. We have established meaningful dialogue wi th several major Congressional committees. Through our dynamic key contact system we have fami l i a r i zed m e m b e r s of Congress w i t h the rea l i t i es of emergency medical practice. Most have been favorably im- pressed. In fact, I am told that, largely through our efforts, emergency physicians are now thought of quite favorably in certain Capitol Hill circles, where we are rightly seen as patient care advocates, dedicated physicians who see and

treat those in need, regardless of abil i ty to pay. But there are many more members of Congress who are completely un- familiar wi th what we are and what we do. The si tuation is even worse in our s ta te leg is la tures . We are, therefore, mount ing a major pol i t ical educat ion effort for our own members, spearheaded by a newly appointed task force. We mus t be able to get our message across and we mus t do it today.

As a result of some of these painstaking efforts, we recently have scored some tangible wins. Thanks to carefully laid groundwork, we will testify before the Physician Pay- men t Review Commiss ion on November 10, 1987. This congressionally mandated commiss ion will l ikely shape the course of phys i c i an r e i m b u r s e m e n t for years to come; ACEP will be there to influence it. A more immedia te and far-reaching win was scored in mid-October. Through the efforts of our Physician Payment Reform Task Force, key contact system, and staff, the Senate Finance Committee has recommended an increase in the Medicare economic index for emergency services, services that would have been frozen by their original del iberat ions. This achievement means that emergency medicine is now recognized by a key congressional commit tee as providing essential medical services to the elderly population. While this is but a single step, it has potential ramifications that, properly pursued, will have positive impact on our entire membership. I guar- antee you this opportuni ty w / / / b e properly pursued.

We are making important tangible strides in Washington. But there is much left to be done, and this next year we will dedicate significant resources and energies to this effort. We have the abil i ty and readiness to mobil ize on the shortest notice because these are opportunit ies that we cannot afford to miss.

Our u l t imate best strategy, however, is not to be reactive but to be proactive. Therefore, we have established a clear payment reform agenda that we will pursue wi th haste and vigor. We have identified for action the eight most critical issues, issues vital not only to our 12,000 members, but als0 to those 31 mil l ion Americans who require access to our skilled services. The issues are: reduction of cost disincentives for Medicare beneficiaries needing or seeking emergency care, improvement of payment levels to emergency physic ians in low fee states, evaluat ion of relat ive value scales as a payment methodology' further work on the Med- icare economic index, correction of inherent ly unreasonably low fee profiles for emergency physicians, defining payment units for emergency physicians, CPT coding issues, and cor- rec t ing inappropr i a t e r e t rospec t ive denia l of bona fide emergencies. Our resolve in addressing these issues is un- wavering, no mat ter what the obstacles may be.

Another reason why our members are hurt ing from the re imbursement crunch is because as payment for services has decreased, the cost of providing those services con- t inues to escalate, pr imari ly through the runaway cost of professional l iabil i ty insurance. Here too, ACEP will take major steps to assist our members. Fresh from a two-day planning session, our Professional Liabili ty Commit tee will moni tor this changing environment to find ways ACEP can impact upon it. Additionally, we will continue to develop and offer to our members assistance in the areas of quality assurance and risk management . In addit ion to our newly published manual on quali ty assurance, an innovative, free- standing course on these subjects is already in the development process. Moreover, the College will continue to pub-


lish foresight, our h ighly acc la imed risk m a n a g e m e n t monograph series.

From another perspective, we are taking a really hard look at the whole issue of professional standards of practice. We have already established a task force on standards in emergency medicine. Yesterday the Board discussed and provided direction for that task force. We are prepared to move ahead with the awesome task of developing and im- plementing s tandards of care wi th in our own specialty. ACEP will once more take the lead in shaping the destiny of emergency medicine ~. i can assure you that if standards will exist for emergency physicians - - and we all know they will - - then those standards will not be developed in the absence of ACEP

AGENDA FOR THE FUTURE Much of what I have stated so far revolves around not

0nly the preservation of the specialty of emergency medicine, but more importantly has reflected the primary goal of this association, patient care. Also to that end, we will read- ily respond to the newest major threat to the health and well-being of America, the AIDS epidemic. Here, we have a duality of purpose, because we are not only the caretakers but also potential victims of this deadly disease. To address both issues, I have appointed a task force on AIDS, a task force that has already begun its work. It will focus its atten- tions on the development of policies, education, and pub- lications to assist emergency physicians in dealing with the disease and its victims, while at the same time protecting their own lives and those of other emergency medical services health providers.

We have a formidable agenda. The issues we must address are vital not only to the future of our specialty but also to the health and well-being of our patients. To accomplish our agenda, we must have a timely, economic, and effective im- plementation system. ACEP is well prepared to meet that challenge, too, through our planning and budgeting process, our committees, our chapters, and our staff. As this Council deliberates on these important issues over the next two days, you can do so with the confidence that you are sup- ported by a modem and effective association structure.

We continue to be in the vanguard in long-range planning as we move into fourth-generation sophistication in this annual process. We have once again established our priority achievement strategies and have fashioned enabling objectives that will make it possible to implement those strategies. The College is on sound financial footing.

To an t ic ipa te sweeping changes in the hea l th care environment, we have once again appointed an elite Blue Ribbon Commission on the Future of Emergency Medicine. It was the first Blue Ribbon Commission of three years ago that facilitated our ability to position ourselves so favorably for the changes in health care today. Similarly, this new c0mmision, which will make its report to the Board of Di- rectors in January 1988, will carry our long-range planning process well into the 1990s. I fully anticipate that another president-elect will stand before the Council in the future and praise the planning process that kept this College in the forefront, and allowed emergency medicine to determine its own destiny.

To facilitate the work of our various College committees, I have revised our committee structure around a concept of integrated networks for education and research, clinical care, emergency medicine practice, emergency medical ser-

vices, public policy, and special committees. This system is a refinement of the prior section concept, and will empha- size the effectiveness of each committee chairman. To pro- mote coordinated effort, each committee is assigned a Board liaison person who will provide policy direction, continuity, and networking with other College committees and efforts.

Much of the work of this College can and should be im- plemented by its component chapters. For instance, the re- cent successes of the California Chapter with its membership drive and in fostering state legislation to assist its members in dealing with the issues of patient transfer could well be emulated by other chapters.

A major goal this year is to enhance chapter effectiveness and to cont inue to strengthen the link between chapters and national. The ongoing cooperative efforts between national ACEP and the New York and New Jersey chapters to influence state emergency department regulations are ex- amples of this linkage.

ACEP will also facilitate chapter long-range planning ac- tivities, as has already been done in Ohio, Delaware, and Arizona. In addition, the Chapter Grant Program will continue to be funded. Moreover, a new publication, Funda- mentals of Chapter Management, is now available to chapters. Finally, we wil l c o n t i n u e to ut i l ize the Chap te r Advisory Panel as a focus group to test new ideas. With all this support, I enthusiastically anticipate major accomplishments by the chapters in the year ahead, and I look forward to reporting those accomplishments to the membership. I also look forward, with m y fellow officers, to the opportunity to visit chapters during the coming year. It is through that kind of dialogue and collegiality that new policies, programs, products, and services are often conceived and developed, at both the state and national levels.

! have thus far focused on our members and their patients. I would like now to remind you of Webster's definition of "college," which I quoted earlier: A group of individuals united by common pursuits, interests, and duties. If we believe that to be true, if we believe that we are a gen- uine college, then the logical and most beneficial conclu- sion is that our staff also constitute the college, for they too share our pursuits, interests, and duties. The relationship between volunteer members of an association and its paid professional staff is truly unique, and does not easily lend itself to comparisons with more traditional business relationships.

It would be absolutely impossible for this association of volunteers to accomplish an iota of what I have described today without the efforts of that other vital component of the College, the staff.~T~ere is no "we-they" relationship here. This is a partnership that flourishes, not only from mutual pursuits, interests, and duties, but also from mutual respect, communication, and professionalism.~lThe staff of this College share with its members a very reef intellectual and emotional sense of ownership of its processes, products, and image. To be sure, the Board of Directors is and must be actively responsible for direction and accountability and I am actuely aware of my daily responsibility in that regard. But I must also tell you from personal experience that this staff is every bit as dedicated to the goals and objectives of this specialty and of this College as we are. We are most fortunate to employ the services of such talented and dedicated individuals. They are, in fact, after our own members, emergency medicine's next most cherished resource.

Emergency medicine and the College have come a long



way since that frightened young intern cared for the surgeon's father so many years ago. Yet, the future agenda is bold, ambitious, and vital to the ongoing success of this specialty, for the assurance of continued availability of the highest quality emergency medical care possible. It is in- deed an honor and privilege to be allowed to lead and therefore serve this organization at this point in its history. I a m grateful to my fellow directors for the confidence shown in me, to the Council, committee chairs, Arizona Chapter, and staff for their continued support and encouragement. Above all, my finest privilege this year will be to so closely associ- ate and work with such an outstanding group of human beings, whom I have always respected, admired, and loved: the people in this room and those whom they represent, the

American College of Emergency Physicians. Mr Speaker, Madame Vice-Speaker, Councillors, I thank

you for the opportunity to address you today. I wish you God's blessing on your important deliberations, and I look forward to your direct ion on the major issues affecting emergency medicine. Your business over the next two days is most serious, for it is this Council that mus t provide grassroots insight and direction on the weighty issues we have just addressed. Throughout your deliberations, I pledge to you my own availability, as well as that of my fellow officers and directors. We have been elected to serve this College and its members, and it is our supreme privilege to do so.


the college — today and tomorrow

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