Residency Spotlight

An Interview with Peter Pons, MD

Jonathan Claud (Class of 2006) sat down with Peter Pons, a Denver Health Emergency Medicine attending of many years, who is nationally and internationally respected as a leader in his field.  After many years of service, Dr. Pons retired from Denver Health in August, 2007.  This interview gives a glimpse of his background and perspective on the past and future of Emergency Medicine.  The result is a fascinating look at a man who played a significant role in the lives and careers of almost every resident who has graduated from the Denver Health Residency in Emergency Medicine.

I've worked with you for several years but I still don't know much about your past, where did you train?

My interest in Emergency Medicine started in college when I wasvolunteering in an emergency room.  I went to medical school and thendid a surgical internship, both in Newark, NJ, and then completed an EM residency here in Denver.  I arrived at "Denver General" in 1977, thefirst year that Peter Rosen and Vince Markovchick were here.

What other programs existed?

It's kind of interesting.  There were actually two separate residencies in Denver prior to 1977.  There was a program based at St. Anthony's and one based at Denver General.  They had been reviewed by what was then the equivalent of the RRC, although it wasn't called that, and their opinion was that both residencies at the time were decidedly average.  In order to make a strong residency, it was suggested that they needed to combine the two programs and that's what they did.  I'm not sure if my year was the first combined year or the year before.

How many people were in your class?

A total of nine residents - names you would recognize including Ben Honigman (the current chair of the University of Colorado Division of Emergency Medicine) and Glenn Hamilton (the current chair in Dayton,Ohio).

When you decided to come here, did you know that Peter Rosen was going to be here?

No, it was after the fact.  In those days, EM was not part of the match, you scrambled to get your own program.  I had interviewed here. I was accepted here first and said yes.  During May of my internship year, I was on call at the VA Hospital and the hospital paged me overhead for a long distance phone call - it was Peter Rosen. I had actually read about him and knew him by reputation.  I had interviewed at the University of Chicago where he was working at the time, but he had been out of town so I had unfortunately not been able to meet him at that time.  I remember sitting at a desk and answering the phone and heard this voice say, "Hi, this is Pete Rosen".  I responded literally by standing up at attention.  He could not have been more gracious as he informed me that he had just accepted the chairmanship at Denver Health and that he was really looking forward to working with the incoming class.  He said he was sorry he hadn't met me when he interviewed in Chicago.  It was just an amazing conversation, certainly not something I ever expected.

Was that conversation indicative of your residency experience as well in terms of the level of respect and camaraderie?

I think so.  Peter is an amazing man and I cannot overemphasize the influence he has had on me, not just as a mentor but almost as a professional father in every good meaning of that word.

Do you remember any specific memories of Peter that still stick out in your mind?

Oh yeah, I was in absolute awe of his knowledge base, not just in medicine, but the breadth of his knowledge was amazing.  He is among the most well read people I have ever met and as a physician, he was extremely demanding.  In many ways, he makes me look like a relative amateur when it comes to being demanding.  I can remember resuscitations where if I started one IV line, he wanted two.  If I started two IV lines, he wanted a central line.  If I did the central line, the patient needed to be intubated.  He was always one step ahead of me and wanted more than I was frequently prepared to provide.

You saw the beginnings of a specialty, what were his motivations considering he is essentially a "father" of emergency medicine?

Well, number one, I'm not sure he ever really thought of himself that way.  We thought of him that way, but I don't think he did.  What really impressed me was that here was a man who had not trained in this specialty, but who had adopted this specialty and he really had a vision for how our specialty should be taught, what the components of a residency training program ought to be and he articulated that vision at both a local and national level.  He was active in what was then the initial version of the RRC and was a very strong advocate for what the components of an EM residency program should be, he didn't compromise on that and he was a strong voice.  He built a program here that I think really in many ways incorporated much of that vision and has led to many of the good things that this program has been able to accomplish.

So when we refer to the DG way or the Denver way, are we in many senses, referring to the Rosen way?

In many ways, yes.  In fairness, it was not just Peter.  Vince had trained with him in Chicago and we had another staff member here at that time also from Chicago. But he had this vision that he was able to articulate and implement here.

Why Denver after Chicago for Peter?

I don't know.  That's a question for him.  Perhaps Vince could tell you.

I think in the minds of many residents your early life is a definite enigma.  I have to admit that it's hard to imagine Peter Pons playing on the playground at age five.

Well, you can't imagine it because it probably didn't happen much. I was born and raised in an apartment in NYC.  I'm not a playground kid, I never owned a bicycle--what can I say, I was a product of New York City.  Quite honestly, my parents were very family oriented and what we did, we did as a family and while I did a fair amount of traveling outside the city, I spent little time at playgrounds and the like.

What did your parents do?

My father was an airplane mechanic as well as an aircraft inspector.  He worked for a major carrier so when an airplane came into LaGuardia or Newark, he would actually inspect the airplane and verify that it was okay to fly and he was the one who signed off on the fact that any maintenance work done on the plane was done properly.

Do you think that in a sense you do the same kind of your work as your dad, he just worked on planes and you work on people?  He must have been a meticulous man.

Very meticulous.

Do you think that contributes to your own meticulous nature in how you run the ED?

I've actually never thought of it in that way but in some ways it is comparable.  In reality, I often don't tell people what I do.  When they ask, I tell them I'm a mechanic in a body shop which is technically accurate.  However, you're right--the parallel is there and it's not something I actually really thought about before.

And your mother?

My mom was a remedial reading instructor in the NYC public schools.

Why do you say you are a mechanic in a body shop, why not just tell people that you're a doctor?

I think the title suggests more than it really is.  It only speaks to the education that I participated in.  What I really want is for people to deal with me on a one to one basis without viewing me as aphysician.  I think that changes the relationship that people have with other people and it's not something that I espouse.

You mentioned your interest in EM in college but what was your first motivation to go into medicine?

Quite honestly, it's the only thing that I ever said I was going to do.  My folks have told me that was true from the time I could speak. Honestly, I couldn't begin to tell you what the initial attraction was.  My parents told the story that at my very first well baby check by our physician, the doctor looked at me - I was probably two weeksold - and he told my mother, "You know he has the hands of a physician".  I don't know what prompted him to say that to my mother, but subconsciously I must have heard it.

So prior to college, how did that desire play itself out?

I volunteered at our local hospital, in the ED, after my family moved to New Jersey.

Any defining moments?

Well I volunteered in the emergency room and I remember watching the physicians there and being amazed at the scope of illness and injury. In those days, the specialty of emergency medicine did not exist and most of the physicians were retired from private practice.  It was a mix of internal medicine physicians and surgeons.  Again, I was impressed with the scope of what they were dealing with and I originally had the idea of being a surgeon, but having watched them and seeing the action in the emergency medicine, I knew that was what I really wanted to do.  As I went to college and medical school, I became aware of training programs that were forming and decided that's what I wanted to do.  It gave me the opportunity to do a little bit of everything and get involved early on in the patient's care--not have it defined by someone else.

Where did you go to medical school?

I went to the College of Medicine and Dentistry of New Jersey in Newark and then I stayed there for my internship.  The emergency medicine residency programs at that time were requiring 24 months of training after an internship while some programs were 36 months.  Atthat time, there were about 30 programs and I interviewed at 10 and got accepted to a number of them.  Before that, when I was applying for internships, I told the interviewers that I intended to complete an emergency medicine residency after my intern year.  After about the third interview, it dawned on me that as soon as I mentioned EM, the temperature in the room would suddenly drop dramatically and it became very apparent that I was choosing a specialty that, at that time, nobody had any belief in, and frankly, I found it very difficult to find an internship.

Going back to your time as a volunteer, you talk about the wide scope of practice, your training was somewhat limited, but do you recall instances where the doctors practicing in the ER were not adequately prepared?

Oh there's no question that I saw care delivered that was clearly less than optimal.  It's a lot easier for me to say it now than it was then because as an eighteen year old volunteer in an ED who had no prior real experience in terms of medicine, you're hard pressed toidentify what was and was not good care.  But you could tell when things weren't going well and even among that group of physicians there were clearly some who were better than others at dealing with certain things whether they were technical or diagnostic.  There was a physician there who was trained in internal medicine who was a superb diagnostician, but when it came to doing anything technical he was terrible. On the other hand, there were two people there who were retired surgeons who were superb technicians who, if you had al aceration, you prayed that they were on duty because they were superb at suturing, but their diagnostic skills were clearly different.  And those sorts of issues actually held true both as a medical student andas an intern.  It terrifies me today to think of the responsibility that many of us had working in an emergency department when we lacked the requisite knowledge.

I'll briefly give you an example.  When I was a surgical intern inthe emergency department at the hospital there in Newark, it was staffed by the intern and a second year surgery resident.  It was broken up into a trauma half and a medicine half and the two of us had responsibility for the entire ED; there were no faculty.  I can remember very vividly in the month of December, we had a family who was caught in a housefire in Newark.  They couldn't get out, they were on the third or fourth floor and they jumped out the window.  This woman was brought into us complaining bitterly of abdominal and back pain. This was in the days when diagnostic peritoneal lavage was first becoming implemented.  This is one of the first patients we ever did one on, and it was positive, and we took her up to the operating room and found her ruptured spleen. We'd been smart enough to also x-ray herback and we diagnosed a compression fracture of the lumbar spine.  We had no concept of the association of calcaneal fractures with those injuries.  She actually had bilateral calcaneal fractures, but she didn't feel them because of the abdominal pain.  And more distressing to me is that, two days later, radiology called and said, "Oh, by the way, you know she's got a widened mediastinum."  She'd been sitting there for two days with a torn aorta.  We weren't smart enough to know this stuff and we had nobody to teach us. That's what emergency medicine was like, or emergency care, I shouldn't say emergency medicine because it wasn't emergency medicine; it was the so-called "emergency room care" in those days.

When I got here suddenly you're learning about this stuff from people who have learned how to assess and treat emergent patients and are teaching it to you.  To this day I think about that patient and think she lived in spite of us.  You just wonder how many others either did or did not survive because of our lack of knowledge, the fact that there was no teaching and that we either had retired physicians who weren't capable of providing the appropriate care or physicians-in-training, like myself, who didn't have the role models, or the educators to appropriately teach us.

Why do you think that happened?  Why do you think in the development of the medical system it got to the point where there was such inequity between care provided to you as an inpatient and care provided when you walked in the door?

The emergency department was always the after thought.  It was a place that you were required to take call in if you wanted medical staff privileges.  In training hospitals, it was a rite of passage, you rotated there for a month or two and in many cases it was a place you retired to or it was the place where physicians who came from another country worked until they could get licensed or approved to work on their own.  It wasn't on the radar screen the way it has been in thelast 30 years. And frankly what I think led to a revolution in emergency care is in many ways related to advances in EMS.  Emergency Medicine followed along in many ways.  What happened is we became aware that from a casualty perspective, the likelihood that you would survive from a battlefield wound in Vietnam was greater than the likelihood that you would survive from a motor vehicle injury or similar penetrating injury in the United States.  And so people started saying there is something wrong with this system.  At the same time we had the development finally of a portable defibrillator which again allowed EMS to bring medical care to the patient and it sort of followed that emergency department care needed to improve at the same time.

It's interesting to hear you say that.  First of all, because Vietnam really was a major impetus - it opened people's eyes on at least on a cultural level to see this reality.  And then I understand that the portable defibrillator was working on the medicine side of things, you have surgery and medicine coming together to, in a sense, fill a vacuum.  Your attribution to EMS is especially poignant in light of recent studies and talk that maybe EMS should be doing nothing but driving.  How do you rectify that? How do you bring that back around?Are we, as a specialty, "killing our mother?"

No, I don't think so, mainly because we never really defined what our mother should do.  What we said, which we can argue about the validity of, was that we can take these things from the hospital setting and utilize them in the out of hospital setting and we believe it should improve mortality.  Unfortunately, and I think it's true in many specialties in medicine, we didn't study it; we just applied it. You're correct: we went hog wild  in EMS without really evaluating what we were doing.  We said we would take all of these things that we think make sense and shove them into an ambulance with a paraprofessional we called a paramedic--an advanced level technician who trained to domany of the things that in days prior only physicians would do--and though, "This isgoing to be great!"

It's only really been in the last decade that we said, ok we did all this stuff, but does it really matter?  We createda system--and please understand, I'm part of that--we created a system that is extremely expensive, that requires, both in terms of educationand equipment, a lot of money to keep operating. And no one really sat back to say let's evaluate what makes sense here.  It became if we can put it in an ambulance, let's do it.  It's very interesting.  When we first started covering the Broncos games, I had a paramedic come up to me and say, "You know you really ought to be taking a thoracotomy tray out there.  We've got a first aid room and a physician and a paramedicout there, and by God if someone's really goes down we ought to be cutting their chest."  Well, we drew the line in the sand at thoracotomies!  But we didn't with most everything else and I think the evaluations we are currently doing, perhaps as rudimentary as they are, are vital to the future of EMS.

The other thing that we did, partly because it's easier because of volume, is to implement all of these things in the urban setting. In most urban settings transport time to a hospital is short and in manyways we've got the system backwards: many of these more advanced interventions are probably more appropriate for longer transports asopposed to shorter transports.  But that's not what we did for a host of reasons both in terms of money and skills maintenance, and everything else.

What kind of battles were you fighting as a residency program in your early years?

Probably the biggest battle was related to the paranoia that existed between the department of surgery and us on a house staff level.  The ED at Denver General used to function such that when a patient was called in by the paramedics, it was actually the nursing staff who would call the consult.  When they heard that a trauma was coming they would call the surgeon. When Dr. Rosen got here he said, "This is going to stop today.  The physician staff is responsible for calling consults."  As you might guess, the concern on the part of the surgeons was that we would start doing all sorts of stuff that they should be doing.  It got to the point where we actually had the surgical house staff trying to sleep out on the loading dock to be sure they didn't miss any calls. They wanted to have a room in the ED so if anything was going on they would be able to hear it.  It was pretty amazing. What happened is that Peter Rosen, both as a former surgeon and with the vision that he had for emergency medicine began working closely with Dr Gene Moore,who arrived about the same time.  Although Gene was not chairman of surgery at that time, he was director of trauma surgery.  They both articulated their vision for how this ought to work and that vision was one of collaboration.  In fact, Emergency Medicine doesn't operate without the surgical staff and it is appropriate that the surgical staff be involved early to see the evolution of the patient during the resuscitation.  They also recognized that surgery is dependent onEmergency Medicine because, if they're operating, they have to depend on us to keep somebody alive long enough for them to get down to the ED.  So Peter Rosen and Gene Moore articulated this vision and insisted that there would be cooperation.  It didn't happen overnight, but certainly having that philosophy articulated at the highest level eventually made its way down to the lowest level.

So with house staff sleeping on the loading docks what kind of arrangements were in place at that time? What would prompt them to do that?  Would you guys perhaps not make the calls that we would bemaking today?

No, we essentially made the same calls that we would make today. The concern was I think much more the change in consult practice and I think there was a fear that we wouldn't call when, in fact, we did.  It took probably a year or two before things really settled down, but the reality is they suddenly discovered we're not here to take over anything, we're here to work collegially with you guys and vice versa. It really settled out fairly quickly to the system that continues to this day.

So that sort of addresses more the surgical aspect, were there any changes in regards to our relationship with medicine if nurses were making consults?

Honestly, not that I can remember.  For as long as I can remember we have always admitted to the medicine service, and for as long as I can remember the policy has been if the emergency attending thinks that the patient needed to be admitted, regardless of service essentially, that patient can be admitted.  I honestly don't remember a lot of hassles.  It's been pretty steady state, at least to my recollection.

How big was the ED when you started and what did it look like?

The ED was about one-third the size of our current layout and we had three resuscitation beds in two rooms.  On the trauma side, we had two 3-bed rooms and one room that was an overdose room.  We had a four bed orthopedic room that in addition had two chairs; if you had something minor you sat in the chair.And then the medicine side we had roughly nine examining rooms, of which one or two were GYN and one was for eye and ear cases.  So it was relatively small.

You mentioned the OD room, what was that?

It was what we called "Room Four."  And in much the same fashion as today you could recognize it by the charcoal stains on the walls.  We referred to it as the OD room because it was a smaller resuscitation room where we tended to put OD's, but it also did double-duty for both trauma and medicine resuscitations as well. Although, we didn't like to use it for those.

So you've been around long enough that you've seen some pretty significant changes in practice: charcoal, introducing ultrasound.  Is there one that really stands out, something that you guys did when you started your training that you can't believe you did or you're amazed at how far diagnostics have come since then?

I would say that, for me, the single biggest revolutionary thing was the introduction of the CT scan.  I've been doing this long enough that I actually remember what it was like before the CT scanner was in place.  When I worked as a volunteer and as a tech in the emergency room if we had someone come in who was comatose and there were concerns the patient had an epidural or a subdural or a subarachnoid, the way you diagnosed it was to try and get a neurosurgeon to come in to do an emergency angiogram and then look for shift of the blood vessels on that angiogram to make the diagnosis.  The CT scanner, if you didn'tgrow up with it, has been revolutionary.  And I would follow that very closely with ultrasound and all the various things we use it for.  When I started here as a resident and you worked any good night shift, you had easily half a dozen peritoneal lavages lined up waiting to either get one, having their fluid run in, or their fluid run out.  Ultrasound has truly revolutionized what we do in terms of both not endangering the patient and in our ability to manage that patient much more efficiently.

When did the CT scanner really become a part of your standard ofpractice? I would presume it followed a revolution similar to MRI today where it might still be hard for us to get it?

Not really.  The scanner made life so much easier both for us and radiology and neurosurgery; it became very accepted very quickly.  When you think about going from cerebral angiography to diagnose an epidural to something like CT, even though the old scanner still took 15-20minutes, it was light years different.  There really wasn't much hassle with that and that really occurred between 1975 and 1980.

So right in the midst of your training?

Yes.

You had a scanner here when you arrived?

Yes, we had a scanner.  I can remember when I was an intern in Newark watching them install the first scanner.

Anytime you talk about an advance in diagnostic technology, you talk about a decline in diagnostic acumen of physicians.  Do you think that has occurred as a result of scanners?

I'm not so sure I would say as a result of the CT scanner.  I do think that the ultrasound has changed that in some ways because now as I sit and watch physicians when a trauma patient comes in, nobody examines the abdomen anymore.  They ask for an ultrasound probe.  To a certain extent, yes, the scanner and the ultrasound have changed ourability to perform a physical examination.  I do think, in some ways, physical exam skills have become secondary to the technology.  I don't think they've exactly deteriorated, but we don't pay as much attentionto them or ascribe as much importance to them as we do to the scanner.  But then take a case like this morning's M&M where it was the physical exam which caused you to lean on a colleague in another specialty to take action - it's crucial.  I think all too often, it has become, "Well, let's just see what the diagnostics show," as opposed to saying, "Let's see what the patient shows."

Are there any patients that you've cared for that stand out in your mind?

It's a classic situation that affects physicians in training inparticular and I think potentially affects all of us.  I have a particular interest in recognizing c-spine injury and the reason for that is because of a case that occurred when I was a resident.  We had a patient, one of two involved in a high-speed car crash who put his head through the windshield.  He had scalp lacerations and was brought in immobilized.  We did our standard work-up which included a cross-table lateral c-spine x-ray.  On one of those patients I lookedat the x-ray as a junior level resident and thought I detected an abnormality in that spine.  I showed it to the attending physician whowas on duty, he looked at it and told me he thought it was okay.  Being brave and not agreeing with the attending, I then took it over to the radiology resident and he also interpreted it as normal.  A little while later the attending physician pointed out to me that the patientwas having significant bleeding from his wounds and felt that we ought to repair the scalp.  In order to gain good access to the wound we rolled the patient up onto his side, repaired the wound and rolled him back.  When we rolled him back, we discovered that the patient was now quadriplegic when he had not been before.  We repeated the x-ray and sure enough, where I had suspected there was a problem, there was a problem and we had now displaced it at that level and damaged his spinal cord.  Unfortunately, this individual was very intoxicated; he had no idea what we did and he ended up being deported back to his home country two months later because he was an illegal alien.  It's a mistake that I guess you could say has haunted me throughout my career.  I made a couple of vows that day.  One was that I would do the best that I possibly could to evaluate spine x-rays.  Second was that I would always listen to that little inner voice that says there is a problem here whether related to the spine or not and not just blow it off.  I'm smart enough to recognize that as a resident you live and die by your attending.  I recognize that every resident that works with me will live and die by the decisions that I make.

How did you discover that he was a quad?  How did that actually play out?

He wasn't moving anymore and he had been before.

What did the doctor say? You had pointed this out. How did the attending handle that?

He handled it quietly; he recognized that he had made a mistake. I'm not sure it affected him as much as it affected me.

Was there any solace from the fact that you had recognized the pathology?

No.

So you started in 1977 and finished in 1979.  Did you immediately become faculty here?

I was appointed to a one year position that was sort of a junior faculty position.  Then I left and moved back to New Jersey and took a job in New York City at Long Island Jewish.  At that time they had very strong desires to start a residency program - it was probably one of the worst experiences of my life (laughing).  It became very apparent to me that they wanted to do nothing that would really foster the growth and development of emergency medicine in that institution at that time.  They since have gotten a residency and have done reasonably well, but at that time they clearly weren't interested in emergency medicine.  Radiology, for example, had a policy that, whenever a radiologist was available, the emergency physician was not allowed to look at the x-rays. Unfortunately, that led to profound delays in the care of all patients.  But immediately at 4:30pm in the afternoon when they went home, we were okay to look at the films again.  I actually ended up leaving that job after four months.  Radiology prompted that departure.  We had set up a meeting with the radiologists and the chairman of the department to talk about the problems that this was engendering.  The day of the meeting he called us about 30 seconds before the meeting was going to start and said he wasn't coming to the meeting because he wasn't changing anything--thanks for calling.  At that point I looked at the person who was the director and said, "This is not going to work. You've got two weeks notice and I'm leaving." It was fighting a losing battle; they weren't ready to make the changes.Then I took a job at the University Hospital in Jacksonville, Florida.  I worked in that residency for two and a half years and then moved back here.

How did that occur?

I had been talking to Peter and I got a very interesting response.  He said that I should not move back here.  I should stay in Florida and work there 3-5 years minimum and then I should seek a directorship someplace.  He thought my talents were appropriate for that.  I talked to him several times about it and thought very hard about what was right for me and I decided I was moving to Colorado.  I just did not enjoy Florida's environment.  I hate heat, and I hate humidity, and I hate big bugs, and all three things were in abundance down there.  I called Peter one day and said, "I appreciate your advice, but I need to move back to Colorado and I would very much like to work for you again."  He had nofull-time jobs, but he let me work here part-time and I worked at St.Joe's.  The end result of that story is that a number of years later he actually hired me to come back here full-time.

He said to me one day after I'd been back in Colorado six or seven years, "You know I need to tell you something.  Do you remember that time you called me and said you wanted to move back and I said it was the worst decision you could make for your career? You know I said you need to go and become a director somewhere." I said, "Yeah, I remember it very well.  Not listening to you was one of the harder decisions in my life."  He said, "I want you to know you made the right decision and the reason I think that is because you did what was right for you, not what was right for me."  And I thought that's really an amazing insight from him.  It's something that I listened to and have tried to pass onto people when they come in and talk about what they should do.  Well, the reality is I can give you the advice that's right for me, but that person needs to decide what's right for them.  Then, when push comes to shove, you don't make a decision because Vince or Lee or I think that's what you ought to do; you'll pick exactly what you think you need todo.

Do you have any particular advice for medical students?

The key issue for me is just the demonstration that you're willing to work hard.  You don't need to be the smartest person in the world. You don't need to be the guy who scored the highest on the boards.  You need to work hard and you need to be willing to say, "I want to do this. I want to do the best I can and be the best I can possibly be." One of the things that has always disturbed me is the reputation that we have had as a malignant program.  If we're malignant, it's because we do want our graduates to be the best they can possibly be.  And if demanding that you work hard to be the best physician that you can possibly be makes us malignant, then we're malignant.

Have we always had that reputation?

We've had it for a long time. It waxes and wanes; it's never gone away fully.  I'll use myself as an example.  I know I can be a pushy SOB, but, by God, I want to be able to know that the graduates we turnout will do the right thing for every patient.  I don't want to have to lie awake at night worrying that if I'm in a car crash and wake up to see one standing over me that I will be afraid.  The responsibility that we have is the most awesome responsibility because we see patients at their worst in so many ways.  We have to make decisions with significantly less data than almost any other specialist; it's an amazing responsibility.  To be able to do it well and to understand that responsibility is the single most important thing that we can impart to a resident in training at any level.  If people understand that and save one patient because of it then we've done our job.

That meshes pretty well with what people do remember you as and I think Deb Houry's interview is a good example of that where she specifically mentioned your voice.  It's still in her head and it makes her do the right thing. I think that really is a testament to you.  What you're saying is if people save one person because of that voice then you've done something.

What about the graduating seniors, what would you say to them?

First, as important as our career is, make sure you have a life.  Medicine is a terrific career, it's a terrific responsibility, it's a terrific income but life is more than just medicine.  Family is important, doing stuff outside of medicine is important; it's crucial not to get caught up in just being a physician.  Maybe that's why I don't advertise that I'm a physician outside of here.  I think I've done reasonably well in balancing medicine with my family.  I'm not sure I've done very well with a lot of other things, but I would encourage everyone to do more than just this job.

Second, if you go through your career in much the same fashion as I did, there's no decision you can make that you can't unmake.  Specifically, I took a job in New York that was terrible; I quit it after four months.  The second job I took I stayed there two years.  I came back here and worked part-time here and part-time at St. Joe's, then I came back to DG for one year.  Then I worked at University for two years, then I came back here.  I mean if you look at my first ten years of employment, you'd be convinced that I couldn't keep a job. The reality is there is no decision that you can make that you can't unmake.  You shouldn't feel like you're locked in.  If you take a job and it's not the right thing, then, by God, don't be miserable - go do something else.  That's what I did.  This goes back to what I said earlier, you've got to do what's right for you.  That has actually served me very well and I would encourage everyone to do that.  That said, it's a little harder to go from privates back to academic medicine - difficult, but not impossible.  I think if you want the academic job, you should try to do that earlier rather than later.

Related to what you said about life outside of work, what's something different or crazy that we might not know about you?

I think most people know I love photography, I love taking pictures, I love the toys that go along with it.  And I'm a civil war buff, I collect civil war stuff.

What's your most prized item?

There are a couple.  I have an autographed Abraham Lincoln letter. I have an envelope that Robert E. Lee sent to Jefferson Davis that was addressed in his hand.  And I have a letter from Stonewall Jackson to Robert E. Lee asking for more troops and artillery.

Why the interest in the civil war?  What do you think pulled you in that direction?

It's another one of those things that for as long as I can remember the Civil War was a phenomenon that has always fascinated me.  Abraham Lincoln, in particular, amazes me.  I have always been astounded by his resilience in the face of incredible difficulty.  I've also been in awe of his eloquence, maybe a little jealous too.  I love his use of language and the larger context of what he articulated.  It's truly poetic and I can't get enough of reading about him and that time.

Is there a quote from Lincoln that is always with you, that has informed who you are?

I think the second inaugural is an amazing piece of writing.  The Gettysburg Address is amazing too - that's the simple answer.  If you look at a lot of his writings, he speaks about in whose hands the fate of the nation rests; he really thinks that we should be coming together and not driven apart.  The content is just amazing. His personal tragedy and political tragedy in terms of what he dealt with and his ability to see through it all to accomplish what he wanted to accomplish is just amazing.

Photography - what's your favorite subject?

I like to do landscapes and scenery.

Do you think that's an escape in a sense from the reality of your job?

Perhaps, I used to do a lot more medical slides; I have a collection that's not bad.  But I particularly like travel photography and the scenery of other countries.  I've been to Italy and Greece four times; I just go hog wild taking pictures.

Would you be willing to let us post a few of your photos on the website, maybe with your commentary?

Yes.

Is there a particular photo that you think of as your Mona Lisa?

No, not really.

None that you thought, "Wow, I'm so glad I got that one, so glad I got that opportunity!"

I suppose there are a couple of them like that one on the wall (photo of the Acropolis in Athens and the Parthenon).

Why that one?

Well, I suppose for a couple of reasons. First, because I shot two rolls of film to be able to get that one image.  Second, it is part of the heritage; I took that shot on our first trip to Greece, which was actually our honeymoon and it was one of the more special trips I've been on.  I'm sure there are a few other pictures as well.

Professionally, outside of your typical duties, what are two or three of your major areas of interest?

Probably number one on the list is EMS.  I was the EMS director for years before Chris and before Vince took it over.  I was very interested in medical care for things like mass gatherings and disasters.

Where do you see our specialty in 10 years?

I think the biggest challenge is the continued and so far unbridled growth of people who don't have health insurance.  I think that will continue to put pressure on Emergency Medicine perhaps more than any other specialty, partly by statute and partly because people have no other alternative.  We are their safety net; we are the only place they can come.  I think emergency medicine may ultimately be on the frontline of introducing healthcare reform because we can't continue the way we've been going.  One, we're seeing larger numbers of people who show up because they have no other alternative, not particularly ill, but who need medical care and have no where else to go.  Secondly,we're seeing larger numbers of people who choose not to seek medical care until they are so sick they have no alternatives.  I think Denver was pretty fortunate, for the most part, up until two or three yearsago.  We didn't have the bed crises we have now; it's gotten worse and I think it will continue to get worse.  I think the biggest challenge and potentially biggest crisis is going to come as these numbers continue to grow.  We've seen no improvement in that, healthcare costs continue to rise and the amount insured people spend on insurance continues to rise.

Isn't it a little ironic that we say emergency medicine may be the impetus for this change, and yet any potential change will likely result in a decrease in the number of patients that we see?

If we in fact solved the crisis, the number of patients may go down, but the financial health of the healthcare system, I would hope, would then improve.  The numbers may go down, but the numbers of people who are supporting it financially in terms of reimbursement would improve.

What will you miss most about this place when you leave?

I'll list a couple of things. First, I'm sure a number of residents will find this hard to believe, but the relationships of having residents around and the daily interactions in the emergency department will be missed.  I think the collegiality here has been better than probably any place I've ever been.  I think that the challenge of trying to stay even semi-smart compared to many of the people that I work with has been a large part of that.  The second thing I'm going to miss is that I like the challenge of running a busy emergency department; I like the logistical challenge of orchestrating what happens.  The one thing I think I will truly miss most is--part of what I missed when I gave up the paramedic division--was orchestrating special events, the logistics, the response to things like the G8 Summit and World Youth Day.  The challenge of organizing a response to those events is enormous and very satisfying when you're able to pull it off.  I really like the logistical planning and execution of those events.

Related to that in a sense, is the emergency room almost like a battlefield, do you draw analogies from the fighting in the Civil War?

It's a battlefield.  It's very similar.

When our residents are in the midst of a busy shift next year what will you be doing?

I will be living on my compound in Montana, hopefully taking pictures, maybe doing a little bit of fishing.  We have a cherry orchard so I'll be doing a little bit of cherry farming.  Other than that, I have no idea.  It's in a valley which, unlike Denver, is green.  It's nestled between mountains on either side and it overlooks a fairly large lake.  It faces west so I'll watch the sunset every day.