By L. Anthony Cirillo, MD, President of the American College of Emergency Physicians (ACEP)
June 25, 2026
In the modern landscape of American healthcare, the Emergency Department (ED) has become a lightning rod for criticism. Often characterized by insurers and policy analysts as a site of fiscal inefficiency and "over-utilization," the ED is frequently scapegoated for the rising costs of the nation’s medical system. However, a recent op-ed published by MedPage Today, titled "The Case Against Calling It ‘Emergency Medicine,’" serves as a poignant reminder of how easily the complexities of acute care can be distorted by narrow economic perspectives.
By miscasting the fundamental mission of emergency medicine, these narratives threaten to undermine the very safety net upon which millions of Americans rely. To address these misconceptions, we must examine the reality of clinical decision-making, the socioeconomic drivers of ED visits, and the essential role of the "prudent layperson" standard in a functional healthcare system.
The Myth of Over-Utilization and Costly Imaging
The prevailing narrative—often pushed by payors—suggests that emergency departments are centers of waste where physicians reflexively order expensive imaging studies, such as CT scans, to protect themselves from malpractice litigation. This argument is not only reductive; it is factually hollow.
Defensive Medicine vs. Diagnostic Accuracy
While the fear of litigation is a constant shadow in medicine, it is not the primary driver of diagnostic testing. The reality is far more altruistic and professional: emergency physicians order imaging because they are tasked with identifying life-threatening conditions in patients who are often "undifferentiated." When a patient presents with chest pain or a severe headache, the physician must rule out a myriad of catastrophic possibilities, from aortic dissection to intracranial hemorrhage, within a limited timeframe.
The drive to order testing is embedded in the professional identity of the emergency physician. It is a commitment to the patient’s safety. To characterize this diagnostic rigor as "over-utilization" is to ignore the clinical stakes. As highlighted in research published in the Annals of Emergency Medicine, efforts to arbitrarily reduce imaging volumes must be approached with extreme caution. A reduction in scans carries a significant risk of missed or delayed diagnoses, the consequences of which are often catastrophic for patients and legally devastating for the healthcare system.
The Problem with Hindsight Bias
Critics often look at negative imaging results—scans that reveal no acute abnormality—and label them as "wasteful." This is a classic example of hindsight bias. It is easy to judge a test as unnecessary after it has confirmed the patient is healthy. However, it is an entirely different burden to be at the bedside of a patient in their most vulnerable moment, tasked with determining whether they are experiencing a lethal event. A 98% sensitivity rate for a decision rule sounds impressive in a textbook, but in practice, a 2% miss rate for a life-threatening illness is a statistical and moral failure.
The Patient’s Perspective: Why They Choose the ED
The argument that EDs are "overused" ignores the lived reality of the American patient. When an individual suffers a sudden, terrifying symptom, they do not have the clinical training to perform a triage assessment. They do not know if their symptoms are benign or terminal.
Braving the Barriers
We must recognize the significant obstacles patients face before they even walk through our doors. In the current climate, many patients arrive at the ED after struggling with fragmented primary care, lack of insurance, or geographic isolation. Furthermore, they are entering an environment currently strained by an historic boarding crisis. Patients often wait hours in crowded, uncomfortable conditions—not because they prefer the ED to a clinic, but because they have nowhere else to go.
They brave the weather, the wait times, and the systemic uncertainty because they possess one fundamental truth: they know that when they are worried, sick, or injured, the emergency department will be there. We are the only part of the healthcare system that is mandated to treat every single person who arrives, regardless of their ability to pay or the complexity of their condition.
Chronology of a Crisis: The Erosion of Emergency Care
To understand the current tension, we must look at the historical timeline of emergency medicine’s role in the U.S.
- The Pre-1980s Era: Emergency departments were often disorganized collections of rotating specialists. The field was not yet recognized as a distinct specialty, leading to inconsistent care standards.
- The Formalization (1979): The American Board of Medical Specialties formally recognized Emergency Medicine as a specialty, creating the standardized training and professional identity that exists today.
- The EMTALA Mandate (1986): The Emergency Medical Treatment and Labor Act (EMTALA) was enacted to prevent "patient dumping." This law codified the duty of hospitals to stabilize and treat anyone in an emergency, effectively enshrining the ED as the nation’s primary safety net.
- The Rise of the "Prudent Layperson" (1990s-Present): As insurers began denying claims for emergency services by retroactively deciding that a patient’s condition wasn’t "severe enough," the Prudent Layperson standard was established. This standard dictates that coverage must be based on the patient’s symptoms at the time of arrival, not the final diagnosis.
- The Modern Boarding Crisis (2020-2026): The intersection of post-pandemic staffing shortages, reduced hospital capacity, and increasing patient acuity has resulted in severe boarding, where patients wait for hours or days for an inpatient bed.
Supporting Data: Efficiency vs. Access
Data regarding ED spending is frequently misrepresented to support the narrative of "overuse." While ED visits are costly, they represent a small fraction of overall healthcare spending—a fact often obscured by those looking to cut costs at the expense of access.
A critical point often missed by critics is that the ED serves as the diagnostic engine for the hospital. By quickly identifying serious pathology, the ED facilitates rapid intervention, which often prevents longer, more expensive inpatient stays. Furthermore, for the uninsured and underinsured, the ED is the only point of entry into the health system. If we reduce access to the ED, we do not solve the health problem; we simply delay care until the condition becomes significantly more expensive to treat—or fatal.
The Official Response: ACEP’s Stance
The American College of Emergency Physicians (ACEP) remains steadfast in its defense of the ED’s mission. For decades, we have fought to uphold the Prudent Layperson standard. This is not merely an insurance issue; it is a fundamental human rights issue.
Our position is clear:
- Access is non-negotiable: Patients must be able to seek care when they are worried without the fear of financial ruin based on the final diagnosis.
- Clinical Autonomy: Emergency physicians must be free to make diagnostic decisions based on clinical judgment, not on arbitrary cost-containment measures that jeopardize patient safety.
- Addressing Root Causes: The "overuse" of the ED is a symptom of a failing primary care and mental health infrastructure. We cannot solve the symptom by destroying the cure.
Implications: The Future of the Safety Net
If the critics succeed in redefining "emergency" to limit access, the implications for the American public will be dire. We will see an increase in preventable deaths, a widening of health disparities, and a loss of trust in the healthcare system.
The emergency department is not a luxury; it is the heartbeat of our medical infrastructure. We are open 24/7, 365 days a year, providing high-quality care to everyone, regardless of the circumstances. We are not going anywhere, and we will continue to advocate for the patients who need us most.
The path forward is not to narrow the definition of an emergency, but to invest in a healthcare system that provides timely, accessible, and affordable care long before a patient reaches their breaking point. Until that day comes, the Emergency Department will remain the last, best hope for the millions who rely on us. It is time we stop viewing this essential service as a burden and start recognizing it for what it truly is: a vital, irreplaceable public good.
