Dr. Ronald Benenson: The ER of the Past, the Present, ...and the Future?

Ronald Benenson, M.D.

We didn’t notice right away that a car had pulled into our driveway. But as soon as my husband spotted it he went out through the garage to greet Dr. Ron Benenson who was waiting patiently at the front door. He ushered our guest in and as we settled into our seats in the living room for the long-awaited interview, we became aware of a barely audible buzzing sound coming from the foyer. 

A few seconds later, Scott, my husband, realized that this was the sound of our doorbell. Dr. Benenson had pushed the switch, the soft ringing started, no one heard it, and the switch got stuck. The weak sound, the sound to alert us that someone was calling, continued unheeded.

“We have a doorbell that doesn’t make a lot of noise. We like it,” I said.

“Oh, okay,” said Ron, with a smile.

“It usually takes a while to know there’s someone at the door,” I said. 

“You have a good doorbell when you hear it and wonder, What’s that sound? That’s as loud as it gets,” said Scott. 

“Wow,” deadpanned Ron.

We laughed. 

(We were without protective masks after being vaccinated against COVID-19 before the more contagious delta variant had us concealing parts of our faces again.)

After a bit more light chatter, I asked Dr. Benenson to tell us his story.

Dr. Ronald Benenson retired from medicine a few months ago, in mid-2021. He said, with a sense of some pride and loyalty, that he and his wife Tracy, a registered respiratory therapist, worked a combined 87 years (87 years!) for the York Hospital, and then WellSpan Health. They had met at a New Year’s Eve party in 1977, during Ron’s internship. At that time, his path in medicine, where he would find his place, was still hidden. In fact, Ron’s entry into medicine altogether was partly the result of unforeseen events. 

The beginning

We will start at the beginning. He was born at the former National Homeopathic Hospital (it became Hahnemann in 1956) in D.C. between 11th and 12th on F off New York Avenue. In the mid-1950s, when he was a youngster, the family moved out of the crowded urban area to more-open Wheaton, near Silver Spring, just off of Connecticut Avenue, he said. 

The 75-bed National Homeopathic Hospital in D.C. circa 1920

His older sister had succumbed to polio at five or six, during one of the recurring epidemics, and his saddened parents, he told me, “wanted a change.” Ron was “shielded” from this by his mother and father, and he has no memory of these frightful times before the Salk vaccine became widely available in 1957.  Since then, worldwide vaccination programs have nearly eliminated the ancient virus from the Earth (a handful of wild-type cases occur yearly in  Afghanistan and Pakistan). 

Ron’s father, an economist who worked for the Department of Labor as an unemployment insurance expert, had emigrated from Belarus. He landed in New York in 1926 where he later met his future wife; both were hearing-impaired (he had scarlet fever, a common cause of deafness then). 

(At a high school event including parents, one of Ron’s good friends whispered, “Let’s go talk to your dad. His accent is great!” Ron was confused: “My dad has an accent?”)

College and medical school

Anyway, young Ron liked science in school and he went to Johns Hopkins University for his undergraduate degree. While there, he worked in a microbiology lab. But he soon realized that he was not cut out for a life of sterile laboratory work. He thought of getting outside and doing environmental biology (at the University of Michigan, maybe), or, “like everybody else at Hopkins,” going into medicine.  So he decided to take the GRE for graduate school as well as the MCAT for medicine.

The night before the GRE, Ron and his friends went to D.C. to catch a few repertory movies at the famous Art Deco Circle Theatre (where double features cost a dollar). Fortuitously (it turns out), on their way back to North Baltimore his 1964 Bel Air broke down with a cracked engine block. He missed the chance to take the test. But he had already sat through the seven-hour MCAT and he interviewed at the University of Maryland Medical School two weeks later. A letter of acceptance followed a week after that and he said to himself, "I guess I'll go to medical school." 

Circle Theatre in D.C. showing 1973's weird "Fantastic Planet" 
(The full movie can be watched here.)

Dr. Benenson didn’t tell me too much about his medical school experience but he did recall that his mentor for physical diagnosis was the master clinician-scientist infectious disease specialist Dr. Richard Hornick (1929-2011). Ron was amazed by Dr. Hornick’s uncanny ability to get the patient’s history and to arrive at the right diagnosis by “asking only four or five questions” before turning to the exam. 

Anyway, Ron likes being with people and talking with people, and he was drawn to the relatively new patient-centered specialty of Family Medicine. When he asked if he could do a rotation at the University, they said they didn’t “have time for medical students.” 

He was advised to look into the program at the York Hospital, an hour north, under Dr. Philip Roseberry, the second director, after Dr. Thomas Hart, of one of the earliest Family Medicine residencies. Dr. Roseberry was welcoming, so Ron did his rotation in York.

When, like many eager students, he wanted to do an emergency room stint in Baltimore he lost out again. The ER rotations at Maryland (the nation's first public medical school) were so popular that they were awarded by lottery. He didn’t “win.” So in 1976, he came back to York for his ER experience as a student.

Davidge Hall at the University of Maryland, the oldest building 
in the Western hemisphere used continuously
 for medical education (from wikiwand)

When it was time to look for a residency Ron picked internal medicine and decided to return to York County once more. 

After Medical School

On the first day of his internship in 1977, he was assigned to the ER. At midnight, (get this) the attending physicians in the ER left the hospital and went home (yes, they went home!). This meant that green Dr. Benenson, just weeks after graduating from medical school, was the only physician staffing the York ER till the morning. Luckily, he noted, he had the support of “an unbelievably wonderful registered nurse,” an LPN, and an aide. But he was the only doctor. 

During the day, when everyone was there, he was taught by ER physicians Drs. George Grossi, Lynn Jensen, and Dave Logan. When he finished his internal medicine residency in 1980, having rotated through the specialties, he still wasn't sure what he wanted to do.  So he stayed in York and worked in the ER.  He told me that  at that time “you did everything.” And “if you didn’t know about it you learned about it.” He spent a lot of time in "the reading room" (before the world's information was literally at the tips of our fingers).

A quiet Philadelphia hospital ER in 1970 (from The Philadelphia Inquirer)

Leaving the ER for Internal Medicine

In 1982, on the gentle urging of cardiologist Dr. Jay Nicholson, Ron decided to leave the ER and to practice general internal medicine (as he was trained). He thought about returning to the D.C. area, but you had to know somebody. Instead, he joined his colleague Dr. Fred Kephart and, with help from a block grant, they opened a practice in Red Lion. 

But Fred and his wife, Dr. Cynthia Patterson, were soon off to a medical mission in South Africa for nine months and Ron was left to run things “solo with one employee."

The practice started out slowly as he saw only thirty patients the first month. It gradually picked up. and Dr. Benenson had only two weekends off that first year. He saw patients in the office, took care of them in the hospital, visited them in nursing homes, and even did a few enlightening house calls. He enjoyed private practice but realized that he liked being in the ER "a little more."

Tracy (a York native whose grandfather, Dr. Paul Brown, was one of the founders of York’s Memorial Osteopathic Hospital), delivered their first child, Daniel, in 1984. By 1987 The “set- hours” and the “variety of patients” of regular ER work, and the opportunity for teaching were attractive and lured Ron back to emergency medicine; there was an open position at York, so he stayed.

Back to the ER

By that time, ten years after his solo night shifts, the nature of ER work had changed. It was evolving and adapting, reflecting the complexity of the often older and much sicker patients, and the major diagnostic and therapeutic advances in medicine and surgery of the late twentieth century.

A busy Brazilian ER during COVID-19 (from Researchgate)

The first full ER residency program had opened at the University of Cincinnati in 1970 and emergency medicine was recognized as a boarded specialty by 1979. The option to be certified without taking a two- or three-year ER residency ended in 1988.  Dr. Benenson, as an internist with previous ER experience, was, as they quaintly say, “grandfathered in” (an odd term). And over time, the ER, the emergency room, became the ED, the full-fledged emergency department.

Tireless Dr. Dave Eitel (1948-2012) had come to York in 1982 from Ontario, Canada, by way of New York to direct and develop York’s new academic emergency medicine residency program. Ron worked closely with Dave and served as Associate Residency Director from 1988 until 2001. Dr. Eitel was one of the co-creators of the still widely-used five-level triage algorithm for ER nurses, the Emergency Severity Index or ESI.

Triage 

Being sorted is the entry point into the ED experience. This triage (employed by Napoleon's Surgeon-in-Chief, Baron Larrey), deciding who should be treated first and who can wait (based solely on the seriousness of the condition) is critical when there are mass casualties, as in war or environmental disasters, or epidemics, and limited resources. It has become a pressing issue during the COVID-19 pandemic as intensive care units here and around the world have often been filled to near-capacity.

Triage: "Baron Jean Dominique Larrey (1766-1843)
Tending the Wounded [of either side] at the Battle of Moscow"
(painting by Louis Lejeune)

So when there are “surges” of the life-threatening viral infection it is important to identify those most in need of care. Dr. Benenson remarked that at academic meetings as far back as the 1990s there was talk of using artificial intelligence, or AI, in the ED to diagnose the cause of chest pain, often a tricky task. The use of AI has expanded and it is being introduced into the problem of triage to rapidly identify patients, including those with COVID-19, who will need intensive care urgently.

A study from South Korea involving nine million (yes, nine million) patients showed that “AI was capable of predicting [the need for] critical care at a confidence interval of 95%, outperforming the Emergency Severity Index.” AI was more sensitive in identifying such patients but it was less specific than the ESI, it was less discriminating. 

However, in the study, using ESI and AI together, combining (warm) human intelligence with (cold) artificial intelligence, was better than either approach alone. (We do better when the two sides of our brains, the left, and the right, connect.) 

The ED of the future?

So when Dr. Benenson playfully shared a vision he had years ago of the automated computerized ED of a future time, a vision where patients are loaded onto a moving conveyor belt to receive a nice cleansing bath, where they receive a venipuncture for analysis of blood samples and then a head-to-toe CT scan, he was only "joking." He was not entirely pleased as he sensed that things in the ED were moving in that direction, moving away from the fundamentals of a detailed history and meticulous physical exam (as he was taught and practiced). 

And now, in late 2021, one could add face recognition and an oral swab for rapid DNA sequencing to complete the mechanized near-future scenario. Powerful AI with so-called neural networks will process the mound of collected information and a machine will spit out a diagnosis and a treatment plan. Patients will be sorted and treated accordingly. 

Cartoon depiction of an automated medical future (from mathematica)

And all of this will happen before the patient is seen or touched. In this vision of the future, there will be little need for direct human contact. Little need for a Dr. Hornick or one of his mentees to ask four or five insightful questions before physically examining the patient to ease her fears.  

While there is no conveyor belt (this reminded me of the moving sidewalk in the 1962 TV cartoon  "The Jetsons"), other aspects of Ron's reluctant prediction are beginning to appear as more roles for artificial intelligence in medicine are identified.

The moving sidewalk behind George Jetson
(artist's cell from the 1962 show)

Improving the process

Dr. Benenson did not venture into the daunting and mysterious AI field himself. But as he took care of patients with all sorts of acute and not so acute problems that resulted in a visit to the ED at any time of the day or night, any day of the week, any day of the year, he also tried to improve the “process” of care by simpler means. Emergency medicine residency programs have long stressed the importance of academic research in addition to clinical doctoring. Dr. Benenson enjoyed this aspect of medicine, even as he stumbled into it almost by accident. 

A member of the group in the ER had done a “tiny study” on infections after mouth lacerations.  Ron casually submitted the paper to an annual Academic Emergency Society meeting. He was baffled when he was notified that it would be used at the plenary session, the opening session with everyone there, including about 400 ER physicians. There were eight presentations in all; his talk was the sixth. (Ron confided in me, with a soft chuckle, that he “didn’t even know what a plenary session was.”)

When he concluded his cautious remarks and his slides by saying that “more study is needed” this drew “a huge laugh” from the audience. This heady experience on the morning of Sunday, May 12, 1991, in D.C., was the birth of Ron’s interest in research.

(His talk? “An Evaluation of the Use of Prophylactic Antibiotics in the Management of Oral Lacerations” by Ronald S. Benenson, et. al., York Hospital. In the 105 patients, a five-day course of penicillin or erythromycin compared to placebo reduced the subsequent risk of infection from 19% to 8%. A simple study, but it was statistically significant and clinically meaningful.)

So, Ron made time for research and went to a variety of academic meetings. He didn’t publish a lot, but, for example, he and Dr. Marc Pollack reported on a protocol for evaluating residents breaking the sad news to the family when there was an unexpected death in the ED, and he worked with infectious disease specialist Dr. John McConville on a pneumonia algorithm to cut the time to giving antibiotics from six hours to 90 minutes after diagnosis. He joined with Dr. Jayaram Thimmapuram and others looking into factors affecting life-work balance in medicine and the widespread problem of burnout. 

Exhaustion (from Medical News Today)

Though he said that “in the ER every story is just a little different,” Ron tried to make the process of taking care of some common problems better and more efficient. And an algorithm, a series of unambiguous rules for diagnosis and treatment, he understood, would also speed patient flow through the terribly overcrowded ED. (Are they busy, you ask? A 2017 University of Maryland study revealed that from 1996 to 2010 ER visits accounted for 44% of all U.S. healthcare visits.)   

The ER doctor no longer sees everything

And as research advanced, the nature of the doctoring in the ED changed quite dramatically from when Dr. Benenson was almost on his own at night. He reminded me that he saw “everything” back then, from the sickest patients requiring immediate resuscitation to those with a minor sprained ankle, or those who needed a few sutures for a simple laceration, or those who just had a cold or a migraine or a bellyache. 

But now, he said, that breadth of experience is harder to come by as minor problems are routinely shunted (triaged) directly to the nurse practitioners or physician's assistants while the doctors tend to those with more complex and difficult conditions. 

And as in all other areas of medicine, there has been a progressive division of labor among ED physicians. Different problems are seen by different practitioners with specific fellowship training and special expertise. For example, emergency physicians may train further in the use of bedside ultrasound, toxicology, pain medicine, sports medicine, or surgical or medical critical care. No longer does a single attending see whatever comes through the automatic doors.

Modern ED floor plan and flow diagram (from Design Collaborative)

In addition, we, as patients, now have other options for where to go for acute medical attention, and the (overburdened) ED can be used more wisely. When the primary care office is closed or fully booked or when there is no primary care physician at all a trip to an urgent care facility is less time-consuming and much less costly than a visit to the hospital. 

In fact, it has been stated that 40% to 60% of ED patients could be seen just as well at urgent care centers. The benefit? The average wait to be seen in the ED is more than two hours, but only 30 minutes at an urgent care center; the ED cost averages $1,400 vs. $100-150 for urgent care, ten times as much.

Ron visits the ED as a patient

As a life-long athlete who has suffered common shoulder and knee injuries, Ron has made a few unplanned trips to the ED himself. However, one ED visit for a different reason was particularly eventful.  He had experienced prolonged episodes of chest discomfort and shortness of breath for a while, but since he could still play competitive soccer in an over-40 league he was sure it wasn’t serious. Until one day in 1999.  He was at the local athletic shoe store and Tracy just happened to be there when he had an attack. He was in pain and sweating profusely; she immediately drove him to the hospital. 

A cardiologist who was there seeing someone else in the ED spotted Dr. Benenson and recommended an emergency stress-echocardiogram. The technician doing the study watched the screen and saw that he had a leaky mitral valve. She asked him how long had he had the murmur. What murmur? It was news to him. The cardiologists treated him, and he was able to go until 2009, still playing soccer, before needing a valve replacement.

(Stubbornly, he didn’t give his soccer cleats away until 2017 when he was in India with Daniel, went after a loose ball, and pulled a muscle.)

Speaking of Daniel, Ron’s kids live together in Philadelphia. Rachel is an oncology social worker at Pennsylvania Hospital; her brother teaches English as a second language and walks dogs. To save on rent, Dr. Benenson purchased a house for them in trendy Fishtown.    

Fishtown street scene (from Philadelphia Magazine)

Looking back on his long career, Ron said that in York, “the practice of medicine has changed dramatically” from the time he started. Back then the hospital “felt like a family” and you knew pretty much all the consultants. This easy familiarity has gradually been eroded as medicine everywhere “has become more corporate.”  

Corporate. In his recent book about AI and the future of medicine, Dr. Eric Topol, cardiologist, and Editor-in-Chief of the physicians' website Medscape writes, for example, that much of the stress and burnout experienced by physicians today can be traced to arbitrary time constraints as a result of the pervasive corporate bottom-line emphasis on productivity. 

He leaves the ED again and focuses on research

So when Ron decided to leave the ED nearly eight years ago ("November 24, 2013, not that I remember," he quipped) he was "spent." Too much of his time was consumed with “more paperwork and more documentation” and “checking boxes (in the electronic health record) to establish the level of care.” And, as a direct result, and most importantly, "there was less time to see the patient." Ron was, he admitted, "burned out."

Physician (and nurse) burnout is becoming increasingly common. It might be less likely in the future, wrote Dr. Topol, with time-saving AI tools. But only if physicians learn to use AI and, in fact, all algorithms wisely, he noted. And with humane understanding of their limitations. He said that while artificial intelligence is really good at narrow tasks like pattern recognition, such as analyzing images produced by CT and MRI, skin lesions, or slides of biopsy tissue, it is less good with softer data. And it is not good at all, said Dr. Topol, when diagnosis and treatment require empathic understanding of a person. 

So Ron felt that he needed to change course and do something else. He turned back to his research experience and spent the last phase of his career working at the hospital’s Emig Research Center where he focused on teaching and mentoring. He especially enjoyed doing the journal clubs with the residents and attendings from different departments. 

He tried to encourage the habit of critical thinking and to provide a basis for understanding simple statistics as he and his colleagues carefully picked apart the latest research studies. He told me that “every article has its flaws” and that it is necessary to know if these are important.

The athlete gets hurt  

Though Ron, as we saw, eventually gave up soccer he has stayed athletic and he’s an avid cyclist. In July 2020 he was riding on the 14-mile Northwest Lancaster County River Trail with his good friend Dr. Dave Neuburger when he crashed as he was speeding up trying to avoid another rider. He fractured his clavicle and his pelvis, the “acetabulum” (the socket where the head of the femur rests), he said. 

Serene view of the Wrightsville bridge
from the Northwest Lancaster River Trail (from traillink)

Dave examined him carefully and called 911. Instead of going to the nearest hospital, as is the rule, Ron asked the ambulance crew to take him across the river to the York Hospital “where everybody knows your name.” After surgery to fix the fracture and ten weeks in a wheelchair he eventually got back on his bike. 

A nostalgic journey back in time, just before college

Apart from athletics, Dr. Benenson also enjoys film and music, so a story from the late 1960s. 

Ron and his friends, in two carloads, headed to the August 15-17, 1969 Woodstock Music & Art Fair, billed as an "Aquarian Exposition." After the car he was in blew a tire on the packed New York State Thruway he was able to make it to his great aunt Ida's house not far from the concert venue; everybody else (along with his clothes) ended up at Bethel, at  Max Yasgur's 600-acre farm. When Ron finally got to the site the crowd had swelled so much that they were no longer checking tickets, so he simply  walked in. (He kept the original program and his unused ticket.)

The peaceful sea of humanity ("kids" according to Max) at Woodstock 

Ron searched and searched for his friends in the throng of (possibly) more than 400,000 peaceful idealistic young concertgoers. That night he slept in a hut fashioned from bales of hay and, amazingly, he finally found his buddies behind the main stage the next day. (Contrary to what is often said, Ron was at Woodstock and remembers the music.) 

Leadership positions outside of the ED  

Anyway, getting back to Dr. Benenson's career, during his many years with WellSpan, he enjoyed serving on a number of important committees. He was vice-chair and (for seven years) chair of the Institutional Review Board or IRB for research studies. He was also chair of the Pharmacy and Therapeutic Committee, and the Pneumonia Clinical Effectiveness team. For a number of years, he was the only physician on the Medication Safety Committee. 

Ron has made time to volunteer in the community with Jewish Family Services (where he was board president until recently), and he and Tracy continue their work with several local food banks.

And as we finish

It was nearly two hours into the interview as we were winding things down that Ron’s phone rang. His daughter Rachel called to say they needed a new doorknob for their place in Philly. She asked him how many spare keys he wanted.  

At this, my thoughts drifted back to our nearly silent and totally useless doorbell. We could update it with a “smart” one with video and AI-enhanced face recognition. It would summon us to let us know that there is someone at the front door. 

And with its prior experience and advanced machine learning skills, it would quickly identify the caller and the likely reason for their visit. That would be helpful, sure, but I will need to peek through the blinds to see for myself who it is before opening the door. If it is kindly Dr. Ron Benenson again, I will gladly let him in.

Aquarius/Let the Sunshine In

When the moon is in the Seventh House/And Jupiter aligns with Mars

Then peace will guide the planets/And love will steer the stars

This is the Age of Aquarius...

(by James Rado, Gerome Ragni, and Galt MacDermot)

References and Suggested Readings:

1. Kang, Da-Young, et.al. "Artificial intelligence algorithm to predict the need for critical care in prehospital emergency medical services." Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, vol. 28, no.1, 4 Mar. 2020.

2. Marcozzi, David, et. al. "Trends in the Contribution of Emergency Departments to the Provision of Health Care in the USA. International Journal of Health Services, 2018; 48(2):267-288.

3.  Topol, Eric. Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again. Basic Books. New York, 2019.

Photo by SC

by Anita Cherry 10/2/21