Objective Among older persons, disability and functional decline are associated with increased mortality, institutionalization, and costs. To determine whether illnesses and injuries leading to an emergency department (ED) visit but not hospitalization are associated with functional decline among community-living older persons. Methods From a cohort of 754 community-living older persons who have been followed with monthly interviews for up to 14 years, we matched 813 ED visits without hospitalization (ED-only) to 813 observations without an ED visit or hospitalization (control). We compared the course of disability over the following 6 months between the 2 matched groups. To establish a frame of reference, we also compared the ED-only group with an unmatched group who were hospitalized after an ED visit (ED-hospitalized). Disability scores (range: 0 [lowest] to 13 [highest]) were compared using generalized linear models adjusted for relevant covariates. Admission to a nursing home and mortality were evaluated as secondary outcomes. Results The ED-only and control groups were well matched. For both groups, the mean age was 83.6 years, and 69% were female. The baseline disability scores were 3.4 and 3.6 in the ED-only and control group, respectively. Over the 6-month follow-up period, the ED-only group had significantly higher disability scores than the control group, with an adjusted risk ratio (RR) of 1.14 (95%CI, 1.09–1.19). Compared with participants in the ED-only group, those who were hospitalized after an ED visit had disability scores that were significantly higher (RR 1.17, 95%CI, 1.12–1.22). Both nursing home admissions (HR 3.11, 95%CI, 2.05–4.72) and mortality (HR 1.93, 95%CI 1.07–3.49) were also higher in the ED-only group versus control group over the 6-month follow-up period. Conclusions Although not as debilitating as an acute hospitalization, illnesses and injuries leading to an ED visit without hospitalization were associated with a clinically meaningful decline in functional status over the following 6 months, suggesting that the period after an ED visit represents a vulnerable time for community-living older persons.

Medicine is a science of uncertainty and an art of probability.-William Osler 1 Reduction of uncertainty is essential to the practice of medicine, but elimination of uncertainty is impossible.-Benjamin Djulbegovic and Sander Greenland 2 Uncertainty is inherent in the practice of medicine. Dermatologists can never be completely certain that a benign-appearing skin lesion is not a skin cancer; radiologists cannot be certain that changes on a chest radiograph are the result of pneumonia. No diagnostic test is 100% accurate, and even with additional testing such as a biopsy or a computed tomography (CT) scan, some degree of uncertainty remains. Until recently, physicians have had little choice but to tolerate uncertainty. Clinical radiography and electrocardiography did not become available until the end of the 19th century, and many other diagnostic tests have become part of routine clinical practice only in the past few decades. Uncertainty has always been a reality, but increased availability of diagnostic options means that the physician's response to uncertainty is now an important factor in clinical care.

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Gender inequity is pervasive in medicine, including emergency medicine (EM), and is well documented in workforce representation, leadership, financial compensation, and resource allocation. The reasons for gender inequities in medicine, including academic EM, are multifactorial and include disadvantageous institutional parental, family, and promotion policies; workplace environment and culture; implicit biases; and a paucity of women physician leader role models, mentors, and sponsors. To address some of the challenges of gender inequities and career advancement for women in academic EM, we established an innovative, peer-driven, multi-institutional consortium of women EM faculty employed at four distinct hospitals affiliated with one medical school. The consortium combined financial and faculty resources to execute genderspecific programs not feasible at an individual institution due to limited funding and faculty availability. The programs included leadership skill-building and negotiation seminars for consortium members. The consortium created a collaborative community designed specifically to enrich career development for women in academic EM, with a formal organizational structure to connect faculty from four hospitals under one academic institution. The objective of this report is to describe the creation of this cross-institutional consortium focused on career development, academic productivity, and networking and sharing best practices for work-life integration for academic EM women faculty. This consortium-building model could be used to enhance existing institutional career development structures for women and other physician communities in academic medicine with unique career advancement challenges.