The Tsunami: Neither Hasten nor Postpone Death

The Centers for Disease Control reports that 8.7% of all ED visits in 2001 were by patients aged 75 and older.[1] At Maimonides Medical Center 16% of our patients fall in this age group. Though I’m a “baby boomer” and he’s not, Daniel G. Murphy, MD, MBA (Hofstra Business School, May 2003) our Vice-Chair and Medical Director for nearly eight years has given much more thought than I to this theme. So let me turn this month’s column over to Dan.


Perhaps I use too many metaphors explaining my thoughts, but one bantered about in Boston this October at various Quality Improvement and Patient Safety Section, Geriatric Section and Benchmarking Alliance meetings during the recent ACEP Scientific Assembly needs sharing among us:

“A tsunami is coming!”

For years, we have worked hard to make our emergency departments more efficient. Best practices, data driven CQI, customer service, error reduction, computerization, decision support, streamlined bed control and standardized peer review processes are just a few of the successful efforts and new paradigms. It’s a good thing too, since the role of emergency departments in America grows more crucial and more burdened annually.

But a tsunami is coming, already visible on the horizon, presaged by choppy and rough surf today (crowding), and it may wipe us out before we retire. The tsunami is the aging ‘baby boomer’ generation and emergency departments and hospitals are (to complete the metaphor) the coastal villages lying directly in its path. It provides a dispiriting backdrop for today’s EM CQI tinker. Input may soon overwhelm a process already lamenting its inability to transfer admitted output (inpatient boarders).

One way to prepare for and assuage this impending disaster is to reconsider how we die in America. We need to die better, with our families, perhaps at home, with no one doing chest compressions and no one putting a tube down our throat. Hand holding, praying, crying and feeling is much better. We just need a major culture change and then implement better end-of-life education and better communication.

I know the following: a) more of my patients are very close to or at the end of life, b) emergency departments and hospitals are horrible places to spend the end of one’s life and c) we do a poor job of caring for patients and guiding families at the end of life.

We need to help identify that point in a person’s (person, not patient) life where there is more value and reward in focusing on planning, comfort, dignity, family and ritual. Life is a terminal condition. Palliative care is a desirable choice for almost all people at some point prior to death, whether it is hours, days, weeks or months before their final breath.

In the July-August 2003 SAEM newsletter, Drs. Quest and Abbott summarized the World Health Organizations definition of palliative care.[2] :

• Active, total care of patients whose disease is not responsive to curative treatment.
• Control of pain and other distressing symptoms.
• Address psychological, social and spiritual problems.
• Achieve the best quality of life.
• Affirm life and regard dying as normal.
• Neither hasten nor postpone death.
• Offer a support system for patients to live as actively as possible before death and to help families cope and then bereave.

But what can we do in the emergency department? The nursing home keeps sending them. The families can’t handle it! There is little expertise and ability at home. Sometimes there seems to be little end-of-life expertise in the nursing home. By the time the dying elder is in the ER, the opportunity for privacy, tranquility and even dignity are lost. If we don’t ignore you, we may intubate you! Our comfort with natural death and dying is notoriously fragile in the ER. We will almost certainly stick some tube into an orifice. It’s our nature.

Some of us in the United States are comfortable with impending death only when paperwork is current and pristine. The documentation includes ‘do not resuscitate’, ‘do not intubate’, other advanced directives, living wills and health care proxies. Is the need for certified, renewed and impersonal contracts reflecting some difficulty of the American healthcare system to connect with our patients at the humane and primary care levels? Do we fail to see the forest, only some frustrating tree, confounded and frightened by medico-legal risk?

As Mildred Solomon, EdD[3] and Linda Kristjanson, PhD[4] explain of the Australian healthcare system, “Long-term relationships between general practitioners, patients and families, coupled with the existence of palliative care services, solve many of the communication problems that, in the United States, advance care directives are intended to ameliorate. Once the decision to accept palliative care is made, people accept that certain things won’t happen, the resuscitation matter dissolves, and patient, family and health care team address each end-of-life question, such as tube feedings or the use of antibiotics, as these issues arise.” Kristjanson continues, “You know your patient, the relationship is very individualized, thus an advanced directive would be seen as a legalistic document that would be incongruent in the context of the relationship.”

Such holistic, generalist, and humane approaches are unusual where we practice. Indeed, too many elders seem to have a neurologist, cardiologist, podiatrist, cardiothoracic surgeon and dermatologist, but no one who takes responsibility for the care of the person instead of an organ system. I witness nursing home admission procedures where patient-physician relationships that have endured decades are terminated just as end-of-life planning is most crucial. As long as our federal healthcare reimbursement model encourages procedures instead of humane, generalist care, form will follow finance and poorly integrated, intrusive and wastefully expensive end-of-life care may predominate.

But I ask again, what can we do in the emergency department? What can we do as emergency physicians?

I believe that our contribution could be significant. We are, after all, generalists. We are capable of seeing the big picture and treating or palliating every sort of ailment and organ system. Are there desired end-of-life services that we are uniquely qualified to provide? Perhaps there is a significant pre-hospital or ED need and market eager for our care, advice and skills.

In the House of God,[5] the term GOMER was first publicized. How ironic to consider the phrase as prescient, desirable and sophisticated. Look out to sea. A tsunami is coming. There may still be time to build an adequate sea wall and save the village. If we work hard and fast, we will just get bumped around and wet like we always do.


[1]McCaig, LF and Burt, CW: National Hospital Ambulatory Medical Care Survey: 2001 Emergency Department Summary in CDC Advance Data from Vital and Health Statistics. No. 335, June 4, 2003.

[2]Quest TE and Abbott J for the SAEM Ethics Committee: Palliative Care and the Emergency Physician: Finding our Way. The SAEM Newsletter XV(4): 14, July-August 2003.

[3]Solomon MZ. Why are Advance Directives a Non-Issue Outside the United States? In: Solomon MZ, Romer AL, Heller KS, eds. Innovations in end-of-life care: practical strategies and international perspectives. 1st ed. Larchmont, NY: Mary Ann Liebert, Inc, 2000: 13-18.

[4]Kristjanson L. Advance Care Planning in the Australian Context. In: Solomon MZ, Romer AL, Heller KS, eds. Innovations in end-of-life care: practical strategies and international perspectives. 1st ed. Larchmont, NY: Mary Ann Liebert, Inc, 2000: 43-46

[5]Shem, S: The House of God. Dell, 2003

When Frustrations Threaten Your Team; also, Implementing Five-level Triage

The tumultuous past few years and the challenges posed have caused all of us to devote energy and time to our community service functions. Whether through disaster planning within our own organizations, community-wide planning as required by the JCAHO or interpreting the newest EMTALA regulations application in our local environment, we’re devoting a great deal of energy and time reacting to these external forces. Some physicians are angrily expressing the frustration that comes from the loss of control—beholden as we are to these requirements and agencies; with income and total work hours under pressure, our stressors accumulate.

Externally and within our own groups, colleagues are speaking out. Polemics advancing polarized remedies of libertarian utopian fantasies of “no pay, no service” or socialistic locked in single-payer models with no option for private sector care are advanced more as rants than as catalysts towards a solution. Meanwhile, as Dr. Kenneth Frumkin, a colleague emergency physician in a recent emed-l posting points out, adequate physician staffing is challenging at least one community-based free clinic, even if malpractice coverage is available. In some communities and regardless of our political position, as a group we are failing in our charitable responsibilities that many would assert should be our professional position. Others respond that’s because we are “forced” to deliver care for free through the EMTALA mandate.

The issues are undeniably complex; I have neither ready remedy nor the column-inches for such a manifesto if I had. Rather, acknowledging that the differences of opinion within my own practice of nearly 30 physicians may lead to tensions—often unspoken—among group members, how can I—and you—as leader of a group with perhaps similar circumstances maintain the effectiveness of our groups? Simple acknowledgment of the monumental differences of opinion among our diverse group of physician colleagues in these times only goes just so far.

Here too, I have no ready answer, but fortunately, since physicians are people and thus tend to find affinity among like-minded colleagues and with most groups smaller than my own, the likely range of opinion on these subjects is relatively small. Still, ignoring the debate outside may not suffice if even one colleague inside your practice persistently puts forward a particularly strong view.

For all the conflict differences of opinion may engender, omitting communication will engender more. So long as the discussion is reasonably focused on the activities of the group, does not include ad hominem attacks and results in an action oriented outcome, political discussion—even that constrained to a tiny fragment of the overall issue.

If you’re to have much success at this endeavor, some preparation is required.

Speak to your most outspoken colleague and offer the opportunity for the discussion. Set forth ground rules as noted above and do set a time limit for the discussion. Insist that if the discussion strays into attacks on others as distinct from differences of opinion that the conversation will stop. Most importantly, determine how the discussion illuminates an issue that you, your group and hospital must address. New regulatory “guidance” can provide an excellent motivation for conducting such a discussion since the compulsion inherent in the regulation often evokes physician frustration and passive-aggressive behavior rather than compliance with the new regulation. Vigorous discussion is a better use of the energy and may help reconcile some to the change.

Elsewhere in this issue of Emergency Medicine News a long-time professional colleague and dare I say friend, Kenneth Frumkin, MD, (the same mentioned above) discusses a “recommendation” for the adoption of a five-level triage system which is apparently pending from both ACEP and ENA. Ken demurs. I won’t restate his case; rather I suggest you read his editorial. Yes, to some degree, Ken is a frustrated physician, angered or at least challenged by the assumption on the part of these professional societies, that their recommendation should necessarily be implemented.

I respect Ken’s point of view and given our own deficiencies in the use of a five-level triage system despite my personal enthusiasm for it, experience is leading me to a grudging acceptance of Ken’s argument.

Yet, allowing that as the manager of the ED and leader of a complex interdisciplinary team I may be overly attentive to both resource allocation and management issues; I’m still persuaded of the management and planning utility delivered by the positive predictive value for resource requirements and for likelihood for admission that was the original reason for the development of the emergency severity index (ESI). If there is a three-level triage system with comparable reliability and predictive value, I’m unaware of it.

Let me explain why these factors matter to me. As a manager I would rather plan in advance and develop and rehearse contingency plans for likely eventualities. I suspect you are sympathetic to that philosophy—narrowly stated and applied—in preference to merely unplanned reaction to circumstances. We have some evidence in emergency medicine (see for example, Hoffenberg S., et.al., AnnEM 38(5):533-540, 2001) that explicit decision rules (i.e., “When the third ambulance gets to triage, assign nurse #2 to triage.” compared to “When the third ambulance gets to triage, a nurse should help out at triage.”) work better than a general statement at reducing length of stay.

Why does this matter? It matters because once we have the data through ESI or another reliable, validated triage tool with high positive predictive value for resource requirements and admission likelihood, we can approach hospital management with the argument that a level of demand for resources of “X” is highly correlated with negative consequences and should mandate a response other than business as usual.

Just as our practice has evolved since 1978 from accepting that half the patients with chest pain admitted to the CCU would “rule out” to today’s model of risk assessment for morbidity and mortality from acute coronary syndrome with consequent referral for care into differing clinical settings, so too might we look forward to a time when triage assessment data will help us go beyond mere counting of patients and admission rates as our only tool for retrospectively assessing our workload. Prospective evaluations facilitated by tools such as ESI may help us deploy resources more effectively and support the case for more resources at any given moment.

In the meantime, Ken may just be right as to the value of implementing five-level triage in your own ED; but then perhaps you may conceive of a larger purpose in going forward with this recommendation. Regardless, rather than merely imposing the change, perhaps some structured, if animated; discussion among clinicians in your ED may help reduce the frustration level.

Developing Your Doctors: Management Complimenting Your Leadership

A decade ago, firmly ensconced in an academic health sciences center and as a relatively recently tenured full-professor I became a participant in an exercise intended to assure the medical school that tenured faculty remained productive. A worthy idea, but various events conspired to leave me with little more to show for it than a loose leaf binder full of barely intelligible notes, some beautifully printed but poorly documented forms and a floppy disk full of WordPerfect™ templates.

Over the years I’ve been at Maimonides, I’ve reworked those forms and the ideas embedded in them for our employed, but non-tenured physician practice. In harkening back to the idea in my column of July 2000 of the “Pyramid of Medical Staff Development” it seemed to me that I needed a management tool that would implement my leadership idea. Then too, as our department focused on developing a residency faculty from out of a clinically focused physician staff, the ambitions of individual physicians manifested—supporting the individual physicians’ professional development and security seemed appropriate to the process.

As shown in Figure 1, medical_staff_pyramid
the “pyramid” develops from recruitment through the phases of managing a medical staff. Like you, I have a fine staff; but do they understand not only the mission of the department but also the strategic objectives the hospital and department have in mind for accomplishing this year, and next? Only if I tell them. Yet at the same time these physicians have ambitions for their own career, and I’m responsible to help them attain those.

So I’ve worked and reworked the decade old forms and instructions and developed a package that we distributed last year; but which I really didn’t fully follow through on implementing all of the steps. This year with the help of my office assistant, I hope to do a better of job of staying on schedule and take this professional development tool from an idea to an accomplishment to a routine component of my work. The essence of the tool is shown in Figure 2.

A cover sheet with a preamble and signature/date blocks for you and the staff member covers how many ever sheets needed for your staff member to describe their ambitions for the forthcoming contract year. The broad areas of accomplishment should fit with your environment. In a small community hospital practice you may include nothing more than “clinical service;” “service to department, institution and community” and “other activities.” At an academic health sciences center, which doesn’t impose its own approach, you may find a single category for “scholarship” overly restrictive. Including an additional sheet allows for the staff member’s personal goal statement for the next 2-5 years (A junior person probably won’t want to look further ahead; a mid-career physician may enjoy the opportunity for expressing a desire for stability or change over the period.). It also provides room for a time breakdown—in percentages—among the categories included.

Mail or email the forms to your staff members and ask them to complete the forms prior to meeting with you at contract renewal time, perhaps in the quarter prior to the new contract year. Regardless of the number of categories selected, the form is a tool that precipitates one-on-one discussion and deliberation with you. It provides you an opportunity for understanding your staff member’s horizon while allowing you chance to share your specific objectives for your department and while coming to a “fit.” Don’t merely accept the input, discuss and “test” it by asking yourself and your staff member how you will both know that the objective has been met.

By encouraging at least two regular meetings annually at which clinical productivity and clinical performance can also be reviewed you provide the feedback necessary for your physician staffs’ growth in performance and confidence in your leadership through conveying your continuing interest and support of your staff member’s overall professional growth and development.

At the beginning of each subsequent year, your staff member returns with both a new set of forms for the forthcoming year and the previous year’s forms completed with their self-assessment of their level of accomplishment. This meeting becomes both a review and a look forward with the forms providing a chronological record of objectives and expectations asserted and a measure of their accomplishment—together a fine management accomplishment in support of your leadership.

Figure 2

[Area of accomplishment & evaluation (see list below)]
(make all boxes auto-resizable in word processor)

Physician Annual Objectives:

List specific, measurable accomplishments; ask staff member to complete this section prior to meeting with you at contract renewal time.  Don’t hesitate to edit and enhance with your staff member during your meeting.

Chair’s Response:

Describe exactly what support will be provided; complete in longhand at time of meeting with staff member for contract renewal.

Level of Accomplishment:

Entries made by staff member continuously as objectives accomplished;  reviewed with chair at ~5-6 months into contract year and again at contract renewal time.

Chair’s Response:

Interim evaluation entered related just to these objectives at mid-year meeting; overall evaluation on these objectives entered at contract renewal time.

Areas of accomplishment & evaluation:
1. Clinical Service
2. Teaching of Residents, Interns and Medical Students
3. Teaching of other than above (might include EMS personnel, nurses, PAs, etc.)
4. Scholarship (including publication in peer-reviewed journals, books and other critically; reviewed forums; invited presentations outside of your institution)
5. Professional Service to department, institution and community (departmental administrative work, speaking to medical staff or other departments, representing the department or institution to community or governmental groups, health fairs, becoming a “nighthawk”, etc.)
6. Other activities (self improvement, including adding ultrasound credentialing, pursuing an advanced degree

Learning How to Learn for ABEM’s Lifelong Learning and Self-Assessment (LLSA) and Then the Lights Went Out

How are you and your colleagues in your practice addressing preparation for the Emergency Medicine Continuous Certification (EMCC) program? I’ve heard that some groups are trying a journal club approach for learning the content of these articles. Many commercial CME opportunities based on the LLSA articles are in development or already advertised. Taking advantage of our residency program and incorporating the LLSA articles into the formally presented content will teach our residents important content and help them improve critical literature review skills, but it may also draw more attending staff to these conferences. This past week’s resident conference session included an hour devoted to analyzing and discussing one of the 20 articles in the 2004 LLSA reading list (http://www.abem.org/faculty/index.htm) as part of our formal presentation of diagnosis and management of pulmonary embolism. It was the first time we directly incorporated this content into our conference and we plan to do work our way through all 20 articles this year.

So, I read the article in preparation for the conference and went as scheduled—and quickly discovered that I had read the words, but not applied critical reading and interpretation skills. I’m learning to read the emergency medicine literature all over again because of LLSA. Doctor Amy Church, our residency director, led off the discussion with a review of concepts: sensitivity, specificity, likelihood ratios negative and positive, etc. I disengaged a bit and then realized that Dr. Church was defining the negative likelihood ratio in a way I’d never heard it described previously. Now, she had my attention.

Things went downhill from there . . . at least for my ego. I’ve read a lot over the past 28 years, for many years I reviewed manuscripts for several emergency medicine journals. Clearly the standards have risen and I’ve obviously slipped in my critical reading skills for the medical literature. So not only do I need to learn the content of these 20 articles, I need to pay attention to the core concepts of evidence-based medicine if I truly wish to grasp the important content. Thus the ABEM EMCC process reminds me that learning never stops at many different levels. This LLSA program is going to be challenging, but I’m certain I’ll learn what I need to learn; I’m not giving up my ABEM certification anytime soon!

But, applying the evidence based principles in the article on diagnostic tests for pulmonary embolism will surely challenge my practice. Fortunately, today we work from practice guidelines more often than not and though our electronic record won’t be implementing decision support for some time yet, the selection of laboratory tests for pulmonary embolism this paper speaks to is something we can mostly work out with our chair of pathology and laboratory director. For surely that’s part of the purpose of the LLSA component of ABEM’s: integration of the important new knowledge into our practice.

And then the lights went out. I was writing this piece, trying to get it in on time (which would have surprised my editor) when the lights went out, in Brooklyn and in much of the Northeast. Once more we activated our emergency response plan as did many of you. We fortunately only operated on emergency power for 12 hours and then the lights came back on, but I learned an important lesson. We have no guidelines, no policies addressing the likely reliability of our generator power and our electronic medical records under these circumstances. Moving to paper or staying with the electronic medical record wasn’t addressed. Perhaps I shouldn’t have even considered the question, but past experiences with hospital generators was not confidence inspiring that the ~24 hours of generator capacity required would be available—in fact though other hospitals needed more than 24 hours of capacity, we needed only 12 hours and our system of five generators performed reliably throughout. Still, we nearly lost our electronic record 7-8 hours into the blackout because the air-conditioning in the computer command center had not been properly connected to generator power and thus didn’t fully function. New cabling installed by flashlight solved the problem, but not until the command center reached 102°F and several of our redundant servers went down.

We’re in the process of moving to the Hospital Emergency Incident Command System (HEICS) a version of the incident command system pioneered by fire services across the nation. A planning function is a specifically defined component of HEICS and would have been helpful during the blackout in addressing questions such as reliability of on-site power generation and consequent implications for continuing use of electronic medical records.

The JCAHO has through its standards essentially mandated the move to HEICS, but I saw the effectiveness of ICS generally during my many years in fire service EMS during the 1980’s. Part of the attraction of HEICS for me is that it allows a calibrated response rather than the all-or-none response of traditional hospital “disaster plans” for once the ICS command structure is in place, the incident commander can decide how much and what components of the plan should be activated. The Saturday following Thursday’s blackout provided a perfect example: we lost our internal telephone system for four hours.

The particular details don’t matter, but the hospital’s senior executive in charge convened the command structure in the telecommunications department rather than in the usual emergency operations center, a conference room. She also did not bring in workers from home—except for telecommunications staff and technicians. On-site staff activated the emergency telephone and walkie-talkie system which met the needs of effective response.

Yes, some imperfect decisions were made in responding to both events; just as in the clinical practice of emergency medicine where clinicians make decisions in the face of uncertainty, so too in potentially injury creating events[1] hospital managers can’t wait to make decisions and must make their decisions in the face of uncertainty. Implementation of HEICS supports both the decision-making process and the decision-maker.


[1]Koenig KL, Dinerman N, Kuehl AE: Disaster nomenclature–a functional impact approach: the PICE system. Acad Emerg Med. 1996 Jul;3(7):723-7.

Potpourri: New Attendings, Regional Competitors and Malpractice Crisis

How are the new attending(s) settling into your department? What’s happening at your regions EDs (competitors and otherwise)? Has the malpractice insurance crisis made a home in your state? This month, for your return from summertime diversions, I thought I’d share a snapshot of three of my September concerns.

This year we brought on several new attending physicians both to increase our staff and because as we transform from a pure service organization to a service and academic organization, we needed a staff with both the credentials and the capacity for academic accomplishment. In an effort at supporting these young physicians we subjected them to nine-days of orientation, which included a fair number and cross-section of staff from around the hospital. They spent an evening with me at the ambulance garage of our closest volunteer ambulance service, Borough Park Hatzolah, where we shared a meal and heard community-based volunteers talk about the importance of true partnership in patient care. They both welcomed the new physician staff and challenged them to learn about cultural imperatives and community based relationships that motivated them to engage our emergency physicians rather intensely at the patient’s bedside. The new physician staff also worked portions of various shifts in the adult and pediatric ED as extra staff so that they could learn the systems—both computer-based and people-based—without feeling pressured for throughput.

You did offer an orientation program to your new staff physicians didn’t you? Of course you did. Besides, orientation helps you define your expectations for your new staff in a supportive fashion at the beginning of their work with you. Even if it was only ten minutes explaining your chart and introducing your new physician to some of the nursing and clerical staff. You remembered to talk about consent and you reviewed your state’s rules for minors consenting for their own treatment. You probably spent a few minutes reminding your new staffer about the requirements for coding a level five visit and shared the number of the hospital’s risk management hotline. So, now it’s September; have you asked your newest staff members how well you prepared them for the summer in your ED? If not, you’ll want to soon, since it both helps you learn how to improve your orientation program for the next time and it demonstrates your genuine concern for your physician’s well being early on in their career with you.

So what’s happening in the neighborhood? In our neighborhood our nearest competitor hospital has started admitting patients to hallway beds on the floors upstairs—when crowded with admissions in the ED—this just as advised by our state health commissioner. When I heard about this I called my counterpart and asked him directly what had transpired and he told me that he had sought and obtained direction from his CEO because of ED crowding with admitted patients. At our institution we’ve discussed this approach but have held off because of perceptions about our community’s preferences—hospital leaders believe that community members would feel that a bed in the hallway by the nurses’ station was inferior to a stretcher in the ED. Availability of medical-surgical beds is a problem for many emergency departments, but perhaps the greatest problem lies elsewhere.

The Greater New York Hospital Association recently published its final report on ED Patient Flow and Best Practices in June 2003. Heading the list of impediments to efficient patient flow was insufficient inpatient bed availability (no surprise there) and within this category, availability of telemetry beds was the single greatest category of beds that were in short supply in the five boroughs of New York. The replying hospitals also identified ED nursing and ancillary support staff and lab and radiology turnaround intervals as substantial contributors.

New York saw an overall 8% increase in malpractice rates this year and there remains no end in sight to the medical liability morass. National ACEP’s resource commitment and active participation with obstetrics and neurosurgical specialty societies in a lobbying coalition should help improve the situation if all engage in the discussion. It’s not my intent here to proselytize for anything other than your activism on this issue. It’s as likely that you and I would disagree as agree on the best remedy for the growing malpractice problem, but I hope we agree that with malpractice insurance costs going up well beyond any reimbursement increases, we are in an unsustainable circumstance. Some democratic group practices have been so seriously challenged by malpractice costs that their continuation has been threatened.

As many of you know, on July 15 ACEP pledged $1 Million in members’ equity in support of the American Association of Neurological Surgery/Congress of Neurological Surgeons led coalition on tort reform believing that now was the best opportunity for gaining political leverage and consequent favorable change in the process.

Engage your colleagues with this news and news on medical liability issues from your state ACEP chapter or other organized medicine resources. Help them write letters to elected officials and state regulators or organize coverage so that they can attend regional or statewide meetings or rallies. Getting active on this issue is important to our future.

Individual activism is important, but so too is engaging the issue at your hospital. Take the opportunity to remind your CEO and other hospital leadership of the negative impact on recruiting and retention that malpractice costs are beginning to demonstrate in the worst affected states across the country. Participate in regional and statewide meetings and other actions and bring your message both as an individual and on behalf of your practice. The more voices the better and differences of opinion should be welcomed because they will stimulate more ideas, which we badly need for tackling this difficult issue.

Leadership of an emergency department entails work in your department, hospital, and community and more broadly at policy levels. Not all of us will do as well with each of these activities. Seek appropriate colleagues within and without your organization to help, but as the leader we must stay alert—and responsive—to the entire range of challenges and opportunities from wherever they come.

We’re in the Business of the Trees.

My title this month came to me after an animated conversation with Rick Heffernan, MPH, Director, Data Analysis Unit, Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene (NYDOHMH). I had received, several days earlier, an email message including the “emergency department syndromic surveillance quarterly report.” Just what is this mouthful and why should it matter to us in the ED? Well, as Rick and I agreed in conversation, the health department is “in the business of the forest” and since we see patients one-by-one, we’re in the business of the trees. Together, we can and should learn more about the community population both the health department and we serve. More about working with your local health department later.

The health department’s Quarterly Report of Syndromic Surveillance was replete with graphs comparing visits to our ED with citywide ED visits secondary to complaints of diarrheal, respiratory and fever-flu syndromes in patients 13 and older, as well as overall ED visits. (See graph examples [editor: please correct plural if only one graph used]) These quarterly reports are of more academic than practical interest, but they presage a future with more real-time scrutiny of patient populations in our own emergency departments.

I’ve yet to find a succinct formal definition for syndromic surveillance, so bear with me as I try to explain what’s happening in New York City and in many other urban centers around the country.

Syndromic surveillance is the organized observation and analysis of patients seeking medical care as part of a monitoring effort for a community at risk of bio-terrorism. In the immediate post-September 11, 2001 period, the Centers for Disease Control and the New York City Department of Health and Mental Hygiene with the cooperation of 15 hospitals set up a manual system watching for a secondary bio-terrorism attack that some feared was likely in the aftermath. The subsequent anthrax bio-terrorism, which was not discovered through syndromic surveillance, was nonetheless another spur for creating automated, rather than manual systems. It is through this approach, which is already being refined that we may find syndromic surveillance operating some day in the future in our own ED.

In the long run, syndromic surveillance must provide value for the physician working in the ED and that will only happen if we are “cued” to look for an illness we otherwise wouldn’t expect. The prepared mind will recognize a pattern that the unprepared will not—that’s why practitioners read and study. Tracking the presenting complaints of our patients and notifying the team on duty in the ED at the time a patient presents with a complaint that’s appearing at higher than usual frequency may encourage the emergency physician and nurse team to contemplate a broader differential diagnosis—even illnesses associated with bio-terrorism.

We could have used such a system earlier this year, when we experienced an outbreak of measles (rubeola) in our community. A colleague missed the diagnosis in a teenage patient who had received the vaccine, both as a toddler and at age 12. We were alerted by the pediatrician a day later—how embarrassing reporting the miss to the health department. On the other hand, we had at least not had the child and parent wait in the waiting room, but had brought them into the ED to a closed room because of the rash and concomitant respiratory complaints. This all occurred during the SARS surveillance we all experienced in April-May 2003 and all of us were focusing on respiratory illness and travel history, not rash. It’s doubtful most physicians would have made the diagnosis in any case given the history of immunization and the relative rarity of an acute presentation.

This one case of measles did alert us to its presence in our community so we—just as you would—created handouts with photos and the key signs for recognizing the disease on presentation. Sure enough, a few days later another child presented to the ED and the treating physician recognized the presentation as most likely measles and obtained infectious disease consultation. Serum for antibody titers was drawn and the pediatrician who had seen the child in a crowded office earlier the same day was called and alerted and advised to check immunization records of the children who had been in his office at the time. Still, we once again missed a required step. No one called the health department for this reportable disease. Over the next week we saw several additional cases of measles and I know from colleagues that the outbreak, and the initial failure to recognize and report the disease, occurred repeatedly across the Brooklyn, Queens and nearby suburban communities. The health department did a marvelous, but onerous job, of contact tracing every identified measles patient and those exposed to them so that vaccine could be administered and isolation encouraged as appropriate.

I enjoyed my conversation with Mr. Heffernan and others at the NYDOHMH. We’ve let our entire physician, nurse and technical support staffs know that the health department wants notification on suspicion of communicable disease and not to wait for confirmation. The group at the health department we worked with around the measles outbreak was not the same as Mr. Heffernan’s group. Yet our experience of the outbreak made our entire staff more aware of the value the NYDOHMH brings across the board. While I think that syndromic surveillance is a wonderful theory, we who see the patients one at a time will be alerting the authorities before they alert us for some time yet—because we’re in the business of the trees.

HospDiar

HospFev

HospResp

HospTot

A Deadly Disease: Management on Numbers Alone.

How shall we pay emergency physicians? The question increasingly resonates through our professional organizations and publications, our gatherings both animate and virtual. Hourly rates, clinical productivity and customer satisfaction as measured by survey are often mentioned and a plethora of other measurable factors also described. Little questioned or discussed is the implicit principle that compensation shall be directly tied to measured clinical productivity. Ron Hellstern on emed-l recently opined:
“The chief value of RVU-measured productivity-based compensation is to better align the physician’s compensation with how the group gets paid. From a practice revenue standpoint, the only meaningful unit of productivity is a billable (meaning appropriately documented in the judgment of a certified coder) RVU of service.[1] The further the physician’s payment methodology from this reimbursement reality (such as paying by the hour, by the patient, by the charges, and etc.) the greater the likelihood of a distortion of the relationship between revenue producer and revenue benefactor.”[2]

Our compensation is important. Just as with our hospitals where, “No margin, no mission” has become an explicit reality; so too for us and our colleagues with our mortgages, student loans, tuitions and routine costs of living; earning our livelihood is no longer an easy assumption. Yet for some emergency physicians, compensation is not the sole basis of their satisfaction with their present professional circumstances. Other factors matter, both pragmatic—their schedules and idealistic—a sense of accomplishment or a desire for improving their practice and hospital.

W. Edwards Deming taught his “System of Profound Knowledge” as a management method inclusive of measurement and knowledge about variation that he insisted must be combined with an appreciation for a system, the understanding of people and their psychology, and a theory of knowledge. Out of his system he called for a transformation in American business and cited “14 points, seven deadly diseases and some obstacles” of management. I have found and continue to find these general principles valuable in my life as a physician-leader and I commend them to you through the sources I’ve listed at the end of this month’s column. Though the current rubric for improvement is proclaimed through Six Sigma®, a term owned by Motorola, much of the tools and the principles of the Six Sigma® approach are contained within the work of Deming, Joseph Juran and other quality leaders, absent the Six Sigma® branding and “board appeal.”

As pressures on our clinical practice environment mount, not the least of these are the pressure we all feel from an emphasis on measurement. I hope I’ve contributed to your efforts at measurement beginning with my first column of April 2000 in EMN proclaiming the importance of measurement, “Without measurement, how will we know that a change is an improvement?” Thus some of you might exclaim, “He’s a proponent of measurement. He’s contributed to the pickle we’re in today. Now he’s recanting—backpedaling; how hypocritical.”

Well, no, I’m not.

One of Deming’s “seven deadly diseases” is commonly stated as in this column’s title: “Management on numbers alone. There are measures of quality that are unknown and unknowable.”

Doctor Hellstern is quite correct regarding the value of RVU based measurement; however, measurement of RVUs alone is insufficient. I believe that Deming, a Ph.D. physicist and practicing statistician, would have insisted that measurement of RVUs was not the problem, rather the reliance on the measurement alone, outside of his system of profound knowledge that’s the problem. My frustration and occasional impassioned rejoinders to colleagues derives from my perceived oversight of the inter-relatedness of the components of profound knowledge and their integration by the practice—a leadership responsibility. The absence of consideration of the “big picture” within which emergency physicians earn their livelihood seems lacking in the mostly oversimplified discussions of emergency physician compensation I referred to at the top of this column. Measurement is not the culprit; rather it is the reliance on measurement alone that infects us with this “deadly disease” of management.

I suggest that you could provoke quite a discussion among colleagues if you asked, “What single vital sign was the most reliable predictor of the need for admission?” Most of my colleagues would think me foolish for asking such a question. So too is it foolish to insist that only RVUs or any other single or simple combination of measurements alone should serve as the basis for an emergency physician’s earnings.

We live in a competitive and capitalist country and I’m glad I do; but we also live with rules that guide us and set limits on competition and regulations that constrain laissez-faire capitalism. As physicians we put our patients first, maintain a special body of knowledge and reserve to ourselves the right to evaluate our own quality.[3] Compensation plans simply can’t be limited to the numbers alone.

I encourage and appreciate the use of measurement in the creation of compensation plans; but a slavish insistence that compensation should be determined solely by formula overlooks the broader principles of what we seek from a “good doctor” and what society seeks from us. Unless within our practices we articulate our mission for the practice and our vision for our practice’s future, we have no basis on which we can develop the “profound knowledge” or guiding principles for our practice—principles that should also derive from our profession and make what we do something more than merely a skilled trade.

Compensating emergency physicians as a formulaic exercise consigns us to suffering Dr. Deming’s “deadly disease” and overlooks our profession’s values and our heritage derived thereby. Perhaps idealistically I believe that physician earnings must include factors beyond the mere measurable. Otherwise, I’m abrogating my responsibilities as a leader and a professional and unthinkingly acceding to untrammeled capitalism triumphing over common sense—just as other skilled trades people have.


[1]RVU= relative value unit. Derived from the Resource-based relative value scale of determining physician work involved in various aspects of clinical care and procedures.
[2]Quoted with permission from an email message posted on emed-l an Internet mailing list by Ronald A. Hellstern, M.D. Thu May 15 2003 – 07:45:10 PDT. Subscribe using the Emergency Medicine list subscriber.
[3]Brent James, MD, M.Stat.: M4 – Managing Clinical Processes: Tools for Physician Participation and Leadership” Presented at the 14th Annual National Forum on Quality Improvement in Health Care; Walt Disney World Swan & Dolphin Hotels, Orlando, Fl; Monday, 9 December 2002; 8:30a – 4:00p; viewed on May 18, 2003 at http://www.ihi.org/conferences/natforum/handouts/M04.pdf.


Suggested sources for reading about W. Edwards Deming and his management methods:

Walton, Mary: The Deming Management Method. Perigee, 1988. ISBN: 0399550003

Deming, W. Edwards: The New Economics for Industry, Government, Education – 2nd Edition. MIT Press, 2000. ISBN: 0262541165 (Recommended of all of W.E.D.’s books because it talks the most about services, i.e., government and education.)

The Staff took Over the Meeting! They changed my Agenda! Wow, am I Proud of Them!

retreat (n)- A period of group withdrawal for prayer, meditation, or study[1]

The best retreats involve a getaway to a location with an atmosphere conducive to both group synergistic interaction and individual reflection. Good meals are key. Our physician staff met at the Brooklyn Marriott for one day with breakfast and lunch and after lunch they discarded my agenda in favor of their own. For an instant I bristled, but fortunately our facilitator took charge and the afternoon—indeed the whole day—came off rather well.

It was the largest gathering of our physician staff probably ever in the history of the department. We minimized staffing for the day; brought in as many per diem staff as we could and got almost three-quarters of the department together. Pretty tough for those of us in emergency medicine since we need to keep the doors open 24×7 and folks do have to sleep.

We’re in the process of transforming the Department of emergency medicine from a purely clinical service organization to a clinical service, teaching and research organization. We’re in the first year of our provisionally approved emergency medicine residency program and many of the emergency physician staff came to work at Maimonides only to care for patients and otherwise get on with their lives. Residency program development hadn’t been part of their plans. Others, mostly recent additions, had joined specifically to participate in the development of a new residency program.

We met in retreat contemplating this transformation and considering the effects upon the physician staff. These women and men had listened to me and other departmental leaders during recruitment and during various departmental meetings talk about the requirements for core faculty and the opportunities engendered by the new residency program, but uncertainty reigned. What did the change mean about the kind of work, scheduling of work, compensation, the clinical environment of the ED. Our helpful facilitator, working with me and our departmental administrator had helped structure a day in which we would address these issues and organize to further explore them and the ramifications of our evolution.

After lunch, the group rebelled. Much to my surprise, they were far less interested in talking about compensation than they were in talking about scheduling and operations improvements. Fortunately our facilitator helped the group articulate its interests and determine a way of proceeding. First by proposing splitting the group into two and then acquiescing to their preference for remaining together as a single group and getting their scheduling issues under discussion. I was encouraged to stay quiet—and I did.

At the closing of the afternoon and of the retreat, we all committed to next steps: working groups on the issues of concern. The coherence of the physicians and their evident satisfaction at the plan was thrilling to me. I learned a lot about what was going well—or well enough: our compensation program—and where improvements were needed: scheduling and continued focus on clinical operations improvements.

The lesson about scheduling was instructive. For the group present, fairness was not defined by evenly sharing nights and weekend shifts. Rather, the unmarried physicians present universally volunteered to work more weekday nights so as to have more weekend time off. The married physicians by and large seemed amenable to this approach; the particular day or night off mattered less to them than that they could organize their time for family activities. We’ll sort the details out on this and other scheduling concerns through a working group of the staff who will develop a plan and present to a staff meeting.

Similarly—and after discussing the scheduling issues—the group moved onto a discussion of various clinical operational issues. Urine specimen collection processes and hemolyzed blood specimens were variously denounced, but several of the more junior staff spoke to the need for flowcharting and understanding the process steps. They were bringing the performance improvement ethic and idea to the group as a whole—an approach that has been somewhat neglected in our department this past year as we implemented our electronic medical record. Though we have used continuous quality improvement techniques within each project; the group was recognizing that our ED Improvement Committee was no longer meeting and neither were any project oriented task forces working on improvements in the clinical center itself.

Perhaps your group has no issues and you as the leader have no concerns; but most of us live in a real world where perceptions vary. Our retreat was a grand opportunity for learning the depth of belief in the fundamental fairness of our department’s operational decisions that most directly affect the physician staff. It also energized me because of the broad participation of our physician staff and because the energy coming out of the room was for building and maintaining improvement efforts around the issues of greatest concern to the physicians themselves. Less than two weeks later, at the regularly scheduled departmental staff meeting, task force membership and charters were confirmed and the groups began working together.

As a department, we’ve felt overwhelmed at times with all the non-clinical work required for function in the hospital; I’m sure you have felt the same from time-to-time. Our retreat, planned in conjunction with and facilitated by a professional facilitator not only identified opportunities for improvement in our department, but created the working groups who will lead those improvements on behalf of the department.

Yes, physicians from our staff took the lead in both defining the issues and organizing to accomplish the work. They pushed my leadership aside; they seek only my support and not my direction. Wow—they are doing me proud.


[1]The American Heritage® Dictionary of the English Language, Fourth Edition; Copyright © 2000, Houghton Mifflin Company.

For Emergency Physicians Multi-tasking is a Core Competency, but is it Safe for Patients?

Recently, a Wall Street Journal article about the “Pitfalls of Doing Too Much at Once”[1] was posted in our ED and physician and nursing staff forwarded me multiple copies. In light of the end of February busyness accompanied by a bit of generalized seasonal affective disorder and a rather frigid and dreary winter, I can excuse my colleagues efforts at concentrating my mind on our challenging environment. The incessant questioning of family members about when their loved one would go upstairs interrupting the care of still other patients remains a constant in our ED and probably yours as well.

The same week the New England Journal Sounding Board article on patient safety, “Residents’ Suggestions for Reducing Errors in Teaching Hospitals”[2] hit my radar screen citing as a problem, “Frequent interruptions with paging.” These public press and peer-reviewed citations of interruptions and multi-tasking provoked reflection and remembrance and I decided to read further and turned to the proceedings of the Academic Emergency Medicine sponsored consensus conference on “Errors in Emergency Medicine” from November 2000 and “The Model of the Clinical Practice of Emergency Medicine.”[3]

I have no prescription after this reading; only an unsettled feeling that perhaps those colleagues who have asserted that multi-tasking is a dysfunctional response may have a point. While we are all doing more and under ever-greater scrutiny, other segments of society are demanding that we focus on high-risk activities. Just what high-risk activity? Driving. In New York and other states holding a cellphone while driving is now illegal. Yet looking at your pager or half-listening for an overhead page while eliciting a patient’s history is not. And we all can tell the tale in caring for a patient with chest pain of working through the history, reviewing the ECG, inquiring about contraindications to thrombolytics when another patient—requiring immediate endotracheal intubation—presents. Yes, we swagger a bit and are proud of “pulling it off” even as these occurrences become more common. Yet, don’t we collectively have responsibility to plan and implement systems that while still maintaining our individual, professional accountability; take into account human factors and our resource constraints—particularly space and personnel? Blaming the patient for seeking “unnecessary” care is merely our displacement of the pressures we feel from elsewhere in the system—from those who ignore the proximity bias of our presence in the ED and blame us for our own circumstances.[4] “You chose the chaos.” They say.

Indeed we did. We in emergency medicine have explicitly raised multi-tasking to the level of a professional skill that requires evidence of competency for completion of residency and indeed successful completion of our certifying examination.

It’s perhaps unrealistic to imagine that emergency physicians will ever merely move from one patient to the next, completing a patient encounter before moving onto the next one. Yet, I do recall that 25 years ago I did work for awhile in a hospital where most days, for most of a shift, I was able to see patients sequentially, write my history and physical and orders before moving onto the next patient, reviewing results or engaging with a consultant. Time for reflection, review and consideration of patient needs was built into that process. Today, we no longer have that opportunity. One of my colleagues longs for a “pod” into which he could slip to close out the interruptions and allow for a controlled environment—not to relax—but rather to review patient data, look up clinical advice on diagnostics or therapeutics and formulate a plan without interruption.

Interruptions of our primary task reduce our efficiency and challenge the developing rapport with the patient in front of us. Forcing multi-tasking on an already busy clinician results in distraction and consequent oversights—of patient complaints, findings, results, etc. Interrupt-drive computer systems can mindlessly return to the tasks waiting in the queue; humans cannot and efficiency and patients may suffer the consequences.[5]

Given that patient acuity and volume isn’t going to diminish in coming years and that in an era of consumer driven healthcare, access for family and bedside visiting will likely become more common; interruptions and multi-tasking will be with us for the foreseeable future. How then can we all stay on track and minimize errors?

Exhorting individual clinicians is not the answer; changing systems, not people is the only way—and no, this doesn’t mean only computer systems. Yes, we have a fully electronic medical record. It includes user settable alerts—the clinician can setup a timed alarm—just like setting an alarm clock—that will result in an icon popping up and display of a text message when the clinician next logs in to the system.

But our staff—by and large—still use handwritten paper lists. We’re all familiar with colleagues who manage their shift with lists, cards or other memory aids. Some of them have fewer episodes of patients or information, “falling into the cracks.” Their relative success undoubtedly includes components of personality and effort, but tools matter too. Just as the NEJM article sought residents’ ideas for error reduction in the teaching hospital environment, focus your staff on addressing the problem of interruptions in the ED environment.

Interruptions and the loss of control they portend is a contributor to clinician stress, which “has important consequences for productivity, quality of task performance, workplace anxiety, fatigue and job satisfaction” according to Kirmeyer.[6] We know these things and bemoan them, yet as a specialty we have barely any research on how to mitigate the effects of interruption on both clinician and patient. The NEJM piece should galvanize our residencies and all of us to our own efforts. I know it will in my hospital.


[1]Shellenbarger, S: “New Studies Show Pitfalls of Doing Too Much at Once.” Wall Street Journal February 27, 2003 in Work & Family Section. Also available at http://online.wsj.com/article/0,,SB1046286576946413103,00.html

[2]Volpp KGM and Grande D: “Residents’ Suggestions for Reducing Errors in Teaching Hospitals.” NEJM 348(9):851-855, 2003.

[3]Core Content Task Force II: “The Model of the Clinical Practice of Emergency Medicine.” Ann Em Med 37(6):745-770, 2001.

[4]Adams JG, Bohan JS: “System Contributions to Error.” Acad Emerg Med 7(11):1189-1193, 2000

[5]Chisholm CD, Collison EK, Nelson DR, Cordell WH: “Emergency Department Workplace Interruptions: Are Emergency Physicians ‘Interrupt-driven’ and ‘Multitasking’?” Acad Emerg Med 7(11):1239-1243, 2000.

[6]Kirmeyer SL: “Coping with Competing Demands: Interruption and the Type A Pattern.” J Appl Psychol 73:621-9, 1988.

Admission Decisions: An Opportunity for Deploying Interpersonal and Communication Skills in Service to Your Medical Staff Colleagues

It happened again, the resident hemmed and hawed and finally said, “We’ll take care of her hip, but I’m not admitting her.” Well, since this elderly woman with a hip fracture and a “lick to the head” clearly wasn’t going home, my ED attending colleague was in the position of “negotiating” with a series of residents and fellows from various services, finally speaking to the chief of general surgery who directed the admission to his service; after all the patient had two injured organ systems.

How easy or difficult is admitting patients at your hospital? Does it depend upon the service? Has capitated managed care affected the responsiveness of your community’s physicians when you call and discuss admitting a patient?

I’ve practiced in an academic health sciences center, various community hospitals affiliated to that center and now I practice at a huge tertiary-care community teaching hospital. The admitting process in each hospital reflected the hospital’s mission and the medical staff preference.

In all of these hospitals, patient care—always a primary mission—was balanced with educational needs of residents and students in the ED and on inpatient services. While I’m sure we can agree that at times some physicians may behave badly, for the purposes of this column, I’d rather ignore that fraction of the experience. In the real world we shouldn’t condition our actions or speech on the responses of an ill-behaved minority.

Experience may be a useful teacher and changing circumstances call for reflection about that experience. Our emergency medicine residency is in its eighth month as I write this and the experience of our attending staff and residents in attempting the admission of patients has been instructive as the example above illustrates.

How shall we as a department respond? How should you? Should you press for admitting privileges for attending emergency physicians—not to their own service, but rather the privilege to admit to any other service? Should we in New York insist upon the prerogative once granted us by the now defunct New York City Ambulance Destination Advisory Council that compelled hospitals to implement policy assuring that emergency physicians could “assign” patients to a service?

Are our internist or orthopedist colleagues who question our admission recommendation “The Enemy?” I hardly think so and neither does Michael P. Wainscott, MD, EM residency director at University of Texas Southwestern, who raised the concern that such contention suggests a fear on our part that discussing an admission was “somehow tantamount to neutering EM as a specialty.” He asks the question, “What message is this sending our residents?”

Of course a resident shouldn’t have the authority to send a patient home that the attending emergency physician believes should be admitted. Certainly admitting a patient to a service and simply informing the house staff could expedite admissions from the ED, thereby reducing waiting time for patients. Of course, there will be some—perhaps five percent—unnecessary admissions, but they can be sorted out the next day.

What then are we teaching our residents? The Accrediting Council for Graduate Medical Education in its outcome project adopted in 1999 six competencies for all residents. Among these competencies is one described as “Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals.”

As my Texas based colleague pointed out in the emed-l (use EDSubscriber at NCEMI to subscribe) discussion, “Emergency physicians don’t simply admit patients in private practice—admitting decisions are discussed with private doctors.” Realistically, the private practitioner may know something about the patient that can avoid the admission and our role as emergency physicians has always had a component of reducing the load on the medical staff so that those physicians need not return to the hospital after hours when their patients show up at the ED. So, while it is certainly true that the incentives for private physicians have changed over time—capitated payments used by many managed care plans may unfortunately contribute a disincentive to hospitalization in some equivocal circumstances and even well intended, assiduous physicians make errors in judgment; nonetheless, excluding the primary physician from decision-making won’t give evidence of quality customer service to the medical staff, which perhaps is second only to excellent patient care in establishing your and your practice’s reputation.

And so, this is the crux of the matter for me. While we are training emergency medicine residents in a variety of sites, most of these residency graduates will practice in community settings where they may interact with residents, but they will certainly admit patients to private physicians. How will their “interpersonal and communication skills” stand up to the challenge? Better I suspect, if as Mike Wainscott suggests, they “. . . embrace the opportunity for physician interactions between emergency medicine and internal medicine in whatever manner is appropriate to our practice setting.” In our practice setting, like Mike’s and given our and his complex patients, this has certainly proved to be the case. Insisting that the attending emergency physician’s judgment is superior to the admitting resident’s—likely a true enough statement—doesn’t accomplish the task of teaching our residents needed skills nor does it well serve your medical staff. As for admitting patient’s with a fractured hip to general surgery; I’m learning that all that is old can become new again since that’s what I saw when I was in medical school under the same rationale for caring for trauma patients.