At SmaccDUB, I got to debate my friend and head wizard of St. Emlyns, Simon Carley. Our topic was, Emergency Medicine (EM) is a Failed Paradigm. I took the pro side–it was a ton of fun. Take a watch and then tell me what you think in the comments section below.
The St. Emlyn's Post
Simon wrote a wonderful blogpost about the debate.
The Slides
Additional Links of Interest
Graham Walker on “Emergentology: Don't Worry; We'll Handle It”
Transcript
(note-it is computer generated so many errors)
The Video
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Scott Weingart
An ED Intensivist from NY.
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Scott, You definitely get my vote as winner of this “Smacc-down”. I would like to offer the opinion that it is not the specialty that has sold out…at least not directly. The specialty has become complicit in rent-seeking behavior toward the entity that is truly responsible for this horrible distortion in the practice of EM. That entity is our governments. Any time a service or commodity is of limited supply (i.e.-all of reality) a price system must be functioning to determine the most objective use of those scarce resources. When you distort this signaling process then costs go up, and quality goes down. When you enact laws that make the price effectively zero, then demand becomes infinite. Since money has a time-value, when currency becomes outlawed, then the currency becomes time. The price then becomes measured in time. In the outpatient sector this is measured by wait lists. In the areas with legally mandated, unrestricted access, the currency becomes wait time. EMTALA was passed as an earmark on the Congressional Omnibus Reconciliation Act (COBRA) of 1986. Medicine has always had a problem addressing indigent care. Prior to 1986 this was done under the Hill-Burton Act of 1946 which placed the… Read more »
Wow! Yes!
But how would ANY of this happen?
Not sure there is a way
There are a LOT more patients than doctors, and no matter how clean the intent, this will be interpreted as an abrogation of patient rights and benefits
Scott, You are correct that there are a LOT more patients than doctors. Currently the entirety of that massive surplus of episodic, non-emergent/non-urgent and especially uncompensated care is being provided by ER doctors with very little help from the rest of the medical community. It is certainly not a right (in the true sense of the word, i.e.-natural rights) for someone to have open access to free care for non-emergent issues. It is also not a benefit for someone to try to get primary care in an episodic care environment. Most of these issues require a continuity of care that ER’s cannot provide. Just because patients choose a path of least resistance does not mean it is of benefit to them. Like you, I am not sure there is a way. Not because it is not possible, but simply because so many politicians have got elected by promising our uncompensated work as a means of sweeping the economic distortions of a government run, third party payment system under the rug. Our patients have been trained to use the ER in this way over the past 30 years. Ideally, I would like to see EMTALA repealed. It has hurt most the… Read more »
I actually like the idea of integrating family practice (urgent care) into the “Emergency Department Medicine” model…and do agree that large portions of the emergency medicine paradigm are failing. Take a look at the free-standing ED models in CO & TX…they’re rampant and expanding like rabbits! This perfectly embodies how “emergent” care is being overrun by “urgent” care, and the need for rapid, self-focused, chronic care is overpowering the current system. What’s most alarming about this current paradigm/model is that we’re allowing it to fail (ie: free-standing EDs, not focusing on mobile integrated healthcare from the healthcare perspective, not by utilizing EMS).
Michael, In re-reading your post, I think we actually agree more than disagree. I agree that rural places do not “need” a separate resus doc, ICU doc etc. Where I do differ is the notion that acuity is lower. This is why I think EM needs to keep it’s training focused on emergent cases, procedures and resus. We also need to defend our turf and any down-time that might result. There is a capacity crisis in medicine and the indication creep around filling our downtime has resulted in a culture where anything and everything gets diverted to the ER. I remember getting an in-service from one of our surgeons on how to take care of complications from lap band surgery. I’m sorry, but if you are going to make a fortune providing this elective procedure you need to give your patients your phone number and deal with your own post-op complications. That this was considered OK just shows how far we have slid with regard to defending our mission. We did a formal study of ED throughput times at my rural shop this summer. What we found was that the biggest determinant of long throughput times was lack of support… Read more »
Hi Scott, This was a great deal of fun and as you know when we take to a debate it’s a requirement to take opposing sides even when the reality of our true opinions may be somewhat closer. We spoke about this at SMACC and as you know the ED that I work in is pretty unusual for the UK in that we still practice critical care as EPs. In many units the care of the seriously ill or injured is not done by EPs but rather is handed over to in house specialities at an early stage of the patient’s journey. I would not be happy working in those places. We also have co-located general (family practice) and so a third of our patients are streamed at our front door directly into primary care. A further proportion are streamed into the nurse led minor injuries stream and so the emergency physicians are left with resus, majors patients and what are sometimes called minors but in reality are ambulatory majors patients (e.g. ?PE, ? ACS with no ECG changes, Abdo pains, etc.). The key to our practice has been to try and focus our efforts on those where the EPs… Read more »
“We also have co-located general (family practice) and so a third of our patients are streamed at our front door directly into primary care. A further proportion are streamed into the nurse led minor injuries stream and so the emergency physicians are left with resus, majors patients and what are sometimes called minors but in reality are ambulatory majors patients (e.g. ?PE, ? ACS with no ECG changes, Abdo pains, etc.).” Simon, Brilliant presentation but I have to agree with Scott on this one. I think the environment you describe above has shielded you from what is occurring in “emergency” medicine in most of the United States. I don’t know a single colleague here who works in a setting like that. In my own shop the combination of EMTALA and the ACA’s Medicaid Expansion drove our visit volumes from 26,000 patients a year to 36,000 patients a year accompanied by nursing staff cuts, dropping plummeting reimbursements, no increase in physician coverage, and a new “jackass-of-all-trades, master of none” EMR. As you might guess, the overwhelming majority of these tourists fell into the “not sick” category. Eleven months ago I saw my last patient, put away the scrubs and stethoscope, and… Read more »
my gosh. What are you doing now? And has it made you happier?
Scott,
Where is this utopia of multiple patients with deranged physiology you speak of. I want to work there. In 1989 I did a EM rotation at Denver General. My first day got in on a thracotomy which lasted 15 minutes, then walked over to the McDonalds in the hospital and got some French fries. Thoracotomy and McDonalds fries in the same building- I’m sold. I have learned to adjust to the real world practice of the not really sick. But I will race my partners to the room for a truly sick patient.
Thank you for all that you do. It adds to my professional happiness.
Jim
Thank-you Dr. Weingart for putting a voice to what goes on in my head. I was so naive entering this specialty and I do have cognitive dissonance from what I tell myself I do. I live for the sick, sick patient and find the time just flies by when in their room. I smile ( rare, rare, rare) and feel satisfaction…please don’t think I am mercenary, I just feel that this was what I signed up for. In contrast, the “prescription refill” comes in and my eyes roll so far back in my head, I see my cerebellum..You couple that with the mind numbingly stupid patient satisfaction, the suit’s “time and interval measurements” and the many checkbook algorithms we are told gives us “value”, and I am left with the persistent thought I should have opened a brewery….And, I do believe you won the debate, hands down.
Great treatment of a really bold topic. I’ve been wondering for years when we’d start talking about this. Thanks.
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Dr. Weingart, great talk – we love your podcast here in Duluth, MN! Your arguments resonate strongly with us in Family Medicine. Our program focuses on training well-rounded physicians for rural practice who graduate very comfortable with resuscitation, managing sick patients in the hospital, and even refilling prescriptions! We share your belief that anyone who walks through our doors (clinic, rural ED, etc.), deserves excellent care, regardless of the complaint. I strongly agree with your statement that EDs should partner with primary care specialties. When I know a patient well, non-urgent issues can be addressed in a fraction of the time and cost. It takes literally 10-20 seconds to refill an Rx by electronic request for a patient I know well. In our program, we offer 24/7 phone services to triage patient concerns, preventing a significant number of ED visits for issues easily managed by phone. Here’s my contribution – re-defining roles in EM to the benefit of our sickest patients will be impossible without redefining primary care. In most settings, there is no incentive for practicing PCPs to provide the types of services I described above. We are happy to do this as part of our training in residency,… Read more »
Great talk Scott,
I think a major problem for Emergency Medicine as such to find its place as resuscitation medicine is that the need only actually exist at major hospitals in major cities. In hospitals with up-take areas of 1-2 million or smaller, which will be most hospitals, the number of proper emergencies will be too small to have a resuscitationist in the A&E, an intensivist in the intensive care unit, and an anaesthetist who lives in the OR. For most hospitals it is reasonable to have one or two critical care doctors that handle the ICU, in-hospital emergencies and resuscitation in the A&E, In the latter case, together with what you call emergency department medicine doctors who can also handle all the other stuff that flows through. A separate resuscitation-only emergency department is simply not feasible outside the absolutely largest of hospitals.
M
Michael, I strongly disagree with your statement that hospitals with up-take areas of 1-2 million will not have the number of “proper emergencies” to have a resuscitationist in the ER. First, your statement has no face validity. Why would the rate of trauma or disease per capita be different is smaller or rural communities? Also, the only thing really lacking in the less populous areas is specialty backup. In my own shop we have no on-site neurology, no neurosurgery, no CV surgery, no ophthalmology and ENT 1/3rd time. A favorite saying of mine is…”I am the trauma team”. I guess I am not arguing that there should be a separate “resuscitationinst, just that ER docs need to have this as their core function and the training needs to reflect that. Also, someone not trained in EM will not be adequate to the task, at least not without extensive supplemental training. From a personal standpoint (I currently work in my rural shop, but also work at the “mother ship/tertiary hospital), I can attest that I do way more resuscitation at my rural shop. Their is still knife and gun club, but way more boating, recreational, 4-wheeler and farming accidents. Also, with… Read more »
Totally agree with your view. In 1994 my shop saw 15k patients per year, now we see 50k per year. The number of intubations, central lines, art lines, major resuscitations has hardly changed over 23 years. I see between 3500-4000 patients per year. I do 10-12 tubes a year, similar for lines. We are a tertiary care center, busiest in our rural state. No need for a resuscitationist in the ED at our place. Maybe the intensivist from upstairs. If that happened I would quit. I live for the truly sick patient, we just get very few. It’s like we were once great dragon slayers. Now there are no more dragons.
Scott, thanks for the nod to Canada and our wait time rules. I am in Manitoba, where we have the longest wait times in the country, which the public and the health system continually lament about.
Interestingly, one of the docs in my little rural hospital (26 rooms, 2 ER beds, 2 Observation beds) commented that he would rather work in an Emergency Department than a walk in clinic (his reference to the majority of patients in our hospital being non acute). So maybe he got the wrong job description. Even in EMS which is my area, we don’t live up to the media glorification of what we do.
Great discussion, keep ’em coming!
Hearing this made me feel better. I always thought that this is just my problem, and these are vicious thoughts coming to my tired brain. Now I feel they are not so vicious once they are explained. I feel that I have less to nag about when I’m on shift, realizing that what I have trained for is different from what I am doing. I’ve stopped resisting and trying to be the EM doctor, when the system really needs an ER doctor. Sometimes we need someone else to explain what we already know. Thanks for doing that. 🙂
It’s movies, shows and reality TV that distorts what EM/EMS does. By the time a Resident, RN, EMT, Paramedic reads the “job description” they are looking for a job. Changing the job description will not solve the issue, redesigning education, or hiring various specialties for job ED is a pipe dream. Bulk of 911 calls in EMS are not emergencies, bulk if ED visits are not emergencies as you stated. Consumers want 24/7 care where they don’t have to take a day off from work, or make an appointment in 1 week to a PCP and sit for 2 hours waiting to be seen for 3 minutes because PCP office schedules 10 people on the same time slot as you. Administration will never get rid of patient satisfaction and will always push for shorter ED wait times, because that is what is reported. I also agree with you that when expert consult is needed with Airway, Trauma, Cardiac, etc you will seldom be sought for your expertise, as its “common knowledge” that em just turf everything with no definitive care rendered. Most hospitals in NYC are hiring PAs to staff EDs and provide internal medicine/fast track etc to reduce wait… Read more »
“Thus my proposal to you is to get 2nd residency in family practice or internal medicine, they you can optimally care for the bulk of people visiting the ED.”
This was said in jest… right?
Nikolay,
Would greatly appreciate if you would constrain comments to either:
1. Things that you think would be helpful or interesting to your fellow readers
2. Questions you have
I am sure it is not your intent, but this is the second time in as many comments on the site that your comment doesn’t really fulfill either of the above. We don’t currently ban folks from the site for non-productive comments, instead we just ask folks to be part of the community.
Regarding this Twitter Thread: @movinmeat I must say I am very surprised to read this thread, Liam. From all of my interactions with you, you have shown yourself to be an intelligent, critical thinker. These tweets show (from my perception) a very visceral response rather than an analytical one. Not a single one of your tweets actually relate to anything I said in the lecture. Not sure why you are going straw man, but if you were to relisten (not that I am advocating doing so) with an eye (ear) to actually finding support in my words for anything you tweeted, I doubt you would find it (unless you ignore the rules of context and intent). What is really strange though is how you went about posting this stuff. In my divorcing twitter wee, I clearly mentioned that I or a member of the team would be checking all @mentions so feel free to reach out that way. But no @mention anywhere in the thread. Let’s pretend you missed that part of the wee or never listened and just saw the title that I am divorcing twitter–you, better than perhaps anyone in EM, know how blogs work. If you genuinely… Read more »
Scott, another well made point. Although Liam did not mention you directly, this may have been due to the fact that he thought it was just a general discussion not requiring a response from you. I personally am amazed at how many people seem not to have actually “listened” to the podcast. Although I have listened to it 3 times, I fully understood your position and arguments on the 1st. hearing. As always, keep up the good work and the thought provoking analyses
Best regards
Scott, thanks for the wonderful content and thought-leadership. I thoroughly enjoy it. A couple of points particularly resonated for me. The story we tell ourselves about what we do is so important, and believing the wrong story leads to cognitive dissonance and burnout, to paraphrase your talk. It is very difficult to focus on resuscitation science and patient experience at the same time. It is very difficult to drive 90 then 15, then 90 again and not feel some disorientation. At the same time, this flexibility really is what defines our specialty, and I think you expressed this is your description of “EDM”. As a Medical Director for a Level 1 Trauma Center ED, I experience tremendous cognitive dissonance on a daily basis as I cycle between the C-Suite, the resuscitation bays, and the fast track. Only a little bit of my energy goes towards patient care, I think I can do that almost in my sleep. A huge amount of energy goes towards telling stories. I tell stories to my colleagues to keep them going, to my administrators to keep them happy, and to myself to keep me in the game. I don’t see this as bad, or good,… Read more »