Chances are, if you’ve ever been to a meeting for a professional society in emergency medicine, you’ve heard the topic of “workforce issues” discussed. There’s also a good chance that you’re thinking these issues have nothing to do with your next shift. In a way, you would be right. However, if you have any interest in emergency medicine as broader system, as an establishment that performs an important role not just for the patients in front of us, but for the public at large, you’ll care about the critical workforce questions. What is the current practice environment? Who practices in the emergency department and where do they come from? What are the challenges and opportunities, both now and in the future? Leaders in emergency medicine have to craft a clear vision of the future that builds on current realities, not wishful thinking, to help us address these issues. As health care reform rises on the horizon, there is opportunity to provide leadership for the future state of healthcare. If we don’t define the future for our patients, someone else will.
Several professional organizations and the Institute of Medicine have looked at workforce issues over the last few years and the snapshot is interesting, including who is working in which EDs. Approximately 62% of physicians practicing in ED in America are board-certified in emergency medicine. Those who are residency-trained are more likely to practice in academic medical centers or larger urban centers that mirror their training environments, with advanced technology and more consultants available. About 38% are not board-certified nor residency trained in emergency medicine. These physicians tend to practice in smaller, suburban and rural facilities. These docs are usually boarded in other specialties but have dedicated their careers to the practice of emergency medicine..
We should be proud of the growth of the specialty, but clearly there are some challenges to overcome. We can debate whether only board-certified docs should be working in the ED. However, the practical aspects make it more of a philosophical issue. According to the IOM, the supply of board-certified emergency physicians is not sufficient to staff all EDs and probably won’t be for decades, if ever at all. The ABEM practice track, one source of board certified EPs, closed in the 1990’s. Also, graduating emergency medicine residents don’t really want to work in rural environments for many reasons including money, resources, and technological resources. My residents at Grady wouldn’t leave the bigger city for a rural hospital, even if I put a gun to their heads.
There are also limits on the workforce that supports emergency department operations, including trauma surgeons, on-call specialists, emergency nurses, mid-level providers, pharmacists and hospitalists. In additional to these overall shortages, maldistribution exacerbates shortages in many areas of the country.
There are many issues that affect the recruiting, retention and longevity of emergency physicians. Among them are outdated reimbursement calculations, uncompensated care, the rise of prohibited balance billing, liability in an increasingly crowded and overworked environment, rising malpractice premiums, stress and lifestyle issues, provider burnout, personal safety, biohazards, and the physical demands of the profession.
So where do we go from here? Clearly, our specialty can’t solve the problems of today using yesterday’s tools that got us into this situation – reliance on more docs, residencies, beds, staff, and money. That tired approach won’t work anymore. And even if we try to create more emergency physicians and specialists, current residency requirements have created a generation of physicians who want limited hours of work and seek greater balance of work and lifestyle issues.
We are at an interesting crossroads in our country. Even though there have always been divergent views and perspectives on healthcare, for the first time, most everyone agrees that it is just too expensive and somehow money has to be cut from the system, and big money at that. I see three likely scenarios unfolding in the next decade.
The Uphill Treadmill
For years, emergency medicine has screamed that our ED’s are overcrowded, many of the patients don’t really need to be here, and that the safety net is falling apart. While all true, we have to be careful what we wish for. Policymakers, payors and others are taking aim at the ED as being too expensive and inappropriately used. As a result, we may find ourselves working harder for less, especially in the current economic environment. Walk-in and urgent care centers are popping up in drug stories, Wal-Marts and shopping centers. Your department is overcrowded? Don’t worry, that volume may just go elsewhere, taking your bottom line with it. As primary care docs lose income, they are adding office hours, recapturing lost revenue seeing patients with insurance and sending the uninsured to the ED.
Hospitals are on the ropes and cutting staff, and your resources. The emergency physician often becomes the highest paid clerk in the building, tracking down lab and ancillary services and other physicians while trying to take care of patients. Uninsured patients will be arriving sicker and with more complex diseases, requiring intense care without any way to pay for the services rendered. Even those patients with insurance have larger co-pays or are often underinsured. Prohibitions on balance billing will leave the emergency physician holding the bag. In the end, emergency physicians will see more sick patients for less money. Running this treadmill with little end in sight is a distinct possibility.
The good news is that there are ways to completely transform the future. Systems thinking, teamwork training, and emerging technologies can revolutionize current ED models. While in their infancy, there are some models for success, some of which are already developing. Efficient practice is critical to our survival.
Whip The ED Into Shape
Option two is to transform ED’s into mean, lean, fighting machines. Unfortunately, cultural resistance and lack of leadership are common challenges to overcome. Wal-Mart can track a pallet of sand around the world; we lose patients in the waiting room, or haven’t a clue about bed availability on the floors. Health care is really the last industry to embrace systems thinking, a concept that swept the business world twenty (yes, twenty) years ago. Each part of the hospital and the medical staff operate independently and don’t understand how each impacts other parts of the system. As a symptom, everything just backs up to the ED. They’ll keep complaining about the performance of the ED until we fix the system that created the problem.
High performing ED’s improve patient care and patient flow during input, throughput, and output phases. Impediments to flow must be identified and addressed by all stakeholders. It may be as simple as changing housekeeper’s hours, moving a computer terminal; or something as complex as installing new programs, creating new roles, regulating floor discharges, or retraining ancillary staff. The bottom line is that when processes improve, patients are happy, the staff is happy and performance improves. Many ED’s are moving the provider to the front end processes, obviating the need for beds and eliminating many of the unnecessary steps of triage and repeated evaluations by different staff.
Many ED’s have a collective of individuals, each doing their own thing, rather than a high performing team. Some have two or three teams – nurses, mid-levels and doctors- that compete, instead of one team working together. Delivering high quality emergency care takes the characteristics of great teams: collaboration, communication, commitment, collegiality, coordination. Many ED physicians think that each doctor can do things differently, instead of committing to an agreed upon approach that allows all team members to get good at “the playbook”. This leads to team dysfunction and poor care processes. Each ED should have well defined goals and teams that work in tandem to “get er done.” Do more with less, rather than for less.
The highest risk to patients is in between settings and in between providers. Creating strong teams is associated with decreased errors, better communications and better decision making. Works for me!
The Integrated ED
In addition to the above scenario, the most exciting aspect of technology is growth of IT infrastructure that allow us to track and care for patients, gather information and support care decision-making, connect specialist and patients at a distance. Teleradiology is now well-established, but recent advancements allow the cognitive decision-making by outside specialists working remotely to be “piped in” to the bedside. Critical care physicians can monitor patients remotely, even “doing a physical” using a digital camera while a nurse helps. Neurologists can support emergency department physicians make decisions about use of thrombolytics in stroke patients. As hospitals become more wired, we can connect large centers and rural hospitals to extend the cognitive reach of more experienced emergency physicians and specialists. The EMR will allow us to share imaging and converse via text messaging with, for example, a distant orthopedist or trauma surgeon covering multiple hospitals. That text messaging trail is captured as part of the record and available at any time as the patient travels through therapy. Rather than transferring out patients for further evaluation by a remote specialist, the information and medical expertise is transferred to the patient. Ah, teamwork! Such a model strengthens the ability of the emergency physician to care for their patients more safely, efficiently and effectively. It also wrings out unnecessary costs and inefficiencies from the health care system and support the growth of regional systems of care.
The television series “ER” has ended, but our show continues to go on. To be most effective for our patients, we need to have greater dialogue on workforce issues. More importantly, we need to weave our existing and emerging resources into future networks that allow us to fulfill our professional mission, and more. Let’s hope that our specialty ensemble cast can get our “act” together and take our show to the next level.
Ricardo Martinez, MD, is the Executive Vice President for Medical Affairs for The Schumacher Group and is on the faculty of the Department of Emergency Medicine at the Emory University School of Medicine