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Dear Editor,
I read with interest and empathy the recent article “Nothing satisfactory about patient sat surveys” (Sept 07). As a practicing emergency physician for the past 23 years I certainly agree with a lot of the points you make. I too frequently made the same points to administrators only to have them fall on deaf ears. I practice in suburban Phoenix, which has the longest wait times and highest level of ambulance diversion in the country (Press-Ganey). There is a severe in-patient bed shortage (national average 2.8 beds/1000 population, Phoenix is at 1.8). All hospitals report increasing problems with specialty coverage. We have one of the lowest per-capita nursing ratios in the country, combined with a very high median age (42).
 
Out of frustration with all that is wrong with EM, a group of EPs opened an acute care general hospital (Gilbert Hospital) in February 2006. Our first year we saw 42,000 patients and we are on track to see 50,000 this year. The ten most important points to a patient in regard to their satisfaction is door-to-doc time. We see 98% of our patients within 31 minutes of arrival. 7,000 patients did not pay the first year. We are expanding. We are profitable. Our satisfaction rate is 98%.
 
Since this hospital is extremely physician centric, labs and X-rays come back very fast. Radiologists read the CT, MRI, US, NM exams with a written report in 30 minutes after the exam is complete. We have one caregiver for every two patients. Paperless EMR with computer in every patient room. Remote scribes. Private rooms (no cubicles or curtains permitted). No overhead paging. Refreshments for all. Zero tolerance for boarding patients in the ED.
Meanwhile, other hospitals in our area operate with the [old] mentality: ED’s fulfill two functions for a hospital (an administrator once told me this); 1. To fill in-patient beds. 2. To lose money. So, they continue rearranging the deck chairs on the Titanic and all the usual problems persist. Given the choice, where do we think patients will go? It is time for physicians to take back control of their hospitals.
Respectfully,
Tim Johns, MD
 
Dear Editor,
I couldn’t read Dr. Elfenbein’s letter (Nothing satisfactory about patient sat surveys, Sept 07) without thinking I wrote it myself. I am so happy to hear a well qualified young physician express their discontent with the status of our field. I know I am 100% in agreement with everything he says except that I don’t just blame the ER community. Primary care medicine has seemed to evolve into nothing but well care check ups, and medication modifiers. Patients are sent o the ED for their X-rays and labs because PCP’s are too lazy to do them, because they are then required to follow them up. Any phone call to a PCP for fever, headache or nausea comes to the ED because it could be meningitis, bone cancer, or appendicitis according to the receptionist. EMTALA is probably the biggest culprit due to the fact that it mandates only ER’s are bound to see and treat regardless of payor status. We all agree this is appropriate for emergencies, but it has turned into ER referrals for every patient that now has an outstanding balance at their doctor. It also trumps the ability to refer patients to specialists because those crazy docs actually want to be paid for their work, and require money up front; novel concept.

I agree with Dr. Elfenbein that it is our job to police ourselves, and kick these drug seekers out of the ED, and be forthright telling our patients that their cold did not require an ER visit now nor when they have their next cold. We all go through too much training and experience to really care that the chronic back pain patient with a drug treatment plan in the ED is on their 30th visit, conveniently on Friday night after hours with the long weekend ahead. It is more important to spend much more time with a family explaining what heart failure means and what we are doing to try and help their loved one.
Respectfully,
Chris Galloway, MD
Colorado Springs, CO
 
Dear Editor,
My best memory of “the good old days” occurred in 1973 when I scored my first “save.” I was suturing a patient in the ER when the patient in the next room made a loud groan. The nurse ran into my room and said I’d better get in there. I dropped my instruments and as I entered the room I saw the patient had been put on a monitor and was in V-tach and was unconscious. I turned to our defibrillator and put the pancake paddle behind him, turned on the sync button and held the paddle on his chest and pushed the button. He converted, woke up and said “what the hell happened.” In my youth and excitement, I said “you died and I brought you back.” From that moment on I knew Emergency Medicine was for me. Has it really been 34 years?
Ron Ellis, DO
 
Dear Editor,
I found the article “Nothing satisfactory about patient sat surveys” (September 07) to be incomplete and would like to offer a different perspective. As a former full time practicing EP, I felt that patient satisfaction surveys were useless, but now, having been in the role of a hospital administrator for over one year and former role of emergency department practice administrator, I find true value in the survey process. The surveys actually do improve care and do not threaten to bring the system to its knees as the author implies.
 
Problem one: getting angry with patients due to their addiction problem, payor class, only adds to the individual EPs frustration and carries over to the sicker patients. There are methods of instituting pain policies, consistency among physicians within a group which influence higher patient satisfaction scores, and can lessen frustration. Recognition of unhappy patients within your current system may assist in developing those policies and procedures.
Problem two: Does a patient sat survey force you to see the less acute first? If in fact you are using the survey tool correctly, you can identify the need for a fast track or possibly a change in your staffing pattern to result in decreased wait times.
Problem three: the idea of legitimizing system abusers is blown a little out of proportion. If you believe you are sending the survey only to system abusers then you may feel this way. If the tool is used properly and randomly, you may find out what a scared young lady who was bleeding in her first trimester felt out about her visit. Did she feel safe, comforted? Did you make sure she wasn’t in pain? Did her family feel relieved when they went home?
Problem five is where I have the most difficulty with Dr. Elfenbein’s assessment. In EM throughout most of the country, you do not work side by side with your colleagues, so your understanding of their practice and how they treat patients can be a mystery. When you find that a physician consistently is not examining patients (yes, it happens), not discussing treatment and test results with patients and families, you are able to find this problem early.
 
The sad reality is that our complacency in policing ourselves has resulted in outside evaluation tools being so helpful for ED directors and hospital administrators. This is money well spent. You can spend millions more by allowing a rogue EP to fraudulently bill, injure patients and create a reputation for your group. Wait until one patient files a lawsuit against your practice because the physician ‘looked in the door’, ordered ‘some shot’ and sent the patient home without a proper history and examination. Finding this problem early will allow the group to continue without stopping salaries cold due to a freeze on your entire group’s A/R.

The last issue he raises is that sat scores have become a game. Well, I say, “Game on!” If you can improve a patient’s comfort, care, willingness to utilize your ED again, then so be it. Finally, the last statement echoes many of medicine’s problems today. ‘If the politicians and hospital administrators will not fix the problem, we need to stand up, exercise some leadership and do so ourselves.’ He is correct. In many arenas the complacency of physicians has forced outside influences. Remember, we as EPs can’t do it all. I think that if we look at the bigger picture, some sense can be made of patient satisfaction scores.
Respectfully,
Frank C. Smeeks, MS, MD
Chief Medical Officer
Frye Regional Medical Center

Dear Editor,
I was intrigued by Amy Levine’s recent tip on removing nasal foreign bodies by saline lavage. Over the years I have tried to have Mom blow in mouth to blow out the offending object or use a neonatal bag and mask to accomplish the same thing. What I have found to work best is to hold the mouth closed and flush the object out by oxygen. I connect the suction tubing to the oxygen valve and set to 15 l/min. I then attach the other end to a barrel connector or even better a neonatal aspirator, available in your newborn nursery. I then papoose the child and put the aspirator in the patent nares and put my thumb over the control. The object usually comes flying in about one second before the child knows what happened. I like the nasal aspirator which is tradenamed BBG aspirator because it allows me to control when the oxygen will begin to flow in the nose. The barrel adaptor blows oxygen all the time and gets the child more upset. The nursery nurses tell me the BBG stands for Booger-Be-Gone but they may be pulling my leg.
Mike Overfield

Dear Editor,
I am finding the series of articles written by Ilene Brenner, MD, on what to do after being served and how to handle the subsequent morass that ensues very well written and on point. How lucky she is to have a med mal father and how very fortunate we are to benefit from her wise advice.
Thank you,
S. Frankel, MD

Dear Editor,
When I was in my ER residency at San Francisco General Hospital in 1979, we did not have a CT scanner. In those days if you had a head injury with possible subdural, if the patient was stable you could do an arteriogram which took about three hours and gave indirect evidence of a mass effect. Otherwise, you took the patient to the OR for burr holes and craniotomy urgently. One night I was covering on the Neurosurgery service for that rotation and a young woman came into the ER from an MVA with head injury, back pain and weakness in the right foot. She was A+O x3, and initial X-rays of her neck and back were normal. She suddenly deteriorated in the ER and became unresponsive and blew her L pupil. She was intubated and given mannitol in preparation for the OR. Unfortunately all the senior Neurosurgery staff were attending a special meeting about 40 minutes away and were not immediately available, but “on their way in” and I had no one available to assist me. Just about that time, the chief of trauma surgery walked into the ER (the original pioneer for trauma centers then). I asked him if he would assist me in the case; he indicated he would be happy to but it had “been a while” since he had done a craniotomy. We then took the patient to the OR, and I had just drained a subdural with burr holes, when the chief neurosurgery resident arrived. After the operation, the patient woke up in the ICU one hour later and pulled her ET tube out; she had an uneventful recovery. It was a great experience. I’m now 56 and still practicing ER half time. I could probably write my own book.
Alan Buchwald, MD
Dominican Hospital/CHW
Santa Cruz, California

Dear Editor,
As a 57-year-old EP I enjoyed your bringing up an important subject (The Age-Old Question, July 2007). What do we do with us soon to be old guys? Fortunately, I am a member of an independent group which for many years has had a policy of exempting from night shifts the two physicians in the group who have been there the longest. What this does is allow me to continue to work longer than I might have if I still had to do nights (I’ve already done 25 years of them). It also shows that if you stay with our group you have the chance to do the same. We all however share equally the holidays and weekends. I don’t mind at all working some shifts for those with young families. I don’t agree that we can’t slow down or limit our practice. I feel, in fact, that one of the great advantages of the ED is that we can do just that. At some future time I will cut back to a smaller amount of hours and accept the lower pay. I have no problem with compensating the night shift at a higher rate, although our compensation is not a simple hourly rate. Many EDs double cover shifts and this is a good place for the older physician to be as is the “Fast Track.” I am happy to take some of the “duller” cases and difficult patients and leave the interesting stuff to my colleagues who want them.

We are already seeing a shortage in board certified EPs and this will only get worse. It makes good economic sense to keep the older EPs working who want to and keep up their patient flow and CME. Our experience should be worth a few perks along the way.

Thanks again for bring up this most relevant of topics.
Peter Manis, MD
Pensacola Florida

Dear Editor,
Joe DeLucia wrote a fine article on aging in emergency medicine (The Age-Old Question, July 2007). I became the oldest doc in my group when my mentor finally had to stop practice at the age of 83. He lived to be 89, and we kept in touch up to the end. I had to stop at 62 due to lung cancer (never smoked, wife never smoked, got it anyway). But, frankly, I’d already announced my retirement date even before the diagnosis was made. There really does come a time in a person’s life when he wants to sleep at night instead of in the afternoon and early evening. I’d done emergency medicine for 33 years, and I could afford to retire. Anyway, you’re supposed to be healthier than your patients, and I’m no longer healthier than the typical emergency department patient.

I’m still a doctor, though. I’ve been doing home visits for hospice patients for 22 years. Fortunately, I’m still healthier than my hospice patients so I can still do house calls.
 
There’s something to be said for having a secondary specialty that’s not as physically demanding as emergency medicine. And while I can’t, for the most part, cure my hospice patients, it’s quite rewarding to bring comfort to people who would otherwise be suffering from terminal illness and from the inability to get their regular doctor to make house calls.
Henry Farkas, MD
 
 
 

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