WhiteCoat

Art Kellermann Rand Rant

One of the posts in my Twitter feed was a re-tweet of something asserted by Dr. Art Kellermann (@ArtKellermannMD). Dr. Kellermann is a distinguished physician. He is the Director and VP of Rand Health. At one point he was a professor at Emory University, but apparently does not practice emergency medicine any more.
Dr. Kellermann’s tweet said the following:

Kellerman Quote

Dr. Kellermann’s tweet references an editorial article that he wrote in the Annals of Emergency Medicine titled “Waiting Room Medicine: Has It Really Come to This? The article was from 2010, so I’m not sure what prompted him to tweet about it in 2013, but nevertheless, the article at least seemed pertinent … until I read it.

The assertion in Dr. Kellermann’s tweet was a quote from his article and was reportedly supported by a 2001 brochure created by the UK Department of Health (.pdf file). The context of Dr. Kellermann’s assertion in the article he wrote is as follows:

The ED is more than a clinical setting; it is a “room with a view” of the best and worst of modern health care. In the United Kingdom, a crowded ED is considered a telltale sign of a poorly managed hospital. If that perspective ever takes hold on this side of the Atlantic, things will change. Until then, it is up to us.

Things will change if our perspective changes. Until then, change is up to us.

What a feel-good nonsensical assertion of nothingness.

How will things change in the face of significant numbers of hospital closures combined with significant increases in emergency department visits (exceeding 136 million in 2011), in the face of overwhelming government regulations that hamper the provision of proper medical care (remember the little story in your article about being cited by a JCAHO investigator because patient privacy was more important than providing medical care in hallways?), in the governmental push for electronic medical records that further hamper the provision of proper medical care, and in the face of medical malpractice judgments often in the millions of dollars that foster defensive medicine along with increasing criminal prosecution and licensure actions against medical providers for adverse patient outcomes?

Assuming that everyone now “accepts” ED overcrowding and we all suddenly change our perspective to rue ED overcrowding, exactly how will things change, Dr. Kellermann?
And if it is up to “us” to change things now, exactly how do “we” go about doing so?
Hit me with some policy suggestions for improvement from that multimillion dollar think tank of yours, won’t you?

The problem with your article and with your tweet is that you point your finger at problems we already know about, you furrow your brow and shake your head, then you walk away. You provide no solutions to those problems. Then you go point out another problem and shake your head. And another. And another.

When one performs a search for “emergency department” on Rand’s web site, one comes up with 870 results. I’m not going to read through all 870 of them, but the the first few pages of results merely seemed to point out several problems in our health care system without proposing any solutions … except diverting patients with minor illnesses to retail clinics. Of course you know federal EMTALA law requires that emergency departments provide a screening exam to every patient seeking care – regardless of the complaint, so that “diversion” technique will do little to affect overcrowding. Every patient that wants an exam in the ED is federally mandated to receive an exam.
When one searches for “emergency department overcrowding” on Rand’s site, there are a total of 4 results, one of which is your enlightening article and the other three of which do not propose any Rand Corporation-certified solutions for solving the overcrowding problem.

If proposed solutions are out there, please provide them to me. If not, maybe you could go back to your desk and create some. You don’t walk up to a patient in an emergency department, point a finger at his EKG, tell him he’s having a heart attack, and then walk away with your arms aloft and wait for applause. You do your best to provide the patient with treatment that makes the problem better.

Almost anyone who has sought emergency medical care knows that overcrowding in emergency department is a problem. My daughter would cock her head to the side, make a funny face, point her finger at her temple and call that a “DUH moment.” Full is full. Surge capacity has its limits within the physical confines of a building. You can only stuff so many people into a phone booth. How many analogies do you want?
Emergency department overcrowding isn’t a sign of a “poorly run hospital” any more than a sold out movie is a sign of a poorly run theater. It’s just that when the movie is full, the theater stops selling tickets. When the emergency department is full, it still has to find a place for the patients.

The NHS article you cited doesn’t support your statement about overcrowding being a “telltale sign of a poorly run hospital”, either. In fact, the NHS article specifically stated

These problems are not the fault of the dedicated staff in these services who are working under real pressure, but due to fundamental problems with the way the emergency care service is organised – a service which is crying out for change

The article discussed changes that needed to be implemented throughout the system. It didn’t single out hospitals and say that they were poorly run because they were more overcrowded than other hospitals. In addition, the NHS article actually made suggestions for improvement – such as spending more money to increase the number of doctors and nurses in the emergency departments, spending more money to expand the number of beds, and spending more money to provide home care services.

That was more than 10 years ago. Has the Rand Corporation suggested similar measures in this country, yet? If so, I couldn’t find them on Rand’s web site.

And another thing, I don’t think any emergency medical providers “accept” ED overcrowding. We work our asses off to safely see as many patients as possible given the constraints that the system imposes upon us (see above). We are just as frustrated by overcrowding as everyone else is. You think emergency department overcrowding is bad now? Wait until millions more patients receive insurance through the Affordable Care Act and then come to the emergency department for their federally mandated medical care. Can’t wait to see your tweets, then.

Dr. Kellermann, you’re the director of one of the largest health policy organizations in the nation. Pointing fingers at a problem, citing an 11 year old UK pamphlet, and shaking your head is the best you can do?

Apparently so …

Kellerman Quote 2

 

P.S. It isn’t an “ER”, it’s an emergency department.

————————————————————————————

UPDATE JANUARY 28, 2013

Sheesh. Away for a weekend and all heck breaks loose over this post.

First, I changed the post above to reflect the correct spelling of Dr. Kellermann’s name. Sorry about the mistake.

Since the original post, there has been a bit of a backlash against me … mostly on Twitter.
I don’t get included on all of the feeds, but the backlash began with Dr. Kellermann tweeting “Glad you care. I’ve worked on the challenge for 25+ yrs. How long 4 you?”
There were several tweets that described Dr. Kellermann’s pedigree and commended him for his past service to emergency medicine.
Dr. Kellermann responded to @skepticscalpel‘s questions and retweets of my posts by stating “Read my articles and learn my record before believing a blog.” Dr. Kellermann also provided a citation to an article he wrote in 1991 and some other nonspecific cites of the several hundred articles that he has either authored or co-authored in the past 25 years. I don’t expect Dr. Kellermann to recall the text of his articles verbatim. I certainly can’t remember everything from all the articles I’ve written.
There were several tweets from other bloggers that alluded to the issue I raised being “nitpicking” and to an anonymous blogger seeking increased site traffic. Dr. Kellermann also made an issue of anonymity when responding to Skeptical Scalpel.  Wasn’t clear whether these comments were directed at me or at @skepticscalpel.
Finally, Seth Trueger and others suggested that ED overcrowding really is a sign of a poorly run hospital.

So … where do I begin?
First, in responding to the negativism regarding the post: Just the facts, folks. Just the facts. Outrage is often used as a counterargument when there is no factual basis for a response. There’s a saying that I’ve heard lawyers use in the past: When the facts of your case are not in your favor, pound the legal arguments. When the legal arguments for your case are not in your favor, pound the facts. When neither the legal arguments or the facts are in your favor, pound the table.
Enough pounding the table.

I’m not disputing Dr. Kellermann’s pedigree. I don’t dispute that he is well-published. I don’t dispute that he has tried to help advance the cause of emergency medicine. Raising those issues in response to my post amount to nothing more than non-sequiturs. Just because someone has done admirable things in the past does not mean that they should never be questioned about their insight or actions in the future. I used to be able to squat 700 pounds. Does that have any bearing on my physical fitness now?

Next, both Skeptical Scalpel and I are anonymous. I’ve been blogging for six years. Skeptical Scalpel has been writing for a few years. A Google search will easily show anyone where to find either of us. The only purpose I can see in questioning our anonymity is to attempt to attack our personal credentials. As if everyone is just going to forget about the issues raised and the person with the biggest CV wins. Or maybe we’ll do some reconnaissance work and see whether WhiteCoat donated money to Al Queda. That would surely make WhiteCoat’s criticism of Dr. Kellermann unwarranted. Anonymous drive-bys from people you’ll never hear from again should be taken for what they’re worth. If my real identity really makes a difference in the veracity of my posts, enough people know who I am to get the word out. Until then, how about we address the issues raised?

Next, the ad hominem attacks. Dr. Kellermann urges his followers to research his history before believing “a blog.” Because “blogs” are untrustworthy and full of soulless minions hell-bent on destroying people’s good names. His response in no way addresses the questions I raised. It only attempts to undermine my credibility. Should we believe Dr. Kellermann’s tweets have any more truth to them than my blog post? Or does this whole process really amount to an issue of pedigree such that no one can ever question Dr. Kellermann ever in his life because of his accomplishments up to this point in time?
Dr. Kellermann also tries to use his pedigree to try to attack my credibility. He’s been working on the challenge for 25+ years, how about me? First, although you may not know it, let’s just say that I do a lot of work to advance emergency medicine as well. And, looking at how overcrowding has arguably gotten worse in the past 25 years, you may not want to use your “working on the challenge for 25 years” comment as the opening salvo in an ad hominem attack against me. It may backfire on you.

I view the “nitpicking” comments as a way of attempting to minimize the issue I raised without having to respond to it. If misrepresenting the cause of emergency department overcrowding is “nitpicking” then it get out the louse comb, folks, because it’s a nit that needs to be picked. Richard Winters (@drrwinters) tweeted that the cause of ED overcrowding was instead multifactorial. That was my point and Dr. Kellermann agreed with him. Good. Now we’re getting somewhere. It isn’t just a poorly run hospital as a cause of overcrowding. Seth Trueger wrote a blog post about the problem and tried to dissect out the issues. I don’t agree with a couple of his premises, but now at least we can debate the issue. That’s good. Seth’s tweets suggest ways to improve overcrowding. That’s even better.

Dr. Kellermann responded to me yesterday asking “Does your hospital give E.D. admits priority over electives when beds are scarce? If so, you are a lucky exception.” His question implies that the only reason for bed assignments in hospitals is whether the patients come from the ED or whether they come from “electives.” That is misstating and oversimplifying the issue. These are the types of assertions that I believe need to be questioned. I responded “My hospital assigns beds to patients most in need regardless of location. Keep casting aspersions, though.” Few, if any, policy issues in medicine have binary solutions.

Problems that prevent us from providing proper medical care need to be addressed. Most people know what the problems are. They aren’t unique to the medical profession, either. See the engineer’s triangle. Underlying almost all of the problems are three main themes: quality, cost, speed.

In medicine, we can’t measure quality, everyone knows that costs are excessive, and the speed with which we provide care is in many cases getting slower, not faster. Now that we have that out of the way … why are things this way? A smart man can always tell you what happens. His boss can always tell you why it happens.

If we want to solve the problems, then let’s discuss solutions. Pointing at the problems and saying “that’s a problem” does nothing to help solve them. Misrepresenting the cause of the problems is a barrier to their solutions.

So now that we’re on each others’ radars, I think we need to expect more accountability from a corporation dedicated to health policy and its Director. I still don’t see any viable solutions being offered.

Any response, Dr. Kellermann? I’d be happy to add a separate blog post here so that you are not constrained by Twitter’s 140 character limit.

10 Responses to “Art Kellermann Rand Rant”

  1. Torgrim says:

    “The doctor shook his head. It was all he could do, under the circumstances, and he did it well.” (Charles Dickens)

  2. Birdstrike says:

    “suggestions for improvement – such as spending more money to increase the number of doctors and nurses in the emergency departments, spending more money to expand the number of beds, and spending more money to provide home care services.”

    Why “spend more money” to improve the system when there is another solution that costs nothing: Tell the EPs and nurses to see more patients faster, or lose their contract and their job.

  3. Retired because of this kind of crap. says:

    And the EMR and CPOE, both federal mandates, cut patient flow rates through the ED by 1/3 to 1/2. Like many of the worst problems in the United States, dysfunctional EDs are largely due to bad federal policy. Get the feds and their minions, the Joint Commission, of our backs and put doctors and nurses back in charge of medical care — things will get better.

  4. Ranting at Dr. Kellerman is no answer either. Spending more money might make sense if we weren’t already spending way to much money and getting not much for it, and if we weren’t bankrupting the country in the process. Now spending the money in a different way (prevention vs. treatment), or addressing the root causes of the boarding problem (like ‘for profit’ health plans, fee-for-service medicine, overly aggressive end of life care, and lack of surge capacity protocols in many hospitals around the country, could make a difference. California ACEP tried to get legislation passed to mandate frequent measurement of ER overcrowding and adoption of hospital-wide surge capacity protocols, but the hospital association killed it. I don’t know if this represents ‘poor running of hospitals’ or hospitals trying to maximize revenues, or just tunnel-vision thinking, but it is not like there aren’t good solutions out there, but they are overwhelmed by a misalignment (or mal-alignment) of incentives.

    Rand can certainly do more to promote these solutions, and should; and emergency physicians, as front line providers, need to keep pushing from the pit to encourage hospitals to do what they can do: but some of the wider cultural issues around health care that need to be changed in this country will be even more difficult to effect. We will need well regarded physicians to lead this effort, and if you have heard Dr. Kellerman speak, you know he is pretty good at that.

    • WhiteCoat says:

      Many of your thoughts are very similar to mine. See my addendum to the post above.
      Measuring overcrowding does nothing to solve the problem. Surge capacity protocols would be an excellent step in the right direction, but what happens when those protocols are overwhelmed? These are the questions we need to ask and answer.
      Aligning incentives – another good solution. Before getting there, we have to dissect out the different incentives and see how they interact.
      “Rand can certainly do more to promote these solutions, and should.” Another one of my points. Hopefully this post will serve as a wake-up call.

  5. Seth Trueger says:

    here are my thoughts on why crowding is a sign of poor hospital management (with the implication that “good management’ = doing what’s best for patients) http://mdaware.blogspot.com/2013/01/empty-dishwasher.html

    • WhiteCoat says:

      You have dishes in your sink? Holy shit. That is a telltale sign of a poorly run household.
      We should have your landlord come and investigate you.
      Insurance companies should come and review your homeowner’s policy – after all, sink dishes could cause a flood, which could start an electrical fire, which could burn down the entire apartment complex, injuring or killing every person on the city block.
      Obviously the problem is because you are trying to wash too many pots and pans which unjustly crowds out the kiddie cups and the cheap food storage containers. You really need to focus on the cheap dishes and shouldn’t wash pots nearly as much. Who cares if you can’t cook your food and eventually you have to leave your apartment? YOU HAVE DISHES IN THE SINK, DAMMIT!

      You’re right that the process involves three aspects of input, throughput, and output. However, you oversimplify the issues involving those three processes.

      I work in a couple of different places and both of their departments become overcrowded for different reasons.

      Viccellio’s study didn’t compare outcomes of ED boarded patients with outcomes of floor hallway patients. It compared patients in inpatient beds versus patients in inpatient hallways. A comparison of outcomes in what we’re trying to measure, including effects on patient flow in the ED and even the effects on hospital income would be a much better way to study the issue. Unfortunately, given the varying acuity of ED patients, the results would likely be difficult to interpret.
      Also, the study didn’t (and probably couldn’t) account for the “high maintenance” patients in the ED. Can’t really put vents, drips, monitors, psych patients, ect in a hallway. What do you do when your ED is full of these patients waiting for beds?

      What happens when the hospital doesn’t have sufficient staffing for the inpatient beds? Still cram patients on the floors and overwork the available nurses? When mistakes increase, then who gets blamed? Would you be OK with your mom being put in a hallway with two nurses trying to cover (and write electronic notes on) 24 patients? If not, why? What’s the maximum number of patients that should be covered per nurse? What if the patients are high-maintenance?
      What happens when nurses become fed up with being overworked and leave for another job. Then there are even fewer staff available to care for patients. Then what?
      What happens when six patients register to be seen in a small ED within 30 minutes of each other, the ED only has 6 beds, and 4 of them are already full? You say it doesn’t happen that much. I work in a rural ED part time and I see it happen all the time. Has nothing to do with “boarding”.

      But you’re on the right track of at least raising the questions and proposing solutions.

      • Seth Trueger says:

        “What happens when the hospital doesn’t have sufficient staffing for the inpatient beds? Still cram patients on the floors and overwork the available nurses?”

        The status quo is to keep all the admitted patients in the ED, where nursing ratios quickly approach or exceed 1:12. Is it somehow safer to keep all of the admitted patients in the ED hallways in order to maintain nursing ratios on the floors? Viccellios main point is that it makes much more sense to put 1 boarder in each inpatient unit instead of keeping them all in 1 unit (the ED) which has a limited supply of nurses, as well as a steady flow of new patients.

  6. BirdStrike says:

    I find it quite ironic that our current national hospital bed, and ED overcrowding crises aren’t enough to make sensible people rethink current “Certificate of Need” laws. It’s just one of countless examples of the government creating and fostering a crisis, then using it as political fuel to get re-elected to “fix” the crisis they’ve created with more false solutions that just perpetuate the cycle.

    We will know when we are serious about solving our health care crises when we stop supporting such policies which are nothing more than a monopoly over such shortages to ensure that hospitals profit from them, at the expense of patients.

  7. Drew says:

    Unbelievable. Do you know how UK hospitals “solved” the problem of ED overcrowding? Why, they just keep the patients waiting in the ambulance outside the hospital! Problem solved! Except now you have another problem where an ambulance is stuck in the hospital parking lot instead of servicing the community. Sorry, no refunds!

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