Failure to Cope: The Hidden Curriculum of Emergency Department Wait Times and the Implications for Clinical Training

Webster, Fiona PhD; Rice, Kathleen MA; Dainty, Katie N. PhD; Zwarenstein, Merrick MD, PhD; Durant, Steve MPPAL; Kuper, Ayelet MD, DPhil

doi: 10.1097/ACM.0000000000000499
Research Reports

Purpose: The study explored optimal intraprofessional collaboration between physicians in the emergency department (ED) and those from general internal medicine (GIM). Prior to the study, a policy was initiated that mandated reductions in ED wait times. The researchers examined the impact of these changes on clinical practice and trainee education.

Method: In 2010–2011, an ethnographic study was undertaken to observe consults between GIM and ED at an urban teaching hospital in Ontario, Canada. Additional ad hoc interviews were conducted with residents, nurses, and faculty from both departments as well as formal one-on-one interviews with 12 physicians. Data were coded and analyzed using concepts of institutional ethnography.

Results: Participants perceived that efficiency was more important than education and was in fact the new definition of “good” patient care. The informal label “failure to cope” to describe high-needs patients suggested that in many instances, patients were experienced as a barrier to optimal efficiency. This resulted in tension during consults as well as reduced opportunities for education.

Conclusions: The authors suggest that the emphasis on wait times resulted in more importance being placed on “getting the patient out” of the ED than on providing safe, compassionate, person-centered medical care. Resource constraints were hidden within a discourse that shifted the problem of overcrowding in the ED to patients with complex chronic conditions. The term “failure to cope” became activated when overworked physicians tried to avoid assuming care for high-needs patients, masking institutionally produced stress and possibly altering the way patients are perceived.

Dr. Webster is assistant professor and educational scientist, Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Ms. Rice is a PhD candidate, Department of Anthropology, University of Toronto, Toronto, Ontario, Canada.

Dr. Dainty is a postdoctoral fellow, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada.

Dr. Zwarenstein is director, Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.

Mr. Durant is a PhD candidate, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Dr. Kuper is assistant professor, Department of Medicine, Faculty of Medicine, University of Toronto, scientist, Wilson Centre for Research in Education, University Health Network/University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Editor’s Note: A Commentary by E. Weber appears on pages 14–15.

Funding/Support: This study was supported through the Centre for Clinical Health Services Sciences at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Other disclosures: None reported.

Ethical approval: The study was approved by the Research Ethics Board at Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Previous presentations: Some of these findings have been presented as an oral presentation at the Canadian Conference on Medical Education, Toronto, Ontario, Canada, 2011; and as a poster presentation at the AMEE Conference, Vienna, Austria, 2011.

Correspondence should be addressed to Dr. Webster, Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 500 University Ave., 5th Floor, Toronto, Ontario, M5G 1V7; e-mail: fiona.webster@utoronto.ca.

© 2015 by the Association of American Medical Colleges