The specialty of emergency medicine has changed over the past 25 years, and is almost unrecognizable when compared with its earlier incarnations. Emergency physicians of the previous generation were often labeled “glorified triage officers,” a phrase used to discourage the would-be emergency practitioner.
“You'll burn out after seven years!” was the truism spouted by seasoned physicians of other specialties. Faculty at a reputable northeastern medical school told at least one medical student, “It isn't even recognized as a medical specialty!” Those brave enough to plunge into the field in spite of these disparagements have seen such comments proven false. What other specialty has gone from illegitimacy to a fully recognized (by the AMA and society) medical specialty, the number one choice of medical students and the focus of its own popular television show in less than a generation? Anyone waiting for CBS to air a new program called “Cath Lab” may be waiting some time.
Aside from newfound legitimacy, the day-to-day practice of emergency medicine has changed insidiously, but have its practitioners fully adapted to the changes? In particular, have physician groups made functional changes in how they are structured and how they operate?
The number of emergency departments in this country has fallen from more than 5000 in the 1970s to 3800 today, according to the American Hospital Association. As the national ED capacity has decreased, the utilization of emergency department services has increased steadily. (Trends in Hospital Emergency Department Utilization: United States, 1992–99. National Center for Health Statistics. March 2004, Series 13, No. 150.) In every three year cycle, 17 percent of the population will visit an emergency department. (“National Ambulatory Medical Care Survey: 2000 Summary.” Advance Data. 2002, No. 328.) The small ED with less than 10,000 visits per year is all but extinct, and practitioners remember fondly departments with 24-hour shifts. The adventurous emergency physician could travel the world after working an entire quota of shifts in one block. Today with the average ED volume at 30,000 visits, the practice of emergency medicine is too hectic for such scheduling, according to VHA ED Consulting Services; which manages a database with information from more than 138 EDs. (www.vhatools.com/ed.)
The nature of emergency medicine practice is changing. Though the emergency physician is well trained and credentialed to run a ventricular fibrillation cardiac arrest, interventional cardiology has changed all that. Can anyone remember the last time they defibrillated a patient? The emergency medicine practitioner now cares for patients who would have died acute coronary deaths several decades ago, but who now survive and present to the ED with chest pain, congestive heart failure, cerebrovascular events, and other chronic illnesses. (Med Care 2002:41:198.)
Occupational and vehicular safety measures have resulted in a relative decrease in ED visits for trauma and injuries and an increase in visits for acute manifestations of chronic diseases and complex medical problems. In actuality, these are two great success stories for our specialty, though to hear the federal government and third party payors talk, you'd think we had created a problem with these medical survivors. The closure of psychiatric facilities coupled with social problems such as drug abuse and homelessness also have made the ED the hub of psychosocial problems in the community.
The net result of these changes is that 21 percent of the time our EDs function with more patients than bed space, and a third of the nation's EDs function with all of their beds full more than 12 hours a day. (“Building The Clockwork ED,” Executive Briefing, Best Practices for Eliminating Bottlenecks and Delays in the ED. Published by H Works, An Advisory Board Company, Washington, D.C., 2000.)
Complex patients spending more time in the ED translates into overcrowding, more subspecialty interactions, and more influence by outside organizations on the practice of emergency medicine. Have emergency medicine practitioners seen the implications for their groups in all these changes?
There may be no other specialty facing the social and economic problems of the community the way they are faced by emergency medicine. It would be impossible to isolate the ED from the effects of public policy because it interfaces with the community and all its social ills with open doors and open arms on a 24/7 EMTALA-mandated basis. On the other side, emergency medicine interfaces with the institution and every other medical specialty as well. (Name a subspecialty you haven't contacted from the ED in the past year.)
Outside decisions have affected the practice of emergency medicine at my facility. When the neurosurgeons refused to take trauma call, a nearby trauma center closed, which affected the entire region. When neighborhood community health clinics filled up and could take no new patients, the number of patients presenting to the ED for follow-up visits increased by 40 percent. When psychiatric beds began closing, the amount of time patients had to spend in the ED waiting for disposition rose dramatically, further burdening the ED. As the gateway to health care in this country, emergency departments are affected by policy decisions made by organizations outside their sphere of influence almost every day. Then they are commanded by JCAHO to fix it.
Do emergency physicians appreciate what they mean to the functioning of their physician group? Do they recognize the very real changes in their own job descriptions as nonclinical tasks increase exponentially? The old model of ED staffing had an ED director who handled all of the nonclinical tasks for the group while the other seven or eight physicians felt comfortable to work their clinical shifts and go home. This model is no longer viable for emergency medicine groups practicing in the 21st century. The size of the ED group is larger, and the interfaces it has to tend to are more numerous. This suggests a new model for the division of labor. There is a critical need for representation and involvement of the emergency physician group at the institutional, state, and local government levels. Areas of expertise required are too many for the old “one-man-show” model of ED group functioning.
The table shows a representation of the old model of ED group functioning and a proposal for a new model addressing the many and varied tasks of the emergency physician group. Local variations exist, and many tasks could be reclaimed by the director. The quality improvement director role in particular needs clarification. In previous decades, QA consisted of episodic chart audits performed more at the request of administrators than because of any particular ideology held by emergency physicians. The explosion of information technology has changed such tasks, and data collection has become much easier.
Departments with robust quality improvement programs can attest to the effectiveness of data collection as a public relations tool, to support the requests for equipment and staffing, to facilitate operational improvement, and to demonstrate such improvements. This data gathering may support the work being done by other group members in other arenas. A better title might be director of ED operations to fully represent the scope of the role. This role is essential to the emergency physician group, and should be supported in creed and in deed.
It also might be argued that the characteristics of an individual willing to chase and mine data relative to ED processes, to analyze spreadsheets and flow charts for efficiency, and to redesign ED operations might be entirely different from the characteristics of the effective director. An ED director needs strong leadership qualities and the ability to politic effectively with institutional authority and outside agencies that affect the emergency department. Perhaps the skills and personality traits required for one role are antithetical to the other.
By delegating ED tasks to other physicians, this new model allows for professional growth and investment as well as development of expertise that benefits the individual and the group. Most physicians long ago realized the benefits that nonclinical duties have for the group, and this understanding is more necessary than ever. The more participatory the group, the more influential it becomes, and this can positively affect practice day to day.
For example, Todd Taylor, MD, at the University of Arizona worked with state and local governments to help find health coverage for indigents in his community, and this makes his department more profitable and sustainable. (ED Crowding Reference and Resource CD; available from email@example.com.) He is currently working on these issues with the American College of Emergency Physicians. Peter Viccellio, MD, at the State University of New York-Stony Brook, worked with the New York Department of Health to develop a program to board patients in inpatient hallways to alleviate overcrowding in the ED. (Emergency Department Full Capacity Protocol; available at www.viccellio.com/overcrowding.htm.) Thom Mayer, MD, at Inova Fairfax Hospital, has developed a team triage program to expedite input at his hospital and a risk reduction program for emergency physicians. (“T3: Team Triage and Risk Reduction in the ED,” presented at ED Benchmarks 2005, Orlando, by Thom Mayer, MD). These are critical innovations for their departments and for the specialty. None of these leaders is currently the medical director of his department.
While many a pony-tailed counter culture type may have entered our specialty with notions of climbing Mt. Everest on his days off, the era of working an ED shift and going home with little participation in the institution and community infrastructure is long past. External pressures and influences on the practice of emergency medicine mandate our participation at every interface. Where we are negligent, we may find regulatory demands upon us which are untenable. If you doubt this, consider the Joint Commission's latest core measures mandate. (JCAHO: Specification Manual for National Implementation of Hospital Core Measures. Version 2.0, 2004.)
It is essential that ED groups look at the factors most influencing their practices and to assign a physician to participate in decision-making in that arena. Often such participation reaps benefits for the physician involved as he takes ownership of an area of the practice and develops critical knowledge and expertise. The tasks of the emergency physician in the 21st century are varied and multifaceted and require serious commitment. The one-man-show model for emergency physician group structure is now defunct in our specialty. What task will you master?