More than 79 percent of the emergency physicians say their hospital administration is not providing adequate support for the ED and its physicians, according to my recent survey. Although half said that support has improved over the past decade, 98 percent of those expressing dissatisfaction and 88 percent of those reporting improvement were direct employees of a hospital. Fewer than 18 percent of contract group physicians (of all sizes and types) expressed even limited approval of hospital administration support.
It's no surprise, then, that more than 70 percent of respondents said hospitals provide more support to emergency physicians who are employees than they do to physicians who are part of a contract group. “When the ED physicians are hospital employees, there is a sense of ownership of the problems that we face, and the hospital tends to be more responsive,” said one physician who has worked as an employee and as part of a group. “When the group is contracted, the hospital may think [it is] paying for a service [it] should get, not realizing that the majority of the problems encountered in an ED are not in the control of the ED physicians, but in the control of the hospital itself.”
On the other hand, contract groups with long-standing contracts report far higher levels of support. Groups with contract durations of more than 20 years report exceptional administrative support and great relationships with other medical departments, but those situations are rare. The majority of survey responses sounded much like this one: “Administration doesn't always provide adequate support. They realize the importance of a strong ED, but don't understand that we cannot always be all things to all people with limited resources.”
Of all the medical departments within the hospital, more than 40 percent of emergency physicians surveyed said radiology was the slowest, most unresponsive, and in a few cases, a source of conflict for stat procedures. Anesthesiology also was singled out as lacking in timely responses and cooperation. The complaints were fairly equal when it came to calling for consults, with orthopedics, OB/GYN, cardiology, and psychiatry being slow to show.
Surgery was the highest rated for answering consult requests, and internal medicine was highly rated by EPs as a supportive in those instances where a hospitalist program is in effect. On the other hand, internal medicine was considered difficult when it came to admissions if no program was in place. “IM puts up great walls for admission and attempts to convince EPs not to admit patients!” one emergency physician wrote.
OF ALL DEPARTMENTS, RADIOLOGY WAS POINTED TO AS THE SLOWEST AND MOST UNRESPONSIVE
Thomas Falvo, DO, who is working on this survey with me, summed it up like this: “When you really get down to it, a lot of the problems EPs have with their colleagues boil down to turf wars.”
I also asked emergency physicians if emergency nurses should report to the hospital or to the ED hierarchy and whether there was a conflict of interest if the nurses work for the hospital and the doctors work for a contract group. A whopping 86 percent said nurses should report to the physician in charge of the ED, and at least 48 percent said there are conflicts of interest, and not just in the scenario provided. One physician said there is no incentive to see more patients and keep things moving because nurses are paid by the hour. “The team concept is defeated,” he said.
Another added: “I think the movement to bring nurses into an equal professional plane with physicians has [created] an adversarial and sometimes confrontational relationship. The right to be part of the team and to take an active role in patient care should not be taken to the extreme of questioning and challenging the physicians; that doesn't promote mutual support and respect.”
Asked what one thing EPs would change about how they are treated, one physician said the administration should understand that ED crowding is a hospital, not an ED, problem. Another noted that he'd like to change the notion that EPs are second-class citizens because they have to see everyone and the perception that the ED is a cost center, not a profit center. “Hospital administration caters to specialties that bring in money,” he said, “and emergency physicians can be viewed as obstacles in keeping these other specialists happy. They need to realize we are the front door and can make them or break them.”
Lastly, I asked what one thing emergency physicians would change about the way other medical departments treat them, and lack of respect was mentioned in almost every answer. One said, “Respect the EP's opinion that there is a need for specialty care and admission,” while another said, “I would change the fact that they don't see us as specialists operating in our own department. We practice in a fishbowl, and they scrutinize what we do without the necessary knowledge and tools to do so. This only promotes hostility rather than teamwork, and ultimately, patient care suffers.”
“I want them to appreciate that we are there to handle sick patients but are not the dumping ground,” said another EP. “Many times we are only as good as the support and backup they are willing to provide. The ED is our office. They should treat it, and us, as they would have us treat their office and practitioners.”
It appears that emergency physicians need to be more proactive in creating strong relationships with hospital administration and other medical departments. While every hospital and ED is different, the same problems seem to exist in the majority of them. Until these issues are dealt with, on the facility or the national level, retaining emergency physicians will remain a difficult task for all types of employers.
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