Welch, Shari J. MD; Hellstern, Ronald A. MD; Seay, Timothy MD; Lyman, John L. MD; John, David P. MD
The 154 emergency medicine residencies in this country provide training in very large, even ultra-large, teaching hospitals with a focus on tertiary care. According to data accrued from the SAEM Residency Program catalog, the majority of residents are trained in programs in high-volume teaching hospital EDs that are Level I trauma centers. Often children's hospital rotations are added to round out the pediatric experience. Less than 20 percent of emergency medicine programs have rotations in medium-volume community hospital EDs (with less than 40,000 visits) without trauma designation, and in these programs the average time spent at the community hospital location is three months.
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Residents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.
In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. The average ED is in a community hospital, and sees fewer than 100 patients a day. This community hospital ED will likely not be designated a Level I trauma center, and the practicing physician will have to make decisions on complicated patients without all of the resources and consultants available at a tertiary care medical center. He will have to make these decisions alone. Given that most graduating emergency medicine residents will practice in such a setting, we should ask ourselves is this the best we can do? Does the current training model best prepare the emergency medicine resident for the kind of practice he will enter?
Though rarely acknowledged, our residency programs train physicians in some of the most inefficient EDs in the land. Relative value units of emergency medicine work per hour in the teaching hospital setting is typically half that seen in private practice. And residents train in a culture where customer service is an unaffordable luxury amid the chaos of the typical academic ED. According to data from the Emergency Department Benchmarking Alliance and Press Ganey, the large urban tertiary care and teaching hospital EDs have the slowest throughput times, the highest left-without-being-seen percentages, low patient satisfaction scores, and high complaint ratios. If emergency medicine residents have never seen emergency medicine practiced in an operationally efficient department with a strong customer service commitment, how will they know how to practice in such an environment? Or more importantly, how will they know how to develop such an environment wherever they practice? The new emergency physician entering practice will immediately find himself confronted with the expectation that he provide highly efficient and patient-satisfying emergency care, though he has had little training in those concepts and skills. Perhaps this is in part why nearly 50 percent of new graduates do not survive their initial practice choice for even five years. Perhaps they simply are not sufficiently prepared to deal successfully with the realities of the community emergency medicine practice.
It is also worth noting that our residencies train physicians in elements and strategies of care that probably are going to be less relevant to their future practices than they anticipate. Though emergency medicine residents will train in facilities with an emphasis on trauma care, for example, few will actually practice in departments where those skills are commonplace. Their training has them fixated on many procedures and technologies that will be largely irrelevant when they enter practice. (When was the last time you put in a chest tube? Be honest!)
This fixation is at the cost of other important skills in difficult medical diagnoses. Though rigorously trained in trauma, the newly practicing physician likely will have many more cases of atypical chest pain and “weak and dizzy” than trauma resuscitations. While bedside ultrasound is uniformly taught to emergency medicine residents, according to a 2006 Yale University survey only 19 percent of non-teaching community hospitals have ED bedside ultrasound available 24 hours a day. Despite the emphasis on this training regarding technology, storing images, and documentation requirements, only 16 percent are billing for this service. This is yet another example of the mismatch between training and practice reality.
Residents at tertiary care centers admit more than 25 percent of the patients they see, and have the luxury of observing patients for longer periods of time in dedicated areas, not to mention that waits and delays of greater magnitude are tolerated in these tertiary care settings. Meanwhile, according to Centers for Disease Control and Prevention data, the typical community ED will admit only 12.8 percent of the patients who present for evaluation. It is likely this community ED will not have an observation area or a clinical decision area. Decisions on patients with complicated and difficult medical symptoms will bedevil the new physician who discovers that waiting patients are dissatisfied patients. He finds himself on the clock, and that clock has fewer minutes than he was allowed in training.
Teaching hospitals provide a disproportionate amount of underfunded and charity care by volume. These safety net patients have nowhere else to go and so will tolerate greater waits and delays without leaving. On the other hand, community hospital patients are more likely to be adequately insured, and have higher service quality expectations. When they leave an ED without being seen (the ultimate patient complaint), they are taking their funding with them. When they leave with their expectations unmet, they will share this negative experience with others in the community. The resident who was oblivious to these issues in training will now find himself meeting his medical director for breakfast the morning after a well-heeled patient or board member complains about his service to hospital administration. The new physician has to cope with an abrupt and steep learning curve, with many unexpected realities such as:
▪ The patients are not as sick as the ones they treated in training hospitals, and the admission rate is much lower.
▪ There are fewer procedures and more psychosocial dilemmas.
▪ There are complex cases, but consultations are not nearly as available as they were in training.
▪ Time constraints color every activity.
▪ Patient expectations are much greater.
▪ Physicians are expected to generate that high starting salary they were given and then some.
Another gap between residency training and the real world involves leadership and management training. Though most residents will leave their programs with certification in ATLS (many at the instructor level) and in ultrasound skills, very few will have leadership or management training. But consider the stark reality that every ED will need a medical director and one or more assistant directors. This reality is quantifiable, and far outstrips the need for ATLS instructors and ultrasound practitioners. Keeping the group's ED contract depends much more on leadership and management skills than on clinical skills. Emergency medicine interacts with virtually all of the specialties in the hospital practice environment as well as government agencies like the Joint Commission, CMS, state and local governments, and the community and public health systems. As hospital-based providers, emergency physicians must know how to relate with and gain the support of the administrative side of health care. Yet we continue to graduate physicians with no proper training in health care management and few of the leadership skills necessary for working in a health system that is increasingly organized around team care and team management.
Many larger physician groups have begun providing extra training to their physicians to help fill these gaps in training. At EMP, for example, the Patient Satisfaction Academy was developed to train physicians in service quality, and it has been highly successful. EMP also developed a Scholars program to build leadership skills. The Schumacher Group, Emergency Service Partners, EPMG, and Premier also offer in-house training of physicians in areas that residency training seems to neglect. CEP America has an administrative fellowship, a Leadership Academy, and utilizes the Studer Group approach to improve nonclinical skills for physicians. With increasing contractual demands from hospitals for measurable emergency department patient satisfaction, smaller groups may outsource this training to entities like the Institute for Healthcare Communication. Other groups send their directors for emergency medicine leadership and management training to ACEP's Emergency Department Directors Academy for formal certification as an ED medical director.
If we were in charge, what changes would we make to train emergency physicians for the real world? First, a much stronger commitment to getting community hospital experience for the residents would go a long way in remedying the mismatches. We believe that residents should complete as much as a third of their training in a setting more analogous to their future practice environments. This time in the real community hospital trenches allows residents to get a glimpse of the differences in the realities of practice between a community hospital and the tertiary care center. Secondly, the educational role of clinical affiliate faculty members from the community should be expanded to provide resident exposure to typical community hospital administrative issues such as leadership, negotiation and conflict management, patient satisfaction, documentation and billing, and risk and operations management. Third, the academic emergency medicine anti-business bias should be replaced with the realization that no emergency medicine practice can survive or prosper without sound business leadership and management skills. These abilities are not typically necessary in the world of academic emergency medicine, but they are imperative in the rest of the practice world.
Recognizing deficiencies in training in areas such as practice leadership, service quality and operations, and practice management is the first step toward fixing them. An excellent next step might be for residency program directors and faculty to survey the recent graduates of their programs to find the answers to questions like: What is the one aspect of your new position you feel least prepared to deal with? What didn't we teach you that we should have?
Today's emergency medicine resident graduates his program with an impeccable knowledge base and a set of world-class technical skills. He won't misstep as a practitioner for lack of factual knowledge or mastery of procedural skills. Yet he is still likely to flounder in the community ED for lack of other proficiencies. Town and gown could fix this easily by working more closely together.
© 2010 Lippincott Williams & Wilkins, Inc.