On an incredibly busy shift last month, my colleague, Scott Campbell, came up with the best analogy for the stressors of working in an emergency department. “We're like the high-functioning child of an alcoholic: trying to please everyone, make everyone happy, keep the family from falling apart with a completely unreliable, broken system that we're supposed to be relying on,” he said.
It is really the perfect analogy for what everyone (patients, our non-emergency colleagues, politicians, society) expects from us while we're pretty much perfectly positioned to break down sometimes.
Scott is also incredibly savvy and adept with numbers and data (especially in health care), and he made me think of that famous optimization struggle that we all have in health care (and in most other systems, too). It is known in consulting terms as the project management triangle, triple constraint, or the iron triangle (my personal favorite because it sounds like it's from Game of Thrones). You have probably seen the chart somewhere. The points are labeled fast, good, and cheap, with the line, “Pick any two.” Health care systems (and other companies as well) are always trying to find that golden sweet spot that optimizes all three, but it's usually impossible. Quality in health care probably has some minimum limit because it's typically frowned upon to receive care from people only pretending to be doctors and nurses.
During said miserable shift, I briefly (very briefly) pondered what was making the shift so difficult for me. The first thing that came to mind, most obviously, were the seven patients who triaged in the first hour of my shift. Next, several of the patients had appointments within the hour to see their primary care physicians for their primary care complaints. Finally, several of the patients were vague, disrespectful, and demanding. I came up with an Iron Triangle of my own (known as the Cynicism, Livelihood-Unhappiness, Sadness Triangle of the ER), and I wonder if shifts with all three components are what lead to professional dissatisfaction and burnout.
The three points of CLUSTER look something like this: busy department, not sick patients, and challenging patients.
Busy Department: Not a lot of explanation needed. When 10 patients triage in an hour and the waiting room is already full, providers feel rushed, are more likely to shotgun tests, and know that quality is going to suffer.
Not Sick Patients: By not sick, I mean patients who have complaints or concerns that do not need emergency department medical care. They are in the wrong place, but because of EMTALA, they're our problem now. “Shoulder pain for six months,” “I want a refill of my methadone,” “My blood pressure is high,” or “I have pain in my entire body, I've had lots of tests, but I want a fourth opinion from you.” These patients are often upset when you tell them you are probably not going to have an answer today, and encourage them to follow-up with their primary care physician. (I'm not pointing a finger at patients with chest pain who don't know that their chest pain is not worrisome, for example.)
Challenging Patients: You probably know what this means as well: vague or changing historians, patients with personality disorders, patients who are argumentative, oppositional, or just plain rude or disrespectful. The ones that bring the whole department down, are on the call bell every two minutes to have their pillow fluffed, or the ones that you actively walk the long way around the department to avoid having to walk past their room. It's incredibly hard to provide accurate, quality medical care when the patient's story changes three times during a shift, or they're disrespectful, angry, or threatening. (There are now data on these patients; a 2016 BMJ study concluded: “Disruptive behaviours displayed by patients seem to induce doctors to make diagnostic errors. Interestingly, the confrontation with difficult patients does however not cause the doctor to spend less time on such case.” [BMJ Qual Saf 2016 Mar 7; http://bit.ly/1rGGtGW.])
I can typically keep up if the department has a maximum of two of these three criteria. When I say, “keep up,” I mean physically, emotionally, mentally, and professionally. You can pick any two, and we'll make it through the shift. Three, however, is one too many. There comes a breaking point in an emergency department's physicians, nurses, techs, and business associates where our spirit breaks. It's these pain points, in my experience, that make a department and its team crack.
Think of some of your favorite shifts, and I bet they have zero of these three criteria: slow shifts with nice, straightforward patients who are sick.
Conversely, we all go into survival mode and feel the stress when the department is busy, the patients are challenging, and the patients have complaints that don't really seem appropriate for the ED. We cannot really affect any one of these in the short-term, but better education about primary care (and better access to primary care) is a solution to all three. Unfortunately, we have burned that bridge in this country over the past 20 years.
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