Figure: contract management groups, corporate medicine, private equity, staffing
Figure What kind of care will our children receive when they roll into an ED without us, especially in today's culture of corporate medicine where EDs are staffed to maximize shareholder profit rather than patient treatment? I found out after my 17-year-old son crashed while snowboarding.
Cole presented with a displaced humerus fracture to an ED near the ski resort he was visiting with his father. I was asleep with my phone on silent, so unfortunately, I was oblivious until I saw the missed texts from Cole and my ex-husband the next morning.
“It felt barbaric,” was how my ex-husband described my son's fracture treatment. He texted me the x-ray, pictured here, and explained, “They splinted it as is, wrote a prescription for pain meds, and told him to follow-up with ortho today. The tech who splinted him seemed uncomfortable doing it; we heard him say he was afraid of causing internal bleeding.
“I had to stop the tech to ask why Cole wasn't getting more meds for splinting. Even the nurse agreed he hadn't gotten enough for pain. I kept asking why they weren't trying to line up his bone better, and they said their on-call orthopedic surgeon said it wouldn't stay anyway, so he needed to call his own orthopedic surgeon today. And the doc never set foot in our room. We only ever saw the PA.”
Orthopedists vary in their recommendations for displaced humerus fractures. The orthopedist on call that night said not to reduce it because it was an operative fracture and unlikely to maintain reduction. I subsequently have heard from multiple orthopedists who have said it should have been reduced. We can't say Cole received inappropriate treatment because no expert consensus exists about the appropriateness of splinting his fracture without attempting to align the bone better.
But medically appropriate treatment is clearly not the same as good care. Cole and his father were decidedly uncomfortable with the encounter. Some people will never be happy, but my son and ex-husband are reasonable people who had appropriate concerns. No one with the level of expertise they were seeking addressed those concerns or involved them in decision-making. Many of the risks in this case were related to the fracture's proximity to the radial nerve, but Cole and my ex-husband heard nothing about any nerve near the fracture.
Betrayed by EM
“I never want to go back there,” Cole said. It broke my heart that my child, who has spent birthdays and Christmases with his mom in the ED to doctor others, didn't feel that he was important enough to see the doctor when he found himself in an ED with a potentially limb-threatening injury. I feel betrayed by the specialty to which I have devoted my life knowing that rather than making my teenage son and his father feel comfortable, an ED basically said, “Here's a splint. Good luck.”
The next day I managed to speak to the attending who had been in the ED when Cole was there. He confirmed that he never saw my son, although he reviewed the x-ray and advised the PA to consult ortho. The reason, he said, was a neonatal resuscitation. As a single-coverage night doc, I get it. The orthopedist made his recommendations to the PA over the phone, also without seeing my son. After years of dealing with orthopedists who refuse to come in at night unless there's an open fracture or neurovascular injury, I get that too.
My son and his dad knew, however, that he was never seen by a physician. The PA never involved her attending beyond showing him the initial x-ray despite my ex-husband expressing concern. The reason the attending offered was that this particular PA had a history of being too autonomous.
Listening to this ED attending, who was sincerely apologetic, I realized that I could have been the one working a neonatal code and unable to see other emergent patients. I've been in his shoes many nights. It's frustrating to feel like we can do our best to save the life of a newborn, but it's still not enough.
Losing Faith
The culture of emergency medicine increasingly embraces PAs as sufficient replacements for EPs. It is failing doctors and patients alike. The pendulum is swinging to an unreasonable point where PAs and NPs are considered interchangeable with MDs and DOs. The other day I signed a consent form that said “proceduralist” where the physician signs.
Terms like proceduralist and provider warn of an upcoming departure by physicians seeing every critical patient. ED patients with acute complaints should have an opportunity to see a doctor. Unfortunately, the way EDs are staffed—frequently with just one EP supervising multiple PAs and NPs—it's now standard for EPs not to see patients unless the nonphysician providers request it. My son's PA thought she didn't need to involve her attending, and like many PAs in many EDs, the autonomy to make that choice was hers.
Nothing is more reassuring to a nervous patient than a physician saying, ‘If you were my child or parent, this is exactly what I'd want done for you.” EPs genuinely want to tell all patients that they are getting the how-I'd-want-my-family-treated gold standard of care. The reality is that we're overextended in a system that is about moving people through with the least amount of resources, and too often we can't give patients the care we would want for our own families.
It's hard as a physician to feel that we're disappointing patients; it's exponentially harder as a parent when the disappointed patient is your child. Hearing about my son's experience at the hands of today's profit-over-patient medical culture gutted me.
Just five days after Cole broke his arm, my dad went to the ED at 2 a.m. with shortness of breath. Fortunately, this time I had left my phone ringer on because I knew he wasn't feeling well. When my mom called to say EMS was at their house, my trust in our health care system was still so shaken by Cole's ED visit that I jumped out of bed and raced to the ED to hover at my dad's bedside.
He got great care, but it's unsettling that I could not feel confident that he would. When my loved ones go to the ED, I know they're at the mercy of today's staffing paradigm that spreads emergency physicians too thin. I've lost faith in our medical system. Cole's care crystallized for me that health care, even more than his humerus, is frighteningly broken.
Dr. Simons is a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD and read her past columns at http://bit.ly/EMN-ERGoddess
