My previous post on this topic described long-term cultural and organizational challenges facing emergency medicine (EM) that pose greater threats to the specialty than temporal challenges (e.g., overproduction of emergency physicians (EPs)). Some challenges are not remediable; they are inherent to the specialty:
- short-term patient relationships
- unpredictable workload/intensity
- frequent, rapid fluctuations of stressful and less-stressful periods
However, many detrimental aspects of EM can be substantially improved. Below, I propose remedies consistent with the human psyche and physiology to address these long-term challenges.
First, new metrics should be incorporated into the physician scorecard reflecting what’s meaningful to EPs as humans (rather than as corporate cogs): personal growth/development, professional development/learning, interesting cases, and communication with colleagues.
How often did you encounter interesting/memorable cases this year?
How frequently did you “stretch your brain” learning new things?
How often did you feel joy during or after a shift?
How often did you share anonymized interesting cases with colleagues?
Did you have mentorship/teaching opportunities built into your job time?
Regular meetings (e.g., monthly staff/faculty) should incorporate time to share interesting/educational cases.
Second, when fixing problems, focus on processes, not people. At my annual meetings with ED administrators, I get the impression that if I worked a bit harder/faster, I’d lower my patients’ average length of stay, which is always slightly above or below the mean. You can’t get blood from a stone. If we stressed ourselves moving faster, we might decrease our collective LOS by 1 to 2 minutes.
But, I’m not the rate-limiting step; things outside my control are. I can’t make the lab process more specimens/hour, the CT technician call patients sooner, transportation push stretchers quicker, or the radiologist reads films faster. Nor would I want to; they all work hard while trying to enjoy their jobs. ED administration shouldn’t nibble at the margins. Big benefits come from changing processes. Radiology and ED collaborated to open near-term ultrasound and CT appointments at my previous hospital. EPs put patients they didn’t believe would benefit from an ED-performed study on a list Radiology collected daily and discharged them for these outpatient studies, saving 6 to 8 hours/patient. Radiology relayed outpatient-performed results to patients. That decreased LOS by hours, not minutes.
Third, apply term limits to allow physicians personal and career growth, a sense of control over their career, and creativity in work (designing/implementing/
Fourth, don’t punish efficiency and quality. Administrators should change the expectation for how many patients/shift a physician should see. One approach is for physicians to see several patients during a shift and then leave. They can leave early if they’ve met their quota. Un-dispositioned patients at the end of a shift time can be signed out. In this model, productivity is not the number of hours one works but the effectiveness of time spent.
Fifth, increase “awe” at work: Some EDs have “fast track” or “urgent care” areas. I’m sure seeing low-acuity patients for 8 to 12 consecutive hours was no one’s reason for choosing EM. Mix less-acute patients with more-acute patients to increase variety and interest.
Sixth, minimize distractions. They’re bad for patient care, decision-making, and mood. Even minimizing small distractions helps; for example, if someone brings me an EKG to sign, please hand me a pen along with it so I don’t fumble for a pen, losing my train of thought.
Seventh, design EDs for greater exposure to nature, such as through wide expanses of windows in areas where outsiders would not be able to see patients or using darkened glass on the outside.
Eighth, eliminate comparison metrics (LOS, Press Ganey). They’re bad for morale (analogous to the effect of social media comparisons on mood). Trust that everyone’s trying their best. Some are naturally faster or more risk-takers; others slower or more conservative. The mix is all right. Except for extreme outliers, let physicians be who they are and practice as they practice.
Ninth, revise scheduling so physicians can have consistency and a regular sleep schedule for at least some prolonged period; for example, schedule in clusters of day shifts for two weeks and then evening shifts for two weeks.
Tenth, create a work environment where everyone works at the top of their license, not below it. Physicians should always be the rate-limiting step. It’s a poor use of physician time to search for supplies, take vital signs, enter pharmacy information, or set up procedure kits. I’ve worked in EDs where medical assistants, ED Technicians, or nurses irrigated a laceration wound, set up the laceration kit, had the correct sutures open, and dressed the wound. All I did was stitch. What a pleasure! Such assistance is satisfying to EPs and ancillary staff practicing at the highest levels of their license.
None of these remedies are easy or cheap. They’ll be met with resistance. But, for the sake of the specialty, they’re necessary.
As the adage goes, a product or service can have three attributes: good, fast, and cheap. But, the service or product can only have two of the three (i.e., nothing can be good, fast, and cheap). EPs and patients want and deserve good, fast quality care and work environment/experience. Health systems should build for good and fast and pay for that quality, which isn’t cheap.
The author is an anonymous physician.