Posted by Guest Blogger on Fri, Dec 04, 2009 @ 05:33 PM
By Ellis Weeker, M.D.
As an emergency physician who's no stranger to working long shifts, a recent study in the online version of the Annals of Surgery caught my eye. In it, nearly 9% of the 8,000 members surveyed from the American College of Surgeons said they'd made a major medical error or lapse in judgment within the last three months. The reason? The study found that 40% of the surgeons who responded said they were burned out and/or depressed.
The authors stated that in August, the same group of researchers reported in the Annals of Surgery that burnout is common among American surgeons and is the single greatest predictor of surgeons' satisfaction with career.
So what about emergency medicine - and the physicians who diligently work long, often stressful shifts? It's true that we talk about fatigue and long working hours. But as emergency physicians, what are we doing to ensure we're not becoming burnout cases or suffering from depression as the study suggests with surgeons?
Working in an emergency department is a mixture of exhilaration and challenge, which creates both physical and mental stress. Yet we know that patients in the emergency room need their treating physicians to be attentive, alert and at the top of their game. This means being fresh and not over-working ourselves - an ideal we don't always achieve.
Often emergency physicians try to squeeze as many shifts as possible into the beginning or end of a month to take a long stretch of time off in between. PAs and NPs also succumb to the siren sound of far away adventures, only achievable by taking long stretches of time off and then trying to cram as many shifts as possible into the remaining time frame to pay for it.
The other trap is to live beyond our means, causing us to work more shifts than we can tolerate, and reducing our effectiveness as physicians.
The antidote is to pace yourself. Remember, emergency medicine can be a long and satisfying career if you don't burn out. And you will provide better care to your patients.
Only work the number of shifts you can handle and don't try to compress them into short time frames. If you want to take a long vacation, place the extra shifts into other months of the year to compensate. And lastly, live within your means.
I look forward to your comments.
Posted by Guest Blogger on Fri, Dec 04, 2009 @ 12:54 PM
By Ellis Weeker, M.D.
As an emergency physician, I know the importance of an emergency department staffed with hard working, conscientious, and skilled Physician Assistants.
That's why in recognition of National Physician Assistant Week, I, along with my emergency physician Partners at CEP America would like to acknowledge the very significant contributions PAs have made - and continue to make - in our organization.
I speak for my fellow Partners who join me in recognizing our Physician Assistants as valuable healthcare professionals and colleagues who play a vital role in providing the highest-quality care in our EDs. We couldn't do what we do without them.
So on the occasion of National Physician Assistant Week, I want to acknowledge our PAs for being the best PAs we have ever worked with - and to thank them for their continued hard work, commitment, and dedication. Please join me in recognizing their important contributions.
Posted by Guest Blogger on Fri, Dec 04, 2009 @ 12:52 PM
By Prentice Tom, M.D.
Flu season officially begins October 4, 2009. With the new H1N1 virus, it is predicted that hospital emergency departments and emergency physicians could see a substantial increase in flu/flu-like illness patients.
The CDC estimates that 40%-50% of the population may be infected by the H1N1 virus in the next two years. Regardless of the actual percentages, it is clear that emergency departments need to be ready for what could be an onslaught.
CEP America has developed a plan to partner with our hospitals throughout the country to address the demand for emergency care resulting from a flu pandemic. It calls for:
- Recommendations for increasing ED staffing using "phantom shifts," call back and call schedules, and phone trees.
- An evaluation/treatment algorithm based on CDC and other published guidelines, as well as links to pertinent H1N1 information websites, and an example of a patient discharge instruction sheet.
- A mechanism for employing community primary care physicians already on staff to help treat flu/flu-like illness patients in the auxiliary treatment areas on the hospital campus.
Successfully addressing prolonged ED volume surge due to a pandemic is a complex problem that requires close alignment between emergency physicians and hospitals. Developing the ability to employ community physicians to help staff disaster treatment areas is one way we can partner with our hospitals and engage the medical community in addressing this possible crisis.
I look forward to your comments and suggestions on what your hospitals or communities are planning.
Posted by Guest Blogger on Fri, Dec 04, 2009 @ 12:50 PM
By Mark Spiro, M.D.
There is a version of the much awaited healthcare bill that has finally seen the light of day this past Wednesday. As all of us in the field of emergency medicine know, this will not be the final bill.
In a press release accompanying the unveiling of the bill, Senate Finance Committee Chairman Max Baucus says the legislation would cost $856 billion over 10 years and would not increase the deficit. The nonpartisan Congressional Budget Office, which put the bill's total cost at a lower $774 billion, says the bill would actually reduce the deficit by $49 billion between 2010 and 2019. Of course, that's if the bill passes as is, which is unlikely.
For those looking for the "highlights" of the bill, I found this Time/CNN page helpful http://bit.ly/T6pJD.
How might this affect Medicare you ask? Here's what Reuters has to say http://bit.ly/eol6E.
The primary question from our perspective is figuring out how healthcare reform will affect Emergency Medicine. And for right now there is no way I can intelligently do anything more than hypothesize.
The above are just a few of the online sites offering information and opinion on the healthcare reform juggernaut - and the debate will surely rage on for the remainder of the year. As discussed in earlier blogs on this page, what we can do is to be vocal advocates for ensuring that Emergency Medicine is acknowledged as the key piece of the Patient Care Safety net.
Reform could be a good thing - and for now I am choosing to be a skeptical optimist. As a personal opinion - which is not shared by everyone in our group - I believe some significant healthcare reform is exceedingly important for the benefit of our patients. I feel basic healthcare should be a right of all Americans (not touching the illegal alien question for now).
It's too soon to tell, but I know that as Emergency Physicians we will respond and adapt to whatever comes our way - that's who we are and what we do.
I welcome your comments and opinions.
Posted by Guest Blogger on Thu, Dec 03, 2009 @ 04:55 PM
By Ellis Weeker MD.
As an Emergency Physician, I'm always looking for interesting articles about my profession. Recently, I came upon a study published by the California Healthcare Foundation. It raises the question about California's hospital-based ED system - and whether it's keeping up with the increased pressures placed upon it. For those of us in emergency medicine, I think its great food for thought.
For the complete study, click on the link:
Is California's Hospital-Based ED System Eroding?
The study states that worsening severity of illness may be a greater factor in ED overcrowding than the growing volume of patients. My thoughts regarding their assertions include:
The supply of California ED beds grew by 17% between 2001 and 2007, while population rose 6% and ED visits increased 2%.
The supply of beds in CA EDs has risen to accommodate the increased need of an aging population as well as the increased and unmet needs for urgent and primary care. Seniors require more procedures and our system currently rewards utilization, in particular procedures. So this is not a surprise. For many hospitals, increased ED beds mean more revenue for inpatients as well as outpatients. An increase of 17% in the supply of CA ED beds can be easily explained.
A higher proportion of ED patients are more severely ill, and a greater share of visits results in hospital admission.
The higher number of critically ill and older patients greatly impacts the efficiency of an ED. More testing and therapy are required. Even after a diagnosis is made, it takes longer to admit these patients. The average percent of patients admitted to hospitals from their EDs is now 51%. So that's another reason for more ED beds.
The numbers of ED visits considered non-emergency have increased.
Lack of urgent and primary care availability to underinsured patients remains a stressor for all EDs. While non-emergency visits have increased, many insured patients have also begun to use EDs as urgent care centers.
The study reports a large variance in the percentages of increased ED visits, hospital closings and construction throughout the state. This is because our system has little or no central planning and largely responds to the local circumstances of an area, i.e. the affluence of the patients. Hospitals and their EDs close where there's poor reimbursement for patients. New hospitals and EDs are built where there's money to support them.
As always, I welcome your comments.
Posted by Guest Blogger on Thu, Dec 03, 2009 @ 11:26 AM
By David Englander, M.D.
I wanted to add my two cents to Dr. Borger's blog in the ER Forum on Tuesday re: potential funding losses to emergency health care by the Feds.
In California alone, more than 70 hospitals have closed in the past ten years due to financial pressures, even though demand for emergency care has dramatically increased.
Our state actually had the lowest national ranking (51st) in access to Emergency Care and received very low grades in other categories of the ACEP National Report Card on the State Of Emergency Medicine.
In 2003, both Democrats and Republicans came together and passed the Medicare Modernization Act (Section 1011), which included federal funding for mandated emergency care - $250 million per year to help hospitals and providers recoup a portion of the costs they incur for providing emergency medical care to patients who cannot pay their bills. This federal reimbursement has been particularly helpful to participating hospitals and providers in border states like California that are disproportionately burdened with providing care to undocumented immigrants. Unfortunately, this funding was temporary and recently expired.
Hospitals and emergency care providers should not be responsible for absorbing the costs of health care for undocumented immigrants. The federal government should bear this responsibility, as it is responsible for securing our borders.
As noted, last year the campaign to extend Section 1011 had bi-partisan support, evidenced in a May 2008 letter to legislative leaders endorsing a two-year extension of the provision under 15 signatures, including those of Barack Obama and John McCain. But that support has been supplanted by other issues.
Extending Section 1011 funding is an important issue that needs to be addressed before it "falls through the cracks". With increased overcrowding, state budget cuts (especially in California) and likely facility closures, it's impossible to believe that quality care will be there if another source of funding for hospitals and providers is withdrawn. Our legislators need to know that this is an important issue involving a wide range of people.
To read the complete article on the topic, visit http://tinyurl.com/moos4n. For insights into ways to reach your representatives, please read a very helpful blog re: Advocacy by Carlos Medina MD. Simply click on this link: http://www.cepamericablog.com/2009/08/be-an-advocate-get-to-know-your-legislators/
I look forward to your support and to seeing any comments you may have.
Posted by Guest Blogger on Thu, Dec 03, 2009 @ 11:12 AM
By Jay Kaplan, M.D.
There's no question that in the current discussions on health care reform, pay for performance will play a central role. Pay for care rendered is going to be replaced by pay for quality rendered. Value-Based Purchasing, the federal government's new name for pay for performance, will be tied to Core Measures for inpatient clinical quality and PQRI for outpatient clinical quality.
Non-government insurers will follow suit, since the outcome is reduced payment to providers. CMS is already withholding payment to hospitals in some cases, and talking about reduced reimbursement for Medicare patients who return for re-admission within 30 days of discharge. Bundled payments are also being contemplated.
A few years ago, the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) was created to measure the patient experience across all hospitals. Right now, in order for hospitals to get their full Medicare market basket update yearly, they participate and publicly report their "scores". Soon they will have to be at the 50th percentile or have improved from the previous reporting period in order to be fully updated/reimbursed.
The three questions currently being asked about physicians are:
During your hospital stay, did doctors:
- Treat you with courtesy and respect?
- Listen carefully to you ?
- Explain things in a way you could understand?
In the early stages of nationwide implementation is the Clinician & Group Consumer Assessment of HealthCare Providers and Systems (CGCAHPS), which asks similar questions about physicians in the outpatient setting. Insurers in Massachusetts are already talking about tying outpatient reimbursement to CGCAHPS results. And don't think that we in the ED are not on the radar screen.
Now for a key point - CMS and the federal government now consider HCAHPS and CGCAHPS to be "quality" metrics. So as much as some of us would like to separate service excellence from clinical quality we and our hospitals will be paid for quality however that is defined. This means service becomes an issue with real fiscal consequences.
Rather than bellyache about an unfair system, we will need to focus on improving patient satisfaction. The good news is we can benefit from the focus on "quality", and in fact, an argument can be made that great patient satisfaction is built upon creating a great place for staff to work and for physicians to practice medicine.
It's an approach that can work - in fact I've seen it work all over the US.
Posted by Guest Blogger on Wed, Dec 02, 2009 @ 12:44 PM
By Prentice Tom, M.D.
Providing emergency medical care is certainly a rewarding, yet complex and demanding business. As a practicing emergency physician for 28 years, I have seen how technological change, increasing numbers of patients (with increasing complexity), lack of treatment space and changing expectations of providers and patients contribute to an increasingly difficult and complex practice environment.
Despite the fact that the United States spends more per capita dollars on medical care than any country in the world, a substantial number of patients who seek emergency medical care still present with serious and sometimes life threatening chronic medical problems having had no or limited access to primary care.
Overcrowding of emergency departments is rampant. Ambulance diversions are common in essentially every State. I frequently read that our emergency departments are at the "breaking point." A number of recent studies have shown that hospital capacity is really the culprit, and that in-patient "boarders" are largely responsible for emergency department diversion.
Cost-efficient, quality driven emergency departments are critical to our nation's health. As an emergency physician, how can I help lead the change necessary to address the issues threatening my ability to care for patients?
Having the opportunity to help manage the largest emergency physician Partnership in the United States has helped me understand that it is only through continuous successful innovation in the practice and management of emergency medicine that we will be able to meet the needs of our patients and our communities. Certainly, there are inefficiencies in our emergency departments. For example, sequential processing of patients through a walk-in, triage, registration, waiting room, ED bed, ED nurse to ED physician algorithm is inefficient, duplicates information gathering, and delays definitive treatment. By parallel processing patients, through programs such as Rapid Medical Evaluation (RME®) and providing definitive treatment at the first point of contact, it has been shown that we can successfully reduce emergency department wait time to less than 20 minutes - frequently less time than it takes for a patient to see his/her primary care physician for a scheduled appointment.
To ensure the future success of emergency medicine, we need to continue exploring and developing innovative solutions. Programs that coordinate physician education with changes in medical knowledge, encourage physician expertise in electronic medical records and health information technology, create strong quality assurance programs, and improve in-patient throughput are all necessary for the future of emergency medicine.
I would like to understand from patients, health care providers, policy makers and those in the medical care financing industry how you view emergency medicine, and what we, as emergency physician providers can do to provide the innovation necessary to ensure our ability to provide the highest level of quality, cost-efficient emergency medical care.
Posted by Courtney Rice on Mon, Nov 30, 2009 @ 05:54 PM
By Mark Spiro, M.D.
As an MD who has practiced emergency medicine for a number of years, I've noticed a definite trend regarding many of the younger ED physicians I come across. Many of them can teach us "more seasoned" ED docs a thing or two about life balance.
I'm not just talking about exercising more and getting enough sleep. I'm talking about younger docs who possess a desire to work less and have more variety in life than just moving forward professionally. Their identity is not simply tied to being an emergency physician - I see them take a greater interest in family, physical health and free time than my brethren from an earlier generation.
Us more mature docs initially looked down and viewed it as a weak work ethic. "What could be more important than healing others?" we would say as we pulled another long shift. But eventually a bell went off and we saw their performance and learned from them. At least I have. I truly feel that I can be a better, more caring physician if the "non-working" part of my life is not neglected. We all get strength from outside activities, whether they involve family, religion, recreational activities, hobbies, and travel. All of these activities promote individual wellness which leads to happier more satisfied physicians and more compassionate care for our patients. I know, because I feel it.
But there's still one area in which younger MDs continue to seek my guidance - and that's financial well being. I tell them when they get into their mid 50's they should be working as an ED doc because they want to - because it's a calling, and not because they have a huge house payment every month. I leave them with three rules that I believe in that will enable them to reach this very reasonable goal:
Spend less than you earn
Diversify your investments
Don't get divorced
Seems simple enough - almost too simple. But the key for me has been to dedicate myself to staying within my means. And not forgetting about my health and wellbeing while I'm worrying about everything else. If you're an MD - emergency or not - I'd love to hear how you feel about this topic.
Posted by Courtney Rice on Mon, Nov 30, 2009 @ 05:48 PM
By Wesley A. Curry, M.D.
As of this writing, the CDC reported 10,053 cases of documented H1N1 infections and 17 deaths likely related to this virus in the United States. As we all know, the emergence of the swine flu as an imminent pandemic has generated global concerns and issues which have brought the status of our preparation and ability to respond to mass casualties and bioterrorism into question.
Hospital emergency rooms are a key to our ability to respond, evaluate, and treat potentially millions of patients in a mass casualty event. The recent swine flu outbreak has been a test - a "dress rehearsal" - for how our emergency rooms will be able to cope with a sudden increase in patient volume. It's been reported that in many emergency rooms, patients are subjected to long waiting times and length of stays.
So what would happen in a scenario where the daily patient volume in our emergency rooms increased up to 60% or more in a major bioterrorism event?
The CDC designation of an imminent swine flu pandemic has recently increased emergency room visits to significant levels beyond the daily historical baseline with the worried well. Recently some CEP America sites topped over 500 patients per day in daily patient volumes. What is impressive was not how many patients arrived daily, but how few patients left without being seen, and how these sites were able to keep the time to provider close to historical levels.
We continue to study the impact of this recent surge in patients on our multiple emergency room practices. What is clear already is that rapid medical evaluation implementation (our version of provider at triage) has worked during this period because it's flexible enough to be modified to respond to surges in patient volume - even by 60% or more.
While this surge in patients did not result in many admissions or critical patients, it has given our hospitals a real time example from which to learn how best to cope with mass casualty or bioterrorism events in the future.
By instituting our provider triage system years ago, we've not only been preparing ourselves for every day patient care, but for situations like the recent events. In the end, preparation is what is needed to ensure a proper response in extreme times of need. But our emergency rooms can't wait until a catastrophe happens.