ACEP’s Scientific Assembly, the premier, annual event for emergency medicine physicians in the United States, is normally focused (as its name would suggest) on advances in clinical care. But at this year’s event, which was attended by over 5,000 emergency physicians and which wrapped up in Denver last week, there was a growing focus on the role of emergency physicians in the context of the widespread changes that are occurring within the American healthcare system.
There are myriad complex problems to tackle and no easy answers. Surely we are past the point of tolerating the high level of uninsured in this country, but neither will the U.S. continue to tolerate rapidly escalating healthcare costs and the rampant inefficiencies that most us know exist. The challenge for leaders in emergency medicine is nothing less than providing higher quality care while lowering costs across the healthcare system.
So how do we achieve that? As emergency physicians we must acknowledge that we are both part of the finest safety net ever designed as well as part of the problem. Whether it’s drug addiction, chronic conditions like hypertension or depression, or simply an uninsured patient, emergency medicine must continue to provide care when no one else will, even when the problems of our collective society continue to show up at our doorstep. We must always be there for our patients and in some ways make up for all the failures not just in our healthcare system, but in our society.
At the same time, emergency medicine has a lot of work to do. Here are some of the things I believe emergency medicine must address as a specialty – and what we must address as a society – to achieve the “triple aim” of improving overall health, improving the experience of individuals, and lowering the cost of care.
Over-utilization occurs every day in every emergency department. There are legitimate reasons for this: no prior relationship with patients, the high risk area in which we practice, and an over reliance on technology to replace a conversation about expectations, for starters. Those reasons must be addressed. We now have more information at our fingertips about prior testing – we need to put it to effective use. When I was considering ordering a CT on a woman with lower abdominal pain a message popped up that she had had ten prior CT scans, including multiple abdominal CTs. I chose to skip the CT and advised her to come back within 24 hours for re-evaluation if the pain continued.
The rampant epidemic of subscription drug abuse and deaths are a problem that we, as a medical profession, have helped create. In emergency departments across the country the pendulum has, mercifully, begun to swing back to a reasonable position. It should not be easy to write the script for percocet or vicodin when the end result is causing an explosion of prescription drug abuse. Regulators must be held accountable as part of this process as we seek to get “top box” scores in patient satisfaction. We can’t provide narcotics simply to avoid bad patient satisfaction scores. News flash: people seeking narcotics to support a chronic habit are not going to be happy when we say no. I have explained to many patients over the last year that my goal as a physician is to treat their pain and not to make them into an addict. We as physicians need to accept the fact that our patients may not be ok with that.
Decision rules such as the PERC criteria to risk stratify PE and many others can now be incorporated into EMRs. Are we, as providers, demanding that this occur and holding ourselves accountable to use them? Are we looking at our high utilizer population and taking the time to develop care plans to better manage complex patient problems? Yes these new processes take time. But doing the same old thing we have always done will not allow us to maintain our position as the safety net to society.
End of Life
End of life care has become a dance few of us in our specialty enjoy. We see the futility of using aggressive treatments for patients just as they are trying to leave this life. We must continue the conversations on the limits of the technology at our disposal and when enough is enough. This involves engaging all patients (and family members) in what is appropriate within the limits of what we can provide. We must switch from a conversation about DNR (do not resuscitate) to one about AND (allow natural death). For those suffering with chronic conditions and worsening health, palliative care should be introduced early to allow each person to understand their disease process and how to best live with it. When the end is near, hospice care and dying with dignity surrounded by family members at home, if possible, should become the norm it once was.
Here is where emergency medicine may be able to have its biggest impact. Today in many departments ER docs have the option to admit to a general medical floor, telemetry, observation unit or critical care bed. Medicare spends $15 billion a year on patients requiring re-admissions within 30 days. We stand at the interface of the outpatient and inpatient worlds of medicine. One is high cost, one low cost. That is where we can have our biggest impact if we look at the system as a whole.
Medical Home Model
Emergency physicians have the expertise to extend the safety net to protection of the oft-touted Medical Home Model. ER docs must work hand in hand with primary care partners when their patients develop unexpected problems by helping to coordinate the appropriate level of care. This may be an emergency department visit, urgent care center visit, observation stay, home based telemedicine or home visit as required by the patient and their medical condition. This coordination requires necessary discussion on changes in payment and going at risk for the population of patients for whom we care.
Finally, as I have written before, each of us must take responsibility for our personal health. Some of us have no choice based on genetics. But most of us can dramatically improve our personal health by eating the right foods, not over eating, not smoking, getting regular moderate exercise (walk!) and limiting alcohol intake. We as medical professionals know the impact lifestyle choices have on our health. We see the end result of poor choices every day.
The Future of Emergency Medicine
So what will emergency medicine look like 20 years from now? I’ll be long retired. My hope is that our specialty has solidified its position in the new health care future. It will have expanded its scope of services while staying true to its role as the society’s safety net. It will have moved to be an integral part of both delivering and coordinating outpatient care as well as supporting the new model of the medical home, and it will be respected and recognized in that role.
Hopefully in twenty years people will say that the profession of emergency medicine did what was right, what we had to do to serve our patients and society. What a future that would be!
- Angelo Falcone, MD (Read other posts by Angelo Falcone)