June 2, 2025 • 38 mins
Interview with David Schriger, Peter Viccellio, and Al Sacchetti, MD's
Four decades of emergency medicine experience reveals how the specialty continues to normalize dysfunction while failing to articulate what emergency care should look like. Veterans explore solutions to the systemic problems that have kept emergency departments "at the breaking point" for over 30 years.
• Emergency physician compensation ranks around 16th among medical specialties—not the financial crisis some portray
• Working conditions, not compensation, represent the true crisis in emergency medicine today
• Emergency departments generate 33-50% of hospital revenue, but this value is rarely recognized by administration
• Physicians have accepted and normalized dysfunctional practices like hallway medicine instead of demanding change
• Simple solutions like elective scheduling smoothing and enhanced discharge programs work but aren't widely adopted
• Emergency medicine needs to define and demand what optimal practice should look like
• The healthcare system tries to solve 7-day-a-week problems with 5-day-a-week solutions
• Hospitals contain chaos in emergency departments to maintain predictability on inpatient floors
• Emergency physicians increasingly moving into hospital leadership roles where they can implement systemic improvements
Listen to our next episode where we'll explore how new emergency physicians can advocate for better workplace conditions despite institutional resistance.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 2 (00:12):
it's a little.
It's a little out of beer.
Speaker 3 (00:14):
He has hair.
The rand corporation and asapcame out with strategies for
sustaining emergency care in theunited states.
Too much fanfare.
It was all about what's wrongwith emergency medicine and how
do we fix it.
And at the same time, there wasa study that came out that
showed that emergency medicinecompensation is about midway
(00:36):
between all the specialties.
We're not right at the top,we're not right at the bottom.
And also at the same time, wefound that this problem with how
many people are matchingemergency medicine is starting
to go away again.
It was really great for 25years, the best and the
brightest, and then peoplestopped matching in emergency
medicine and then they are again.
So I got together, thesecrotchety old guys, to talk
(00:57):
about this stuff from ahistorical perspective, to talk
about this RAND report and totalk about what's wrong with
emergency medicine and how wecan fix it.
And what you're going to havehere is a group of people who've
been doing this for over 40years that can tell you what's
new and what's not new.
And when I think about the RANDCorporation and the ACIP report
, I'm thinking of that quote.
(01:19):
I think it was from CharlieMunger that said show me the
incentives and I'll show you theoutcomes.
Let's talk about it from thatpoint of view.
What are the incentives here?
What are the outcomes we'relooking for?
Are the two aligned?
Speaker 4 (01:32):
It's a good summary, but it's tricky.
Speaker 3 (01:36):
That's Peter Fajelio from Stony Brook in New York.
Speaker 4 (01:39):
Emergency physicians are paid in very different ways,
and the one thing that's beenclear in the last few years is
that the emergency physiciansthat are at greatest risk are
physicians that work for privateequity firms, a number of which
have gone bankrupt.
(02:00):
I love one of them that theytook out a one point five
billion dollar loan.
They awarded the board fivehundred million of that and then
declared bankruptcy and lefttheir physicians hanging.
But the what is it?
The Becker Hospital report.
(02:22):
I just got it in the emailtoday.
It ranked the 29 top physiciansalaries and we were number 16.
We were better than obstetricsand just below pulmonary.
So in terms of a public message,of life is terrible.
It sucks.
So the solution is to pay usmore is a message that I don't
(02:48):
think carries, but I think it isa Look.
I think absolutely.
Should we get paid more?
Yes, I should be paid twice asmuch, three times as much, but
that's a separate issue thanwhat's going on in the emergency
department.
And what I found about the Randreport is it's almost identical
(03:08):
to reports from three years ago,six years ago, nine years ago,
12 years ago, ASEP sort ofpromoted this as the emergency
department at the breaking point.
The first time there was everan article that I'm aware of
that I recall, of emergencydepartments being at the
breaking point was in 1987, TimeMagazine, and then in 1991, and
(03:30):
then in 1995.
So we're constantly at thebreaking point and our response
has been I think the world needsto be fixed.
Emergency departments need tobe better, Public health needs
to be better, Primary care needsto be better, Mental health
needs to be better.
Everything needs to be better.
We need to pour a lot moremoney into it, and that all may
(03:52):
be well and true, but in termsof emergency medicine, it would
be nice to focus on what it isexactly that's broken, both
structurally and financially,and what specific things need to
be done to fix it, Because Ithink that this report in many
ways buries the lead.
Speaker 3 (04:14):
Right, thanks, dr Vecchile.
Okay, al Cicchetti, what do youget to say?
Speaker 5 (04:17):
I think you bring up something that struck me about
the report, which was I mean Iadmit you bring up something
that struck me about the report,which was I mean I admit the
report was more financiallybased.
But from my perspective, goingto work I find most difficult is
not what I'm being paid perhour.
You know where I work.
I'm expected I'm going to see alarge number of people who
(04:37):
aren't going to be able toafford their care, and that's
fine.
I mean I made that selection.
What bothers me the most is thebiggest problem with emergency
medicine is really not thatfinancial.
You put it in now, peter, we'redoing okay.
Everybody would like to be paidmore, I agree.
But the biggest problem for meis the conditions under which we
are practicing our specialty.
(04:58):
I mean, you know the boardedpatients, the lack of consultant
support these days.
You know the increase in theviolence against health care
providers.
I think the bigger thing is,aside from the violence, is the
lack of respect.
I mean I don't have to be hitby a patient to recognize the
fact that they hurt me when theytell me I don't know what I'm
(05:19):
doing because they readsomething about some holistic
medicine that I should knowabout.
The biggest problem withemergency medicine is not
necessarily what was featured inthat RAND report, but all the
other ancillary things that gointo what happens when you walk
into the department for yourshift.
Speaker 4 (05:35):
But, al, let's go back to the inciting event
Emergency medicine.
What was the evolution ofemergency medicine?
We were always the adolescentsat the table of medicine when I
first started out and emergencydepartments were crowded.
We were boarding patients in1980.
What did we do?
What did we say about it?
(05:56):
We blamed it on the unnecessaryvisits.
Did it help us?
No, what did it do?
It told insurance companies oh,you have unnecessary visits,
okay, we won't pay for themanymore.
Imagine surgery instead hadtaken over emergency medicine.
Now the surgeons I know theydon't do two cases in the same
(06:16):
operating room.
The cardiologists don't put twopatients in the same room.
Nobody does this except for us.
We have never defined what ourworkplace should look like.
You know, if we have 75 bedsand we can double up some rooms
and put people in hallways so wecan maybe take care of 100 at
(06:37):
once and we have 150 patientstotal there.
I think if surgeons had takenover this because surgeons get
their way instead of a 75 bedemergency department they have a
200 bed emergency departmentand they'd have three CAT scans
in there.
They'd have two operating roomsand they would have more
nursing staff than you couldthink of.
We have a tradition ofaccepting mediocrity.
(07:00):
We have a tradition of tryingto solve problems by seeing
patients in hallways and inwaiting rooms, and we have done
what Patrick Moynihan veryclearly described as defining
deviancy down.
We have accepted this as ourfate.
There's not one singlestructural article out of our
(07:21):
organizations that say this iswhat emergency medicine should
look like.
We don't have any prideourselves in what we're doing.
Speaker 5 (07:30):
But you're making my point.
I mean that is the whole point.
Here's a report that focusesstrictly on the finances of it
and missed out completely on allthose things that you mentioned
that those of us have beenadvocating for for years Now.
Part of the reason you get yourway and if you're a surgeon you
get your way is you generatemore money for the hospital.
(07:52):
I think we've done a very badjob of selling the amount of
money that we generate for thehospital.
I mean, when they look at theincome from the emergency
department, they look at theincome of patients you saw in
discharge, anybody you admitgets, I guess, credited to the
upstream people, so that MI youadmit gets credited to
cardiology when they go to thecath lab.
(08:13):
Well, you know what, if youtake the money that you generate
off your admitted patients,turns out that you generate and
we've done this a couple oftimes you generate at least a
third to a half of the revenuefor the hospital.
But we've done a very big jobof selling that to the hospital.
We did it at our institutionand it opened a lot of eyes.
But nationally we don't, whichis why, exactly what you said,
(08:37):
we don't have all the thingsthat the surgeons would have if
they were running the emergencydepartment, because the hospital
has traditionally bought into.
The surgeons generate money.
They don't buy into the amountof money that we generate and
we've done a bad job of sellingthat.
Speaker 3 (08:50):
Right, let's bring in Dave Schrager, professor of
Immunosuppressant Medicine atUCLA, who has some very
interesting ideas about how weshould fix this.
Speaker 2 (08:59):
I mean, I think there is.
But again, I think it's biggerthan all of this, which is, you
know, first of all, this is nota national problem in the sense
that every state's a little bitdifferent.
You know, you go to Marylandand seeing a Medicaid patient is
not a problem because they paythe same as private insurance.
You go to California, it's avery different kettle of fish.
You know, at our hospital,which is a quaternary care
(09:20):
hospital, they lose money onalmost every patient we admit
from the emergency department,unlike what Al was saying,
because they make money onlywhen they're high profit margins
, which means the right patientswith the right insurance but,
most importantly, with the rightdiseases.
So they can't make money on astraight Medicare DRG.
Now, that may be their problemin terms of efficiency and other
(09:41):
things, but they lose money andthat patient.
So what they figured out is thebest thing to do is to keep
that patient in the emergencydepartment for their entire stay
while a more lucrative patientis admitted electively to take
the bed.
So I don't care if your ER has75 beds, 150 beds or 400 beds.
If they're all filled withborders, you're not practicing
(10:02):
emergency medicine.
But my point would be two points, one of which is this is larger
than emergency medicine, and Iagree with both of you in terms
of some of the ways that youargue that we have framed
ourselves to a disadvantage overtime.
You know, either not behavinglike surgeons or, on the flip
side right now, saying we arenot primary care doctors, we're
(10:22):
specialists, which at timesduring this cycle would have had
an advantage that we haven'ttaken care of.
But the bigger point for me isthat everything we're talking
about is symptomatic of a largerproblem, so that right now,
management, which is an evil initself, is constantly trying to
optimize what we do, given thesituation, rather than saying we
(10:49):
need to blow up this wholesituation.
Seeing patients in the hallway,seeing patients in the waiting
room, seeing patients thataren't properly undressed all of
those things are not goodmedicine and we shouldn't
practice them.
Until we're willing to throwdown the gauntlet and say we're
not going to do that anymore,let the waiting room back up,
let the press come and let theC-suite deal with that.
Until we're willing to do that,nothing's going to change.
(11:10):
And my final point would besimply that the billing
analytics of this are simplistic, because the fact is, most
people are practicing emergencymedicine in a way that it
shouldn't be practiced.
So ordering a troponin, aD-dimer and a CAT scan on every
patient who walks in the doorand then saying you're not
paying us for adequatecomplexity is a bunch of BS,
(11:31):
because what they should bepaying us for is to think and to
not order those tests whichwould save the system money.
And instead everyone's in thisrace to front order everything
in quote, unquote the name ofefficiency.
So when the patient doesfinally get to see a doctor,
everything is done, but itcoincidentally works out that
that's what makes the most moneyfor the hospital.
And so we are doing a bad jobon all counts.
(11:53):
We're not sticking up forpatient rights and saying we're
not going to see patients insuboptimal conditions.
We're not willing to bear theheat of that, and we also are
practicing in a way which is notgood medicine and is just
convenient.
So I think a lot of this fallsback to us.
Speaker 5 (12:09):
Yeah, but you wind up cutting off your nose to spite
your face if you say I'm notgoing to see patients in the
hallways, I'm going to let thewaiting room back up.
Well, you know what?
I went into medicine to helppeople, and I'm not helping
somebody if I let them sit inthe waiting room long enough for
them to leave and not get theirproblem treated.
Speaker 2 (12:26):
So yeah, we.
Let me just disagree with thatfor a second, which is that may
be true for a small cohort ofpatients, but do that for a
little while and the totalnumber of people you will help
by changing the system is fargreater than the few that are
hurt on the days when you go onstrike.
Speaker 5 (12:42):
essentially, yeah, but I don't see that happening.
I see that the hospital justsaying look you guys, they're
just incredibly inefficient,we're going to get rid of you
and get somebody else in.
It just doesn't, it doesn'tfloat that they're going to
respond to that.
All we're going to do is tickoff the patients.
Speaker 2 (13:01):
Well, as a one-off that may be true, but if we
actually unionized and did thistogether, we would be in much
different circumstances and wemight push the healthcare
systems to larger solutions.
So that kind of incrementalthinking that got us exactly
where we are right now.
Speaker 4 (13:16):
Al, I have tracked what we say publicly for now 40
years, and what we say is thingsare terrible.
But what we don't say is thisis exactly what we need to do to
fix it.
We just say it's terrible.
Oh, woe is me and pay me more.
(13:38):
Now I think a lot of ourconclusions are driven by our
premises, so I think that thereare a few myths out there that
are premises that I don't thinkare true.
The first is, as I mentioned,the unnecessary visits.
I don't think that that is ourissue at all in emergency
medicine.
Our emergency department is notbeing brought to its knees by
(14:01):
having too many sprained anklesthere.
The second is in terms of money.
Now, in the 80s there wasliterature that, oh, every
emergency department admissionis a money loser.
But one thing changed, and itchanged in a big way.
It was with documentation.
I no longer was admitting apatient with pneumonia, I was
(14:23):
admitting a patient with low-barpneumonia and lactic acid doses
and septic shock, et cetera, soforth.
And guess what?
The payment for that isfantastic.
And the third idea here is thatwe leave admissions in the
emergency department because theC-suite has it together so well
that they have figured out thatthey are going to leave
(14:44):
admissions in the emergencydepartment for financial benefit
.
I don't think that's true tobegin with and I don't think
you're given that.
Speaker 3 (14:52):
I think you're given let me say that may be true at a
quaternary place.
Speaker 4 (14:56):
I think what drives our boarding in the emergency
department is they simply justdon't know what to do to fix it
and it's not strategic.
It's not like they have emptybeds upstairs while we're
boarding 30 patients, there areno beds upstairs to send the
people up.
So I think that to credit themwith this very clever strategy I
(15:18):
think given too much credit Nowagain at a given particular
institution, this may be so.
We fill the hospital withadmissions.
They make money off theseadmissions.
I think that starting that as afundamental premise is that the
reason we have boarding andcrowding in the emergency
department is because it'sfinancially beneficial to the
hospital is.
(15:39):
I think there's objective datato argue that.
If that's what they think, theyare wrong, Because when you get
people upstairs, they have ashorter length of stay.
If you discharge them early,they get a shorter length of
stay.
If you get discharged onweekends, they have a shorter
length of stay, and shorterlength of stays correlate with a
lot more money for the hospital.
Speaker 5 (16:01):
I think, dave, you are right at your institution
but at our shop we're much morelike what Peter alluded to,
which is, you know, when we didthese studies at our shop, what
we found was that you know eventhe non-s a little bit more of a
mindset of, yeah, we do have topay attention to the emergency
department.
I think one of the things thatwe fight against a lot is just
(16:32):
history.
I mean, it's been traditionthat's been drilled into a lot
of as Peter alluded tomisinformed administrators that
the way you make money is youignore the emergency department
and pay attention to theelective admissions.
I don't think that's the case.
I think you know, when we lookat it, the vast majority of our
(16:56):
really sick acute patients arecoming in through the emergency
departments and they're the onesthat you know generate a lot of
income off of procedures.
We are an urban emergencydepartment in the poorest city
in the nation, but yet we canpull in from some of the suburbs
you know for our tertiary careand we do okay.
So I think you know solving theproblems, the logistical
(17:21):
problems in the emergencydepartment, is a much bigger
goal for, I guess, theleadership in emergency medicine
than simply looking at the RANDreport and saying we don't have
enough money because it goesback to what Peter said we're
number 16 on the hip parade.
That's not so bad.
Speaker 4 (17:41):
But I think the correct answer to electives
versus emergency patients is notpitting them against each other
.
Institutions have to figure outhow to take care of both, and
if there are certain patientsyou don't make much money on,
like, for instance, people thatcan't pay you offset that with
other patients, but you have tofigure out how to take care of
(18:01):
everybody that shows up.
There's a right way to do itand a wrong way to do it, but we
have not defined or laid out aroadmap, an architectural
drawing of what emergencydepartments need to look like.
We incorporate dysfunction intoour architectural drawings when
(18:22):
designing a new emergencydepartment.
There was one thing in the RandCorporation report where they
said well, emergency departmentsshould build extra areas so
that they can have a place toput their admissions.
That's been looked at.
If you build 10 beds to putadmissions, then by the time
you're done building, you'reboarding 20 admissions.
This is not the solution to theproblem.
Speaker 2 (18:45):
Well, I would just say that these two highly
respected gentlemen, I believe,are doing exactly what they both
suggested we shouldn't do,which is trying to fix an
impossible problem, and that'sin the spirit of emergency
medicine to do that, and Iadmire both of them.
But the fact is this is anon-solvable problem in our
current health care system.
All of this is symptomatic of adisease which permeates the
(19:08):
entire health care system.
And so until you are willing,as I said before, to throw down
the gauntlet and say stop, weare not going to try to optimize
crap, we are not trying toperform alchemy.
We are going to point out whatthe problems are in the system
at a larger level than just EDcare, and blow the system up.
(19:28):
Nothing will change except inthe most incremental ways.
Speaker 5 (19:32):
Right, but you're going to need buy-in, and I
agree with you 100%.
The system sucks, but in orderto fix it you're going to need
buy-in from every specialty.
I mean, everybody's got to buyinto it.
In the interim we still have to, you know, take care of of um,
the people who come to us, and I, I I like to see someone come
(19:53):
up with that, that universalmodel that incorporates every
aspect of medicine, and andapply it.
But I don't see it.
I see, you know people say, oh,um, you know we should solve it
this way.
I think Peter's got one of thebest success stories ever where
his institution was going tobuild a big new tower and Peter
(20:14):
said wait a minute, just, youknow, extend your operating room
hours, move your critical casesto not just Monday, tuesday,
wednesday but to the rest of theweek, and all of a sudden it,
you know, eliminated the needfor the tower.
That's a classic example of ofthe thinking that that would
work.
Speaker 2 (20:32):
I have nothing wrong with that thinking.
But let's look at it this waythe average person in this
country is lucky to be making 30bucks an hour.
Okay, at that wage, the societycannot afford the product that
is currently being delivered asmedicine in this country.
Ok, and until you get those twothings on par with each other,
(20:55):
you might optimize one littlelocus over here or one little
locus over here, but when youare delivering a product that
the society cannot afford, youare not going to find a solution
.
You're just going to move thepieces around and hurt somebody
or somebody else, and that'swhat needs to be addressed.
Speaker 4 (21:13):
Well, this was one thing lacking in the Rand report
.
In most places there actuallyare solutions to this without
building towers, without havingto triple the size of your
emergency department or whateverelse, and there's a handful of
solutions.
One is elective smoothing.
(21:33):
That was the example that Alwas talking about at Cincinnati
Children's is once they smooththeir elective schedule.
This was just over five days.
This was not a seven-day-a-weekexercise schedule.
This was just over five days.
This was not a seven-day-a-weekexercise.
They canceled the building of a100-bed tower because they
(21:54):
didn't need it and the amount ofvolume they were able to
increase through their operatingroom without adding operating
rooms was to the tune of $130million a year.
Nyu did an early dischargeprogram.
They went from single digits to40% out by noon and they did it
for financial reasons.
Their CFO said if patientsdon't get upstairs until
afternoon, their length of stayis a half a day longer.
(22:17):
Well, their O to E dropped by0.8.
That creates a huge amount ofspace.
The guy at Montefiore weekenddischarges.
He enhanced weekend discharges.
They went from boarding 30patients a day to closing a
30-bed unit because they didn'tneed it.
That can benefit boarding, canbenefit the emergency department
(22:40):
, can benefit the staff andinpatient services and
dramatically improve thefinancial bottom line of the
hospital.
So why don't we do that?
Because that's just not the waywe do things.
I mean, it's just inane as towhy these sort of actions don't
(23:03):
take because there's so muchbenefit to so many people.
That's not outlined in the RANDCorporation.
The RAND Corporation reportsmostly things are horrible.
Things are terrible and we needa roadmap for these are the
specific solutions that youcould do.
How many people are still in thehospital after they no longer
(23:24):
need it because they're sick?
A lot of people are becausethey're waiting for PT, they're
waiting for an echo, they'rewaiting for this, that and the
other.
It's very costly to the systemto do that and very
short-sighted to not addressthat.
And it can be addressed withoutadditional staff, without
additional cost.
(23:44):
It's just shifting thingsaround.
If you have 10 echo techs thatcome in from 8 to 4, if you just
shift some of those up to 8 or9 pm, you clear the queue for
that day and the patients canget out the next morning.
But we are not doing appropriatesystems interventions to do it
(24:08):
and so our solution is always astypical we need more money, we
need more space, we need morestaff, we need more everything.
We need to change from the1960s hospital of a nine to five
, monday through Friday, withthe skeleton crew on evenings,
nights and weekends.
We just never.
We're like the frog that wassitting in the water that's
(24:30):
slowly heating up.
We never changed, and so nowwe're still trying to solve a
seven day a week problem with afive day a week solution.
Speaker 2 (24:39):
I don't disagree in the sense that I think there are
all kinds of inefficiencies inthe system that could be
improved.
I think non-medical managers areprobably the worst people to do
that, and I do have a biasagainst management.
I think that physicians are theones who understand patient
care and need to solve theseproblems many of them.
But fundamentally, if you addup, I believe, peter, even if
(25:00):
you did everything you saideverywhere, you still have the
problem that, at a median incomeof $40,000 to $50,000, we are
delivering a product that thepopulace cannot afford, and
that's because we're orderingtoo many tests, we're doing too
many unnecessary procedures,both diagnostically and
therapeutically, and we're notpracticing optimal medicine.
(25:22):
We need to clean up themedicine too.
We're also not training Mel youput in the match stuff.
I mean, we're not trainingdoctors to be doctors anymore,
we're training doctors to bekind of widget movers in the
emergency room.
You know, show me all the labresults and maybe I'll get
around to this.
Following a patient, no history, no physical examination, no
thought.
So create a system which paysus to think rather than to do,
(25:47):
and maybe we can make someheadway.
Speaker 5 (25:50):
I was going to say one of the things is, dave, what
you're saying, some headway.
I was going to say one of thethings is, dave, what you're
saying?
All those changes also have totake place in the background of
keeping people, I guess, beingpaid for their jobs.
(26:12):
I mean, when you look at that,I am amazed when I see a patient
who was discharged from ourhospital about you know, last
week or two weeks ago, a monthago and I go to the discharge
summary and I can't figure outwhat the hell happened to that
patient.
There's all little categoriesthat are blocked off, like you
know, I asked this and I didthat and I did this, and it's
all the checkoff boxes forreimbursement, but you can't
(26:33):
figure out what the hellhappened.
There's no little paragraphthat tells you what the hell
happened.
And what you're advocating isgreat, but any hospital or
whatnot's going to say I can'tmake those changes until you
make changes in the payers toreimburse me for doing it
differently.
Otherwise, I'm going to writethese discharge summaries.
(26:53):
I'm going.
I'm going to write thesedischarge summaries.
I'm going to have my staffwrite these discharge summaries
and just check off a whole lotof boxes to maximize our
reimbursement.
Speaker 2 (27:00):
But if physicians let the managers whether they're
financial managers or othermanagers drive the ship, we will
get nowhere.
And until we're willing to sayno, we are not going to document
for the purpose of billing.
We're going to document for thepatient, for the purpose of
optimal patient care.
We're not going to order testsfor the purpose of optimizing
(27:21):
income.
We're going to order practicegood medicine.
Until we're willing to do that,nothing will change.
Speaker 5 (27:28):
Depends on the doc.
I mean, it's funny, from fromday one, my incentive was keep
the waiting room empty.
It just was.
And you know, as, as a result,you don't document, as well, as
a result, that the other doc,who doesn't pay attention to the
waiting room but it'smeticulous in their docking
documentation, um, their, theirincentive works out great.
(27:50):
Um, so it's a, it's a wonderfulstatement and I agree.
But if your incentive ispatient care and keep the
waiting room empty and do allthose other things, yeah, your
reimbursement is going to suffer.
Speaker 4 (28:04):
I could not disagree more.
I don't order 65 things beforeI see the patient.
That's just, and our departmentdoes it.
Now we do have an area wherepatients are preliminary seen
and orders are started if theycan't get into a bed.
But, Dave, I have complained,for instance, about radiology
(28:29):
turnaround times and what's theresponse?
Well, you would not have aproblem if you didn't order so
many tests, and I guess that'strue.
If I didn't order a single CATscan, then there'd never be a
wait for a CAT scan.
But I think, Mel, you askedwhat's the incentive of the
system and I think there is alarge incentive in the system as
(28:51):
a whole is to contain the chaosin the emergency department so
that the inpatient floors can bemethodical and rational and
predictable.
So you know, you're on aninpatient ward, there's only a
certain number of beds and acertain number of nurses, and
that's predictable and it's notchaotic.
(29:13):
They can get rid of one patientbefore they take on a new
patient.
And how does that happen?
That happens because the chaosis contained on this side of the
line in the emergencydepartment, and so we reap the
unfortunate consequences of thatneed for the inpatient services
(29:36):
to not have the chaos moveupstairs.
Speaker 5 (29:41):
I've often been told that we are our worst own
enemies and we enable the restof the hospital to function
inefficiently because we takecare of them.
So if interventional radiology,you know, is not efficient,
we'll do the paracentesis forthem in the emergency department
.
You know, if our outpatientpediatrics just can't seem to
(30:07):
get their act together to see akid, well, we'll bring that
three-month-old with a feverback to see us and we'll take
care of them.
So what Peter has said is veryaccurate.
You know, the more that we arereally good at what we do, the
(30:27):
easier we make it for the restof the hospital to be really bad
at what they do.
Speaker 4 (30:32):
Well, I've been fortunate enough in my career
I'm a PGY 48 now I've beenfortunate enough in my career to
always work in a dysfunctionalenvironment.
So I never got to see thechange from a functional place
to a dysfunctional place.
From the start we were boarding, crowding people in the waiting
(30:54):
room.
I think what changed inemergency medicine honestly was
that culturally when I startedit was fine to let people wait
eight, 12 hours and you justdidn't really give a damn.
And culturally we have changedin that we don't feel that
that's right to those humanbeings.
So we have adapted in a verydysfunctional way.
(31:15):
You know, build me a tent, I'llsee somebody in a hallway do a
rectal exam in a closet.
I'll do whatever I can to helpthe patient.
But what Dave is suggestingcan't be done at a local level.
If you do it in your owninstitution, then you're going
to be replaced, but nationallywe need to define what we look
(31:40):
like.
Look at what medicine is now.
I work in a 600-bed hospital.
If they knocked it down andthey put me in charge of
building it, I would take those600 beds and 200 of them would
belong to the emergencydepartment, because if we
expanded our scope of care, we'dbe able to get a lot of those
people out of the emergencydepartment and then we could
(32:01):
even minimize critical careadmissions by taking care of
them and then distribute peopleout to the other areas.
If the inpatient services ranlike the emergency department
services do meaning I want thetest now, I want the results now
and I'm going to take actionnow that would transform in
(32:21):
hospital medicine and it wouldtransform the length of stay, it
would transform the number ofbeds available so that you
wouldn't have this issue withboarding.
Speaker 2 (32:31):
Well, I think that local level can lead to the kind
of problems that these otherdistinguished gentlemen have
identified, which is they couldjust fire you and it won't be
noticed.
So I think that we need to bandtogether, that ASEP, for
example, could articulate thathave never been clearly
(32:52):
articulated before, because eachof those principles may have
negative consequences to somepart of the constituency.
So I don't think we've beenvery bold in terms of
articulating a future.
That would be a better futureand I think we could do a better
job of doing that, certainly.
But I think you know lookwhat's happening in this country
everywhere.
You know, to all aspects of thecountry at this particular
(33:13):
moment, and I think you know tosome extent we need to get
outside of our local problems.
And I was kind of surprised thatyou sent over the match results
, because you'll see all kindsof publicity within emergency
medicine that oh, there were 60unmatched spots instead of 90
unmatched spots or 200 unmatchedspots, and people will focus on
that and that's really takingtheir eye off the prize which we
(33:35):
are heading collectively as asociety.
And it's not just the US, Imean, there's boarding in plenty
of other countries.
But you know we need tofundamentally rethink some of
these things about how societieswork, how health care is
delivered and how the healthcare system is organized, before
any of this will be solved.
Sure there'll be some successstories I'm not quibbling with
(33:57):
that and sure there's lots ofinefficiencies in the ED and at
the hospital level that could befixed.
But the fact is that this ismuch larger than that.
Until we address the largerissues coherently and
collectively, we won't get anymeaningful solution.
Speaker 4 (34:13):
But the boldness has to be preceded by a clear vision
of what the world should looklike.
And I don't see that.
I just see a cry of distress oh, the emergency department's at
the breaking point, which hasbeen a mantra for at least 30
years, and that clearly somebodyshould figure out that.
(34:34):
That's that.
That is not a battle cry,because you're telling the
public it needs to be fixed.
Well, who's the expert atfixing it?
The public's not the expert atfixing it.
Congressmen aren't the expertat fixing it.
We should.
We should be the experts, butwe need to define a vision and
then be bold about it.
Speaker 5 (35:00):
I think it's interesting that you know, at
least in this area.
What I'm seeing is more andmore chief medical officers or
whatever that you want to namethe title for the hospital are
becoming emergency physicians,because I think emergency
physicians are the ones whounderstand every aspect of
medicine.
You know, if you've got aninternist, who traditionally was
that position, well you knowthe OB people could come to them
and feed them whatever linethey want and they would have to
(35:22):
buy it.
Same thing with pediatriciansand everything else.
But I'm seeing more and more ofthese high level executives
being emergency physicians andwhen you begin to look at now,
they can do it exactly what Davesaid they can take a step back
and look at the global picture,not just their little area.
Speaker 4 (35:39):
There's something I do want to say, mel is again,
part of the adolescent nature ofemergency medicine is to bash
people beyond your walls eitherthe patients in this direction
or the C-suite or whatever else.
I have to say the people I'veworked with from other
departments the people in theC-suite and the middle manager,
(36:01):
administrators and whatnoteverybody has a good heart about
what they're trying to do.
They really are trying.
Nobody likes this.
There's no one that's chucklingin their office saying ha ha ha
, aren't we just doing great?
Everybody wants this fixed, butthey need, I think, some help
in what is it that we need to do, in what order and with what
(36:24):
priority, to address this andfix it in a systematic way.
I've found the same thing withthe health department.
They've come out with somecrazy stuff, but in working with
them I've always found theirhearts in the right place.
They really want to do theright thing.
Sometimes they misinterpretsomething or misunderstand
something, but everybody in thesystem that I work with, they
(36:48):
want to do the best that theycan for the patient on an
individual level and on a systemlevel.
We just are not getting aroundto figuring out what we need to
do in order to make that happen.
Speaker 2 (37:01):
I want to go back to Munger's quote that Mill offered
up a few minutes ago, which isI don't disagree with you, but
if you incentivize the C-suiteto maximize profit, they will
behave logically to do that.
If you incentivize them with adifferent goal, which is to
treat all people equally andfairly and quickly, they will
figure out ways to do that.
And it all comes down toincentives, and the incentives
(37:23):
are money and until we fix thaton both sides, which is the
demand and the supply, we willnot get anywhere.
Speaker 4 (37:31):
I actually I wish that were true, because if it
were true, every hospital wouldhave smoothing of elective
surgery, every hospital wouldhave a program for early
discharge, every hospital wouldfigure out how to get people out
on weekends, because all ofthose things result in a huge
financial benefit to theinstitution.
So they may be wanting tomaximize income, but they're
(37:56):
looking within the dysfunctionalsystem as to how to maximizing
it, rather than stepping backand saying how can we rearrange
the chairs on the deck here sowe can actually get better
throughput, get more patients in, get them out quicker, and
we'll all do better as a result.
Speaker 3 (38:14):
So there you have it.
Thanks to Dave Schroeger, toPeter Vecelio, to Elsa Keddie
for their thoughts, for theirideas and hopefully some
inspiration that perhaps thepeople who are best equipped to
fix our problem is actually us,and maybe we haven't been doing
that and maybe it's time.
it's a little.
It's a little out of beer.
Speaker 3 (00:14):
He has hair.
The rand corporation and asapcame out with strategies for
sustaining emergency care in theunited states.
Too much fanfare.
It was all about what's wrongwith emergency medicine and how
do we fix it.
And at the same time, there wasa study that came out that
showed that emergency medicinecompensation is about midway
(00:36):
between all the specialties.
We're not right at the top,we're not right at the bottom.
And also at the same time, wefound that this problem with how
many people are matchingemergency medicine is starting
to go away again.
It was really great for 25years, the best and the
brightest, and then peoplestopped matching in emergency
medicine and then they are again.
So I got together, thesecrotchety old guys, to talk
(00:57):
about this stuff from ahistorical perspective, to talk
about this RAND report and totalk about what's wrong with
emergency medicine and how wecan fix it.
And what you're going to havehere is a group of people who've
been doing this for over 40years that can tell you what's
new and what's not new.
And when I think about the RANDCorporation and the ACIP report
, I'm thinking of that quote.
(01:19):
I think it was from CharlieMunger that said show me the
incentives and I'll show you theoutcomes.
Let's talk about it from thatpoint of view.
What are the incentives here?
What are the outcomes we'relooking for?
Are the two aligned?
Speaker 4 (01:32):
It's a good summary, but it's tricky.
Speaker 3 (01:36):
That's Peter Fajelio from Stony Brook in New York.
Speaker 4 (01:39):
Emergency physicians are paid in very different ways,
and the one thing that's beenclear in the last few years is
that the emergency physiciansthat are at greatest risk are
physicians that work for privateequity firms, a number of which
have gone bankrupt.
(02:00):
I love one of them that theytook out a one point five
billion dollar loan.
They awarded the board fivehundred million of that and then
declared bankruptcy and lefttheir physicians hanging.
But the what is it?
The Becker Hospital report.
(02:22):
I just got it in the emailtoday.
It ranked the 29 top physiciansalaries and we were number 16.
We were better than obstetricsand just below pulmonary.
So in terms of a public message,of life is terrible.
It sucks.
So the solution is to pay usmore is a message that I don't
(02:48):
think carries, but I think it isa Look.
I think absolutely.
Should we get paid more?
Yes, I should be paid twice asmuch, three times as much, but
that's a separate issue thanwhat's going on in the emergency
department.
And what I found about the Randreport is it's almost identical
(03:08):
to reports from three years ago,six years ago, nine years ago,
12 years ago, ASEP sort ofpromoted this as the emergency
department at the breaking point.
The first time there was everan article that I'm aware of
that I recall, of emergencydepartments being at the
breaking point was in 1987, TimeMagazine, and then in 1991, and
(03:30):
then in 1995.
So we're constantly at thebreaking point and our response
has been I think the world needsto be fixed.
Emergency departments need tobe better, Public health needs
to be better, Primary care needsto be better, Mental health
needs to be better.
Everything needs to be better.
We need to pour a lot moremoney into it, and that all may
(03:52):
be well and true, but in termsof emergency medicine, it would
be nice to focus on what it isexactly that's broken, both
structurally and financially,and what specific things need to
be done to fix it, Because Ithink that this report in many
ways buries the lead.
Speaker 3 (04:14):
Right, thanks, dr Vecchile.
Okay, al Cicchetti, what do youget to say?
Speaker 5 (04:17):
I think you bring up something that struck me about
the report, which was I mean Iadmit you bring up something
that struck me about the report,which was I mean I admit the
report was more financiallybased.
But from my perspective, goingto work I find most difficult is
not what I'm being paid perhour.
You know where I work.
I'm expected I'm going to see alarge number of people who
(04:37):
aren't going to be able toafford their care, and that's
fine.
I mean I made that selection.
What bothers me the most is thebiggest problem with emergency
medicine is really not thatfinancial.
You put it in now, peter, we'redoing okay.
Everybody would like to be paidmore, I agree.
But the biggest problem for meis the conditions under which we
are practicing our specialty.
(04:58):
I mean, you know the boardedpatients, the lack of consultant
support these days.
You know the increase in theviolence against health care
providers.
I think the bigger thing is,aside from the violence, is the
lack of respect.
I mean I don't have to be hitby a patient to recognize the
fact that they hurt me when theytell me I don't know what I'm
(05:19):
doing because they readsomething about some holistic
medicine that I should knowabout.
The biggest problem withemergency medicine is not
necessarily what was featured inthat RAND report, but all the
other ancillary things that gointo what happens when you walk
into the department for yourshift.
Speaker 4 (05:35):
But, al, let's go back to the inciting event
Emergency medicine.
What was the evolution ofemergency medicine?
We were always the adolescentsat the table of medicine when I
first started out and emergencydepartments were crowded.
We were boarding patients in1980.
What did we do?
What did we say about it?
(05:56):
We blamed it on the unnecessaryvisits.
Did it help us?
No, what did it do?
It told insurance companies oh,you have unnecessary visits,
okay, we won't pay for themanymore.
Imagine surgery instead hadtaken over emergency medicine.
Now the surgeons I know theydon't do two cases in the same
(06:16):
operating room.
The cardiologists don't put twopatients in the same room.
Nobody does this except for us.
We have never defined what ourworkplace should look like.
You know, if we have 75 bedsand we can double up some rooms
and put people in hallways so wecan maybe take care of 100 at
(06:37):
once and we have 150 patientstotal there.
I think if surgeons had takenover this because surgeons get
their way instead of a 75 bedemergency department they have a
200 bed emergency departmentand they'd have three CAT scans
in there.
They'd have two operating roomsand they would have more
nursing staff than you couldthink of.
We have a tradition ofaccepting mediocrity.
(07:00):
We have a tradition of tryingto solve problems by seeing
patients in hallways and inwaiting rooms, and we have done
what Patrick Moynihan veryclearly described as defining
deviancy down.
We have accepted this as ourfate.
There's not one singlestructural article out of our
(07:21):
organizations that say this iswhat emergency medicine should
look like.
We don't have any prideourselves in what we're doing.
Speaker 5 (07:30):
But you're making my point.
I mean that is the whole point.
Here's a report that focusesstrictly on the finances of it
and missed out completely on allthose things that you mentioned
that those of us have beenadvocating for for years Now.
Part of the reason you get yourway and if you're a surgeon you
get your way is you generatemore money for the hospital.
(07:52):
I think we've done a very badjob of selling the amount of
money that we generate for thehospital.
I mean, when they look at theincome from the emergency
department, they look at theincome of patients you saw in
discharge, anybody you admitgets, I guess, credited to the
upstream people, so that MI youadmit gets credited to
cardiology when they go to thecath lab.
(08:13):
Well, you know what, if youtake the money that you generate
off your admitted patients,turns out that you generate and
we've done this a couple oftimes you generate at least a
third to a half of the revenuefor the hospital.
But we've done a very big jobof selling that to the hospital.
We did it at our institutionand it opened a lot of eyes.
But nationally we don't, whichis why, exactly what you said,
(08:37):
we don't have all the thingsthat the surgeons would have if
they were running the emergencydepartment, because the hospital
has traditionally bought into.
The surgeons generate money.
They don't buy into the amountof money that we generate and
we've done a bad job of sellingthat.
Speaker 3 (08:50):
Right, let's bring in Dave Schrager, professor of
Immunosuppressant Medicine atUCLA, who has some very
interesting ideas about how weshould fix this.
Speaker 2 (08:59):
I mean, I think there is.
But again, I think it's biggerthan all of this, which is, you
know, first of all, this is nota national problem in the sense
that every state's a little bitdifferent.
You know, you go to Marylandand seeing a Medicaid patient is
not a problem because they paythe same as private insurance.
You go to California, it's avery different kettle of fish.
You know, at our hospital,which is a quaternary care
(09:20):
hospital, they lose money onalmost every patient we admit
from the emergency department,unlike what Al was saying,
because they make money onlywhen they're high profit margins
, which means the right patientswith the right insurance but,
most importantly, with the rightdiseases.
So they can't make money on astraight Medicare DRG.
Now, that may be their problemin terms of efficiency and other
(09:41):
things, but they lose money andthat patient.
So what they figured out is thebest thing to do is to keep
that patient in the emergencydepartment for their entire stay
while a more lucrative patientis admitted electively to take
the bed.
So I don't care if your ER has75 beds, 150 beds or 400 beds.
If they're all filled withborders, you're not practicing
(10:02):
emergency medicine.
But my point would be two points, one of which is this is larger
than emergency medicine, and Iagree with both of you in terms
of some of the ways that youargue that we have framed
ourselves to a disadvantage overtime.
You know, either not behavinglike surgeons or, on the flip
side right now, saying we arenot primary care doctors, we're
(10:22):
specialists, which at timesduring this cycle would have had
an advantage that we haven'ttaken care of.
But the bigger point for me isthat everything we're talking
about is symptomatic of a largerproblem, so that right now,
management, which is an evil initself, is constantly trying to
optimize what we do, given thesituation, rather than saying we
(10:49):
need to blow up this wholesituation.
Seeing patients in the hallway,seeing patients in the waiting
room, seeing patients thataren't properly undressed all of
those things are not goodmedicine and we shouldn't
practice them.
Until we're willing to throwdown the gauntlet and say we're
not going to do that anymore,let the waiting room back up,
let the press come and let theC-suite deal with that.
Until we're willing to do that,nothing's going to change.
(11:10):
And my final point would besimply that the billing
analytics of this are simplistic, because the fact is, most
people are practicing emergencymedicine in a way that it
shouldn't be practiced.
So ordering a troponin, aD-dimer and a CAT scan on every
patient who walks in the doorand then saying you're not
paying us for adequatecomplexity is a bunch of BS,
(11:31):
because what they should bepaying us for is to think and to
not order those tests whichwould save the system money.
And instead everyone's in thisrace to front order everything
in quote, unquote the name ofefficiency.
So when the patient doesfinally get to see a doctor,
everything is done, but itcoincidentally works out that
that's what makes the most moneyfor the hospital.
And so we are doing a bad jobon all counts.
(11:53):
We're not sticking up forpatient rights and saying we're
not going to see patients insuboptimal conditions.
We're not willing to bear theheat of that, and we also are
practicing in a way which is notgood medicine and is just
convenient.
So I think a lot of this fallsback to us.
Speaker 5 (12:09):
Yeah, but you wind up cutting off your nose to spite
your face if you say I'm notgoing to see patients in the
hallways, I'm going to let thewaiting room back up.
Well, you know what?
I went into medicine to helppeople, and I'm not helping
somebody if I let them sit inthe waiting room long enough for
them to leave and not get theirproblem treated.
Speaker 2 (12:26):
So yeah, we.
Let me just disagree with thatfor a second, which is that may
be true for a small cohort ofpatients, but do that for a
little while and the totalnumber of people you will help
by changing the system is fargreater than the few that are
hurt on the days when you go onstrike.
Speaker 5 (12:42):
essentially, yeah, but I don't see that happening.
I see that the hospital justsaying look you guys, they're
just incredibly inefficient,we're going to get rid of you
and get somebody else in.
It just doesn't, it doesn'tfloat that they're going to
respond to that.
All we're going to do is tickoff the patients.
Speaker 2 (13:01):
Well, as a one-off that may be true, but if we
actually unionized and did thistogether, we would be in much
different circumstances and wemight push the healthcare
systems to larger solutions.
So that kind of incrementalthinking that got us exactly
where we are right now.
Speaker 4 (13:16):
Al, I have tracked what we say publicly for now 40
years, and what we say is thingsare terrible.
But what we don't say is thisis exactly what we need to do to
fix it.
We just say it's terrible.
Oh, woe is me and pay me more.
(13:38):
Now I think a lot of ourconclusions are driven by our
premises, so I think that thereare a few myths out there that
are premises that I don't thinkare true.
The first is, as I mentioned,the unnecessary visits.
I don't think that that is ourissue at all in emergency
medicine.
Our emergency department is notbeing brought to its knees by
(14:01):
having too many sprained anklesthere.
The second is in terms of money.
Now, in the 80s there wasliterature that, oh, every
emergency department admissionis a money loser.
But one thing changed, and itchanged in a big way.
It was with documentation.
I no longer was admitting apatient with pneumonia, I was
(14:23):
admitting a patient with low-barpneumonia and lactic acid doses
and septic shock, et cetera, soforth.
And guess what?
The payment for that isfantastic.
And the third idea here is thatwe leave admissions in the
emergency department because theC-suite has it together so well
that they have figured out thatthey are going to leave
(14:44):
admissions in the emergencydepartment for financial benefit
.
I don't think that's true tobegin with and I don't think
you're given that.
Speaker 3 (14:52):
I think you're given let me say that may be true at a
quaternary place.
Speaker 4 (14:56):
I think what drives our boarding in the emergency
department is they simply justdon't know what to do to fix it
and it's not strategic.
It's not like they have emptybeds upstairs while we're
boarding 30 patients, there areno beds upstairs to send the
people up.
So I think that to credit themwith this very clever strategy I
(15:18):
think given too much credit Nowagain at a given particular
institution, this may be so.
We fill the hospital withadmissions.
They make money off theseadmissions.
I think that starting that as afundamental premise is that the
reason we have boarding andcrowding in the emergency
department is because it'sfinancially beneficial to the
hospital is.
(15:39):
I think there's objective datato argue that.
If that's what they think, theyare wrong, Because when you get
people upstairs, they have ashorter length of stay.
If you discharge them early,they get a shorter length of
stay.
If you get discharged onweekends, they have a shorter
length of stay, and shorterlength of stays correlate with a
lot more money for the hospital.
Speaker 5 (16:01):
I think, dave, you are right at your institution
but at our shop we're much morelike what Peter alluded to,
which is, you know, when we didthese studies at our shop, what
we found was that you know eventhe non-s a little bit more of a
mindset of, yeah, we do have topay attention to the emergency
department.
I think one of the things thatwe fight against a lot is just
(16:32):
history.
I mean, it's been traditionthat's been drilled into a lot
of as Peter alluded tomisinformed administrators that
the way you make money is youignore the emergency department
and pay attention to theelective admissions.
I don't think that's the case.
I think you know, when we lookat it, the vast majority of our
(16:56):
really sick acute patients arecoming in through the emergency
departments and they're the onesthat you know generate a lot of
income off of procedures.
We are an urban emergencydepartment in the poorest city
in the nation, but yet we canpull in from some of the suburbs
you know for our tertiary careand we do okay.
So I think you know solving theproblems, the logistical
(17:21):
problems in the emergencydepartment, is a much bigger
goal for, I guess, theleadership in emergency medicine
than simply looking at the RANDreport and saying we don't have
enough money because it goesback to what Peter said we're
number 16 on the hip parade.
That's not so bad.
Speaker 4 (17:41):
But I think the correct answer to electives
versus emergency patients is notpitting them against each other
.
Institutions have to figure outhow to take care of both, and
if there are certain patientsyou don't make much money on,
like, for instance, people thatcan't pay you offset that with
other patients, but you have tofigure out how to take care of
(18:01):
everybody that shows up.
There's a right way to do itand a wrong way to do it, but we
have not defined or laid out aroadmap, an architectural
drawing of what emergencydepartments need to look like.
We incorporate dysfunction intoour architectural drawings when
(18:22):
designing a new emergencydepartment.
There was one thing in the RandCorporation report where they
said well, emergency departmentsshould build extra areas so
that they can have a place toput their admissions.
That's been looked at.
If you build 10 beds to putadmissions, then by the time
you're done building, you'reboarding 20 admissions.
This is not the solution to theproblem.
Speaker 2 (18:45):
Well, I would just say that these two highly
respected gentlemen, I believe,are doing exactly what they both
suggested we shouldn't do,which is trying to fix an
impossible problem, and that'sin the spirit of emergency
medicine to do that, and Iadmire both of them.
But the fact is this is anon-solvable problem in our
current health care system.
All of this is symptomatic of adisease which permeates the
(19:08):
entire health care system.
And so until you are willing,as I said before, to throw down
the gauntlet and say stop, weare not going to try to optimize
crap, we are not trying toperform alchemy.
We are going to point out whatthe problems are in the system
at a larger level than just EDcare, and blow the system up.
(19:28):
Nothing will change except inthe most incremental ways.
Speaker 5 (19:32):
Right, but you're going to need buy-in, and I
agree with you 100%.
The system sucks, but in orderto fix it you're going to need
buy-in from every specialty.
I mean, everybody's got to buyinto it.
In the interim we still have to, you know, take care of of um,
the people who come to us, and I, I I like to see someone come
(19:53):
up with that, that universalmodel that incorporates every
aspect of medicine, and andapply it.
But I don't see it.
I see, you know people say, oh,um, you know we should solve it
this way.
I think Peter's got one of thebest success stories ever where
his institution was going tobuild a big new tower and Peter
(20:14):
said wait a minute, just, youknow, extend your operating room
hours, move your critical casesto not just Monday, tuesday,
wednesday but to the rest of theweek, and all of a sudden it,
you know, eliminated the needfor the tower.
That's a classic example of ofthe thinking that that would
work.
Speaker 2 (20:32):
I have nothing wrong with that thinking.
But let's look at it this waythe average person in this
country is lucky to be making 30bucks an hour.
Okay, at that wage, the societycannot afford the product that
is currently being delivered asmedicine in this country.
Ok, and until you get those twothings on par with each other,
(20:55):
you might optimize one littlelocus over here or one little
locus over here, but when youare delivering a product that
the society cannot afford, youare not going to find a solution
.
You're just going to move thepieces around and hurt somebody
or somebody else, and that'swhat needs to be addressed.
Speaker 4 (21:13):
Well, this was one thing lacking in the Rand report
.
In most places there actuallyare solutions to this without
building towers, without havingto triple the size of your
emergency department or whateverelse, and there's a handful of
solutions.
One is elective smoothing.
(21:33):
That was the example that Alwas talking about at Cincinnati
Children's is once they smooththeir elective schedule.
This was just over five days.
This was not a seven-day-a-weekexercise schedule.
This was just over five days.
This was not a seven-day-a-weekexercise.
They canceled the building of a100-bed tower because they
(21:54):
didn't need it and the amount ofvolume they were able to
increase through their operatingroom without adding operating
rooms was to the tune of $130million a year.
Nyu did an early dischargeprogram.
They went from single digits to40% out by noon and they did it
for financial reasons.
Their CFO said if patientsdon't get upstairs until
afternoon, their length of stayis a half a day longer.
(22:17):
Well, their O to E dropped by0.8.
That creates a huge amount ofspace.
The guy at Montefiore weekenddischarges.
He enhanced weekend discharges.
They went from boarding 30patients a day to closing a
30-bed unit because they didn'tneed it.
That can benefit boarding, canbenefit the emergency department
(22:40):
, can benefit the staff andinpatient services and
dramatically improve thefinancial bottom line of the
hospital.
So why don't we do that?
Because that's just not the waywe do things.
I mean, it's just inane as towhy these sort of actions don't
(23:03):
take because there's so muchbenefit to so many people.
That's not outlined in the RANDCorporation.
The RAND Corporation reportsmostly things are horrible.
Things are terrible and we needa roadmap for these are the
specific solutions that youcould do.
How many people are still in thehospital after they no longer
(23:24):
need it because they're sick?
A lot of people are becausethey're waiting for PT, they're
waiting for an echo, they'rewaiting for this, that and the
other.
It's very costly to the systemto do that and very
short-sighted to not addressthat.
And it can be addressed withoutadditional staff, without
additional cost.
(23:44):
It's just shifting thingsaround.
If you have 10 echo techs thatcome in from 8 to 4, if you just
shift some of those up to 8 or9 pm, you clear the queue for
that day and the patients canget out the next morning.
But we are not doing appropriatesystems interventions to do it
(24:08):
and so our solution is always astypical we need more money, we
need more space, we need morestaff, we need more everything.
We need to change from the1960s hospital of a nine to five
, monday through Friday, withthe skeleton crew on evenings,
nights and weekends.
We just never.
We're like the frog that wassitting in the water that's
(24:30):
slowly heating up.
We never changed, and so nowwe're still trying to solve a
seven day a week problem with afive day a week solution.
Speaker 2 (24:39):
I don't disagree in the sense that I think there are
all kinds of inefficiencies inthe system that could be
improved.
I think non-medical managers areprobably the worst people to do
that, and I do have a biasagainst management.
I think that physicians are theones who understand patient
care and need to solve theseproblems many of them.
But fundamentally, if you addup, I believe, peter, even if
(25:00):
you did everything you saideverywhere, you still have the
problem that, at a median incomeof $40,000 to $50,000, we are
delivering a product that thepopulace cannot afford, and
that's because we're orderingtoo many tests, we're doing too
many unnecessary procedures,both diagnostically and
therapeutically, and we're notpracticing optimal medicine.
(25:22):
We need to clean up themedicine too.
We're also not training Mel youput in the match stuff.
I mean, we're not trainingdoctors to be doctors anymore,
we're training doctors to bekind of widget movers in the
emergency room.
You know, show me all the labresults and maybe I'll get
around to this.
Following a patient, no history, no physical examination, no
thought.
So create a system which paysus to think rather than to do,
(25:47):
and maybe we can make someheadway.
Speaker 5 (25:50):
I was going to say one of the things is, dave, what
you're saying, some headway.
I was going to say one of thethings is, dave, what you're
saying?
All those changes also have totake place in the background of
keeping people, I guess, beingpaid for their jobs.
(26:12):
I mean, when you look at that,I am amazed when I see a patient
who was discharged from ourhospital about you know, last
week or two weeks ago, a monthago and I go to the discharge
summary and I can't figure outwhat the hell happened to that
patient.
There's all little categoriesthat are blocked off, like you
know, I asked this and I didthat and I did this, and it's
all the checkoff boxes forreimbursement, but you can't
(26:33):
figure out what the hellhappened.
There's no little paragraphthat tells you what the hell
happened.
And what you're advocating isgreat, but any hospital or
whatnot's going to say I can'tmake those changes until you
make changes in the payers toreimburse me for doing it
differently.
Otherwise, I'm going to writethese discharge summaries.
(26:53):
I'm going.
I'm going to write thesedischarge summaries.
I'm going to have my staffwrite these discharge summaries
and just check off a whole lotof boxes to maximize our
reimbursement.
Speaker 2 (27:00):
But if physicians let the managers whether they're
financial managers or othermanagers drive the ship, we will
get nowhere.
And until we're willing to sayno, we are not going to document
for the purpose of billing.
We're going to document for thepatient, for the purpose of
optimal patient care.
We're not going to order testsfor the purpose of optimizing
(27:21):
income.
We're going to order practicegood medicine.
Until we're willing to do that,nothing will change.
Speaker 5 (27:28):
Depends on the doc.
I mean, it's funny, from fromday one, my incentive was keep
the waiting room empty.
It just was.
And you know, as, as a result,you don't document, as well, as
a result, that the other doc,who doesn't pay attention to the
waiting room but it'smeticulous in their docking
documentation, um, their, theirincentive works out great.
(27:50):
Um, so it's a, it's a wonderfulstatement and I agree.
But if your incentive ispatient care and keep the
waiting room empty and do allthose other things, yeah, your
reimbursement is going to suffer.
Speaker 4 (28:04):
I could not disagree more.
I don't order 65 things beforeI see the patient.
That's just, and our departmentdoes it.
Now we do have an area wherepatients are preliminary seen
and orders are started if theycan't get into a bed.
But, Dave, I have complained,for instance, about radiology
(28:29):
turnaround times and what's theresponse?
Well, you would not have aproblem if you didn't order so
many tests, and I guess that'strue.
If I didn't order a single CATscan, then there'd never be a
wait for a CAT scan.
But I think, Mel, you askedwhat's the incentive of the
system and I think there is alarge incentive in the system as
(28:51):
a whole is to contain the chaosin the emergency department so
that the inpatient floors can bemethodical and rational and
predictable.
So you know, you're on aninpatient ward, there's only a
certain number of beds and acertain number of nurses, and
that's predictable and it's notchaotic.
(29:13):
They can get rid of one patientbefore they take on a new
patient.
And how does that happen?
That happens because the chaosis contained on this side of the
line in the emergencydepartment, and so we reap the
unfortunate consequences of thatneed for the inpatient services
(29:36):
to not have the chaos moveupstairs.
Speaker 5 (29:41):
I've often been told that we are our worst own
enemies and we enable the restof the hospital to function
inefficiently because we takecare of them.
So if interventional radiology,you know, is not efficient,
we'll do the paracentesis forthem in the emergency department
.
You know, if our outpatientpediatrics just can't seem to
(30:07):
get their act together to see akid, well, we'll bring that
three-month-old with a feverback to see us and we'll take
care of them.
So what Peter has said is veryaccurate.
You know, the more that we arereally good at what we do, the
(30:27):
easier we make it for the restof the hospital to be really bad
at what they do.
Speaker 4 (30:32):
Well, I've been fortunate enough in my career
I'm a PGY 48 now I've beenfortunate enough in my career to
always work in a dysfunctionalenvironment.
So I never got to see thechange from a functional place
to a dysfunctional place.
From the start we were boarding, crowding people in the waiting
(30:54):
room.
I think what changed inemergency medicine honestly was
that culturally when I startedit was fine to let people wait
eight, 12 hours and you justdidn't really give a damn.
And culturally we have changedin that we don't feel that
that's right to those humanbeings.
So we have adapted in a verydysfunctional way.
(31:15):
You know, build me a tent, I'llsee somebody in a hallway do a
rectal exam in a closet.
I'll do whatever I can to helpthe patient.
But what Dave is suggestingcan't be done at a local level.
If you do it in your owninstitution, then you're going
to be replaced, but nationallywe need to define what we look
(31:40):
like.
Look at what medicine is now.
I work in a 600-bed hospital.
If they knocked it down andthey put me in charge of
building it, I would take those600 beds and 200 of them would
belong to the emergencydepartment, because if we
expanded our scope of care, we'dbe able to get a lot of those
people out of the emergencydepartment and then we could
(32:01):
even minimize critical careadmissions by taking care of
them and then distribute peopleout to the other areas.
If the inpatient services ranlike the emergency department
services do meaning I want thetest now, I want the results now
and I'm going to take actionnow that would transform in
(32:21):
hospital medicine and it wouldtransform the length of stay, it
would transform the number ofbeds available so that you
wouldn't have this issue withboarding.
Speaker 2 (32:31):
Well, I think that local level can lead to the kind
of problems that these otherdistinguished gentlemen have
identified, which is they couldjust fire you and it won't be
noticed.
So I think that we need to bandtogether, that ASEP, for
example, could articulate thathave never been clearly
(32:52):
articulated before, because eachof those principles may have
negative consequences to somepart of the constituency.
So I don't think we've beenvery bold in terms of
articulating a future.
That would be a better futureand I think we could do a better
job of doing that, certainly.
But I think you know lookwhat's happening in this country
everywhere.
You know, to all aspects of thecountry at this particular
(33:13):
moment, and I think you know tosome extent we need to get
outside of our local problems.
And I was kind of surprised thatyou sent over the match results
, because you'll see all kindsof publicity within emergency
medicine that oh, there were 60unmatched spots instead of 90
unmatched spots or 200 unmatchedspots, and people will focus on
that and that's really takingtheir eye off the prize which we
(33:35):
are heading collectively as asociety.
And it's not just the US, Imean, there's boarding in plenty
of other countries.
But you know we need tofundamentally rethink some of
these things about how societieswork, how health care is
delivered and how the healthcare system is organized, before
any of this will be solved.
Sure there'll be some successstories I'm not quibbling with
(33:57):
that and sure there's lots ofinefficiencies in the ED and at
the hospital level that could befixed.
But the fact is that this ismuch larger than that.
Until we address the largerissues coherently and
collectively, we won't get anymeaningful solution.
Speaker 4 (34:13):
But the boldness has to be preceded by a clear vision
of what the world should looklike.
And I don't see that.
I just see a cry of distress oh, the emergency department's at
the breaking point, which hasbeen a mantra for at least 30
years, and that clearly somebodyshould figure out that.
(34:34):
That's that.
That is not a battle cry,because you're telling the
public it needs to be fixed.
Well, who's the expert atfixing it?
The public's not the expert atfixing it.
Congressmen aren't the expertat fixing it.
We should.
We should be the experts, butwe need to define a vision and
then be bold about it.
Speaker 5 (35:00):
I think it's interesting that you know, at
least in this area.
What I'm seeing is more andmore chief medical officers or
whatever that you want to namethe title for the hospital are
becoming emergency physicians,because I think emergency
physicians are the ones whounderstand every aspect of
medicine.
You know, if you've got aninternist, who traditionally was
that position, well you knowthe OB people could come to them
and feed them whatever linethey want and they would have to
(35:22):
buy it.
Same thing with pediatriciansand everything else.
But I'm seeing more and more ofthese high level executives
being emergency physicians andwhen you begin to look at now,
they can do it exactly what Davesaid they can take a step back
and look at the global picture,not just their little area.
Speaker 4 (35:39):
There's something I do want to say, mel is again,
part of the adolescent nature ofemergency medicine is to bash
people beyond your walls eitherthe patients in this direction
or the C-suite or whatever else.
I have to say the people I'veworked with from other
departments the people in theC-suite and the middle manager,
(36:01):
administrators and whatnoteverybody has a good heart about
what they're trying to do.
They really are trying.
Nobody likes this.
There's no one that's chucklingin their office saying ha ha ha
, aren't we just doing great?
Everybody wants this fixed, butthey need, I think, some help
in what is it that we need to do, in what order and with what
(36:24):
priority, to address this andfix it in a systematic way.
I've found the same thing withthe health department.
They've come out with somecrazy stuff, but in working with
them I've always found theirhearts in the right place.
They really want to do theright thing.
Sometimes they misinterpretsomething or misunderstand
something, but everybody in thesystem that I work with, they
(36:48):
want to do the best that theycan for the patient on an
individual level and on a systemlevel.
We just are not getting aroundto figuring out what we need to
do in order to make that happen.
Speaker 2 (37:01):
I want to go back to Munger's quote that Mill offered
up a few minutes ago, which isI don't disagree with you, but
if you incentivize the C-suiteto maximize profit, they will
behave logically to do that.
If you incentivize them with adifferent goal, which is to
treat all people equally andfairly and quickly, they will
figure out ways to do that.
And it all comes down toincentives, and the incentives
(37:23):
are money and until we fix thaton both sides, which is the
demand and the supply, we willnot get anywhere.
Speaker 4 (37:31):
I actually I wish that were true, because if it
were true, every hospital wouldhave smoothing of elective
surgery, every hospital wouldhave a program for early
discharge, every hospital wouldfigure out how to get people out
on weekends, because all ofthose things result in a huge
financial benefit to theinstitution.
So they may be wanting tomaximize income, but they're
(37:56):
looking within the dysfunctionalsystem as to how to maximizing
it, rather than stepping backand saying how can we rearrange
the chairs on the deck here sowe can actually get better
throughput, get more patients in, get them out quicker, and
we'll all do better as a result.
Speaker 3 (38:14):
So there you have it.
Thanks to Dave Schroeger, toPeter Vecelio, to Elsa Keddie
for their thoughts, for theirideas and hopefully some
inspiration that perhaps thepeople who are best equipped to
fix our problem is actually us,and maybe we haven't been doing
that and maybe it's time.
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