Croakey recently published part 3 of their series on health reform in Australia. It features comments from Dr Clare Skinner, an emergency medicine registrar in Sydney, on the introduction of the ‘4 hour rule’ to Australia’s emergency departments.
Dr Skinner highlights that,
Implementation will require major cultural and workplace change, including improved co-operation between clinicians working in the Emergency Department and inpatient specialist teams.
She goes on to highlight a problem that will ring true with emergency doctors Australia-wide – as well as many of our colleagues overseas:
During a recent shift, I watched a senior Emergency Physician spend almost four hours on the telephone, negotiating admission of a single patient with a relatively simple primary problem, but complex medical history, to a specialist inpatient unit.
Perhaps an even worse predicament – and one of my pet peeves – is that of the public hospital emergency doctor looking after a privately insured patient who needs admission. I am not alone in having spent countless hours on the telephone speaking to private hospital ‘bed state’ managers and on call private physicians while trying to find placement for a patient with private insurance. Given that it is presumably in their business interests to have patients, surely they should be ringing us and not vice versa? Maybe I just don’t understand private medicine. In fact, I’m sure I don’t – is it an oxymoron?
“Since…gomers [Get Out of My Emergency Room] don’t die…the tern [intern] had to find other ways to turf them…The problem with the turf was that the patient might bounce, i.e. get turfed back…The secret of the professional turf that did not bounce, said the Fatman [a supervising Resident], was the buff…‘Because you gotta always remember: you’re not the only one trying to turf. Every tern and resident in the House of God is lying awake at night thinking how to buff and turf these gomers somewhere else.”
“‘[That doctor’s] so scared of missing something by sending the patient back home that he admits them all. He’s a sieve…he lets everyone through…Be a wall. Don’t let anyone in.’…A mind-boggling thought: the delivery of medical care consisted of buffing and turfing the seeker of care to somewhere else. The revolving door with that eternally revolving door always waiting in the end.”‘The House of God‘ by Samuel Shem
Dr Skinner also mentions a solution offered by a recent must-read qualitative study by Nugas P, et al (2009) – namely the teaching of ‘Selling, Marketing and Packaging 101 to Emergency Physicians and GPs’. Dr Skinner, however, offers another solution:
“Open more beds, aiming for 85% occupancy, to put an end to chronic bed block. Re-invigorate generalism, through funding and employment strategies which reward holistic medical care, rather than super-specialised procedural work. Appreciate and support Emergency Physicians and trainees, with their unique skill-set and system-based approach, as they aim to provide the best care to their patients.”
While we wait (and hope) for this particular pig to start flying, we simply have to accept that the selling and marketing of patients is a sad reality of current emergency medicine practice. Indeed it is impossible to be a productive emergency medicine doctor without developing powers of telephone persuasion.
Intern to researcher: “I’ll ring the med reg [medical registrar]”.
Phoned: “Hi, it’s ‘Trudy’ here from emergency. I have a patient that needs admitting…He’s got a history of acute appendicitis
[Consultant behind — looks exasperated]…OK. Bye.”
[Consultant]: “What did he say?”
Intern:”He said call the surg reg.”interview excerpt from Nugas P, et al (2009)
[Consultant]: “Of course he did.You don’t tell him he’s got a history of appendicitis.That’s an easy bounce straight to surgery.”
I’ve poked fun at this marketing side of emergency medicine practice before, using the superb satirical work of Grant Innes on the disposition of the ‘Patient Without Discernible Pathology‘ (PWDP). However, I’ve also emphasized the serious need for teaching junior doctors the communication expertise necessary for referring patients from the emergency department, as championed by the work of Chad Kessler. Using these skills, if the objective of ‘do what is best for the patient’ and the ‘platinum rule’ of ‘treating others as they would like to be treated’ are remembered, it is possible to ‘market’ patients to admitting teams ethically and effectively.
But can it remain so under the 4 hour rule?
- Innes G (2000). Successful hospitalization of patients with no discernible pathology. CJEM, 2000; 2(1): 47-51
- Nugus P, Bridges J, Braithwaite J. Selling patients. BMJ, 2009; 339: b5201
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.