There exist three hospitals in parallel dimensions. This may be the root of all service delivery problems in public healthcare systems, including the spectre of access block. A bold statement, I know, but read on…
The idea of three parallel hospitals was first introduced to me by a mentor and colleague, Dean Powell, and I believe addressing it with top-down leadership is the key to unlocking some of our greatest problems.
The three hospitals are:
- The hospital the administrators and the board think they are running
- The hospital the consultants think they are running
- The real hospital – the one run by junior doctors that comes out to play after hours
In the specialty of Emergency Medicine we are probably the only group of specialists who recognise and truly understand the parallel hospital issue. Things go bump(y) in the night. Unfortunately most of our patients experience this third hospital too.
Until this is also widely acknowledged and addressed by administrators and inpatient consultants, things like obstructiveness, bullying, overinvestigation, undertreatment, delays to decision making, ED length of stay, and ultimately access block will continue to plague our attempts to provide a consistent service to the acute healthcare of our population. We are doomed to failure in meeting the NEAT (National Emergency Access Target) unless we are realistic about the real hospital.
We in ED need to start by consistently and firmly defining what our specialty is to inpatient junior docs. The first step is convincing specialty juniors that coming to ED to admit a patient is NOT THE SAME as consulting a patient on the wards. My ideas about our role are listed below:
- We are, above all things, advocates for the patient in a service industry
- We are not your resident or intern or your clerk or secretary
- We are not just extended triage, and we are not just the department of available medicine
- More importantly, we will not just be defined by what we do not do
- We ARE resuscitationists, and doing your non-urgent inpatient related duties for you interferes with doing this properly
- We ARE dispositionists, and we can and will decide (largely correctly) where people should GO and under WHOM. We are prepared to get this wrong and we will wear that
- Occasionally definitive diagnosis helps, and tests will inform points 5. and 6., but I won’t be adding on your serum rhubarb for you, nor will I be calling you back to re-refer after all the tests are done
- We will assess and treat all comers, but we will stop and give them to you when we no longer value-add to a given patient’s care, and you do. We will define this transition point, then we’ll let you know
So lets define the limits of what we do, rather than let it be defined by what others won’t do or are used to having done for them. A culture change needs to be led from the top. ED shouting from the basement can only do so much. Administrators and hospital consultants need to stand up, and if they won’t, in the words of Greg Henry, let us “bring our lion’s heart into our lion’s throat and give a roar in defence of the patient.”
Remember, in Greg’s words, we are the last doctors who deserve to carry the staff of Ascelapius. Let us wield it.