Three hospitals in parallel dimensions

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:

  1. We are, above all things, advocates for the patient in a service industry
  2. We are not your resident or intern or your clerk or secretary
  3. We are not just extended triage, and we are not just the department of available medicine
  4. More importantly, we will not just be defined by what we do not do
  5. We ARE resuscitationists, and doing your non-urgent inpatient related duties for you interferes with doing this properly
  6. 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
  7. 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
  8. 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.

Specialist Emergency Physician from Ireland currently based in Tasmania, Australia

18 Comments

  1. Outstanding and very well written. Now the challenge is getting buy in from the consultants and the administration. No small feat!

  2. Matthew Mac Partlin
    Matthew Mac Partlin

    Hey Domhnall,

    I’m with you on the parrallel hopsital concept. But thereafter we part company. I suspect you might find that most doctors, in- or out-patient, junior or senior, function on the basis that they are aiming to provide as best they can for any given patient. It is certainly easy to feel used and abused in ED, but to be honest, I have found the same in ICU, though at least here we have a ceiling bed capacity. However even this ceiling is breached in certain circumstances, particularly if not doing so would compromise a patient’s care (I can already hear the retorts…)

    In ED, yes we are resuscitaionists and dispositionists, but these are not the limits of our scope of practice. In providing a service that caters for all comers, we open ourselves to taking on more than we thought we had bargained for. That’s the price of a wide net.

    I whole-heartedly agree that there is no place for interspecialty bullying and high-handed tactics, but I do not believe that it is directed specifically or only at ED. To be honest, I feel that a great deal of this behaviour is rooted (easy there Aussies, not that kind) in two sources. First, in general, most practicioners are genuinely busier than they have resources to deal with fully and so the reflex defense is to try and redirect or delay work. I might be sending you my highest priority patient, but it might not be your highest priority patient at that time. Some just deal with that pressure better than others.

    Secondly and in my opinion more importantly, we don’t know eachother as well as we used to. As a junior in Ireland, regardless of how crappy the week was, everyone headed to the hopsital local on a Thursday night for what today would be called a debrief. It’s so much easier to get a cardiology consult when you’ve had a few pints with the guy the night before. The death of the res party has had more downsides that most administrators realise. We are no longer a village of colleagues; we are a city of strangers thrust together. Maybe this is a function that social media can serve today. Why limit the tweets and hangouts to an inner circle? For them to understand us, perhaps we first need to understand them (Oh dear, how Gandhi of me.)

    Take care

    Matthew

    • Fantastic comment. I do not doubt the motivations of the individuals, but I do doubt the adequacy of the system, and this is why I stress that it is leadership that is required…

  3. Powerful and oh-so-true. These eight points need to be posted on the walls of ERs everywhere.

  4. that Mathew guy makes an awful lot of sense. pity about his drinking problem..

  5. well put sir.

    There is a definite gap or disconnect between what the wide-angle view shows and what the macro shot shows (let me know if i’ve cocked up those analogies, i wouldn’t be surprised…) We have very few consultants in EM in Ireland so they can’t really get a close up view of all the craziness that goes on in EDs – it’s we Registrars and other juniors who know how crazy the floor really is.

    i don’t mean that one view is more “true” than another (a whole different argument) but they definitely aren’t the same.

  6. its interesting and thankyou as you and Mathews comments reminded me of a similar arguement put forward by anaesthetists. I come from a close circle of anaesthetists and we have debated about the role of such professional as being a pivotal contact in the hospital just as you have described for EM and Mathew has for ICU.

    To be honest this arguement can become somewhat circular and self indulgent. Many disciplines can argue the toss about their role being pivotal and central in the course of a patients care.

    Mathews point about the lost social context of medicine is stunningly insightful, and that it comes from his craft of ICU is a noble sign that we are not beyond help as a profession and vocation. How the specialisation of medicine has allowed us to drift into a disconnected existence and how that has affected patient care and indeed the quality of care is the defining challenge for us as healers, is it not?

    The one constant throughout these three parallel dimensions you describe is patient suffering and indeed ultimately our own as we remain disconnected?

    Which is why the candle of FOAMed and the networks it produces kindles hope that we are not hopelessly lost, that there is a way back from the descent into the abyss.

    • Thanks for your comment Minh. In these days of shrinking beds and growing presentations and acuity I am afraid that I do not see inpatient specialists or anaesthetists rolling up their sleeves and joining us in the trenches. We in ED are increasingly seen as the bad guys who create unpredictable work. I see junior docs defending their diminishing beds and controlling their workloads in a way we cannot. I do not believe this is what their bosses envisage as a good service but it is what really happens. Many people advocate for patients already under their care with passion. But I believe we in ED advocate for the patient not yet seen who languishes on a trolley, in a waiting room chair, at home waiting for an ambulance that is ramped or even not yet ill or injured. We see the big picture from our “room with a view” buried in the bowels of the hospital. I don’t see any other specialty giving a damn about these patients frankly. Meanwhile the disconnect and us and them mentality grows unchecked. My patients need the hospital to have leadership from upstairs and we have to work out ways to help “them” lead.

    • Oh and indeed FOAMed may be a beacon but again we must engage beyond the borders of the cross-discipline group that we are into the world of those who aren’t FOAMed yet. The way you and I and Matthew engage through FOAMed gives hope that we can all keep talking and return to making it all about the patient again rather than the turf wars and “not-my-job-ism” that has begun to poison our relationships in the “real” world. It’s bad at my shop. It saddens me. I fear for my patient yet to be seen.

  7. Well put Domhnall.

    Unfortunately we in ED are at the pointy end of the resources crunch. We haven’t yet come to the point where we have to rationalize all resources (eg. investigations) but all of us (Ed and in-patient docs) are having to rationalize one of our greatest resources – our time. We, in ED, see a number of patients at the same time and are fully aware of all the patients in the waiting room and on the ramp that need our time and care. Therefore every day we are having to rationalize that resource – our and the other ED staff’s time and care. I know that if I had more time to spend with each patient and think about all of their issues that they would get better care and I would provide more information for my in-patient colleagues, but there is only so much time that the staff in ED get per patient or per thought process before another issue demands our attention. I find this the most stressful part of the job because there is such tension between the service I know I could be providing and the one I am able to.

    I think that this is what a lot of doctors throughout the hospital system are feeling and is really the source of a lot of the this conflict. All of us went into this career with the intention of making life better for our patients and when we know that we are not doing the best that we can for them because we don’t have the resources (namely time) to do so, it is very stressful. It used to be that when a critically ill and/or difficult patient was in ED often the in-patient specialist consultants involved would come into ED and we would discuss the best course of action for the patient, as a group, collaboratively. This process was very rewarding both for the patient but also for us and paved the way for much easier communication between the specialties. Now, unfortunately, everyone is being pulled in all directions – multiple patients to see on the wards, in clinics etc. so no-one has time to come to ED and WE have little time to spend consulting with others. Therefore the majority of our contact with each other is stressful – we are giving in-patient teams more work and because we feel pressured to move on to the next patient we feel like they are giving us more work by not taking some of the burden and often adding to it by asking us to do EVEN more jobs to do!

    I wish I knew how to solve this problem. I could then solve the issue of resource allocation in health and after that move on to world peace. I think the answer lies in us trying to understand each other more and being aware of the pressures on us and the effect this has. But, in the heat of the shift, all I can usually see is the mounting number of people out in the waiting room, the line of people behind me and the in-patient registrar in front of me that just won’t admit the patient!

    I think a pint, good food and time to talk to our colleagues would be a great place to start though. I’m definitely up for that!

  8. Wow. Have never seen it better put. Made my hairs stand on end.
    Should be sent to every hospital executive, head of unit and health minister in the land.
    The only solution I can think of is the sending of patients to the ward when the ED physician thinks it is time…no arguments. However when there are no beds to send them to this strategy falls down and just adds to the powerlessness we all feel. I’m sick of being consulted about admitted patients who have been in my dept for 20 hours, yet the desire to advocate for the patient remains strong.
    Access block will drive the best of our specialty out.

  9. I’m actually thinking of getting scrubs with the 8 points printed on them..maybe 4 front 4 back and make them the uniform for our ED docs..
    Could be quite empowering!!!

    • Ha! I’ve just put in a new order for scrubs myself, and hadn’t thought of that! Still, I think it is important that we convince LEADERS rather than foot soldiers so having conflict with disempowered junior doctors is unlikely to fix the issue. I don’t think we should perpetuate or worsen the us and them mentality – I think we need to be “persuaders” of consultants and administrators so that they feel like it is them making positive changes.

      • While I agree with the concept, I have to reflect on the unprecedented closure of an acute surgical ward at my institution..the protests by from all levels of staff fell on deaf ears.
        This was BEFORE the PREDICTABLE winter peak. It comes down to dollars..
        If you leave hospital boards in charge they will slash and burn to bottom lines
        The solution they cried was to put those beds into hospital in the home…
        Vascular surgery in the home?
        Complex elderly multiple chronic pathologies just struggling to live in their own homes…at home?
        Ahhh
        We need real top down leadership…and that doesn’t mean from “executives” with no comprehension of the issues
        Get rid of state health ministers for a start

        Ok better stop there…its late and now I’m ranting!!

  10. Did Greg mention the daughter of Ascelapius, was Panacea, the goddess of universal remedy!

    To change this culture of seeing the ED as a Panacea for all, we need to take the opportunity to educate the future medical workforce, when they are with us as our med students and residents, as well as when they visit as junior inpatient docs/registrars.

    Also agree with the need to make ourselves heard and the need to get change from the top down. To help get heard we can take advantage of what will be a culture in the future of increasing patient centred care – when patients will be listened to, we will need to help them find their voice to shout with us.

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