Monday, April 14, 2003

Admission Decisions: An Opportunity for Deploying Interpersonal and Communication Skills in Service to Your Medical Staff Colleagues

It happened again, the resident hemmed and hawed and finally said, “We’ll take care of her hip, but I’m not admitting her.” Well, since this elderly woman with a hip fracture and a “lick to the head” clearly wasn’t going home, my ED attending colleague was in the position of “negotiating” with a series of residents and fellows from various services, finally speaking to the chief of general surgery who directed the admission to his service; after all the patient had two injured organ systems.

How easy or difficult is admitting patients at your hospital? Does it depend upon the service? Has capitated managed care affected the responsiveness of your community’s physicians when you call and discuss admitting a patient?

I’ve practiced in an academic health sciences center, various community hospitals affiliated to that center and now I practice at a huge tertiary-care community teaching hospital. The admitting process in each hospital reflected the hospital’s mission and the medical staff preference.

In all of these hospitals, patient care—always a primary mission—was balanced with educational needs of residents and students in the ED and on inpatient services. While I’m sure we can agree that at times some physicians may behave badly, for the purposes of this column, I’d rather ignore that fraction of the experience. In the real world we shouldn’t condition our actions or speech on the responses of an ill-behaved minority.

Experience may be a useful teacher and changing circumstances call for reflection about that experience. Our emergency medicine residency is in its eighth month as I write this and the experience of our attending staff and residents in attempting the admission of patients has been instructive as the example above illustrates.

How shall we as a department respond? How should you? Should you press for admitting privileges for attending emergency physicians—not to their own service, but rather the privilege to admit to any other service? Should we in New York insist upon the prerogative once granted us by the now defunct New York City Ambulance Destination Advisory Council that compelled hospitals to implement policy assuring that emergency physicians could “assign” patients to a service?

Are our internist or orthopedist colleagues who question our admission recommendation “The Enemy?” I hardly think so and neither does Michael P. Wainscott, MD, EM residency director at University of Texas Southwestern, who raised the concern that such contention suggests a fear on our part that discussing an admission was “somehow tantamount to neutering EM as a specialty.” He asks the question, “What message is this sending our residents?”

Of course a resident shouldn’t have the authority to send a patient home that the attending emergency physician believes should be admitted. Certainly admitting a patient to a service and simply informing the house staff could expedite admissions from the ED, thereby reducing waiting time for patients. Of course, there will be some—perhaps five percent—unnecessary admissions, but they can be sorted out the next day.

What then are we teaching our residents? The Accrediting Council for Graduate Medical Education in its outcome project adopted in 1999 six competencies for all residents. Among these competencies is one described as “Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals.”

As my Texas based colleague pointed out in the emed-l (use EDSubscriber at NCEMI to subscribe) discussion, “Emergency physicians don’t simply admit patients in private practice—admitting decisions are discussed with private doctors.” Realistically, the private practitioner may know something about the patient that can avoid the admission and our role as emergency physicians has always had a component of reducing the load on the medical staff so that those physicians need not return to the hospital after hours when their patients show up at the ED. So, while it is certainly true that the incentives for private physicians have changed over time—capitated payments used by many managed care plans may unfortunately contribute a disincentive to hospitalization in some equivocal circumstances and even well intended, assiduous physicians make errors in judgment; nonetheless, excluding the primary physician from decision-making won’t give evidence of quality customer service to the medical staff, which perhaps is second only to excellent patient care in establishing your and your practice’s reputation.

And so, this is the crux of the matter for me. While we are training emergency medicine residents in a variety of sites, most of these residency graduates will practice in community settings where they may interact with residents, but they will certainly admit patients to private physicians. How will their “interpersonal and communication skills” stand up to the challenge? Better I suspect, if as Mike Wainscott suggests, they “. . . embrace the opportunity for physician interactions between emergency medicine and internal medicine in whatever manner is appropriate to our practice setting.” In our practice setting, like Mike’s and given our and his complex patients, this has certainly proved to be the case. Insisting that the attending emergency physician’s judgment is superior to the admitting resident’s—likely a true enough statement—doesn’t accomplish the task of teaching our residents needed skills nor does it well serve your medical staff. As for admitting patient’s with a fractured hip to general surgery; I’m learning that all that is old can become new again since that’s what I saw when I was in medical school under the same rationale for caring for trauma patients.