Sunday, September 14, 2003

Potpourri: New Attendings, Regional Competitors and Malpractice Crisis

How are the new attending(s) settling into your department? What’s happening at your regions EDs (competitors and otherwise)? Has the malpractice insurance crisis made a home in your state? This month, for your return from summertime diversions, I thought I’d share a snapshot of three of my September concerns.

This year we brought on several new attending physicians both to increase our staff and because as we transform from a pure service organization to a service and academic organization, we needed a staff with both the credentials and the capacity for academic accomplishment. In an effort at supporting these young physicians we subjected them to nine-days of orientation, which included a fair number and cross-section of staff from around the hospital. They spent an evening with me at the ambulance garage of our closest volunteer ambulance service, Borough Park Hatzolah, where we shared a meal and heard community-based volunteers talk about the importance of true partnership in patient care. They both welcomed the new physician staff and challenged them to learn about cultural imperatives and community based relationships that motivated them to engage our emergency physicians rather intensely at the patient’s bedside. The new physician staff also worked portions of various shifts in the adult and pediatric ED as extra staff so that they could learn the systems—both computer-based and people-based—without feeling pressured for throughput.

You did offer an orientation program to your new staff physicians didn’t you? Of course you did. Besides, orientation helps you define your expectations for your new staff in a supportive fashion at the beginning of their work with you. Even if it was only ten minutes explaining your chart and introducing your new physician to some of the nursing and clerical staff. You remembered to talk about consent and you reviewed your state’s rules for minors consenting for their own treatment. You probably spent a few minutes reminding your new staffer about the requirements for coding a level five visit and shared the number of the hospital’s risk management hotline. So, now it’s September; have you asked your newest staff members how well you prepared them for the summer in your ED? If not, you’ll want to soon, since it both helps you learn how to improve your orientation program for the next time and it demonstrates your genuine concern for your physician’s well being early on in their career with you.

So what’s happening in the neighborhood? In our neighborhood our nearest competitor hospital has started admitting patients to hallway beds on the floors upstairs—when crowded with admissions in the ED—this just as advised by our state health commissioner. When I heard about this I called my counterpart and asked him directly what had transpired and he told me that he had sought and obtained direction from his CEO because of ED crowding with admitted patients. At our institution we’ve discussed this approach but have held off because of perceptions about our community’s preferences—hospital leaders believe that community members would feel that a bed in the hallway by the nurses’ station was inferior to a stretcher in the ED. Availability of medical-surgical beds is a problem for many emergency departments, but perhaps the greatest problem lies elsewhere.

The Greater New York Hospital Association recently published its final report on ED Patient Flow and Best Practices in June 2003. Heading the list of impediments to efficient patient flow was insufficient inpatient bed availability (no surprise there) and within this category, availability of telemetry beds was the single greatest category of beds that were in short supply in the five boroughs of New York. The replying hospitals also identified ED nursing and ancillary support staff and lab and radiology turnaround intervals as substantial contributors.

New York saw an overall 8% increase in malpractice rates this year and there remains no end in sight to the medical liability morass. National ACEP’s resource commitment and active participation with obstetrics and neurosurgical specialty societies in a lobbying coalition should help improve the situation if all engage in the discussion. It’s not my intent here to proselytize for anything other than your activism on this issue. It’s as likely that you and I would disagree as agree on the best remedy for the growing malpractice problem, but I hope we agree that with malpractice insurance costs going up well beyond any reimbursement increases, we are in an unsustainable circumstance. Some democratic group practices have been so seriously challenged by malpractice costs that their continuation has been threatened.

As many of you know, on July 15 ACEP pledged $1 Million in members’ equity in support of the American Association of Neurological Surgery/Congress of Neurological Surgeons led coalition on tort reform believing that now was the best opportunity for gaining political leverage and consequent favorable change in the process.

Engage your colleagues with this news and news on medical liability issues from your state ACEP chapter or other organized medicine resources. Help them write letters to elected officials and state regulators or organize coverage so that they can attend regional or statewide meetings or rallies. Getting active on this issue is important to our future.

Individual activism is important, but so too is engaging the issue at your hospital. Take the opportunity to remind your CEO and other hospital leadership of the negative impact on recruiting and retention that malpractice costs are beginning to demonstrate in the worst affected states across the country. Participate in regional and statewide meetings and other actions and bring your message both as an individual and on behalf of your practice. The more voices the better and differences of opinion should be welcomed because they will stimulate more ideas, which we badly need for tackling this difficult issue.

Leadership of an emergency department entails work in your department, hospital, and community and more broadly at policy levels. Not all of us will do as well with each of these activities. Seek appropriate colleagues within and without your organization to help, but as the leader we must stay alert—and responsive—to the entire range of challenges and opportunities from wherever they come.