Monday, November 15, 2004

Thriving in an Environment of Imperfection

But first maestro, a small fanfare . . . Yes! I took and passed the 2004 Lifelong Learning and Self Assessment (LLSA) on-line examination! No, it wasn't bad at all. In fact I rather enjoyed the on-line testing.

Despite having read everything ABEM published about Emergency Medicine Continuous Certification and the LLSA process, I was still intimidated by it all. I spent a day off work scanning the 20 articles I'd previously read and marked up over a period of months. I quizzed and was quizzed by a colleague before each of us logged on and took the examination late on a Friday afternoon. It was an investment of time that gave me confidence in dealing with the test, but next year I'll just take the 2005 exam after I finish reading the articles and not make such a major event of the whole thing. For the LLSA seems more about learning than about testing. I especially liked being able to go back and reread sections of the articles for the questions I fumbled and get that, "ah ha" of understanding, even if late in the game.

Such imperfections as may exist in the LLSA process and my imperfection in taking the examination--no, I didn't score a 100%--along with the multitudes of failings in daily work and leadership constantly remind me that living is the ultimate humbling experience.

Adherence to JCAHO requirements is often fraught with imperfection. The 2004 national patient safety goals newly challenged us when a consultant raised questions about how we had implemented the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery(TM) in the ED as of July 1, 2004. This JCAHO requirement has generated a fair number of questions both locally and among participants on various email lists as it has become apparent that it applied equally to our less urgent procedures performed in the ED. I've heard concerns about physicians overlooking the "time out" component when only they are at the bedside, regardless of how the resulting documentation reads. Some in EM question the circumstances when site and side must be marked before performing procedures.

A few months ago I suggested that when speaking to hospital administrators an emergency physician leader might rely less upon the pronouncements of our professional societies and more upon the recommendations of organizations that speak to administrators. I received some negative feedback from physician colleagues and an admiring note from an administrative colleague. Indeed, that kudos is why I write this column, in an effort of persuasion addressed to you, my physician colleagues, that we must be heard by those in the hospital with whom we work.

A colleague recently wrote, "We are in a time of increasing strife between physicians and hospitals. Physicians who figure out how to compromise and work with their institutions will survive and prosper. Hospitals are changing, economic forces are changing, and so we too must adapt." Compromise with hospital administrators sounds like the very definition of imperfection to me.

My colleague went on to write in an email message, "When physicians ask me what sets them or a practice apart, it is the expertise and commitment they bring to the organization. It might be in business management, technology adoption or risk management; but it is no longer clinical expertise which is now pretty much a level playing field. For hospital leaders it is the ability to 'play well with others', to work to maximize the financial viability of the hospital--not necessarily of the group itself--and to serve the mission of the organization."

The practice model doesn't matter in this partnership with the hospital; a democratic group devoted to one institution might achieve these goals or a larger entity with the economies of scale that support the development and exercise of the required expertise. The physician owners/partners/employees of all the possible practice partners to the hospital may all practice high quality care, but the edge will go to the practice that can do it all in partnership with the institution.

As to individual physician leaders, hospitals urgently need those who understand the 'dysfunctional system' from an advocacy and finance perspective and who can work with the hospital to optimize patient, family and community service while continuously improving operational efficiency and revenue. In this imperfect environment, each physician should choose the model that best fits their clinical practice and personal needs and tolerance for risk, yet also consider their own desire for participation and expertise with relevant non-clinical tasks. Thriving in an environment of imperfection requires not that we personally undertake every last detail of partnership with our institutions, but that we do support--at least equally--our colleagues who embrace those challenges.

As to the challenge of implementing the Universal Protocol(TM) . . . and assuring adherence, I refer you to the JCAHO and ACEP while I join you in training our respective staffs while seeking to minimize onerous documentation requirements. At least for our sickest patients, remaining at the bedside obviates the site and side marking requirements and I've been cheered by the number of staff I see checking wristbands lately.

My colleague who unknowingly provoked this month's column with his question: "One must thrive in an environment of imperfection to really enjoy EM--don't you think?" was recounting an anecdote about the criticism supplied by a specialist utilizing the clinical retrospectoscope. Those of us who lead a practice of emergency medicine surely grasp his point--don't you think?

Friday, October 15, 2004

Colleagues, Conferences, Clinical Guidelines and Communication: Collaborative Medical Practice Today

Mornings are not my favorite time of the day, but I’m finding myself in the cafeteria before 7:00 AM several days a week now. No, I’m not getting coffee before an early shift, but I am doing so before the Surgery Morbidity and Mortality or Multi-specialty conference or just sitting down with a pack of proceduralists in radiology, GI, cardiology and other specialties.

I started back at this ritual, one I undertook for several years when I first started at Maimonides because I was hearing a growing number of complaints about our practice. Several physicians complained about the number of unnecessary cardiac enzyme studies drawn at triage, another complained about the one set of blood cultures rather than two, a third complained about antibiotic selection. What’s going on here?

In addition to breakfast, I went to meetings with the complaining physicians and the Chairman of Medicine. I went to meetings with the Chairman of Pediatrics and his staff. Our COO visited with physician staff and shared his observations about the complaints. At the sessions I attended, I listened, I took notes and mostly I heard about communication. Listening to the anecdotes and recounted (one-sided) telephone conversations, I realized that our colleagues were focused on their one patient, while our attending (or resident) was often distracted by other concerns and information even when they were on the telephone. Or worse yet, the call was “intended” but never completed.

I’m not saying that the clinical concerns originally raised as the issue don’t have merit and aren’t happening. In ~46,000 adult visits and ~20,000 admissions, more than 20% over age 65, I’m sure that clinical errors have and will happen. The real problem is that our admitting physicians don’t know our emergency physician staff well enough. It is a huge medical staff with over 400 internists and we’re a group of more than two dozen, but that’s no excuse. Sure we’re distracted and constantly interrupted while working in the ED; “You chose that practice,” our colleagues remind us.

Where would you go from here? I’m interested in your ideas since as leaders and members of your practice you’re challenged to introduce your newer colleagues to long-time medical staff members.

The usual advice we’ve all taught and heard is that the relationship between emergency physician and voluntary primary care physician is formed over the patient. Certainly this was my experience. Today, with most physicians in the hospital less, the telephone has become more important, perhaps we should train our emergency physician staff for telephone communication.

One thing I see, is as hospitalist practices develop and solo and small group practices diminish in number, my emergency physician colleagues are focusing on those physicians they see the most. Perhaps this is an artifact of our community teaching hospital and those of you practicing in non-teaching hospitals continue to see your primary care colleagues regularly. I’m sure diverse practice environments and hence professional relationships with colleagues foster different approaches to the problem.

We’re going to use the regulator’s growing evaluation of adherence to practice guidelines as one tool for improving communication. I’m not quite clear on the details—in fact we’re still working them out—but reminding colleagues of the JCAHO “Core Measures” for pneumonia (Figure 1) which includes evaluation of the timing of antibiotic administration allows us to put the emergency physician on the same team as the internist who is charged with assuring pneumococcal and influenza vaccination among other requirements. It will also present an opportunity to suggest that if they prefer a different antibiotic, they need not continue the antibiotic we’ve started—a choice we make using our infectious disease division’s recommendations as built into our ordering pathway.

I’m hoping that we can pull together a joint conference on the combined emergency department and inpatient management of the several core measure related disease processes we care for together: pneumonia, myocardial infarction and heart failure. Discussing our processes may enable learning that can improve the way we work, but will at least develop an appreciation for the difficulties we each face in our own clinical milieu.

With these efforts we’ll have precipitated a discussion around clinical pathways which is a pretty good place for physician colleagues to start learning about each other. Certainly it will be more productive than arguing over the timing of calls for notification of patient admissions.

If you’ve been coping with similar challenges I’d love to hear from you. Please share your problems and solutions with me by email and I’ll share them with all readers if you’ll let me.

In the meantime, I expect I’ll be dragging myself to surgical morbidity and mortality conference on Friday mornings at 7:00 AM for many years to come.

Figure 1. Pneumonia Core Measure as of April 2004

  • Oxygenation assessment

  • Pneumococcal vaccination

  • Blood cultures

  • Adult smoking cessation advice/counseling

  • Antibiotic timing

  • Initial antibiotic received within 8 hours of hospital arrival

  • Initial antibiotic received within 4 hours of hospital arrival

  • Initial antibiotic selection for PN immunocompetant – ICU

  • Initial antibiotic selection for PN immunocompetant – Non ICU

  • Influenza vaccination

Tuesday, September 14, 2004

Billing for your Group’s ECG Interpretations: Decision-making at the Intersection of Power and Money

Are you billing for ECG interpretations? Are you being paid? Have you been billing for years or did you just start recently? Increasingly emergency physicians are submitting bills for ECG interpretations for payment by third party payers, both commercial and governmental. Since you and your colleagues are doing the work of interpreting the ECG and making the decisions that directly affect the patient, its right that you be paid. But, uh oh, here comes a cardiologist in high dudgeon.

Advance notice of a change in billing practices, a “no surprises” policy, would have alerted your administration and other interested parties—such as that cardiologist—that you intended to begin billing for the work you and your staff are doing: interpreting the ECG and making the relevant clinical decision.

The Centers for Medicare and Medicaid Services (CMS formerly HCFA) has been quite clear in saying:

“In the case of a licensed physician who has furnished a covered service (that is not payable through another code) to a Medicare beneficiary in an emergency room, it is not readily apparent to us upon what basis the claim can be denied. There is no portion of the Act upon which to base a decision that only board-certified radiologist can furnish x-ray interpretations or board-certified cardiologists can furnish EKG interpretations. (Where the Congress has determined that there should be special qualifications in order to furnish a service, as in the case of mammography, a provision was made in the statute.) Our proposed policy for x-ray and EKG interpretation is consistent with how we generally treat other physician services.”

So there’s no question you’re well within the law in billing and pursuing collection for ECG interpretation and reporting. There are many sources of information on requirements and process for billing for ECG interpretation, one of these on the ACEP website includes information on all aspects of the law, regulations and billing process. Query your billing service and find out if they are billing for other of their customers. Certainly a consultant can help but is probably not necessary. I won’t elaborate on the process here since I’d rather discuss the leadership and change-management opportunities and pitfalls.

But in billing as in life just because a thing is possible, doesn’t mean it’s the right choice. Is billing for ECG interpretation and reporting the right choice for you at your hospital? I raise the question because just as with politics, so too all EDs are “local”. Your local practice environment, your relationship with the medical staff and your relationship with hospital administration may all factor in to a decision whether or not to bill for ECG interpretation.

First you should evaluate just how much will you make by billing for ECG interpretations. What’s the likely collection for the ECGs you presently perform. Look to your billing database or if ECGs aren’t separately tabulated there, sample your charts and count the number of ECGs done and look at the payer mix and the patient dispositions for those patients who have ECGs. That way you’ll know how much revenue you’ll collect from each payer and for admitted vs. discharged patients.

Now that you know the potential gain, consider the relationships and what you may lose in those relationships when you pursue the additional revenue, billing for ECG interpretation will bring your practice.

For example, as I write some New Yorkers are avidly watching the musical chairs game playing out among hospitals and their cardiac catheterization groups. One name group relocated recently and now several others are reportedly “in play.” While the $9-10 per ECG that Medicare pays (and comparable amounts from other payers) doesn’t seem like much of a “loss” to a cardiology group, it’s not the money that’s really the issue, it’s the image—and power. Relinquishing income to the “ER group” is not something you’ll find much support for when your hospital CEO is negotiating to keep a busy invasive cardiologist happy and on staff.

Alternatively, you could approach your cardiologists yourself. Rather than demand that they forgo billing for ECG interpretation for your patients, suggest a consulting arrangement for the purpose of assuring the quality of the emergency physician ECG interpretations. Offer a fixed rate, perhaps as little as $2-3 for over-reading of your interpretations as the studies flow into your hospital’s ECG filing system and medical records. No, they won’t be happy about the reduction in income, but you’ll get a hearing and using the information on the ACEP and CMS websites you may be able to persuade them that they face some risk of fraud allegations. At least you’re offering a way for them to preserve some of the ECG income.

In most environments, the issue will really be just about the money and in that setting you’ll have to carefully undertake an educational approach to the regulation and payment policies of CMS with regard to electrocardiography in the ED. In any case, simply implementing the change and precipitating the likely consequent shouting match across the hospital CEO’s desk isn’t the best plan for though you may prevail in this instance, the ill-will generated can only hurt you and your colleagues in the long run. Yes, the money matters, but so does the way you claim it.

Saturday, August 14, 2004

The Signal-to-Noise Ratio when Communicating to Administration

As with many of these columns, this month’s edition is inspired by a recent experience. I hope that by reading and thinking about this story of a “teaser” subscription, you’ll learn some of the same lessons I’ve learned, but less painfully.

Administrators at Maimonides Medical Center commonly forward me copies of advertisements, newsletters and anything that mentions emergency medicine, “ED” or “ER”. Yes, I see solicitations for contract staffing groups that want to staff our ED, but that’s not what I want to talk about today. I want to tell you about what your hospital administration is reading, because it sure scared me to learn that my administrative colleagues were reading this junk.

I recently received a sample newsletter forwarded by the VP for Regulatory and Professional Affairs. The newsletter, produced by a subsidiary of a large, renowned medical newsletter publisher (that also operated a famed consulting organization subsidiary) was apparently one of a series devoted to credentialing standards for physicians in different specialties. This subsidiary of the publishing company publishes a monthly newsletter devoted to credentialing information for hospitals. Each “professionally produced” 16 page newsletter gives the appearance of rigor and credibility. The back list was impressive covering every specialty I’ve ever heard mentioned. Of course, the one in my hand was devoted to emergency medicine.

Discussion of the regulatory basis for credentialing and privileging generally were followed by detailed descriptions of two emergency medicine professional societies’ policy statements on credentialing of emergency physicians. The professional societies themselves were first briefly described. A one page boxed summary of recommended credentialing guidelines ended the document. At first glance, it seemed pretty well done. Then I examined it in detail; I was appalled. Did you know that you can be credentialed as an emergency physician if you see as few as 100 patients/year? When I wrote the publisher, seeking a source for the recommendation, I was told:

“In regard to the recommendation that an emergency medicine practitioner must be able to demonstrate that he or she has provided emergency medicine services to at least 100 patients in the past 12 months, we tried to come up with a number that hospitals could work with but which was not unduly restrictive for practitioners. As we talked to people in the emergency medicine field, it was considered that an average of two patients per week was not unreasonable. The number is not etched in stone, and hospitals can establish their own criteria according to their needs.”

In other words, let the hospital staff with anyone who is available so long as they have seen two patients weekly. Forget training, board certification, full-time practice in our field; your hospital administration is being told that 100 patients/year is sufficient for credentialing as an emergency physician.

As a clinician seeking to stay abreast of current clinical practice in emergency medicine, we’ve all selected a means of accomplishing that goal. We read journals, participate in CME programs on the web, attend conferences locally or with travel; but we’re familiar with the authorities in our field and we have the knowledge and the contacts to help us make an informed selection. Yet, we’re constantly receiving solicitations for all manner of publications beyond those we’ve already selected. It’s the American way of marketing and because we’re exposed to new publications, the “old ones” have to maintain a standard or we’ll switch.

The same thing pertains in hospital administration and your hospital’s administrators are equally inundated with publications. “Sample Issues” are a particularly potent form of marketing. Combine that marketing approach with the “quality” content I’ve described above and you could find yourself on the wrong side of an issue with your administration.

How might you avoid the problem or respond effectively in the event your administration raises an issue brought up in one of these sample newsletters from publishers or consultants?

Begin by reading the document yourself. Don’t attack the source. Express your reservations, “I’m not sure I consider this material authoritative. I’d like to have a day or two to find some other material that might be more on point.”

Then, go to our professional societies’ web-sites and search for material on the topic and read it. Do not anticipate that this content will solve your problem. Your administration is looking at the issue from the point of view of the hospital while you and the professional society are looking at it from the point of view of the physician. To you, your administration’s sample newsletter has lots of noise and very little signal; to administration, your professional society’s policy position also has more noise then signal.

After you feel informed on the topic, go to sources your hospital administration will value. Look at your regional or state hospital website—if your regional or state hospital website doesn’t have much content, look to other states or regions. Both California and New York have extensive web-sites as does the Greater New York Hospital Association. Obviously if you’re working at a small semi-rural hospital, there won’t be much on point at GNYHA, but then you can look to other more rural states’ hospital associations.

Another authoritative source used by more than 50% of the hospitals in the country is the Healthcare Advisory Board. If you’re on the medical staff of a hospital that’s a member, you can have access for free; the hospital has already paid for it. Look to authoritative sources beyond these free sources. It may cost you some money, but Joint Commission Resources, is widely viewed as an authoritative source. I’ve included the web-site URLs for all of these organizations below.

Disagreeing on an issue with your administration is a regular occurrence for emergency physician leaders. Establish your credibility and authority by referencing sources your administration considers credible. They are more likely to tune in and hear your message through the noise.

Greater New York Hospital Association

Hospital Association of New York

California Healthcare Association

California Healthcare Foundation

American Hospital Association

Joint Commission Resources

Healthcare Advisory Board

Wednesday, July 14, 2004

Incentive Compensation and training residents. How shall we manage the intersection? (Part 2)

Last month I told you about the economic challenges we were confronting out of the transformation of our practice into one with both clinical and academic missions. I wrote about our charting improvement initiative and engaging concerned staff colleagues in both developing solutions and seeking the engagement of the broad group in the implementation of the solutions. I’ve promised that this month I would discuss modifying incentive structures so that an academic mission can be explicitly accommodated. Let’s consider some relevant observations.

As long-time readers know I have a bias towards quantitative evaluation whenever possible, thus, the recent publication[1] of a relative value scale for teaching gives me some hope for including more quantitative evaluation of teaching contributions among physician staff; however, this tool alone, even fully implemented as described by the authors probably won’t serve as the sole measure for academic productivity. Aside from my general reluctance based on Deming’s warning about management on numbers alone (see my July 2003 column) in the case of teaching and scholarly activities, how shall we assign value when the work done benefits the worker—the teaching physician—too?

Just as maximizing revenue isn’t unique to clinical practices—as an emed-l poster commented, “academic programs in particular, considering the payer environment most of them are in, need the clinical production efficiency every bit or more than the community ED.” referring to using RVUs as the driver for all compensation. Yet, in a double coverage ED, the process of supervising residents, particularly supervising senior year residents who are themselves overseeing the work of more junior residents, I would accumulate many more RVUs/hour worked than a physician in the same ED just seeing patients. Since the other physician's work indirectly facilitates me spending time with the residents and accumulating their RVUs, some adjustment is probably appropriate to fairness.

In the context of direct teaching activity, while Khan and colleagues’ approach shows some merit, as another poster has opined in the past, “One must have adequate protected time (which is quite expensive) to further the department's goals. Someone who runs the department, runs the residency, runs a course in the medical school, directs the research for the department—all of these need protected time. I've seen papers published about how protected time is counted, and am quite shocked, to be frank, that attendings are given (paid) protected time to attend (not teach, just attend) resident conferences and faculty meetings. Not that I don't think they shouldn't attend. But, if you have to divvy up for every minute that your faculty member spends beyond strictly clinical hours and reward it with paid protected time, you're paying out hundreds of thousands of dollars a year just to have your folks come sit in a room, with little to show at the end of the year. It is crucial that protected time unfunded by outside resources be used wisely, if we hope to progress as a specialty. If you have to ‘spend’ it for every minute outside of a clinical shift, nothing will be left for the larger stuff, like having a productive department as a whole.”

This colleague works where the group has come to a common understanding, where certain duties are “just part of the deal . . . there were some irreducible contributions as faculty which would not be measured against ‘protected time’. This included attending faculty meetings, grand rounds, and being asked to give a talk on some subject every month or two, if needed. It may also include participation in hospital and medical school committees.”

You might argue that we should be separately compensated or supported for all of the non-clinical activities and that's a nice idea but not reality at our hospital or in the academic environments I know. I don't think full support for academic activities exists anywhere; that corner of our society is still a bit of a social welfare state.

So taking all these inputs together, I've chosen to consider the issue along the lines of the “Leading Beyond the Bottom Line” principles I've written about, adapting these principles first articulated by American College of Physician Executive authors.

It seems to me that our developing clinical and academic department should strive for the pareto optimum among patient care, community service, organizational economic well-being, staff well-being (economic, professional development and others) and unique to the academic environment, a fifth good: academic accomplishment (perhaps measured through RRC approval, peer academic recognition, scholarly productivity including grant funding and others as per Khan). I don't believe that it is possible to divorce clinical center productivity from the rest and optimize it alone. We teach residents from almost every specialty, a significant fraction of patients admitted in most teaching hospitals come through the ED, we teach medical students, etc. These academic interactions matter in our institutional standing, and for those at the medical school seeking promotion and tenure (hence compensation) and other tangible and intangible aspects of life in our clinical and academe.

I still think we're in an era of “local solutions.” I'm a big supporter for all of these metrics as inputs, but not direct drivers of resource allocation decisions or incentive pay. Ultimately, in seeking a pareto optimum, I subscribe to Deming’s admonition (his seventh “deadly disease”) that not all measures are known or even knowable. As a consequence a degree of subjectivity remains and it's the leader's responsibility to exert that subjectivity “fairly.”

Yet, as we at Maimonides Medical Center undertake to develop a fair allocation method, I’ll offer this essay and references to my colleagues on our Faculty Practice Finance Committee and seek their solutions and their engagement of their colleagues in crafting a solution. When we get there I’ll let you know how it turns out.

[1] Khan NS, Simon HK. Development and implementation of a relative value scale for teaching in emergency medicine: the teaching relative value unit. Acad Emerg Med, 10(8):904-7, 2003.

Monday, June 14, 2004

Incentive Compensation and training residents. How shall we manage the intersection? (Part 1)

Next month our third class of EM residents will start and we’ll have attained a full complement of emergency medicine residents, taking another step in our transformation from a purely service focused organization to a department delivering service and education while undertaking scholarly activities.

As I write this column the transformation comes to mind since we’ve just distributed our semi-annual profit-sharing and incentive payments, based as in the past on measurable clinical, academic, administrative productivity and my subjective evaluation of the individual physician’s contributions to the department. One quarter of the profit-sharing “pot” attributable to each factor. (I’m describing only our profit-sharing plan and not our base compensation plan which is that of hospital employed physicians.)

The residency program has imposed its own demands on practice earnings, though we’re not a medical school and thus pay no “dean’s tax.” I had agreed long ago when contracting with the hospital, that the faculty practice would support certain aspects of the residency in lieu of a dean’s tax. That agreement and the steadily increasing pressure on revenues all of us in medical practice have experienced over the years have appropriately raised staff concerns about profit-sharing income.

This month and next I’m going to describe our department’s efforts at improving financial performance while broadening the group members’ understanding of practice finances and fulfilling our educational mission. This month I’ll focus mostly on our billing improvement and educational efforts. Next month I’ll share some early thoughts about transforming our incentive program in keeping with the transformation of our department.

Recently, several outspoken physicians have worked on improving our charting quality as a first step to improving our revenues. We long ago had implemented straight-forward, housekeeping improvements: assuring charts were completed and signed, making sure we didn’t lose charts for billing, confirming that updates of insurance information to the hospital were shared with the practice. These and other best practices have been taught by many and I won’t review them here.

What’s new is our giving of near real time feedback to our physicians regarding the completeness of their charts. Though the value of regular feedback is obvious to all, making it happen can be a challenge with emergency physicians working shifts—coming and going each on his/her own schedule. In the era of paper charts and given realistic concerns regarding billing practices it had been impossible for us to accomplish. However, more recently our electronic medical record and the hospital’s virtual private network have permitted our staff to logon from home to complete their charts. One of our physician staff built a web based application that our coders use to send email to each physician about their incomplete charts and that tracks the physician’s completion of these incomplete charts as appropriate. Not all charts are appropriate for completion.

In consultation with hospital compliance and legal staff and discussion with several professional EM chart coding companies, we decided that only charts missing entire sections: history of present illness, past medical/surgical history, social history, family history, review of systems or physical examination would be referred for completion. Charts that addressed each area but appeared to our coders as lacking usual documentation would be referred for “educational review” but no expectation of chart completion would attach to the referral and coding and billing would be based on the original chart. We set a 72 hour limit on the physician’s response to the request. After 72 hours, even woefully incomplete charts are coded as-is.

Through this feedback and education process, coupled with attention to our coders’ training we’ve seen a reduction in incomplete charts and a general improvement (measured as RVUs/patient) in charting quality. It’s no surprise that some physicians have shown greater improvement than others. We anticipate revenue improvements as these early charting improvements translate into higher charges.

I’m sure you’re equally enthusiastic for improving collections, but not everyone has an electronic medical record and a hospital supported virtual private network. Yet, everyone does have colleagues who are not as preoccupied as you are. Engaging them in solving your revenue problem makes all the difference. It’s not merely a matter of demanding the behavior change; rather you want others invested in making the behavior change across all group members and make the change stick.

Supporting those junior colleagues requires both structure and constant mentoring from you. For a structure, I’ve created a faculty practice finance committee that will I expect develop further improvement ideas. For mentoring, I’ve offered my time and unfettered access to the semi-annual accounting of the practice plan’s revenues and expenses—though individual physician’s compensation will be available only in aggregate. I’ve also just ordered them each a copy of a book I first mentioned in my May 2000 column: Fisher and Sharp: Getting It Done: How to Lead When You’re Not in Charge. HarperBusiness, 1999; ISBN: 0887309585

With these efforts I expect that our team will not only develop solutions, but will bring others in the group in so as to improve upon the solutions the committee itself develops. Next month I’ll discuss how our group, now engaged in both clinical service and residency teaching might go about developing a profit-sharing plan that suits all medical staff even though physicians’ activities differ.

Friday, May 14, 2004

Patient Satisfaction Surveys and the Emergency Department

We just received preliminary and sobering results of our annual fourth quarter patient satisfaction survey, but more about our results later. The process we and our hospital use differs from the usual commercial patient satisfaction survey so, but since its value to us in the ED is so great, I thought it might be worth sharing with you. I’ve also recently learned of another approach—driven by the emergency physician group practice itself—that may hold some interest for you. So let me review these approaches; while neither may work as a “drop-in” for your environment and both have real expense, perhaps you can learn something you can use.

Our hospital conducts structured over the telephone interviews on admitted and discharged patients, interviewing sufficient numbers of patients to garner completed interviews with 100 patients monthly. Patients are interviewed in their language of choice including English, Spanish, Yiddish, Russian and more recently Mandarin Chinese. Arabic may be next. During the months of October, November and December both Pediatric inpatients and ambulatory patients are surveyed. We also survey ER outpatients and the care-givers of pediatric ER outpatients using an instrument designed in parallel with the adult/pediatric inpatient tool. The inpatient tool attempts to determine both by direct questioning and by confirmatory questions whether the patient was first whether the patient was admitted through the ER and if so asks seven questions relevant to the ER experience, only one of which could be considered to ask about the emergency physician. The question is broadly focused asking about all physicians that may have been involved in the patient’s care. We do not tie the individual patient’s comments back to a specific provider.

Both we and hospital administration look at the survey results as giving us useful information about systems and processes, not individual providers. What we do get is wonderful information that allows us to compare the experience of adult and pediatric patients admitted and patients discharged from the ER as well as longitudinal results over time.

Results include an analysis of both positives and negatives. We aim for no more than 10% in the bottom “strongly disagree” box and 90% in the top two “agree” and “strongly agree” boxes. Survey items are all posed in the affirmative. Our results since 2001 (survey conducted monthly, results reported quarterly) conform to Boudreaux and O’Hea’s findings that patient satisfaction is most affected by the quality of interaction with the ED provider.[1] Waiting time, perceived or real and the discordance among perception and expectation were a secondary factor in this literature review and analysis of opportunities for further study.

I’ve learned of two variations on an emergency physician centered patient satisfaction “survey” both of which I would characterize more as “callback” efforts intent upon enriching the patient encounter and improving patient satisfaction themselves. In both instances the emergency physician practices themselves conduct the process.

Tom Scaletta, MD, Chair, Dept. of Emergency Medicine, Edward Hospital in Naperville, Illinois, the emergency physician who designed and implemented the process describes his approach thusly:[2] “The callback clerk attempted to reach a cohort of all discharged patients. She called about 3,000 a month and reached about one-third. What she said was carefully scripted. Patients getting worse were told to call their PCP [primary care provider] or come back to the ED immediately. No further medical advice was given by the callback clerk though, if requested, the call was transferred to a nurse. The cost (about $36K a year) was about $1 per patient attempted or $3 per patient reached. This was a fulltime position by an administrative assistant with great interpersonal skills. Her job was facilitated by a callback database (FileMaker Pro™) which uploaded the prior day's census, automatically dialed, and served as a user-friendly way to store the data.”

“The callback information was used to improve satisfaction—the act of checking on patient’s well being was positively received. We uncovered problems quickly and made recommendations to correct or documented improvement and assured adequate follow-up. All this helps minimize risk. Finally, we collected data on opportunities for the physician, nurse, and system to improve. We used a letter grade since patients immediately understood what we were getting at and a portion of the doctors’ bonus was tied to this grade. Overall, the docs received an ‘A’ 70% and a ‘B’ 25% of the time. The ratio of A:B was more influential than A/B:C/D/F in comparing the docs. The docs received monthly feedback and many were able to change their means of interacting with patients and improved their scores significantly.”

The other physician driven approach takes advantage of integrated information systems and telecommunications technologies to use automated dialing to leave a message in the physician’s voice to the patient. The message advises the patient to call 911, return to the ED or see their primary care provider if not improved or worse. It then goes on to solicit feedback with any concerns or comments regarding the patient’s care or experience in the ED. A patient request for a callback from the physician receives that response.

Our patient satisfaction survey results served as a sharp rejoinder to any complacency, reminding me that while excuses abound: space, staffing resources, upstairs-downstairs communication and conflicts; I must periodically remind myself and re-energize all staff in our commitment to care of our patients within the resources available. Patients and their families take for granted that they are getting good clinical care; caring for the patient must go beyond the clinical realm alone.

[1] Boudreaux ED and O’Hea EL: Patient Satisfaction In The Emergency Department: A Review Of The Literature And Implications For Practice, J Emerg Med 2004; 26(1) 13-26

[2] viewed on 2004 March 16

Thursday, April 15, 2004

The Price of Shift Work

Many have chosen emergency medicine for the reliability of scheduled shifts and willingly take their turn as the schedule calls for it. Yet, as some are quick to assert, working shifts on a schedule imposes a discipline that can be costly both physically and emotionally.

A recent exchange on emed-l, (subscribe using the ED Subscriber) the emergency medicine mailing list, about the challenges of shift work in emergency medicine raised issues including drug and alcohol use, sleep patterns, family schedules and support, scheduling arrangements, compensation arrangements and personal preferences for particular shifts. Though not mentioned in that discussion, another “price” I observe in some settings is how scheduled shift work seemingly contributes to an erosion of professionalism among emergency physicians more generally.

The discussion included an exchange regarding various pharmaceutical agents as a tool for shifting between days and nights. This portion of the discussion included some personal experience, but mostly was theoretical or focused on military operations and advice for seeking neurological, sleep or psychiatric evaluation as appropriate. The nature of the discussion was both supportive of individuals and concerned about risk of inappropriate use of pharmaceutical agents.

One colleague in the discussion proffered a comment that “ . . . ours is an unforgiving specialty, that demands great health and is difficult to practice when one is not 100%. If you are one step slower and can’t pull your weight (especially under a compensation system that is based upon RVUs) you lose the esteem of your colleagues who pick up the slack. I have not seen much discussion about this issue as related to the ‘unexpected consequences’ of implementing this type of incentive [compensation] system. Clearly, as our thought processes and bodies slow, we will develop divides in groups.”

Regular readers know that I?ve long focused on internal motivation and supporting that internal motivation as key to both achievement and well-being in our profession. This past week, in presenting a conference on the history of resident training in emergency medicine, I had several founders of our specialty call into the conference. Without any prompting they included as a common theme in their closing remarks the joy they experienced in their sixth and seventh decades of life from their practice and the importance of maintaining physical and emotional fitness.

It’s for that reason of wellness and my observations of my colleagues’ struggles in coping with shift work that causes me take up the topic this month. So even as I’ve dusted off my own NordicTrack©, I’ve begun investigating some of the practical advice raised in the emed-l discussion that was new to me.

I was particularly struck by one commentator’s recommendation to move eight hour shift starts to 4 AM, Noon and 8 PM as a means of assuring that both part of every night would be spent in one’s own bed and so that commuting times would be offset from rush hours. Seemed pretty sensible to me, until I spoke to several women physicians in our group, even those who commuted by car were unhappy with the prospect of driving city streets at 4 AM. So, further evidence that the solution will have to be local to your group.

Another discussion point was the suggestion that for a reduction in income of a $5-8000 annually, enough money could be pulled together to support several physicians who would preferentially work night shifts. One contributor elaborated, “I recommend a solution that creates wide enough differentials for night and weekends until ‘happiness is maximized.’ I suspect there is no ideal formula. At my last job, we increased the base rate by 25% for all hours after 8 PM and for weekends. We also had two weekend days and three weekend nights (Friday, Saturday, and Sunday). Further I think our specialty should promote career night owls, just like we see with nurses. I think such docs assuming they have excellent clinical and interpersonal skills are worth twice the usual rate.”

Several commentators remarked upon how with a reduction in hours and incomes they had simplified their lives, reduced their possessions in number and grandeur and were enjoying more time with their families. Yet, others at different points in the cycle-of-life remarked that they couldn’t forgo the income such a reduction in hours would necessitate.

Lastly, the discussion brought out a considerable body of opinion that there were likely genetic and personal preference factors for shift work and night work especially that would always be part of the mix. One participant remarking, “A neurologist who specializes in sleep disorders told me that there is no solution to shift work—some people like it and some are constitutionally not suited for it. I personally don’t think that playing around with circadian rhythms helps anybody. I’ve been doing nights for 30 years and I like it. One thing I’ve found it is that the ‘night after’ is important. This is the night when you’re re-acclimating, and you’re not good for much, so it’s a night of ‘entitlement,’ when you can see a schlock movie, read a mystery story, watch a cable basketball game—whatever, with no guilt.”

Though many residents are graduating training in emergency medicine every year, we “baby boomers” constitute a considerable fraction of current practitioners. Getting this issue out into your group discussions and planning can only be worthwhile. I encourage you to review some of the resources I’ve noted below, but then raise the discussion in your own group and soon.


1. ACEP policy statement on Emergency Physician Shift Work (Policy #400166) approved September 2003.

2. Frank JR and Ovens H: Shiftwork and emergency medical practice. CJEM/JCMU 4(6):421ff, November 2002.

Monday, March 15, 2004

Implementing Emergency Ultrasound at the Bedside

The only constant in life is change. Change in ourselves and our practices is a reality and it’s ostensibly why those who regulate us prescribe minimum continuing medical education, periodic specialty recertification and other requirements. We ourselves mostly strive for more than those minimums for our own self-satisfaction and our patients’ well-being. Yet, try as we might, maintaining the clinical edge can be wearing.

My inspiration for this column comes from every clinician’s struggle for clinical currency, particularly as I observe colleagues over the past year or more adding emergency bedside ultrasonography to their practice armamentarium. At weekly case discussions, opportunities for bedside ultrasound are scrutinized for the effect on the patient’s outcome. Unspoken, but obviously considered by some of my junior colleagues is why wasn’t a particular patient studied with bedside emergency ultrasound in a particular instance? Did it have anything to do with the experience and training of the emergency physician?

Introducing emergency ultrasound (EUS) at my hospital has been more than a year-long project, fraught with difficulty and expense. I’m glad we proceeded and today have staff utilizing EUS regularly. Obviously, we needed to have a trained faculty if we were to teach our residents the skill, now required for an approved EM residency. Though we have a process for privileging our staff for EUS, the rate of acquisition of those privileges remains painstakingly slow. Am I supporting our physicians appropriately? How should I speed up the rate of acquisition of EUS skills among our nearly 30 physician staff?

First, since I know from conversations with colleagues that EUS isn’t universally deployed and so some of you may be interested in how we proceeded. Your hospital may require some variation, but in general, if you’re adding a new procedure to your list of privileges—and EUS was clearly a new procedure for us—the JCAHO requires that your medical staff process oversees the addition of EUS to your privileging list.

Since it’s likely that most of your staff, even if residency trained, completed training prior to the routine deployment of EUS, you’ll have to address the training and experience deficiency as part of the implementation. Therein lies much of the difficulty and expense—depending on the size of your staff, even more expense than the capital acquisition of and ultrasound machine itself.

We were fortunate because one of our staff had some relevant ultrasound experience from her obstetrical training, undertaken for several years before entering and completing an emergency medicine residency. She, as assistant residency director had been with us for several years and was a well respected by colleague, even by more senior staff. It would have been difficult if our only potential leader for our EUS program came from the ranks of newest graduates on our staff.

My somewhat experienced colleague had urged the purchase of an ultrasound machine for some time, so we went ahead and purchased one after a seeing several machines from different vendors. We tried several out for a week or so each in the ED before making the decision to buy. We had few users, but the availability of the device meant that some consultants could also use the machine and surgeons, cardiologists and obstetricians all did make use of it.

My colleague, though she was eager to proceed, felt that she needed to complete more formal training, both because of the limited focus of her previous experience and the period that had elapsed since her obstetrical experience. So we supported her for a month upstate where at another ED with an established EUS program she completed a self-study, didactic and practical program that gave her the skills and experience recommended by ACEP for an emergency physician performing EUS. Of course we paid her salary during this time and we paid her tuition, travel and living expenses at the other facility as well.

There she learned the techniques for the five core indications:

1. fluid, i.e., blood, in the abdominal cavity secondary to trauma or other causes including ruptured ectopic pregnancy;

2. echocardiography for cardiac activity and pericardial effusion/tamponade;

3. abdominal aortic aneurysm;

4. biliary ultrasound for cholelithiasis and cholecystitis;

5. renal ultrasound for obstruction.

She performed each of these studies in scores of patients so that she could gain experience both with normal and abnormal studies. All of her studies were reviewed by an experienced emergency physician and ultrasonographer—some in real-time, but many through static images and chart alone.

After returning home we then took our draft credentialing process to the chairman of radiology—merely as a courtesy—and to the chairman of the medical staff credentials committee. I also met with several of the medical staff officers and with several surgeons who were performing intra-operative ultrasound of the liver during intra-abdominal cancer surgeries. I brought not only our documents, but the documents from ACEP and SAEM on EUS and adopted AMA resolutions relevant to overlap of credentials among specialties and the entitlement of departments to credential their own staff.

I won’t tell you that all was smooth sailing thereafter. It was not. I was disappointed when the chairman of radiology rather than confronting me directly, instead wrote to the chair of the credentials committee. The same radiologist later relented and stood aside. He recognized that his department wasn’t providing the service around the clock and that our residency was dependent upon our developing facility with these focused studies which aid in answering specific clinical questions.

We ultimately gained executive committee support and implemented the ACEP guidelines as our process. A weekend of formal training for half the staff and the ardent support and engagement of a number of junior faculty who were trained in their residency means that we are doing more examinations all of the time. Yet, still some lag in acquiring the skill. How shall I address it?

Though our staff expect testing on ultrasound in the ABEM recertification program going forward, the pace of adoption remains slower than I like. I’ve continued my persuasion, arguing the value to patients of early decisions, consultation and disposition of bedside EUS. How have you brought this skill to the entirety of your staff or are you struggling also? Offering the training alone hasn’t been sufficient; what am I missing? Please write and share your thoughts.

Sunday, February 15, 2004

Ambulance Diversion, Crowding and Patient Flow: The Headbone’s Connected to the Footbone—and Everything In-between

Sometimes we hear it said that things “come in threes.” I guess those believers were talking about my 309 patient day (in an ED built for 140 patients/day), the EMS Insider cover story reporting that Memphis had adopted a “No-Ambulance-Diversion” Policy[1] and the JCAHO’s promulgation of a new patient flow standard, LD.3.4., which includes, for example, among the nine elements of performance two elements covering space and facilities for both admitted patients held in temporary areas such as the ED and for ED patients themselves.

Memphis’ experience in doing away with diversion excited me. During the decade plus that I served as Philadelphia’s EMS Medical Director, I used to hear plenty of complaints from colleagues about patients brought to an already busy ED that had been “closed” to ambulance patients. I always responded that any ED, regardless of how stressed, had more resources than did two paramedics on the ambulance. It wasn’t a popular response. I’m not sure how my colleagues at Maimonides would feel about not using diversion. Seeing 80,000 patients annually in 17,000 square feet is a strain; seeing 309 patients in a day in the same space is a patient-safety nightmare.

Perhaps the space constraints of my Brooklyn emergency department limit the opportunity for a Memphis style experiment, though I am not one who would invoke the clich├ęd, “New York is different.” Los Angeles is struggling too: In the January 2004 Annals of Emergency Medicine Eckstein, Chan and colleagues report on “The Effect of Emergency Department Crowding on Paramedic Ambulance Availability.” This symptom of system overload and pending failure has now been scientifically measured and its impact quantified in one large city. Yet this report demonstrates to me yet again that departmental leadership of system improvements alone may be an inadequate response. Why? Because “form follows finance.”

Last month in this space, my colleague Dan Murphy commented, “Form follows finance,” in talking about palliative care and the need to focus on the whole person, not merely an ill organ system. He’s right about that, but implicit in his comment I also see the resource mismatch we confront (almost) every shift. Though few of us seem prepared for planned rationing, the phenomenon is already here in our overcrowded emergency departments and our requests for ambulance diversion.

Overcrowding and its consequences for patient safety are on my mind as I contemplate the 2004 JCAHO patient safety goals—effectively mandates. Patient identification by two means not to include the patient’s location is one of these “goals.” Not relevant to me in the ED you may think; my patient declares his or her need for intervention right in front of me, identification isn’t an issue. But has the wrong patient ever received the wrong x-ray in your ED? Such occurrences are more common than we’d like to acknowledge. Too often the complex cascade creating such error includes the all too “human error” of inadequate identification not because the transport aide and x-ray technologist just don’t care, but because they are harried by too many competing demands—perhaps fed by overcrowding.

As the expression goes, “The headbone’s connected to the footbone” and everything in-between. We’ve all come to realize that the functioning of the whole hospital connects to overcrowding in the ED. Improving patient flow and moving admitted patients out of the ED more quickly can reduce strain on the ED staff.

Just recently we had Carolyn Santora, RN and Peter Viccellio, MD of SUNY Stony Brook; speak to a wide cross-section of our hospital staff—including nursing leadership about their approach to managing over-crowding and patient flow. At Stony Brook they admit patients to the hallways. Of interest to me was their finding that over 40% of their patients admitted to hallways are moved into a room either on arrival (~20%) or within an hour of arrival to the floor (~20+%). The nursing units where these patients are admitted are nominally staffed at a ratio of one nurse to six patients. Contact Peter or Carolyn through Peter’s assistant ( for further information about the Stony Brook experience. For a variety of operational and cultural reasons, this is an unlikely step at Maimonides, though our nearest competitor hospital has implemented just such a process.

At Maimonides we are implementing tracking and communication software throughout the hospital that will make bed status explicit to everyone while facilitating communication with patient transport staff through pagers and telephone based interactive voice-response. This tool purportedly achieves substantial improvements in the speed of bed turnovers. Presumably, consequent to the publication of bed resources and their statuses along with improved communication and enhanced accountability of all staff responsible for bed turnover all steps in bed turnover take less time and beds become available more quickly. I’m optimistic for improvement in patient flow, but mindful that these measures are more “tinkering” when one looks at the totality of the hospital environment and how “form follows finance.”

Nonetheless, within my scope as director of a single emergency department this is what I can do. As a younger man through political activity and what’s come to be called, “direct action” I endeavored along with others to change our world. A bit older and somewhat battered—hopefully not cynical—I’m making efforts at the level where I can have some effect and sharing some of these efforts with you through this column.

I’ve regularly mentioned the emergency medicine mailing list, “emed-l.” (Join using the ED Subscriber) in this column. Setting your preferences to “digest” will result in only one message a day in your e-mail inbox, yet you can still read or quickly skip through the comments. As at least one presidential candidate has shown this season, the internet can provide a powerful organizing for a leader with a vision. Perhaps somewhere in the mix of clinical, financial, operational and political issues discussed on emed-l there may be some opportunity to address the “form follows function” observation and engender a formal public policy debate on healthcare rationing rather than limit ourselves to tinkering with ambulance diversion, ED crowding and patient flow.

[1]“Memphis Adopts No-Ambulance-Diversion Policy," EMS Insider 30(12):1-3; December 2003.

Thursday, January 15, 2004

The Tsunami: Neither Hasten nor Postpone Death

The Centers for Disease Control reports that 8.7% of all ED visits in 2001 were by patients aged 75 and older.[1] At Maimonides Medical Center 16% of our patients fall in this age group. Though I’m a “baby boomer” and he’s not, Daniel G. Murphy, MD, MBA (Hofstra Business School, May 2003) our Vice-Chair and Medical Director for nearly eight years has given much more thought than I to this theme. So let me turn this month’s column over to Dan.

Perhaps I use too many metaphors explaining my thoughts, but one bantered about in Boston this October at various Quality Improvement and Patient Safety Section, Geriatric Section and Benchmarking Alliance meetings during the recent ACEP Scientific Assembly needs sharing among us:

“A tsunami is coming!”

For years, we have worked hard to make our emergency departments more efficient. Best practices, data driven CQI, customer service, error reduction, computerization, decision support, streamlined bed control and standardized peer review processes are just a few of the successful efforts and new paradigms. It’s a good thing too, since the role of emergency departments in America grows more crucial and more burdened annually.

But a tsunami is coming, already visible on the horizon, presaged by choppy and rough surf today (crowding), and it may wipe us out before we retire. The tsunami is the aging ‘baby boomer’ generation and emergency departments and hospitals are (to complete the metaphor) the coastal villages lying directly in its path. It provides a dispiriting backdrop for today’s EM CQI tinker. Input may soon overwhelm a process already lamenting its inability to transfer admitted output (inpatient boarders).

One way to prepare for and assuage this impending disaster is to reconsider how we die in America. We need to die better, with our families, perhaps at home, with no one doing chest compressions and no one putting a tube down our throat. Hand holding, praying, crying and feeling is much better. We just need a major culture change and then implement better end-of-life education and better communication.

I know the following: a) more of my patients are very close to or at the end of life, b) emergency departments and hospitals are horrible places to spend the end of one’s life and c) we do a poor job of caring for patients and guiding families at the end of life.

We need to help identify that point in a person’s (person, not patient) life where there is more value and reward in focusing on planning, comfort, dignity, family and ritual. Life is a terminal condition. Palliative care is a desirable choice for almost all people at some point prior to death, whether it is hours, days, weeks or months before their final breath.

In the July-August 2003 SAEM newsletter, Drs. Quest and Abbott summarized the World Health Organizations definition of palliative care.[2] :

• Active, total care of patients whose disease is not responsive to curative treatment.

• Control of pain and other distressing symptoms.

• Address psychological, social and spiritual problems.

• Achieve the best quality of life.

• Affirm life and regard dying as normal.

• Neither hasten nor postpone death.

• Offer a support system for patients to live as actively as possible before death and to help families cope and then bereave.

But what can we do in the emergency department? The nursing home keeps sending them. The families can’t handle it! There is little expertise and ability at home. Sometimes there seems to be little end-of-life expertise in the nursing home. By the time the dying elder is in the ER, the opportunity for privacy, tranquility and even dignity are lost. If we don’t ignore you, we may intubate you! Our comfort with natural death and dying is notoriously fragile in the ER. We will almost certainly stick some tube into an orifice. It’s our nature.

Some of us in the United States are comfortable with impending death only when paperwork is current and pristine. The documentation includes ‘do not resuscitate’, ‘do not intubate’, other advanced directives, living wills and health care proxies. Is the need for certified, renewed and impersonal contracts reflecting some difficulty of the American healthcare system to connect with our patients at the humane and primary care levels? Do we fail to see the forest, only some frustrating tree, confounded and frightened by medico-legal risk?

As Mildred Solomon, EdD[3] and Linda Kristjanson, PhD[4] explain of the Australian healthcare system, “Long-term relationships between general practitioners, patients and families, coupled with the existence of palliative care services, solve many of the communication problems that, in the United States, advance care directives are intended to ameliorate. Once the decision to accept palliative care is made, people accept that certain things won’t happen, the resuscitation matter dissolves, and patient, family and health care team address each end-of-life question, such as tube feedings or the use of antibiotics, as these issues arise.” Kristjanson continues, “You know your patient, the relationship is very individualized, thus an advanced directive would be seen as a legalistic document that would be incongruent in the context of the relationship.”

Such holistic, generalist, and humane approaches are unusual where we practice. Indeed, too many elders seem to have a neurologist, cardiologist, podiatrist, cardiothoracic surgeon and dermatologist, but no one who takes responsibility for the care of the person instead of an organ system. I witness nursing home admission procedures where patient-physician relationships that have endured decades are terminated just as end-of-life planning is most crucial. As long as our federal healthcare reimbursement model encourages procedures instead of humane, generalist care, form will follow finance and poorly integrated, intrusive and wastefully expensive end-of-life care may predominate.

But I ask again, what can we do in the emergency department? What can we do as emergency physicians?

I believe that our contribution could be significant. We are, after all, generalists. We are capable of seeing the big picture and treating or palliating every sort of ailment and organ system. Are there desired end-of-life services that we are uniquely qualified to provide? Perhaps there is a significant pre-hospital or ED need and market eager for our care, advice and skills.

In the House of God,[5] the term GOMER was first publicized. How ironic to consider the phrase as prescient, desirable and sophisticated. Look out to sea. A tsunami is coming. There may still be time to build an adequate sea wall and save the village. If we work hard and fast, we will just get bumped around and wet like we always do.

[1]McCaig, LF and Burt, CW: National Hospital Ambulatory Medical Care Survey: 2001 Emergency Department Summary in CDC Advance Data from Vital and Health Statistics. No. 335, June 4, 2003.

[2]Quest TE and Abbott J for the SAEM Ethics Committee: Palliative Care and the Emergency Physician: Finding our Way. The SAEM Newsletter XV(4): 14, July-August 2003.

[3]Solomon MZ. Why are Advance Directives a Non-Issue Outside the United States? In: Solomon MZ, Romer AL, Heller KS, eds. Innovations in end-of-life care: practical strategies and international perspectives. 1st ed. Larchmont, NY: Mary Ann Liebert, Inc, 2000: 13-18.

[4]Kristjanson L. Advance Care Planning in the Australian Context. In: Solomon MZ, Romer AL, Heller KS, eds. Innovations in end-of-life care: practical strategies and international perspectives. 1st ed. Larchmont, NY: Mary Ann Liebert, Inc, 2000: 43-46

[5]Shem, S: The House of God. Dell, 2003