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?