Home Commentary Kumbaya in the ED

Kumbaya in the ED

November 2011

Published in the November 2011 issue of Today’s Hospitalist

ADMITTING PHYSICIANS AND ED DOCS have a storied and stormy "Hatfield-McCoy"-like relationship dating back to the advent of their respective specialties. I would assume that well over half the conversations between the respective groups are followed by a large dose of character defamation, with such utterances as "he/she has two neurons, and they aren’t even connected!" being the most commonplace.

Why so much discord? I cannot speak personally to the origins of contempt, but you don’t need a PhD in the history of medicine to understand that each group’s discontent is deeply rooted in its divergent interests. For ED physicians, their agenda is very simple: triage or admit. And according to some, just a few years ago they dreaded having to try to admit a patient. Most on-call rosters were stocked with doctors of all specialties who were forced to take their turn admitting the "unassigned." For many of them, fighting the admission was a knee-jerk reflex, even if it usually resulted in the same outcome.

REM and donuts
For traditional GPs mired in outpatient and inpatient practices with call every third night, the fact that they did not welcome a call from the ED should come as no surprise. REM sleep interrupted by a harried ED physician simply was not the right environment to produce lasting friendships.

A typical every-morning dialogue might go like this:

ED doctor: "Mrs. Jones is here with chest pain."

Primary doctor: "Is the work up negative?"

ED doctor: "Yes."

Primary doctor: "That is the third time she has come in for this. Send her home."

ED doctor: "No problem, the chart is on the desk, and if you see a Dunkin’ Donuts on the way in, do you mind grabbing me a cup of coffee?"

Needless to say, health care has many problems, and the shaky relationship between traditional practitioners and ED docs does not rank as one of the most prominent. However, let’s not shortchange the importance of the new synergistic relationship that has developed between ED doctors and hospitalists.

Sharing shifts and employers
I believe this is especially true because the very nature of the relationship has changed: Now, it takes place between two consenting parties. Hospitalists for the most part welcome admissions from the ED, especially those that have received the appropriate workup and initial treatment. Perhaps more importantly, when things don’t go as smoothly as they might, any good program is going to collaborate with the ED to improve the process rather than retreat into disdain and disgust.

Not only do we take admissions, but we generally welcome all types of admissions. Concern for mission creep notwithstanding, most hospitalists are now willing to accept just about anyone who is still breathing (and even those who aren’t, at least on their own). This is a tremendous help to your friendly ED doctor and your hospital, especially in an era when it is increasingly difficult to keep subspecialists on call. The fact that we are willing to admit most hand patients, for example, has gone a long way to keep hand surgeons on our call rosters.

Given this new working relationship and the fact that we have very similar jobs, our peace accord should come as no surprise. They live in the hospital; so do we. They work shifts; increasingly, we do too. And more and more, we seem to share the same employer. There is a growing trend to employ the ED physicians and hospitalist groups under one employed or contracted model to try to improve efficiencies.

"Dialogue, not warfare"
Further, the roles of both the ED doctor and the hospitalist are evolving quickly because of our ability to work so closely together. An example: Some EDs now involve the hospitalist much earlier in the admission process. While some hospitalists might push back at the concept of an incomplete ED workup, others believe it only makes sense to avoid duplicating work, given the fact that we will be the ones running the show once the patient is admitted.

The other day, an ED doctor with more than 10 years’ tenure grabbed me in the hallway and said that a bunch of the "old-timers" were recently reminiscing about the pre-hospitalist era.

"I can’t tell you how much more I enjoy my job knowing I won’t be fighting with someone when I decide to admit a patient," he said. "And if you guys disagree with our work-up, we resort to dialogue, not warfare."
At that moment, I think he started to reach out to hug me. Awkwardness ensued, and the interaction concluded with a clumsy pat on the shoulder.

Kumbaya indeed.

Erik DeLue, MD, MBA, is medical director of the hospitalist program at Virtua Memorial in Mt. Holly, N.J. Check out Dr. DeLue’s blog and others on the Today’s Hospitalist Web site at www.todayshospitalist.com.