Give us con­trol

Physi­cians must di­rect ER staffers in fact—not just in name

Modern Healthcare - - Opinions Commentary -

There is an un­seen epi­demic of need­less deaths in U.S. emer­gency de­part­ments. Un­der the law, when ED physi­cians give or­ders to the med­i­cal pro­fes­sion­als work­ing un­der our di­rec­tion—nurses and ra­di­ol­ogy and res­pi­ra­tory tech­ni­cians—they are sup­posed to carry out those or­ders. And, they are of course not sup­posed to ini­ti­ate treat­ment of pa­tients without a physi­cian’s or­der.

How­ever, if they don’t do what we tell them to, there is al­most never any­thing we can do about it.

That’s be­cause in al­most all U.S. hos­pi­tals, we emer­gency room physi­cians are not hospi­tal em­ploy­ees, but rather in­de­pen­dent con­trac­tors work­ing for emer­gency physi­cian groups that con­tract with a hospi­tal. By con­trast, the peo­ple we “su­per­vise” are al­most all hospi­tal em­ploy­ees, and of­ten union­ized and es­sen­tially tenured. In a face­off, as em­bar­rass­ing as it is for us to ad­mit, the re­al­ity is that em­ploy­ees win a lot more of­ten than we do.

It is such an un­even play­ing field, in fact, that al­most all emer­gency physi­cian groups in­struct their physi­cians not to crit­i­cize the work of hospi­tal em­ploy­ees, ex­cept in the most ex­treme cir­cum­stances.

In my fi­nal ED med­i­cal di­rec­tor po­si­tion, I ran a fast-track clinic of the depart­ment. My ad­min­is­tra­tor was smart, car­ing and en­er­getic—the best I had worked with. He was also, like most ad­min­is­tra­tors, com­pletely un­trained in med­i­cal care.

He hired as our nurs­ing di­rec­tor a woman who not only had no pre­vi­ous ex­pe­ri­ence in an ED, but also who had been work­ing as a file clerk be­fore join­ing us. She turned out, among other things, to not know how to do an elec­tro­car­dio­gram.

For more than two years, I shared a clinic with a nurs­ing di­rec­tor who was liv­ing on an­other planet, and who, at one point, be­rated me dur­ing a team meet­ing for or­der­ing a chest X-ray on a 2-week-old in­fant at risk for pneu­mo­nia. She also blocked get­ting lab­o­ra­tory equip­ment to de­tect uni­ver­sally fa­tal cases of bac­te­rial menin­gi­tis be­cause it meant more work for her nurses. In the end, seven pa­tients suf­fered un­nec­es­sary, life­long health losses for the same rea­son—wait­ing far longer in the wait­ing room than nec­es­sary be­cause of de­lib­er­ate work slow­downs.

This stand­off came to a head one day when I was tak­ing care of a sick pa­tient, and our most prob­lem­atic staff nurse ar­rived. She im­me­di­ately be­gan to ma­lign the pa­tient. I called my ad­min­is­tra­tor, and, af­ter lift­ing the phone up so he could hear the lan­guage this nurse was us­ing, he thun­dered that “over my dead body” would she be al­lowed to keep her job. The ter­ri­fied pa­tient pulled out his IV, bolted to his car and left for a com­pet­ing hospi­tal.

The nurses, how­ever, led by the nurs­ing di­rec­tor, went to higher-ups and com­plained, block­ing the ef­forts of my ad­min­is­tra­tor to ter­mi­nate the prob­lem­atic nurse. Both my dis­cour­aged ad­min­is­tra­tor and I moved on to other posts.

When I re­count this story to ER med­i­cal di­rec­tor col­leagues, not only are none of them sur­prised, but al­most all of them have per­son­ally wit­nessed un­nec­es­sary deaths be­cause of the be­hav­ior of un­su­per­vised ER em­ploy­ees.

What can be done? First, the fun­da­men­tal is­sue is that in the vast ma­jor­ity of our ERs the direc­tors of the var­i­ous units—physi­cians, nurses, ra­di­ol­ogy techs and so on—re­port to an ad­min­is­tra­tor who is not only rarely present in the ER, but also who is not in a po­si­tion to ref­eree med­i­cal dis­putes. A far more ra­tio­nal struc­ture would be for the ER physi­cian med­i­cal di­rec­tor to di­rect the en­tire ER team and re­port to a hospi­tal ad­min­is­tra­tor. Such a struc­ture is the norm in sev­eral Euro­pean coun­tries, and re­sults in ER teams that are re­ally teams.

Sec­ond, ad­min­is­tra­tors and ED physi­cian direc­tors need to meet fre­quently on a reg­u­lar ba­sis to dis­cuss the per­for­mance of the em­ploy­ees. We need to do so in an or­ga­ni­za­tional cul­ture in which we doc­tors feel as­sured that our ad­min­is­tra­tors will back us up against any em­ployee back­lash.

Third, all con­cerned need to pay more at­ten­tion to what the laws say. Cal­i­for­nia, where the above vi­gnette took place, has a very strong Cor­po­rate Prac­tice of Medicine act that specif­i­cally pro­hibits such acts as hospi­tal em­ploy­ees coun­ter­mand­ing a di­rec­tive from the physi­cians to keep im­por­tant equip­ment on hand. And ev­ery other state at least has a law lim­it­ing the prac­tice of medicine to li­censed physi­cians.

In my 10 years as a med­i­cal di­rec­tor of var­i­ous ERs and clin­ics, I’ve never met an ad­min­is­tra­tor whom I didn’t like and re­spect. But I’ve also never felt that my ad­min­is­tra­tor and I fully un­der­stood each other.

Imag­ine if, once a year or so, we ER doc­tors and you ad­min­is­tra­tors could go on a re­treat to­gether, per­haps in a re­lax­ing re­sort like Maui. Imag­ine if we could meet to­gether around a big ta­ble and share our vi­sions of hos­pi­tals of the fu­ture in which we could all take deep pride in our ser­vice to the pub­lic.

How­ever we go about it, you hospi­tal ad­min­is­tra­tors and we ER physi­cian direc­tors need to work to­gether to make our ER teams more of a real team, and to pro­tect and guard the lives of the pa­tients in our care. Alan Bon­steel teaches at the Stan­ford Uni­ver­sity

and Uni­ver­sity of Cal­i­for­nia at Davis med­i­cal schools and has

writ­ten a med­i­cal text­book, Ba­sic Clin­i­cal Skills, that will be pub­lished this year

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