Give us control
Physicians must direct ER staffers in fact—not just in name
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