Getting Beyond Turf Wars

Published on May 21, 2014
Emergency medicine progress in Europe is going to require emergency physicians to put aside turf battles and work hand in hand with intrenched groups of specialists.

Around the world similar dramas unfold. Healthcare needs shift and then entrenched specialties feel threatened by advances in emergency care. Dr. Peter Cameron explains that the way forward is simple common sense. Crunch the numbers, follow the money and play nice.

EPI: I understand that you’ve recently spoken at a meeting of anaesthetists in the UK. What is the relationship currently between anesthesia and emergency medicine in Europe?

PETER CAMERON: Within each country there are varying relationships between the anesthetists and the emergency guys. In some of the European countries, the anesthetists basically do the emergency work. In a few countries, there’s a bit of a schism between the professional groups. And in other countries, it’s a good relationship. So it varies quite a lot. In the continental European context the issue has been that the anaesthetists have traditionally controlled critical care, operating theaters, and pre-hospital care. They see the specialty of emergency medicine as a sort of threat to them. Despite this, some anesthetists just want to do operating theaters and they actually quite like having some professional help so that they don’t keep getting distracted by emergencies. It’s very much dependent on the location.

EPI: Is Europe unique in this regard?

CAMERON: In continental Europe, there’s a fundamental problem. The professor (or academic chair) “owns” everything in their clinical discipline. They get all the money and then they distribute it. Therefore a new specialty group on the block might represent a threat to power and also their actual income. On the other hand, if you are in Australia or the U.S. it doesn’t really matter that much. You get paid according to the work you do. And if the work’s easier and not as stressful, then you’re happier. It sort of depends on what your threats and motivations are.

EPI: In Europe, or other places where there are competing incentives, how do you turn the turf war into teamwork?

CAMERON: First you need to understand what the motivation is. And it’s not just anesthetists. It’s basically any professional group that feels threatened. I’ve heard stories from some countries where the ER docs see every patient when they come in and have the income distributed in different ways. They can either get nothing or everything. Either the inpatient specialist guys upstairs say: “Well, we look after the patients ultimately, so we get all the money,” or the ER docs determine where they go and how much money is distributed after the encounter. At one particular hospital, the emergency department said to the administrators, “We’ll take the money and then we’ll determine what’s left after that.” This has the potential to leave a lot of people unhappy. It also depends on the model of care. If the model of care is based on billing, then the way the billing occurs is fundamental to the power struggles that occur. If you can reassure people they’re not going to miss out on income, then they’re usually pretty happy. If you can’t do that and they feel a threat to their livelihood, you’ll have trouble getting buy-in.

EPI: On a practical level, how do you go about reassuring an entire specialty that they’re not going to get cut out on income?

CAMERON: I think the money always follows where the work is. If you can work with the specialty group and say: “We’re all doctors. We’re all working together towards an ultimate outcome, which is better patient care,” you can agree on the essential facts. Despite what an anesthetists group or a surgeon group might say about getting less money, the individuals are actually getting the same amount. It’s just that some are now relabeled, if you like, as emergency physicians. I think it’s this sort of external threat and the threat of the unknown that makes it most difficult. The problem in some of these European countries is that the professor, the academic head at the top of the traditional specialties, is most threatened: they’ve got a big empire which might well shrink.

EPI: Given that model, how do you recommend that physicians go forward trying to find a common ground? Do you think it has to happen more at the hospital level? Or more at the system level?

CAMERON: You can’t tackle this on the ground. You’ve got to tackle that at a governmental level. If you’re going to have a new group of people working in the system, they’ve got to be funded appropriately. I guess the easiest way is if it comes from above. But sometimes that is too slow. In places like Belgium and Belize, those guys have tried to do it from within. But I think it’s really too slow for what is required. So the only way that’s going to happen is by a change in government policy and a change in the way medical services are funded.

EPI: In coming together with the anesthetists in UK for this recent meeting, have you found that there have been any misconceptions about what emergency physicians do?

CAMERON: A lot of anesthetists just have to work and do elective operations and don’t really know much about what happens in the emergency area. But I think – and this is in the U.K. – the anesthetists are under a lot of stress at the moment. They’ve had funding cuts, which has resulted in there being a common external threat. And I think from that point of view, the medical professionals tend to feel more arm-in-arm than caught in hand-to-hand combat. A common external threat always makes people work better together.

EPI: Have you noticed any major public misconceptions about emergency medicine in Europe?

CAMERON: There’s been a lot of media about emergency medicine – I mean, everyone perceives that it’s under threat. You know, it was in the paper today. One of the things that’s common is that people tend to blame the overload of emergency medicine on the general practice patients and the problems they cause. But the general practice patients on the whole are the easiest group to deal with within emergency medicine. They represent very large numbers but not a very high workload. The real issues in emergency medicine are around the management of the more seriously ill. But the public gets focused on the minor cases, and then we end up with all these diversion strategies in place. Now in the UK there are ‘navigators’ to take non-emergency cases out of the emergency department. They have walk-in clinics. They have GPs. They have all sorts of alternatives. But when you actually look at the cost of the diversion rather than the cost of actually treating a lot of these simple conditions, turns out they would be better off just treating the simple conditions. And that might involve nurse practitioners, physicians’ assistants. You know, a lot of this is very simple stuff: “I’ve got a runny nose. Should I take antibiotics?” I mean, it takes you two seconds. “I’ve got a cut finger. Do I need a Band-aid or stitches or a plastic surgeon?” These things are really very simple and straightforward to someone who is experienced. And to divert people around the system just because they came through the wrong door is actually not very efficient.

EPI: During your trip to the UK, what conclusions have you drawn about how emergency medicine could be improved?

CAMERON: In terms of casual observations, it comes down to this very problematic diversionary strategy. Which again comes down to money. The GPs commission services for the hospitals, meaning that they buy hospital services on behalf of their patients from the healthcare trusts. What’s happened is the general practitioners say: “Well, these minor cases we can look after,” which is true. But what they’re really saying is “We won’t pay you for these minor cases. We’ll see them.” But because the patients have turned up to the emergency department, you’ve got to start with spending money on triaging and diverting these patients, which is paid for by the hospital but not by the general practice trust. And the general practice trusts are not paying the emergency departments for the cost of the visit. When they operate this way, they say, “Look at how much we’ve saved the emergency department by saving 20 percent of medical visits.” Meanwhile, the emergency departments effectively are seeing them because they worked out their minor complaints and then dealt with how to refer them. But that’s not actually included in their numbers. EPI: Are there any tips you’d give to practicing docs on the ground about how to address these systems issues?

CAMERON: I think most ER docs are actually pretty switched on to what the issues are. But the ability to influence policy is obviously very tricky, depending on which system you’re in. This is high politics. Just look at what’s in the newspaper. Every day there’s an article about emergency medicine. So, in terms of politics, that makes it very high profile. Politically, governments have to have quick fixes that the public can understand. But improvements to emergency systems are not quick fixes. They are complicated compromises. As doctors on the ground, we can’t afford to let some bureaucrat or administrator determine these policies because they come up with stupid answers. In terms of practical advice, each jurisdiction is going to be different. And you can’t say something that works in Melbourne will work in London. And London’s solution certainly won’t work in Doha, where I am at the moment. At a hospital level you can influence policy. In terms of influencing politics, there are national organizations and lobbying groups which you can use to push the agenda. But most of those are local solutions. Work together with local GPs. Work together with hospital administrations. Some of these things are actually solvable at a local level. But when you get into funding mechanisms, obviously there are state and national jurisdictions which you have to work through.

EPI: What does that actually mean on a really granular level to reach out to GP’s and to try to solve some of these smaller problems on a hyper-local level?

CAMERON: The first thing is to understand what your numbers are. A lot of this is blown out of proportion. People say: “Oh, we had ten unnecessary visits today.” Well, ten out of a hundred probably doesn’t actually matter. Ten out of a thousand certainly doesn’t matter. You will remember well the things that upset you because they just seem so stupid. But in terms of the overall impact on the department, they’re not very important. And really you just say: “Oh, well, it was a bit stupid but let’s get on with it.” The things which are actually interfering with the main flow or the main treatment pathways are the important groups of emergency patients – they’re the things you’ve got to tackle. And so getting the numbers right is critical. Once you’ve got that, it helps you work with whoever you need to work with, from GPs to inpatient units. Then you need to work out what it is that motivates these people to come to you as opposed to some other more appropriate venue. For example, in Doha we have a lot of minor patients. But we actually deal with them fairly effectively. We see about 800 cases a day that could be dealt with by primary care if that existed. But the patients that cause the most angst actually are a small minority, like patients with dependency, for example. So we work with other groups to help manage that special subset of patients.

EPI: You mention data collection and benchmarking. Just how important is benchmarking in emergency medicine’s strategic success?

CAMERON: It’s the same all over the world. If you haven’t got your numbers straight, you can’t really work out what your strategy should be. Now you’re never going to get it perfect. You’re never going to get perfect numbers. But even just sort of very basic numbers – like the total number of attendances, admissions, total number of patients you can turnaround quickly, and the types of patients – are crucial to understanding where to focus your efforts. And a lot of this is pretty black and white. The thing that emergency physicians do most is blame everyone else. Because we’re in the middle of so much stuff, it’s easy to say: “Well, it’s his fault, it’s her fault.” It’s harder to say: “Well, actually I can manipulate this and get the right outcome.”

EPI: As a final thought, anything you’re observing now in Doha in terms of new challenges, new trends that are worth mentioning?

CAMERON: There’s all the same old problems of patient flow; getting the clinical pathways with in-patient units worked out. I think the business about emergency systems and emergency networks is quite important. Medicine is very specialized and to link up the various specialties, both physically and logistically, is very difficult. And one of the problems we’re dealing with in Doha, which is similar and I’ve noticed in a few places, is actually the physical separation of clinical specialties. You know, it might be cardiac, neuro and trauma in separate institutions and how do you actually, across a region, link up those specialties for emergency patients? Because most patients have more than one organ or specialty involvement. Our job as emergency specialists is to actually work out how to make these emergency networks and systems work well.

It’s a real challenge in Doha, where we’ve got a heart hospital and a cancer hospital and a women’s hospital and plans for various other types of hospitals. And it’s even a problem in places like the U.K. where traditionally the older specialties have wanted to have their own hospitals, like a plastics hospital or a heart hospital.

What we’re trying to do is work out how to integrate these concepts so that you have bridges between the various powers of knowledge. Emergency is effectively on the bottom, if you like, as the entrance to this vast array of specialization. But the question is: As you progress through, how do you deal with things like radiology and intensive care theaters? And how do you make them an integrated whole? Medicine is becoming so fragmented that specialties like emergency and critical care are going to be like the glue that brings these specialization powers together.

But how you actually translate that into a physical whole is quite an interesting thing as well. The physical building we’re looking at in Doha is like a kilometer across. It becomes quite a big entity.

That’s the challenge of the future. We’ve got extreme specialization. We’ve got these groups like the “strokologists” telling us we’ve got to get people to have treatments within an hour of arrival. We’ve got cardiologists. We’ve got trauma guys. And then we’ve got all the issues with infectious disease. Everybody’s subspecialty now needs expert attention immediately. So how does that work when you’re on the ground faced with an undifferentiated emergency patient? That’s where emergency medicine is critically important in terms of bringing all this together.

EPI: Any final thoughts?

CAMERON: There is a tendency to think that you can’t change the system. But if you work at it and you work collaboratively, you can. I think emergency medicine being a fairly nascent specialty has underestimated the influence it can have on developing systems of care. Whether it be trauma or other emergencies, you don’t have to fight the other specialties; you just work with them. It’s basically common sense. I mean, I see my job as providing common sense and stopping silliness. That’s about it, really.

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