At the Intersection of Health, Health Care and Policy Cite this article as: Kamran S. Hamid A Resident Helps Redesign How One Institution Provides Emergency Care Health Affairs, 32, no.12 (2013):2216-2219 doi: 10.1377/hlthaff.2013.0381
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/32/12/2216.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2013 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on June 19, 2015 by guest
Narrative Matters
DOI:
10.1377/HLTHAFF.2013.0381
A Resident Helps Redesign How One Institution Provides Emergency Care A front-line provider explains why doctors-in-training are best positioned to increase the value of care for patients. BY KAMRAN S. HAMID
P
ast midnight, with several hours left in my shift, I hear a charge nurse yelling down the hall: “The leg is with the patient!” My heart sinks with the thought of more work. As the orthopedic surgery resident on call, I have been scrambling around our chaotic emergency department (ED) providing consultations all day and night, still woefully behind with 2216
Health Affairs
a number of patients scattered throughout the ED waiting to see me. So far, I have seen a sprained wrist, a broken hip, torn tendons, and seventeen other unfortunate injuries. I’ve had to apply splints, drill a steel pin through a thighbone using carefully placed local anesthetic at the bedside, obtain written consent from patients for surgery, counsel them on the life-changing event that has just occurred, and—like any profession,
D e c e m b e r 20 1 3
3 2: 1 2
and particularly medicine—fill out soulcrushing amounts of paperwork. I do this while simultaneously fielding nursing calls for the nearly 160 existing patients my team is managing outside the ED in the main hospital. There is another more senior orthopedic surgery resident on call tonight, but he is busy in the operating room with our supervising staff surgeon, performing surgery on the patients I send their way. I see an x-ray of a shattered knee out of the corner of my eye at an ED physician’s monitor and stop to preemptively gather the patient’s information before his treating physician calls me. I cannot help but feel overwhelmed and sorry for myself as the work continues to pile up. A page for a “Level I Trauma Code: Motorcycle Collision/Amputation” summons me, ED residents, trauma surgeons, and nurses to the grandest stage in the hospital: the “trauma bay.” In this moment the ED focuses its energy, chatter is put on hold, and crash carts are wheeled to the main forum. It is 1:30 a.m., and there is electricity in the air. This is the heart-pounding action ED residents signed up for. My colleague, Dr. Watkins, a thirdyear emergency medicine resident, has already donned a yellow impermeable gown, blue nitrile gloves, facemask, and eye shield. Surrounding him are similarly dressed nurses, technicians, and ED residents. The trauma surgery residents tie on their scrub caps and pace at the foot of the empty bed. Multiple hospital departments are represented on this team by groups of physicians, technicians, and nurses. I, however, am the only one from the Department of Orthopedic Surgery. The four medical students in the room whisper to each other in excitement. The stage is set. As for the other ED patients waiting for me to conduct an evaluation: They will have to wait longer and longer, wondering whether they have been forgotten. The doors fly open at the south entrance of the ED, and paramedics, faces flushed from running, rush our patient
Downloaded from content.healthaffairs.org by Health Affairs on June 19, 2015 by guest
Illustration By Brett Ryder
to the trauma bay. The lead paramedic shouts out the patient’s history as he approaches, “Mr. Jackson is a twentyfour-year-old male who was riding a motorcycle and was struck by a SUV running a red light. He had a brief loss of consciousness but was oriented and stable upon EMS [emergency medical services] arrival at approximately 1 a.m. His right leg was traumatically amputated and was transported in a bag on ice. A tourniquet was applied above the level of his injury at the scene…” Before the paramedic can finish, his message is drowned out as eager nurses and physicians rush forward to help this patient. The trauma machine is in full swing. As the ED doctors and trauma surgeons scan Mr. Jackson for lifethreatening injuries to vital organs, I examine the amputated leg that was brought with the patient. It is badly mangled and unsalvageable. The wound on his right leg, where the limb was torn off, is contaminated with dirt and grass. But, incredibly, it is barely bleeding. I turn to the young man and explain his dire situation and the need for emergent surgery, and then I tell him that we won’t be able to salvage his limb. As we sprint through the consent forms for surgery and potential blood transfusions, my pager beeps incessantly with requests for additional consultations elsewhere in the ED. “Thank you for helping me, doctor,” the young man says. His stoicism makes me immediately ashamed about feeling sorry for myself tonight. The patient’s wife and mother cry at his side in the trauma bay, but he does not. I wheel Mr. Jackson’s bed to the operating room, steeling myself for the surgery ahead. Yet I also find myself wondering how I am going to appease my next patient: Ms. Fuentes, thirty-two years old and healthy, came to the ED many hours ago for consultation on a localized finger infection. The requesting ED physician thinks the affected area needs an incision before she goes home with antibiotics but defers this decision to me for legal reasons. Unfortunately, I cannot stop in Ms. Fuentes’s room, provide a quick and focused exam, and make a simple recommendation for the ED doctor. Although this may be valuable to the patient, it
as the sun rises at the end of my twentyfour-hour shift. Exhausted, I hand him the consultation pager. “Good luck.” A trauma page sounds, and he’s off to the trauma bay—by himself.
The Patient Value Problem
doesn’t generate revenue for the medical center or protect me against liability. Instead, I must provide a full consultation and make the incision myself. The patient’s infection could have been diagnosed and treated in a supervising hand surgeon’s clinic in minutes. Instead, she was unaware of the clinic option and came to the ED, where she has had to wait well over six hours to see the leastexperienced member on the orthopedic team. I know she is going to be terribly angry, and rightfully so, when I finally meet her. I worry that she will ask, as they all do, why it has taken me so long, why only one resident is available, and why the supervising surgeon is not present. I don’t have good answers. When I finally did see her, Ms. Fuentes forgave my extreme tardiness. She was actually very pleasant and grateful, which made me feel even guiltier for being unable to provide her with more timely care. I created a small incision beside the nail bed of her index finger to release a droplet of pus, gave her antibiotics, and briefed her on her followup care. “It’s very important that you follow up in our hand surgery clinic, so we can make sure you are doing better,” I told her. She thanked me. My portion of her lengthy stay took less than twenty minutes. I never saw her again. There was no tracking of her satisfaction, no knowledge as to whether her infection was eradicated, and no measure of cost at the end of her care cycle. The next resident arrives to relieve me
Six months later the chair of orthopedic surgery at our hospital calls me into his office. This often signifies bad things for residents, so I nervously prepare for the worst. When I arrive, Dr. Koman stands by a blank dry-erase board with a marker in hand. “We have a problem,” he tells me. “Our ED wait times are atrocious.We need to do something about this.” On the board he scribbles out the times our patients typically wait in the ED to receive care: around four to seven hours per patient. Sadly, this sounds about right to me. From the perspective of the individual patient, these numbers are appalling. But for a major teaching hospital, they are par for the course. Not surprisingly, a recent deluge of written and oral complaints make it clear that our “customers” are not happy. Dr. Koman sits down across from me at his desk and asks me a simple question, “Why does it take so long to care for these patients?” A thousand answers flash through my head—most of them are specific issues that residents must face every day, but I am sure Dr. Koman isn’t even aware of them. I don’t know where to begin. “The workflow is set up so that few people develop expertise. Equipment is not easily accessible. And senior residents and attending surgeons are theoretically available to help with ED patient care but are generally unavailable due to clinic or operating room duties,” I tell him. Additionally, I discuss a number of day-to-day problems with how care is delivered to patients in the ED, such as lengthy delays in delivering pain medications to patients and the inability to make outpatient follow-up appointments at night and on weekends. Then, I take a step back to identify what I believe to be the mistake that underlies all of these problems. “Basically, our system is set up around doctors instead of patients,” I tell him. He takes this information in. We discuss the work of Joseph Scanlon, a steelworker and local union leader in the 1940s, who believed that
December 2013
32 : 1 2
Downloaded from content.healthaffairs.org by Health Affairs on June 19, 2015 by guest
Health Affairs
2217
Narrative Matters selves.” Those words came to mind as I thought about how we could provide better value to the patients with orthopedic injuries in our ED. In our residentdriven service, inattentiveness to details was causing us to waste time, make mistakes, and duplicate efforts. Our gravest error was not one of incorrect diagnosis or improper treatment—it was allowing ineffective systems to proceed unchallenged. Residents knew where the inefficiencies lay; we just feared the repercussions of trying to fix them. We needed empowerment. We needed a Dr. Koman.
Real-World Change
the workers closest to problems were the ones most likely to identify them; find practical solutions; and, if empowered, drive these solutions through completion. Dr. Koman and I thought the analogy was apt for our own situation. Then Dr. Koman did something most chairmen would not do: He relinquished control of a monumental redesign project to me. I was a junior resident at the time, second only to medical students and interns as the lowest form of life in the academic food chain. “You are closer to the problem than I am,” he said. “Make it better for our patients. A lot of doctors are not going to be happy with us, but we can no longer afford to turn a blind eye to the things that matter.” I left the meeting with a sense of optimism—hopeful that a resident’s voice would be heard.
The Role Of Residents Prior to my surgical training, I took a career detour and spent a year as a pediatric intern in California. As a young physician trainee, I witnessed the in2218
H e a lt h A f fai r s
efficiencies prevalent in academic medicine, which relies heavily on residents to provide care. My pleas for change fell on deaf ears in the administration. Until one day, a sage neonatologist divulged a trade secret to me. “If you want to make a difference,” he said, “you need to realize that administrators don’t read the New England Journal, they read the Wall Street Journal.” I took his words to heart. To be the voice of change, I would need to learn how to align ethics and individual interests with profitability. After my year as a pediatric intern, I took a second career detour, this time to study health care delivery in Boston. During my studies, several friends and I trekked through the bitter cold across the Charles River to hear strategy guru Michael Porter talk about providing value—that is, better health outcomes per dollar spent—to patients. From then on, I decided that I would drive all of my efforts toward that aim. An elderly sandwich shop owner at my alma mater once said, “Keep an eye on the pennies—the dollars watch them-
D e c em b e r 2 0 1 3
32:12
Two years after that initial meeting with Dr. Koman, we launched a Musculoskeletal Emergency Center at our teaching hospital. The center represents a team environment developed jointly by physicians and nurses in the Departments of Emergency Medicine and Orthopedic Surgery. It is built wholly on the principle that all processes should revolve around measuring and improving value to patients. Embedded in this integrated practice unit is a rigorously tested checklist for management of orthopedic injuries, standardized procedures, and revamped workflows. A database captures patientcentered clinical outcomes and time invested by providers as a surrogate for cost—all initiated by resident doctors. We’ve faced several obstacles to change since beginning this effort. Some feared that the initiative would lead to more work for orthopedists and less support staff for ED physicians. Others warned that it would disrupt patient care efficiency or decrease educational opportunities for residents. The most substantial barrier was a fear that either department would suffer financially and individual physicians would see a reduction in their bonuses. What we really faced was fear of the unknown. We wanted to overcome these fears. So the team made incremental changes over short periods of weeks to months while closely monitoring the process and collecting data. After the first month we saw substantial improvement in ED wait times for patients with extremity injuries, without any less compensation to individual physicians or departments.
Downloaded from content.healthaffairs.org by Health Affairs on June 19, 2015 by guest
Measuring and tracking patient satisfaction remains a tricky endeavor that we continue to refine, but so far we’ve seen fewer written complaints. Although there is much progress left to be made, many patients have already benefited greatly. Ms. Jones, ninetythree years old, came to the Musculoskeletal Emergency Center with a broken hip suffered after a fall at her nursing home. Evidence-based guidelines recommend that elderly patients with hip fractures undergo surgery within twenty-four to forty-eight hours of their injury to reduce their risk of mortality. Within four hours of arriving to our medical center, Ms. Jones was in the operating room. Within twenty-four hours after her surgery, she was walking with the assistance of a physical therapist. Although the world of health administration has fallen in love with the thought of new paradigms and radical “innovation,” it is important to realize that the most elegant innovations are often subtle and unrecognized. They are delicate political masterpieces put together with painstaking care. They are just as much about nurturing professional relationships and courage as they are about health policy and science.
Convenient Negligence Finding champions at the highest levels of administration is an integral part of creating patient-centered systems of care. In the early days of implementing the Musculoskeletal Emergency Center, we discovered that health policy is the easy part; it is health politics that is inconceivably hard. Much has been written about creating “patient-centered value,” but finding cost-effective means to create real improvement requires more than scholarly articles. It requires an indepth working knowledge of front-line
It is important to realize that the most elegant innovations are often subtle and unrecognized. They are delicate political masterpieces put together with painstaking care.
es where we train our doctors, cultivate cutting-edge research, and care for those with nowhere else to go—to lead the way in providing value to patients. We should focus on providing value not despite having residents but because we have them. They are Scanlon’s steelworkers, closest to the problem and most apt to provide brilliant solutions if empowered.
Walking Again health care delivery, operational authority to enact changes, and a liberal dose of persistence. Although residents may provide insights not visible to administrators and staff physicians, empowering these doctors-in-training to fully voice their ideas is just as crucial for success as the ideas themselves. Too often, residents embrace a certain learned helplessness early on in training. They are taught that suffering is a necessary part of education and that making mistakes on patients is somehow a justifiable part of a larger system. They are told that challenging the historical practices of academic medicine is wrong; indicative of laziness; or, even worse, futile. The error we make at teaching hospitals is that of “convenient negligence.” We turn a blind eye to what is actually happening in resident-driven clinical practice, which often relies on the uninitiated to manage complex problems through trial and error. Little attention is paid to how patient care is being managed on the day-to-day level. When it comes to delivering care, academic medicine has long been exempt from criticism because of its educational mission and the complexity of cases treated therein. In the emerging world of value-based health care, these responses will be inadequate. It is time for academic medical centers—the plac-
After three surgeries and several months of rehabilitation, Mr. Jackson is functioning well in his day-to-day activities with his prosthetic leg. He is unaware of how chaotic the ED was the night he lost his limb, and that critical antibiotics might not have been administered had it not been for an astute nurse. He doesn’t know that I used his case as an example when developing checklist protocols for injuries with open wounds. My latest interaction with Mr. Jackson reminded me of the most important reason for our initiative: the patients. At Mr. Jackson’s most recent clinic appointment, I put him on the spot. “Do you remember the first question you asked me when we met in the ED?” “Was it, ‘Am I going to live?’” he asked. “No.” He laughed. “I don’t really remember a whole lot from that day!” I shook his hand and patted him on the back. “The first question you asked me was: ‘Is the other person in the accident OK?’” ▪
Kamran S. Hamid ([email protected]) is an orthopedic surgery resident at Wake Forest Baptist Medical Center, in Winston-Salem, North Carolina. Patients’ names in this article have been changed to protect patient confidentiality.
December 2 013
3 2: 12
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H ea lt h A f fai r s
2 219
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/32/12/2216.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2013 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on June 19, 2015 by guest
Narrative Matters
DOI:
10.1377/HLTHAFF.2013.0381
A Resident Helps Redesign How One Institution Provides Emergency Care A front-line provider explains why doctors-in-training are best positioned to increase the value of care for patients. BY KAMRAN S. HAMID
P
ast midnight, with several hours left in my shift, I hear a charge nurse yelling down the hall: “The leg is with the patient!” My heart sinks with the thought of more work. As the orthopedic surgery resident on call, I have been scrambling around our chaotic emergency department (ED) providing consultations all day and night, still woefully behind with 2216
Health Affairs
a number of patients scattered throughout the ED waiting to see me. So far, I have seen a sprained wrist, a broken hip, torn tendons, and seventeen other unfortunate injuries. I’ve had to apply splints, drill a steel pin through a thighbone using carefully placed local anesthetic at the bedside, obtain written consent from patients for surgery, counsel them on the life-changing event that has just occurred, and—like any profession,
D e c e m b e r 20 1 3
3 2: 1 2
and particularly medicine—fill out soulcrushing amounts of paperwork. I do this while simultaneously fielding nursing calls for the nearly 160 existing patients my team is managing outside the ED in the main hospital. There is another more senior orthopedic surgery resident on call tonight, but he is busy in the operating room with our supervising staff surgeon, performing surgery on the patients I send their way. I see an x-ray of a shattered knee out of the corner of my eye at an ED physician’s monitor and stop to preemptively gather the patient’s information before his treating physician calls me. I cannot help but feel overwhelmed and sorry for myself as the work continues to pile up. A page for a “Level I Trauma Code: Motorcycle Collision/Amputation” summons me, ED residents, trauma surgeons, and nurses to the grandest stage in the hospital: the “trauma bay.” In this moment the ED focuses its energy, chatter is put on hold, and crash carts are wheeled to the main forum. It is 1:30 a.m., and there is electricity in the air. This is the heart-pounding action ED residents signed up for. My colleague, Dr. Watkins, a thirdyear emergency medicine resident, has already donned a yellow impermeable gown, blue nitrile gloves, facemask, and eye shield. Surrounding him are similarly dressed nurses, technicians, and ED residents. The trauma surgery residents tie on their scrub caps and pace at the foot of the empty bed. Multiple hospital departments are represented on this team by groups of physicians, technicians, and nurses. I, however, am the only one from the Department of Orthopedic Surgery. The four medical students in the room whisper to each other in excitement. The stage is set. As for the other ED patients waiting for me to conduct an evaluation: They will have to wait longer and longer, wondering whether they have been forgotten. The doors fly open at the south entrance of the ED, and paramedics, faces flushed from running, rush our patient
Downloaded from content.healthaffairs.org by Health Affairs on June 19, 2015 by guest
Illustration By Brett Ryder
to the trauma bay. The lead paramedic shouts out the patient’s history as he approaches, “Mr. Jackson is a twentyfour-year-old male who was riding a motorcycle and was struck by a SUV running a red light. He had a brief loss of consciousness but was oriented and stable upon EMS [emergency medical services] arrival at approximately 1 a.m. His right leg was traumatically amputated and was transported in a bag on ice. A tourniquet was applied above the level of his injury at the scene…” Before the paramedic can finish, his message is drowned out as eager nurses and physicians rush forward to help this patient. The trauma machine is in full swing. As the ED doctors and trauma surgeons scan Mr. Jackson for lifethreatening injuries to vital organs, I examine the amputated leg that was brought with the patient. It is badly mangled and unsalvageable. The wound on his right leg, where the limb was torn off, is contaminated with dirt and grass. But, incredibly, it is barely bleeding. I turn to the young man and explain his dire situation and the need for emergent surgery, and then I tell him that we won’t be able to salvage his limb. As we sprint through the consent forms for surgery and potential blood transfusions, my pager beeps incessantly with requests for additional consultations elsewhere in the ED. “Thank you for helping me, doctor,” the young man says. His stoicism makes me immediately ashamed about feeling sorry for myself tonight. The patient’s wife and mother cry at his side in the trauma bay, but he does not. I wheel Mr. Jackson’s bed to the operating room, steeling myself for the surgery ahead. Yet I also find myself wondering how I am going to appease my next patient: Ms. Fuentes, thirty-two years old and healthy, came to the ED many hours ago for consultation on a localized finger infection. The requesting ED physician thinks the affected area needs an incision before she goes home with antibiotics but defers this decision to me for legal reasons. Unfortunately, I cannot stop in Ms. Fuentes’s room, provide a quick and focused exam, and make a simple recommendation for the ED doctor. Although this may be valuable to the patient, it
as the sun rises at the end of my twentyfour-hour shift. Exhausted, I hand him the consultation pager. “Good luck.” A trauma page sounds, and he’s off to the trauma bay—by himself.
The Patient Value Problem
doesn’t generate revenue for the medical center or protect me against liability. Instead, I must provide a full consultation and make the incision myself. The patient’s infection could have been diagnosed and treated in a supervising hand surgeon’s clinic in minutes. Instead, she was unaware of the clinic option and came to the ED, where she has had to wait well over six hours to see the leastexperienced member on the orthopedic team. I know she is going to be terribly angry, and rightfully so, when I finally meet her. I worry that she will ask, as they all do, why it has taken me so long, why only one resident is available, and why the supervising surgeon is not present. I don’t have good answers. When I finally did see her, Ms. Fuentes forgave my extreme tardiness. She was actually very pleasant and grateful, which made me feel even guiltier for being unable to provide her with more timely care. I created a small incision beside the nail bed of her index finger to release a droplet of pus, gave her antibiotics, and briefed her on her followup care. “It’s very important that you follow up in our hand surgery clinic, so we can make sure you are doing better,” I told her. She thanked me. My portion of her lengthy stay took less than twenty minutes. I never saw her again. There was no tracking of her satisfaction, no knowledge as to whether her infection was eradicated, and no measure of cost at the end of her care cycle. The next resident arrives to relieve me
Six months later the chair of orthopedic surgery at our hospital calls me into his office. This often signifies bad things for residents, so I nervously prepare for the worst. When I arrive, Dr. Koman stands by a blank dry-erase board with a marker in hand. “We have a problem,” he tells me. “Our ED wait times are atrocious.We need to do something about this.” On the board he scribbles out the times our patients typically wait in the ED to receive care: around four to seven hours per patient. Sadly, this sounds about right to me. From the perspective of the individual patient, these numbers are appalling. But for a major teaching hospital, they are par for the course. Not surprisingly, a recent deluge of written and oral complaints make it clear that our “customers” are not happy. Dr. Koman sits down across from me at his desk and asks me a simple question, “Why does it take so long to care for these patients?” A thousand answers flash through my head—most of them are specific issues that residents must face every day, but I am sure Dr. Koman isn’t even aware of them. I don’t know where to begin. “The workflow is set up so that few people develop expertise. Equipment is not easily accessible. And senior residents and attending surgeons are theoretically available to help with ED patient care but are generally unavailable due to clinic or operating room duties,” I tell him. Additionally, I discuss a number of day-to-day problems with how care is delivered to patients in the ED, such as lengthy delays in delivering pain medications to patients and the inability to make outpatient follow-up appointments at night and on weekends. Then, I take a step back to identify what I believe to be the mistake that underlies all of these problems. “Basically, our system is set up around doctors instead of patients,” I tell him. He takes this information in. We discuss the work of Joseph Scanlon, a steelworker and local union leader in the 1940s, who believed that
December 2013
32 : 1 2
Downloaded from content.healthaffairs.org by Health Affairs on June 19, 2015 by guest
Health Affairs
2217
Narrative Matters selves.” Those words came to mind as I thought about how we could provide better value to the patients with orthopedic injuries in our ED. In our residentdriven service, inattentiveness to details was causing us to waste time, make mistakes, and duplicate efforts. Our gravest error was not one of incorrect diagnosis or improper treatment—it was allowing ineffective systems to proceed unchallenged. Residents knew where the inefficiencies lay; we just feared the repercussions of trying to fix them. We needed empowerment. We needed a Dr. Koman.
Real-World Change
the workers closest to problems were the ones most likely to identify them; find practical solutions; and, if empowered, drive these solutions through completion. Dr. Koman and I thought the analogy was apt for our own situation. Then Dr. Koman did something most chairmen would not do: He relinquished control of a monumental redesign project to me. I was a junior resident at the time, second only to medical students and interns as the lowest form of life in the academic food chain. “You are closer to the problem than I am,” he said. “Make it better for our patients. A lot of doctors are not going to be happy with us, but we can no longer afford to turn a blind eye to the things that matter.” I left the meeting with a sense of optimism—hopeful that a resident’s voice would be heard.
The Role Of Residents Prior to my surgical training, I took a career detour and spent a year as a pediatric intern in California. As a young physician trainee, I witnessed the in2218
H e a lt h A f fai r s
efficiencies prevalent in academic medicine, which relies heavily on residents to provide care. My pleas for change fell on deaf ears in the administration. Until one day, a sage neonatologist divulged a trade secret to me. “If you want to make a difference,” he said, “you need to realize that administrators don’t read the New England Journal, they read the Wall Street Journal.” I took his words to heart. To be the voice of change, I would need to learn how to align ethics and individual interests with profitability. After my year as a pediatric intern, I took a second career detour, this time to study health care delivery in Boston. During my studies, several friends and I trekked through the bitter cold across the Charles River to hear strategy guru Michael Porter talk about providing value—that is, better health outcomes per dollar spent—to patients. From then on, I decided that I would drive all of my efforts toward that aim. An elderly sandwich shop owner at my alma mater once said, “Keep an eye on the pennies—the dollars watch them-
D e c em b e r 2 0 1 3
32:12
Two years after that initial meeting with Dr. Koman, we launched a Musculoskeletal Emergency Center at our teaching hospital. The center represents a team environment developed jointly by physicians and nurses in the Departments of Emergency Medicine and Orthopedic Surgery. It is built wholly on the principle that all processes should revolve around measuring and improving value to patients. Embedded in this integrated practice unit is a rigorously tested checklist for management of orthopedic injuries, standardized procedures, and revamped workflows. A database captures patientcentered clinical outcomes and time invested by providers as a surrogate for cost—all initiated by resident doctors. We’ve faced several obstacles to change since beginning this effort. Some feared that the initiative would lead to more work for orthopedists and less support staff for ED physicians. Others warned that it would disrupt patient care efficiency or decrease educational opportunities for residents. The most substantial barrier was a fear that either department would suffer financially and individual physicians would see a reduction in their bonuses. What we really faced was fear of the unknown. We wanted to overcome these fears. So the team made incremental changes over short periods of weeks to months while closely monitoring the process and collecting data. After the first month we saw substantial improvement in ED wait times for patients with extremity injuries, without any less compensation to individual physicians or departments.
Downloaded from content.healthaffairs.org by Health Affairs on June 19, 2015 by guest
Measuring and tracking patient satisfaction remains a tricky endeavor that we continue to refine, but so far we’ve seen fewer written complaints. Although there is much progress left to be made, many patients have already benefited greatly. Ms. Jones, ninetythree years old, came to the Musculoskeletal Emergency Center with a broken hip suffered after a fall at her nursing home. Evidence-based guidelines recommend that elderly patients with hip fractures undergo surgery within twenty-four to forty-eight hours of their injury to reduce their risk of mortality. Within four hours of arriving to our medical center, Ms. Jones was in the operating room. Within twenty-four hours after her surgery, she was walking with the assistance of a physical therapist. Although the world of health administration has fallen in love with the thought of new paradigms and radical “innovation,” it is important to realize that the most elegant innovations are often subtle and unrecognized. They are delicate political masterpieces put together with painstaking care. They are just as much about nurturing professional relationships and courage as they are about health policy and science.
Convenient Negligence Finding champions at the highest levels of administration is an integral part of creating patient-centered systems of care. In the early days of implementing the Musculoskeletal Emergency Center, we discovered that health policy is the easy part; it is health politics that is inconceivably hard. Much has been written about creating “patient-centered value,” but finding cost-effective means to create real improvement requires more than scholarly articles. It requires an indepth working knowledge of front-line
It is important to realize that the most elegant innovations are often subtle and unrecognized. They are delicate political masterpieces put together with painstaking care.
es where we train our doctors, cultivate cutting-edge research, and care for those with nowhere else to go—to lead the way in providing value to patients. We should focus on providing value not despite having residents but because we have them. They are Scanlon’s steelworkers, closest to the problem and most apt to provide brilliant solutions if empowered.
Walking Again health care delivery, operational authority to enact changes, and a liberal dose of persistence. Although residents may provide insights not visible to administrators and staff physicians, empowering these doctors-in-training to fully voice their ideas is just as crucial for success as the ideas themselves. Too often, residents embrace a certain learned helplessness early on in training. They are taught that suffering is a necessary part of education and that making mistakes on patients is somehow a justifiable part of a larger system. They are told that challenging the historical practices of academic medicine is wrong; indicative of laziness; or, even worse, futile. The error we make at teaching hospitals is that of “convenient negligence.” We turn a blind eye to what is actually happening in resident-driven clinical practice, which often relies on the uninitiated to manage complex problems through trial and error. Little attention is paid to how patient care is being managed on the day-to-day level. When it comes to delivering care, academic medicine has long been exempt from criticism because of its educational mission and the complexity of cases treated therein. In the emerging world of value-based health care, these responses will be inadequate. It is time for academic medical centers—the plac-
After three surgeries and several months of rehabilitation, Mr. Jackson is functioning well in his day-to-day activities with his prosthetic leg. He is unaware of how chaotic the ED was the night he lost his limb, and that critical antibiotics might not have been administered had it not been for an astute nurse. He doesn’t know that I used his case as an example when developing checklist protocols for injuries with open wounds. My latest interaction with Mr. Jackson reminded me of the most important reason for our initiative: the patients. At Mr. Jackson’s most recent clinic appointment, I put him on the spot. “Do you remember the first question you asked me when we met in the ED?” “Was it, ‘Am I going to live?’” he asked. “No.” He laughed. “I don’t really remember a whole lot from that day!” I shook his hand and patted him on the back. “The first question you asked me was: ‘Is the other person in the accident OK?’” ▪
Kamran S. Hamid ([email protected]) is an orthopedic surgery resident at Wake Forest Baptist Medical Center, in Winston-Salem, North Carolina. Patients’ names in this article have been changed to protect patient confidentiality.
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