Editorials
Pap Smears in a Public Hospital Emergency Department: A Failure of the System Robert A Lowe, MD, MPH, FACEP Michelle Berlin, MD, MPH
Pap Smears in a Public Hospital Emergency Department: A Failure of the System See related article, page 933.
Academic Emergency Medicine Harvey W Meislin, MD, FACEP
Ketorolac in the Treatment of Acute Pain: The Pendulum Swings Donald M Yealy, MD, FACEP
AUGUST1992
21:8
ANNALS OF EMERGENCY MEDICINE
"Cervical Cancer Screening in an U r b a n Emergency D e p a r t m e n t , " by Hogness et al, in this issue of Annals, demonstrates that good-quality P a p smears can be obtained in the emergency department, that 8% of patients had cervical dysplasia or carcinoma, and that 70% complied with follow-up. Although the study initially appears to have limited relevance, it raises crucial questions about the role of the ED in preventive care. In this commentary, we address the b r o a d e r question: W h a t is the responsibility of emergency medicine in p r i m a r y care? The location of the study, Highland General Hospital, exemplifies the problems facing public hospitals in the 1990s. In such hospitals, patients wait many hours to be seen in the EDs;.many leave without being seen.l, 2 The clinics are so overburdened that patients can wait months for follow-up appointments, where, as the authors report, "Follow-up procedures on those who returned...were still occasionally inadequate." Limited clinical and administrative resources thwart attempts at improving such facilities. It is difficult to collect the data necessary to evaluate proposed changes. Medical record retrieval is problematic, and clinicians may be too overwhelmed to cooperate with data collection. When longitudinal information is necessary, the anger and helplessness felt by many inner-city patients decrease the probability that they will comply with follow-up instructions. The p a p e r brings us encouraging news from such an environment. The authors show that it is possible to conduct clinically useful, policy-relevant research in such a setting. With a small research team, they were able to enlist the cooperation of clinicians, collect data in the ED, and obtain follow-up data on most of the patients studied. The findings are impressive. Twenty-nine percent of women did not know when they had last received a P a p smear. Eight percent showed evidence of dysplasia or carcinoma, mandating follow-up, four times the p r o p o r t i o n in comparison groups cited by the authors. A disproportionate number of young, black, and Hispanic women had
982/1
13
EDITORIALS
abnormal tests. Screening and follow-up through the ED were effective. The Pap smears obtained were of comparable quality to other settings, and the 70% follow-up rate was similar to that in gynecology clinics with aggressive follow-up (60% to 83t~). 3,4 It is true that the study design had limitations. The total number of women receiving pelvic examinations in the ED was not recorded, so we do not know what proportion of eligible women received Pap smears and whether these women differed from those not included in the study. The researchers were unable to answer one of their research questions, whether ED testing was more effective than referral, because clinicians were unwilling to schedule patients to a special clinic performing only Pap smears, in addition to referring them to the gynecology clinic. However, these limitations do not detract from the study's key finding. If the role of primary care medicine includes screening, then the authors have clearly documented a failure of primary care in Highland's service area. The United States Preventive Services Task Force recommends Pap smears every one to three years for all women who have been sexually active. 5 Only 64% of women in the Highland study reported testing within three years, a lower n u m b e r than the 1987 National Health Interview Survey, which found that 79% of black, 73% of white, and 65% of Hispanic women had received a Pap smear within three years. 6 Patients with sexually transmitted diseases are at increased risk of cervical neoplasia, so the absence of adequate screening in this high-risk ED population represents an even greater danger than it would in a standard clinic population. Lack of screening for cervical cancer is not the only failure of primary care in our public hospital system. Other public hospital EDs have found unmet needs for immunizations,7-9 hypertension screening, 10 breast examinations, 10 and mammography. 10 By showing that they can provide preventive services in the El), Hogness and colleagues suggest a solution to this system failure. But demonstrating that we can perform primary care and prevention in the ED does not show that doing so represents the best use of scarce resources. Should public hospital EDs accept responsibility for yet another component of primary care? While patients leave without being seen because of El) overcrowding, with substantial numbers having adverse outcomes as a result, 1,2 should we further delay care by channeling resources into nonemergency problems? Notifying a patient of an abnormal result required up to 14 telephone calls, home visits, a n d repeated correspondence; is this an appropriate use of overburdened ED personnel? If emergency physicians accept responsibility for Pap smears, where will we set the limits? Many of us are already providing follow-up visits for wound checks, blood pressure checks, and febrile children, because clinics are too crowded to ensure prompt follow-up. We know that if we do not provide these services, patients will experience preventable sicknesses and deaths. However, as the primary care system continues to collapse, will we find ourselves providing immunizations, well-child care, deliveries, and postpartum checks? As EI)s become overloaded by providing primary
114/983
care for medically indigent patients, who will provide emergency care? As emergency physicians, we are confronted daily with patients whose illnesses could have been prevented had they received early screening and ongoing care, so we are acutely aware of the catastrophic impact of inadequate access to primary care. However, each of us must decide whether to use the El) to compensate for that failure, based on the resources available at our own institution. The costs of providing primary care in the ED are paid by the patients who must wait while overburdened emergency medical staff provide services that could be provided more efficiently in another setting. Some patients may die in the waiting room; others will leave without being seen and suffer at home. Will we serve the health care needs of this country best by providing a patchwork of primary and preventive care to a subset of those at risk, at the expense of patients truly in need of emergency care? Attempts to rescue the primary care system through expanding the scope of ED care are doomed to fail, and they may also create the illusion that emergency medicine~can patch the holes in the safety net. In order to preserve the specialty of emergency medicine as a resource for patients in need of true emergency care, we must advocate for universal access to primary care; we must ensure that our patients can obtain the care they need, in the most appropriate setting. I n our opinion, that is the true duty of our specialty in health promotion and disease prevention. Robert A Lowe, MD, MPH, FACEP Michelle Berlin, MD, MPH Prevention Sciences Group Division of Emergency Medicine Department of Obstetrics and Gynecology University of California San Francisco 1. Bindman AB, Grumbach K, Keane D, et al: Consequences of queuing for care at a public hospital emergency department. JAMA 1991;266:1091-1096. 2. Baker DW, Stevens CD, Brook RH: Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences. JAMA 1991; 286:1085-1090. 3. Marcus AC, Crane LA, Kaplan CP, et al: Improving adherence to screening follow-up among women with abnormal Pap smears: Results from a large clinic-based trial of three intervention strategies. Med Care1992;30:218-230. 4. Michiellutte R, Diseker RA, Young LD, et al: Noncompliance in screening follow-up among family planning clinic patients with cervical dysplasia. PrevMed1985;14:248-258. 5. US Preventive Services Task Force: Guideto ClinicalPreventiveServices:An Assessmentof the Effectivenessof 169Interventions.Baltimore, Willia ms and Wilkins, 1989,p 57-62. 8. Harlan LC, Bernstein AB, Kessler L6: Cervical cancer screening: Who is not screened and why? Am J PublicHealth1991;81:885-891. 7. Polis MA, Smith JP, Sainer D, et al: Prespects for an emergency department-based adult immunization program. Arch Intern Med 1987;147:1999-2061. 8. Polis MA, Bavey VJ, Corlins ED, et al: The emergency department as part of a successful strategy for increasing adult immunization. Ann EmergMed 1988;17:1016-1018. 9.6oldman JM, Stemhagen A, Erban S: Preventive medicine in the emergency department: Influenza vaccine as a model (abstract). Ann EmergMed 1990;19:487. 10. Boldman JM, Feifer R, Stemhagen A, et al: Is there a need for preventive health care in emergency medicine? (abstract) Ann EmergMed 1990;19:487.
ANNALS 0FEMERGENOYMED[CINE
21:8
AUGUST1992
EDITORIALS
Whilethe authors accept responsibility for the contents of this editorial, they acknowledgethe helpful suggestions and editing of Andrew Avins, Andrew 8indman,Jesus Bucardo, Barbara Gerbert, Peter Lurie, EugeneWashington, andthe Prevention Sciences 6roup peer review seminar.
Academic Emergency Medicine Seerelated article, page 94Z
More than 20 years ago the visionaries of our specialty realized that the credence of emergency medicine and its evolution would lie in the establishment of graduate training programs and the possession of a major role within colleges of medicine. These two important endeavors would stimulate the creation of standards for training and credentialing, would lead to continuing medical educational efforts, and would stimulate the propagation of new and improved research methodologies. Their wisdom was profound, and the proof of their visions materialize as we review academic emergency medicine today. The article in this issue of Annals, "Academic Emergency Medicine: A National Profile With and Without Emergency Medicine Residency P r o g r a m s , " by Chernow et al demonstrates the effect emergency medicine has, and will continue to have, on academic medical centers. Comparing major university hospitals, with the variable being the existence of an emergency medicine residency program, reveals much in the area of clinical care and education. The establishment of an emergency medicine residency p r o g r a m in an academic medical center, according to the authors, significantly enhances the emergency department faculty attending coverage. This expanded coverage equates to more faculty in emergency medicine available for the training programs, thus also augmenting the research effort, as evidenced by the increased number of publications in programs with emergency medicine residencies. The quality of the faculty also is magnified, with more board-certified emergency physicians found in academic centers with residency programs. Recruitment becomes easier, housestaff curriculum is improved, and medical students' rotation and educational conferenc~es exist in greater numbers. These facts may lead us to u n d e r s t a n d why more than 40% of the programs without residencies were actively planning a program, and an additional 40% were considering future development of an emergency medicine residency program. We are at the stage of m a t u r a t i o n in our specialty where physician credentialing for b o a r d certification requires successful completion of an Accreditation Council for Graduate Medical Education-approved emergency medicine residency program. There are presently 93 approved residency programs with a prediction for 100 programs by match time 1993. Chernow's article predicts that major teaching hospitals are now claiming that close to 30 new residency programs are being actively planned, with an equal n u m b e r to be created in the future. It is not unreasonable to assume that the t u r n of the century will see more than 140 emergency medicine residency programs in place.
AUGUST1992
21:8 ANNALS OF EMERGENCY MEDICINE
The effect such enhancement of academic growth is obvious, as has been presented in this article and by others. Robert Petersdorf, in his address to the Society for Academic Emergency Medicine, during his Kennedy Lecture in May 1991, noted the success of emergency medicine and admonished us to enhance our academic pursuits, but stated that within a single physician generation, "you've come a long way baby."l Academic attendings in the ED, more q/~alified clinicians practicing emergency medicine, enhanced educational programs, reasonable clinical hours for honsestaff, improved conferences and medical student education in emergency medicine, and increased research productivity are desirable accomplishments in the pursuit of academic excellence. It appears that having an emergency medicine residency in an academic institution is the variable to achieve these successes. This article, along with others that relate the academic work style of emergency physicians, demonstrates the fact that attrition among academic emergency physicians is relatively low. 2,3 These facts serve as evidence of the stability of emergency medicine, as well as a p r e d i c t o r for continued positive academic growth. Stability of a specialty and the enhancement of quality education, research and patient care are the p a r a m e t e r s of excellence any medical system must strive to achieve. The specialty of emergency medicine must support the advancement of emergency medicine in academic institutions. This includes the development of residency programs, the establishment of academic departments of emergency medicine, and funding the research efforts of emergency medicine faculty. We should demand that our teaching hospitals provide excellence in emergency medical care and training. Our hope has been that the specialty of emergency medicine will survive, evolve, and meet its needs through academic emergency medicine. The article by Chernow et al gives us evidence of that fact and will serve as a monitomng tool to gauge the effectiveness of the academic emergency medicine base. I laud the authors for their work and encourage them to continue these pursuits and further study the development of academic emergency medicine over the years. Harvey W Meislin, MD, FACEP Sectionof EmergencyMedicine University of ArizonaHealthSciencesCenter EmergencyMedicineResearchCenter Tucson 1. Petersdorf RG:The place of emergencymedicinein the academic community.Ann
EmergMed1992;21:193-200. 2. Hair KN, Wakeman MA, LevyRC, et al: Factors associatedwith career longevity in residency-trained emergencyphysicians.AnnEmergMed1992;21:291-297. 3. Meislin HW, Spaite DW, ValenzuelaTD: Meeting the goals of academia: Characteristics of emergencymedicinefaculty academic work styles. AnnEmergMed 1992;21:299-302.
984/1
15
Pap Smears in a Public Hospital Emergency Department: A Failure of the System Robert A Lowe, MD, MPH, FACEP Michelle Berlin, MD, MPH
Pap Smears in a Public Hospital Emergency Department: A Failure of the System See related article, page 933.
Academic Emergency Medicine Harvey W Meislin, MD, FACEP
Ketorolac in the Treatment of Acute Pain: The Pendulum Swings Donald M Yealy, MD, FACEP
AUGUST1992
21:8
ANNALS OF EMERGENCY MEDICINE
"Cervical Cancer Screening in an U r b a n Emergency D e p a r t m e n t , " by Hogness et al, in this issue of Annals, demonstrates that good-quality P a p smears can be obtained in the emergency department, that 8% of patients had cervical dysplasia or carcinoma, and that 70% complied with follow-up. Although the study initially appears to have limited relevance, it raises crucial questions about the role of the ED in preventive care. In this commentary, we address the b r o a d e r question: W h a t is the responsibility of emergency medicine in p r i m a r y care? The location of the study, Highland General Hospital, exemplifies the problems facing public hospitals in the 1990s. In such hospitals, patients wait many hours to be seen in the EDs;.many leave without being seen.l, 2 The clinics are so overburdened that patients can wait months for follow-up appointments, where, as the authors report, "Follow-up procedures on those who returned...were still occasionally inadequate." Limited clinical and administrative resources thwart attempts at improving such facilities. It is difficult to collect the data necessary to evaluate proposed changes. Medical record retrieval is problematic, and clinicians may be too overwhelmed to cooperate with data collection. When longitudinal information is necessary, the anger and helplessness felt by many inner-city patients decrease the probability that they will comply with follow-up instructions. The p a p e r brings us encouraging news from such an environment. The authors show that it is possible to conduct clinically useful, policy-relevant research in such a setting. With a small research team, they were able to enlist the cooperation of clinicians, collect data in the ED, and obtain follow-up data on most of the patients studied. The findings are impressive. Twenty-nine percent of women did not know when they had last received a P a p smear. Eight percent showed evidence of dysplasia or carcinoma, mandating follow-up, four times the p r o p o r t i o n in comparison groups cited by the authors. A disproportionate number of young, black, and Hispanic women had
982/1
13
EDITORIALS
abnormal tests. Screening and follow-up through the ED were effective. The Pap smears obtained were of comparable quality to other settings, and the 70% follow-up rate was similar to that in gynecology clinics with aggressive follow-up (60% to 83t~). 3,4 It is true that the study design had limitations. The total number of women receiving pelvic examinations in the ED was not recorded, so we do not know what proportion of eligible women received Pap smears and whether these women differed from those not included in the study. The researchers were unable to answer one of their research questions, whether ED testing was more effective than referral, because clinicians were unwilling to schedule patients to a special clinic performing only Pap smears, in addition to referring them to the gynecology clinic. However, these limitations do not detract from the study's key finding. If the role of primary care medicine includes screening, then the authors have clearly documented a failure of primary care in Highland's service area. The United States Preventive Services Task Force recommends Pap smears every one to three years for all women who have been sexually active. 5 Only 64% of women in the Highland study reported testing within three years, a lower n u m b e r than the 1987 National Health Interview Survey, which found that 79% of black, 73% of white, and 65% of Hispanic women had received a Pap smear within three years. 6 Patients with sexually transmitted diseases are at increased risk of cervical neoplasia, so the absence of adequate screening in this high-risk ED population represents an even greater danger than it would in a standard clinic population. Lack of screening for cervical cancer is not the only failure of primary care in our public hospital system. Other public hospital EDs have found unmet needs for immunizations,7-9 hypertension screening, 10 breast examinations, 10 and mammography. 10 By showing that they can provide preventive services in the El), Hogness and colleagues suggest a solution to this system failure. But demonstrating that we can perform primary care and prevention in the ED does not show that doing so represents the best use of scarce resources. Should public hospital EDs accept responsibility for yet another component of primary care? While patients leave without being seen because of El) overcrowding, with substantial numbers having adverse outcomes as a result, 1,2 should we further delay care by channeling resources into nonemergency problems? Notifying a patient of an abnormal result required up to 14 telephone calls, home visits, a n d repeated correspondence; is this an appropriate use of overburdened ED personnel? If emergency physicians accept responsibility for Pap smears, where will we set the limits? Many of us are already providing follow-up visits for wound checks, blood pressure checks, and febrile children, because clinics are too crowded to ensure prompt follow-up. We know that if we do not provide these services, patients will experience preventable sicknesses and deaths. However, as the primary care system continues to collapse, will we find ourselves providing immunizations, well-child care, deliveries, and postpartum checks? As EI)s become overloaded by providing primary
114/983
care for medically indigent patients, who will provide emergency care? As emergency physicians, we are confronted daily with patients whose illnesses could have been prevented had they received early screening and ongoing care, so we are acutely aware of the catastrophic impact of inadequate access to primary care. However, each of us must decide whether to use the El) to compensate for that failure, based on the resources available at our own institution. The costs of providing primary care in the ED are paid by the patients who must wait while overburdened emergency medical staff provide services that could be provided more efficiently in another setting. Some patients may die in the waiting room; others will leave without being seen and suffer at home. Will we serve the health care needs of this country best by providing a patchwork of primary and preventive care to a subset of those at risk, at the expense of patients truly in need of emergency care? Attempts to rescue the primary care system through expanding the scope of ED care are doomed to fail, and they may also create the illusion that emergency medicine~can patch the holes in the safety net. In order to preserve the specialty of emergency medicine as a resource for patients in need of true emergency care, we must advocate for universal access to primary care; we must ensure that our patients can obtain the care they need, in the most appropriate setting. I n our opinion, that is the true duty of our specialty in health promotion and disease prevention. Robert A Lowe, MD, MPH, FACEP Michelle Berlin, MD, MPH Prevention Sciences Group Division of Emergency Medicine Department of Obstetrics and Gynecology University of California San Francisco 1. Bindman AB, Grumbach K, Keane D, et al: Consequences of queuing for care at a public hospital emergency department. JAMA 1991;266:1091-1096. 2. Baker DW, Stevens CD, Brook RH: Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences. JAMA 1991; 286:1085-1090. 3. Marcus AC, Crane LA, Kaplan CP, et al: Improving adherence to screening follow-up among women with abnormal Pap smears: Results from a large clinic-based trial of three intervention strategies. Med Care1992;30:218-230. 4. Michiellutte R, Diseker RA, Young LD, et al: Noncompliance in screening follow-up among family planning clinic patients with cervical dysplasia. PrevMed1985;14:248-258. 5. US Preventive Services Task Force: Guideto ClinicalPreventiveServices:An Assessmentof the Effectivenessof 169Interventions.Baltimore, Willia ms and Wilkins, 1989,p 57-62. 8. Harlan LC, Bernstein AB, Kessler L6: Cervical cancer screening: Who is not screened and why? Am J PublicHealth1991;81:885-891. 7. Polis MA, Smith JP, Sainer D, et al: Prespects for an emergency department-based adult immunization program. Arch Intern Med 1987;147:1999-2061. 8. Polis MA, Bavey VJ, Corlins ED, et al: The emergency department as part of a successful strategy for increasing adult immunization. Ann EmergMed 1988;17:1016-1018. 9.6oldman JM, Stemhagen A, Erban S: Preventive medicine in the emergency department: Influenza vaccine as a model (abstract). Ann EmergMed 1990;19:487. 10. Boldman JM, Feifer R, Stemhagen A, et al: Is there a need for preventive health care in emergency medicine? (abstract) Ann EmergMed 1990;19:487.
ANNALS 0FEMERGENOYMED[CINE
21:8
AUGUST1992
EDITORIALS
Whilethe authors accept responsibility for the contents of this editorial, they acknowledgethe helpful suggestions and editing of Andrew Avins, Andrew 8indman,Jesus Bucardo, Barbara Gerbert, Peter Lurie, EugeneWashington, andthe Prevention Sciences 6roup peer review seminar.
Academic Emergency Medicine Seerelated article, page 94Z
More than 20 years ago the visionaries of our specialty realized that the credence of emergency medicine and its evolution would lie in the establishment of graduate training programs and the possession of a major role within colleges of medicine. These two important endeavors would stimulate the creation of standards for training and credentialing, would lead to continuing medical educational efforts, and would stimulate the propagation of new and improved research methodologies. Their wisdom was profound, and the proof of their visions materialize as we review academic emergency medicine today. The article in this issue of Annals, "Academic Emergency Medicine: A National Profile With and Without Emergency Medicine Residency P r o g r a m s , " by Chernow et al demonstrates the effect emergency medicine has, and will continue to have, on academic medical centers. Comparing major university hospitals, with the variable being the existence of an emergency medicine residency program, reveals much in the area of clinical care and education. The establishment of an emergency medicine residency p r o g r a m in an academic medical center, according to the authors, significantly enhances the emergency department faculty attending coverage. This expanded coverage equates to more faculty in emergency medicine available for the training programs, thus also augmenting the research effort, as evidenced by the increased number of publications in programs with emergency medicine residencies. The quality of the faculty also is magnified, with more board-certified emergency physicians found in academic centers with residency programs. Recruitment becomes easier, housestaff curriculum is improved, and medical students' rotation and educational conferenc~es exist in greater numbers. These facts may lead us to u n d e r s t a n d why more than 40% of the programs without residencies were actively planning a program, and an additional 40% were considering future development of an emergency medicine residency program. We are at the stage of m a t u r a t i o n in our specialty where physician credentialing for b o a r d certification requires successful completion of an Accreditation Council for Graduate Medical Education-approved emergency medicine residency program. There are presently 93 approved residency programs with a prediction for 100 programs by match time 1993. Chernow's article predicts that major teaching hospitals are now claiming that close to 30 new residency programs are being actively planned, with an equal n u m b e r to be created in the future. It is not unreasonable to assume that the t u r n of the century will see more than 140 emergency medicine residency programs in place.
AUGUST1992
21:8 ANNALS OF EMERGENCY MEDICINE
The effect such enhancement of academic growth is obvious, as has been presented in this article and by others. Robert Petersdorf, in his address to the Society for Academic Emergency Medicine, during his Kennedy Lecture in May 1991, noted the success of emergency medicine and admonished us to enhance our academic pursuits, but stated that within a single physician generation, "you've come a long way baby."l Academic attendings in the ED, more q/~alified clinicians practicing emergency medicine, enhanced educational programs, reasonable clinical hours for honsestaff, improved conferences and medical student education in emergency medicine, and increased research productivity are desirable accomplishments in the pursuit of academic excellence. It appears that having an emergency medicine residency in an academic institution is the variable to achieve these successes. This article, along with others that relate the academic work style of emergency physicians, demonstrates the fact that attrition among academic emergency physicians is relatively low. 2,3 These facts serve as evidence of the stability of emergency medicine, as well as a p r e d i c t o r for continued positive academic growth. Stability of a specialty and the enhancement of quality education, research and patient care are the p a r a m e t e r s of excellence any medical system must strive to achieve. The specialty of emergency medicine must support the advancement of emergency medicine in academic institutions. This includes the development of residency programs, the establishment of academic departments of emergency medicine, and funding the research efforts of emergency medicine faculty. We should demand that our teaching hospitals provide excellence in emergency medical care and training. Our hope has been that the specialty of emergency medicine will survive, evolve, and meet its needs through academic emergency medicine. The article by Chernow et al gives us evidence of that fact and will serve as a monitomng tool to gauge the effectiveness of the academic emergency medicine base. I laud the authors for their work and encourage them to continue these pursuits and further study the development of academic emergency medicine over the years. Harvey W Meislin, MD, FACEP Sectionof EmergencyMedicine University of ArizonaHealthSciencesCenter EmergencyMedicineResearchCenter Tucson 1. Petersdorf RG:The place of emergencymedicinein the academic community.Ann
EmergMed1992;21:193-200. 2. Hair KN, Wakeman MA, LevyRC, et al: Factors associatedwith career longevity in residency-trained emergencyphysicians.AnnEmergMed1992;21:291-297. 3. Meislin HW, Spaite DW, ValenzuelaTD: Meeting the goals of academia: Characteristics of emergencymedicinefaculty academic work styles. AnnEmergMed 1992;21:299-302.
984/1
15
