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Happy Thanksgiving to all those in Emergency Medicine

November 25, 2009

This message was sent out to members of Medical Emergency Professionals (MEP). It is a reminder that there are many good people working tirelessly in health care. As we give thanks for our many blessings may your Thanksgiving be a joyous and safe one.

On Thursday many of us will sit around a table with family or close friends and give thanks. Some of us will be working, doing what members of MEP and selected professions do, taking care of people. In many ways it is a privilege to be working when every one else is hunkering down to enjoy a perfectly prepared turkey with all the fixings. It’s a reminder to me of the uniqueness of what we do every hour of every day. It is our role in medicine to watch over the communities we serve. In some small ways we are the guardians and I prefer to think of us in such a noble role.

We are the Marines of the medical profession. We are the first line of defense of health care. We are ready at a moments notice to respond to the call. Many times the job is less than glamorous. There is not much thrill in draining an abscess (well maybe some) or in caring for your umpteenth case of non-cardiac chest pain. However for that patient who couldn’t find a PCP to take care of his MRSA abscess or the woman who’s Mom died of an MI in her forties we provide care and comfort.

So in the midst of the debate of how to cover the 40 plus million citizens in this country currently uninsured I give thanks to you. Every day you are there picking up a chart, walking into a room and introducing yourself to the next patient with a simple question. “How can I help you today?” That is a powerful statement about the difference between emergency medicine and the rest of the medical profession. Regardless of social class or insurance status we are here to care for you.

At times it is easy to become insensitive to patients who at times are less than thankful for the care they receive. That is an easy and slippery slope to move towards. I prefer to remember and talk about the thank yous that I, as well as many of you, have received over the years for the care we provide. Thank you for standing beside me and helping to care for that next patient.

And by the way who’s bringing the cranberry sauce tomorrow?

Be well,

Angelo Falcone, MD

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Planning for our Future in Medicine

November 13, 2009

angheadshotwhitecoatMan makes plans and God laughs

This past week our physician group did what many companies do once a year, strategic planning. The format is pretty standard. Pick a place away from your usual site for business, gather together the leadership of your organization, develop priorities on how to make your company better and make a plan to deliver on critical results. We’ve been doing this for the last 9 years in some form or fashion. The success of these endeavors is in not where you start but where you end up. The conversations are open and, occasionally, heated. The intent is to engage the combined intellect of the group to end up in a better place than any one person could forsee or plan to achieve.

For the most part that is what occurs. As I reflect on this past week my mind is drawn to recent debates on the changes afoot in health care and how it will impact health care delivery in the future. Of course, I am also thinking about the movie “2012” and how we might not be around in 3 years to worry about anything. I hope that is not the case but you never know. Back to strategic planning. So, why should anyone take the time to plan?  That’s a good question and one I have thought about seriously over the last few years. Many events are out of our control; weather, acts of God, an unexpected illness or injury and any myriad of bad (and good) things that occur in our individual lives. If you live long enough you know of what I speak. The reason we have decided to plan is that if we are going to hope for a future, it might have a slightly higher chance of occurring if we actually worked for that future to occur.

So we set our priorities for the year and ask what we need to do to achieve these goals. Somewhere in the process of what we discuss and lay out in our plans there is an acknowledgment of the role each of us plays in that future. As we have our discussions we become engaged and energized that the possibility exists to achieve that for which we plan. In medicine so many people believe things are too far out of our control. Blame the insurance companies, the tort climate, the uninsured patients or the government. That is an easy trap in which many people fall. I prefer to believe that the future belongs to those who plan with good intentions and work hard to achieve it.

One of my favorite quotes is:

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
Margaret Mead

But I like this one even better:

I have never been especially impressed by the heroics of people who are convinced they are about to change the world. I am more awed by those who struggle to make one small difference after another.”
Ellen Goodman

So in this time of high rhetoric about the end of days (2012) or the end of health care as we know it, I have chosen to take some time to plan. I look forward to a future in which I will make a small difference. I have chosen to help people with whom I have the privilege to be associated plan for our future together. That future is yet to be determined. Events will unfold before us that will alter our course. Through all of the rises and falls may we continue to endeavor for that future we envision to occur. As we look forward to it may it be so with optimism and hope for a better tomorrow.

Science vs. the Art of Medicine and the use of Medical Scribes

November 6, 2009

angheadshotwhitecoatAre we losing the art of medicine as science advances? That is an interesting question. One of the challenges we constantly face in delivering clinically compassionate care is to continue to insure that appropriately skilled people are performing critical jobs. Just as important is to continue remove the non – essential tasks from those critical individuals so they may focus on the patients we serve. Some people use different business processes such as Six Sigma or LEAN to constantly evaluate job functions and make them more efficient. Reducing wasted effort and steps is hailed as the key to making the difference in efficiently (and profitably) delivering a product or service in the marketplace.

I am part of a CEO group thorough my membership in Vistage. It is a group of business CEOs from disparate industries who meet once a month to discuss business challenges and share ideas on how to improve our businesses and live more productive lives. My group is always amused when I tell them the more technology we add to medicine, in the form of EMRs (electronic medical records), the more Inefficient I have become as the provider. I am reduced to a computer data entry operator as I input clinical information or search for patient results from lab and x-ray so I can make decisions on patient dispositions. This occurs while patients continue to stack up and wait for me, and my fellow providers, to continue to receive care. The same can be said for the nursing staff as they have become computer “slaves” tied to the COWS (computers on wheels) to input more and more data, which takes them further and further away from direct patient care.

Of course the march of technology will continue and it has led to stunning advancements in medicine as well as hospital productivity. Numerous examples exist such as digitized radiology systems and electronic medical records available at the touch of a button. The ability for me to perform a simple bedside exam with a portable sonogram machine to diagnose a rupturing abdominal aortic aneurysm was unheard of 10 years ago and does dramatically impact patient care. There is a constant balancing of the “art” and “science” of medicine.

The solution in this high tech world – add more people to the equation! I know it makes no sense that the more technology we infuse the more people we need to carry out some tasks but for our group it does makes sense. Over the last several months we have begun the use of medical “scribes” at Washington County Hospital in Hagerstown, MD. Scribes are individuals who are attached to the doctor’s hip and record the patient encounter, enter the information into the computer, search and track results and alert me when all the information has returned so that I may make a final disposition on a patient.

In my personal experience it has made me 20-25% more efficient (as measure by patients I treat per hour) then before I had a scribe. This is also the typical increase (20%) in productivity that has been seen by Scribe America. (MEP has engaged Scribe America to provide service in all of our locations.) Scribes are not for everyone and I can’t help but think that they will be a viable solution to groups that are searching to improve provider productivity. This is especially true when you are faced with the additional challenges of being unable to add more staffing due to recruitment challenges or financial considerations.

One of the most unexpected benefits of a scribe, for me, has been the ability to be completely focused on the patient during my history and physical exam. I do not need to constantly change the focus from the patient to the piece of paper on my lap to furiously write down all the essential documentation elements so the chart can be appropriately coded, and I can be appropriately paid, for the work I do. I can sit next to the patient and just talk for an uninterrupted few minutes while we have a conversation about why they are here. Perhaps some of the art of medicine may be re-found because of the person sitting over my shoulder or across the bed capturing the critical elements of the patient – doctor exchange.

The art versus science is an interesting contrast. Sometimes it is at odds and often competing for resources in our world of health care. I don’t know the answer but what I do know is that we are going to have to explore new efficient ways to provide care while simultaneously finding way to improve the human component of how that care is delivered. As the use of technology expands and becomes yet more integrated into the patient experience those most successful will be the individuals and organizations who learn how to elevate the human element while the march of new technology continues in the background of the care we provide.

Health Care Reform

October 19, 2009

angheadshotwhitecoatFor my first blog on a topic I thought I’d start small. How about healthcare reform? Seems like a nice manageable issue to get through in a few paragraphs. Since we all know stories are the way to best express an issue, let’s talk about a few patients that I’m sure any of us who work in emergency medicine can relate. Names are fictitious but the description of these patients are realistic as to what we see on a daily basis in the ER (I use ER for emergency departments- I also liked the show when it first started).

Denise Johnson is a 19 yo community college student who has been feeling nauseous and having some lower abdominal pain. I diagnose her with her first pregnancy at 8 weeks. She has no health insurance and no PCP. We write her a script for phenergan, prenatal vitamins and folate and instruct her to follow up with the OB-Gyn on call to start prenatal care.

Bill Maxwell is a 50 year old part time construction worker feeling “dizzy”. You note his BP as 180/100. His symptoms appear to be benign vertigo after a full workup in the ER. He has a family history of heart disease and has no PCP or health insurance. You give him a script for meclizine for his vertigo and start him on cardizem as his blood pressure does not significantly drop in the ER. You have him follow up with the internal medicine doc on call and also give him the number for the local clinical that takes uninsured individuals.

Both cases demonstrate good ER care and appropriate management. Both patients fall into the 13% of uninsured patients in the United States. The statistic that is quoted is about 20% of patients who visit your typical ER is listed as “uninsured”. In some areas the number is higher and some lower. Some of these patients will pay some portion of their bill for care although that will vary greatly depending on where that care is delivered. In the best of cases each will find their way to a caring doc or clinic that will appropriately manage their condition and minimize the worst of the complications of their condition.

I think I’ve described the situation pretty accurately for most of us who practice emergency medicine in the US. I believe the system works well, especially for acute care where I think we are the best in the world, for any person who needs it. It is the patients on the fringe and who are more complicated where we lack good preventative care. This is, at least, in comparison to other “wealthy” or “developed” countries. If you look at most of the World Health Organization rankings you have heard the same story. We spend the most and get good but not great results (in comparison) for what is spent. We are the leaders in technology and high tech care. I’m sure some people will take exception with the statistics and to that I would agree. All statistics can be debated and they should be.

The real question for me as an ER doc is this. When I send Ms. Johnson to the OB-Gyn and Mr. Maxwell to the internist am I certain they will get the right care they need with the minimum of hassle? That is a question we each have to answer but for me the answer is mostly yes, for the most part. The reason they will get care is that the likelihood is the OB-Gyn or Internist will do the right thing and accept another non insured patient. Each practice may also try and find an appropriate clinic for the patient to go to minimize the patients’ out of pocket expense because one thing is for sure. In America, more than any other country, if there is a void someone is trying to fill it.

I have heard we volunteer more time and give more to charity than any other country. That is the American way and the American experience. When I was growing up I was a volunteer EMT. It was a service my community needed and to buy the apparatus we held bingos, summer carnivals and door to door campaigns to raise money. I was proud of that effort and the service I provided to my community. The question becomes at what point does the burden of the good people to fill the “gaps” in any system become too great and require a more coordinated, some read government, response. For every person the answer is different and that seems to be where we are in the health care debate.

Most people can get care if you look hard enough or travel far enough. Is it perfect care – well since no country provides perfect care we are left with the question what are we willing to tolerate as a society? And in the end there are people who can’t find that care or travel to get it. They make choices not to manage their pregnancy properly or take their anti-hypertensive drugs. Five months later our neonatologist will be there to treat the premature infant with the latest NICU technology. When they come in 10 years later with their stroke from uncontrolled hypertension our “stroke center” will be ready to treat them.

Some countries tolerate longer waits for elective procedures as the offset to cover all (or most) citizens with robust primary care. Some relatively underpay physicians to provide basic services to all. Almost all are lacking in something; rapid access to advanced elective procedures, restrictions on high cost pharmaceuticals or medical devices which may be lifesaving. These may also only offer a few more months of life or a modest improvement in “quality of life” at a high cost. Occasionally though, they provide a life changing improvement or that “cure” for the patient’s cancer. Who should decide?

The one debate we are certainly NOT having regarding health care is what I am willing to give up. Every interest group in the debate knows there must be some give. Whether you are a health insurer, pharmaceutical company, “high cost” specialist doctor, malpractice attorney, holder of a “Cadillac” insurance plan, AARP member, healthy young person (electively uninsured) or member of hundreds of other interest groups you gotta give up something. The only ones who shouldn’t give up anything are the primary care docs (God Bless You) and patients who have no access to insurance.

Finally (for this missive) people need to take some responsibility for themselves. Stop overeating, not exercising and allowing our kids have astronomical rates of childhood obesity. Enough excuses about it’s too easy or cheap to get fast food for dinner again tonight. That is surely not something Americans like; being told to do (or not do) something!

So I’ll keep thinking about Ms. Johnson and Mr. Maxwell in this debate and try and measure whether any of the plans working their way through Congress will really make it better for them and cheaper for all of us in the long run. I know I am the eternal optimist! Maybe I’ll continue this conversation as the debate moves its way through Congress. I certainly don’t have the answers, just lots more questions.

My first blog!! Angelo Falcone, MD

October 16, 2009

angheadshotwhitecoat

Why am I starting a blog?  That is a good question. I have been debating starting a blog for a while. Several reasons come to mind. The first is that each of us, regardless of  what work we do, what status in life we hold or special talent with which we have been blessed leads a unique life. Through the lens of that life we can offer comments and interpretation on events around us that may assist another person in understanding an issue or feel that they are not alone. It is also a chance to contribute to the massive explosion of knowledge we are witnessing in today’s electronic age. I’d also like to learn from people who may eventually respond to something I write and help me gain a new perspective on an issue or overcome a challenge I may be facing.

This blog will begin from where I reside. I am an emergency physician, practicing in my chosen field for the last 15 years. It is a specialty of medicine that accepts all people without regard to social status, demographic group or citizenship. In the “noise” of all the negative things said about medicine I have always been proud that those of us who practice emergency medicine (and I include the entire team; medics, nurses, techs and clerks) have always been and will always be the safety net of medicine. It is a unique and humbling place to be. We see the unfiltered version of life and respond with compassion and technical skill to improve the health of the people we serve. It is not a perfect practice and we have all seen our share of grizzled veterans who are burned out from one too many encounters with drunks, agitated psychiatric patients and occasionally unappreciative parents of a 2 year old child with a cold who really doesn’t need an antibiotic. Those who reside in “pleasant society” seem to ignore the fact that these are our fellow human beings who really do exist and need care just like you.

My unique perspective also comes from the fact that I have the privilege of helping to lead an organization that cares for 275,000 patients per year in Maryland. Medical Emergency Professionals (MEP) has been, and likely will be, the only organization in which I will spend my professional career. I mention this to give people who do not know me some perspective of what I will be speaking about in the upcoming posts. Our organization provides care in suburban hospitals, rural facilities, trauma centers and freestanding emergency departments. It is through this experience that we have learned a few things about providing emergency care. We are not perfect, no organization is, and we do try to be open and honest when we realize things are amiss. This blog is another step in that evolution in that I am asking for feedback and will take to heart (for the most part) what is posted in reply to my musings.

Finally what is written is the responsibility of me, Angelo Falcone. At times I may ask a few of my colleagues to contribute to the blog since these are people whom I respect and have something impactful to share. Like most blogs I may place links to some interesting articles or opinions over time. I hope you will find it to helpful in understanding how an emergency department functions, how to provide better care and perhaps be more sensitive to the challenges we face.

Thanks for reading. May it be an interesting journey for us all.