Much debate occurs around what the future holds for health care and for emergency medicine in particular. Some believe the world of emergency medicine is eroding, with the growth of urgent care, freestanding emergency departments, retail clinics, and virtual care that can compete for patients. On the other hand, some believe that same change in the landscape is evidence of an expansion of our specialty. I tend to believe the latter: with an aging population, an increase in the insured, and a shortage of providers, there will always be a continued need for unscheduled acute care. No matter where those patient needs are, we want to be there. Emergency medicine actually exists to fill that gap.
The road ahead will be a challenging one, with turbulence and days of unease. Things will likely get worse before they get better as the landscape transforms. The growth of high-deductible health care plans, the possibility that “essential health benefits” that include emergency care may be reversed, and the likelihood that reimbursement will enter a downward spiral all present significant challenges. The opportunity lies with carving out a well-defined and integrated role that creates needed value. Three key concepts can help emergency physicians take greater control over their destiny.
So where is all of this going? Emergency medicine must define itself in this new world, or someone else will. The good news is that we’ve done this before. Simply look at the ACEP logo. It is a series of squares with one missing. Early emergency physicians pointed out that our specialty needed to exist in order to fill a gap in health care. It took decades to establish our profession and fill that gap, but it all started with a single vision of caring for the patient and relentlessly articulating and building that unifying vision together.
The dialogue about health care reform has been focused on other issues: the uninsured, coordinating chronic care, and new payment models. Looming ahead is a focus on unscheduled and emergent care, including that for increasingly complex patients. Today’s emergency care is often fragmented and poorly integrated across a region. Integrated, regionalized emergency care can be the lynchpin that unites the various health care resources together around the needs of the patient. Primary care medical homes and accountable care organizations don’t yet address this need. Opportunity is knocking.
While issues like reimbursement, malpractice, and workload are truly important to the profession, those messages offer neither a compelling vision nor differentiate emergency physicians from any other specialty. I worry that, all too often, these are seen as our messages. Inversely, unfailingly articulating a vision that emergency medicine fills a growing gap in health care with an integrated and high-performing system of quality emergency care for our acutely ill or injured patients 24-7 begins to bring that need into focus. We are there when our patients need us the most. It must be all about our advocacy for our patients’ needs. When policymakers, payers, and the public grasp that, then the opportunity to better express our professional issues will open.
Leadership is required on both national and local levels. Local leadership is incredibly important to both define and execute a clear vision of what the emergency department does and what emergency care is. Emergency medicine leaders at a local facility must clearly articulate and define what the role and function of the emergency department is, how it fulfills that function, and its relationship to the public, patients, the hospital and other health care assets, and the community. When that does not occur, the emergency department is defined by others and is often mischaracterized as being “all things to all people.”
Each clinician and staff member on every shift must know the roles, responsibilities, values, and leadership philosophy of the emergency department. Without vision, people perish. That vision should not change each shift according to the whims of the physician on duty or the medical staff. That is a recipe for dysfunction, confusion, and poor performance.
Health care is rapidly transforming from individual autonomous practice patterns into team-based care. The emergency department is one of the best-suited environments to hardwire effective teamwork. Organizations go through phases, from performing as multiple individuals to working as a group to becoming an operational team. Simply working together does not make a team. In an effective team, all members give up some independence and autonomy to become something bigger than themselves. More important, they truly care about one another and about their mission and work hand in hand to ensure its fulfillment. A team is committed to a shared vision and goals, has clear roles and responsibilities, communicates constantly and collegially, places a high value on competence and performance, and holds individuals and the team accountable. Outcomes are everything. Most important, a team attracts and retains the best people much more easily than a group of individuals. A high-performing team is where our future lies.
The emergency department can be a best-practices example of teamwork and provides an opportunity to expand this important concept across units, facilities, and health systems.
3. Systems Thinking
Peter Senge published his seminal book, The Fifth Discipline, in the 1990s, and almost every industry readily adopted it. That is, of course, except health care. Emergency physicians, by their role in health care and from their experiences, have a jump on others with regard to systems thinking. We spend so much of our day trying to unclog the organization and create flow for our patients that we have improved our understanding and identification of upstream and downstream opportunities. As consolidation occurs in health systems and additional spokes (both brick-and-mortar and virtual) are added to the delivery model, systems thinking will become more highly valued and a requisite for success. How do you move patients through at the highest quality and lowest cost? Efficiently and effectively.
There are various approaches to systems thinking—such as Lean, the Deming System of Profound Knowledge, the International Organization for Standardization, and others—but the bottom line is about mindset and the ability to look broadly. Despite the complexity of our health systems, narrow views are still common. What is most amazing is that decision makers often use “proximity bias” as their answer for any blockage in patient flow. Proximity bias means that those closest to the patient must be the problem. Yet when those same executives find their flight is delayed, they don’t rush to judge the pilot or flight staff but naturally understand that there is a flow problem somewhere in the aviation system. Why some do not apply that same thinking in health care is beyond belief, but it does present an opportunity for emergency medicine to expand its leadership beyond the patient and the facility to the system and the region.
As the health care landscape changes, let’s take ownership of building an emergency care system that meets the needs of our patients 24-7 and does not require the patient to meet the needs of the system, as often happens now, leading to delays in care, duplication of testing, and unnecessary transfers. There’s opportunity for leadership, teamwork, and systems thinking and, more important, opportunity to create greater value in emergency care.
Dr. Martinez is chief medical officer and vice president of North Highland and assistant professor of emergency medicine at Emory University in Atlanta, and an ACEP Now Editorial Advisory Board member.