Code Black: Putting a face on America's access problem

A new documentary takes viewers inside America's busiest ER at Los Angeles County Hospital, where patients are known to wait 12, sometimes 18, hours or more to receive treatment, because they have nowhere else to go.

Code Black, which received the Best Documentary award at the LA Film Festival, was directed by Ryan McGarry, MD. He balanced filmmaking with his ER residency, filming the stories of the hundreds of patients who came through the ER each day, and the physicians and nurses who treat them.

For those in the healthcare industry who haven't been to an urban safety-net hospital like LA County, the film is eye opening. Safety-net hospitals make up 2 percent of all hospitals but provide 20 percent of all charity care in the country.

McGarry began filming during his first year of residency at LA County's old public hospital, the birthplace of emergency medicine and home to the first emergency medicine residency in the 1940s.

Over the course of four years, McGarry profiles the patients and providers as they transition from the old LA County — and its chaotic, outdated and too-small ER — to a new multimillion dollar facility (required by state earthquake code), which in the words of one attending, "moved the ER forward two decades in a single day." This creates a unique opportunity to see the effects of healthcare's increasing regulation and bureaucracy on providers who previously were exempt (thanks to federal waivers).

The documentary sets out to define what it means to be a doctor at this time in America, explains McGarry.

At old LA County, quarters were cramped but camaraderie was high, and physicians and staff spent almost all their time on direct patient care. At the new LA County, forced to comply with a bevy of federal and state regulations, the doctors find themselves spending less and less time with patients, despite no slowdown in volume. Several scenes show physicians alone, logging in and out of EMRs, looking for one of several paper forms, or hunched over while filling out pages of paperwork.

Jaimie Eng, MD, an ER resident profiled in the film, explains the impact: "It takes four times as long to document than to treat the patient."
The film doesn't ignore the benefits of regulations, such as HIPAA's privacy protections, but shows that such regulations do take considerable time away from direct patient care.
"We're not comfortable with this...we became doctors to be with our patients," says McGarry.

McGarry doesn't debate the law's intention — "We all want privacy and we all think it's important," he says. But so many delays in care delivery are caused by minutes spent on HIPAA-mandated minutiae. Anything that takes time away from direct patient care is worth examining, especially during a Code Black — when the ER is overrun with patients waiting hours upon hours to be seen.

At LA County, patients presenting to the ER are given a score from 1 to 4, with 1 denoting patients with the most emergent conditions. At LA County, level 2 patients can wait from 10-15 hours to be seen.

The film puts a face (or rather, faces) on America's healthcare access problem and highlights some of the other "well-intentioned" policies that end up exacerbating access issues.

For example, a state-regulated nurse-to-patient ratio forces ER administrators to shut down a wing. In California, where nurses are in high demand, LA County's ER lost 15 nurses during a four-month span during filming. And, privacy regulation prohibit doctors from treating patients anywhere other than a private room, creating backlogs of patients as doctors wait for rooms to turnover.

"The message is there needs to be balance," McGarry said after the screening. "It seems like we've gone maybe a bit too far in the other direction. Well-intentioned policy doesn't really benefit you the patient or you the provider."

McGarry's documentary is moving and brings to life the struggles of thousands of patients who pass through LA County's ER each year, as well as the commitment and calling of the physicians who treat them. McGarry was called to medicine after overcoming stage 4 lymphoma during college; another resident, Andrew Eads, MD, entered the specialty after surviving a car accident. A friend who was with him never recovered and remains in a vegetative state today. Because the friend was an illegal immigrant, the family struggled to receive even sub-par care for their son. Eads pursued emergency medicine, in part, to prevent this from happening to another person and family.   

The film doesn't include a call to action, and as McGarry explained in a question and answer session after its Chicago premiere, this was intentional. Instead, he simply hopes to provide an informative, realistic backdrop for the various ongoing debates around healthcare reform and access. After all, McGarry and his colleagues like to recommend people debating healthcare reform conduct the debate in the waiting room of LA County.  

McGarry's documentary is a must-view by anyone in healthcare and is proving popular with non-healthcare audiences as well. CBS has optioned the rights to a show based on the film, which McGarry will executive produce. He was quick to note though that he will not give up his shifts and will remain a clinical doctor, even if only for a few nights a week.


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