The emergency department: Finding hope in the place where public policy fails

This speech was written and delivered by Dr. Anne Zink upon her acceptance of the Alaska Public Health Association Health Care Achievement Award on January 18, 2018. It has been edited for print.

I went into emergency medicine to clinically care for patients. But what I have come to realize is that to truly care for my patient, I must also care about public health and public policy.

Sadly, I have learned that the Emergency Department is where all public policy comes to fail.

It is the place where you understand our glaring lack of social connections and mental healthcare as you sign out 10 psychiatric patients — who literally wear out their paper scrubs waiting a week or more to get transferred — to be evaluated.

It is the place where your life can be threatened if you don’t give a patient what they want as fast as they want, and just how they want it — and for the price they want.

It is the place where people get a trespassing violation because they are too anxious to actually leave the emergency department. This ends up being the only way to get them the behavioral help they truly need.

It is the place where you know some patients so well they think you are the only ones who will come to their funerals.

It is the place you can see someone almost 500 times in three years and if they get another x-ray it crashes the system as there are too many images to load.

It is the place federally mandated to see everyone, any time, for anything — and accept the malpractice risk of their care while knowing less than one-third of the care will be paid for.

It is the place you can declare someone dead five shifts in a row, likely related to overdosing on opioids.

Failing to connect

I have learned the Emergency Department is also the place where you see how silos within our system make it hard to give good patient care.

It is a place where the electronic medical records do not even talk to the other side of the hospital.

It is a place where you figure out where a confused patient has been because of the number of wrist bands he or she wears from the neighboring emergency departments.

It is a place where every emergency department within a hundred miles and five care management companies all have care plans for a patient, yet no one knows.

I have learned in the Emergency Department how misaligned the incentives are.

It is the place where it is easier to get a head CT because you will bring in more money for the hospital, minimize your malpractice risk, make the dad happy, and not risk missing an injury even if the data is clear it is not indicated.

It is the place where it is easier to order imaging for back pain than it is to have a real conversation about the obesity causing the pain.

It is the place I order thousands of dollars of tests before I have seen a patient for fear of missing a “quality” metric.

It is the place where it is easier to write an antibiotic prescription for a child’s ear infection than it is to explain the risk of antibiotics and the probability that the infection is viral, and deal with a parent’s complaint letter — which is in vain, because the pediatrician already started the patient on an antibiotic two days later.

It is the place where you are graded on door-to-doctor times, patient satisfaction scores, and “doing everything possible” for someone's pain, rather than health outcomes.

Embracing hope

In my time working in the Emergency Department I have come to terms with the fact that awful cancers attack the nicest patients, safety contacts for suicidal patients don’t always work, and tragic accidents take lives and mangle bodies way too soon.

However, what I have not comes to terms with is that policies that we make and we can change fail patients every day.

I believe we have a moral obligation to create systems where, as Dr. Butler says, “making the right choice is the easy choice.”

Too often I see systems that bring out the worst in each other. Systems that make patients angry, violent, and disrespectful. Systems pushing physicians to make choices that are not in the best interest of the patients. Some days I believe it is only our Hippocratic Oath and the sheer willpower of people like you in this room holding this multi-trillion-dollar healthcare system together.

Too often I see us blaming each other instead of recognizing it is usually good people, doing their best in a broken system. I read the newspaper, where physicians are vilified, and the comments on social media platforms on “who not to use,” or I am yelled at by a consultant at 2 a.m., and again I am reminded how much easier it is for us to find villains rather than solutions.

Each time the system fails us, each time we blame the person instead of the system, it dents our souls and takes us a step further from finding real answers.

However, every time this happens I am also reminded what a wise attending physician, Dr. Foshnocht, told me in residency: “Anne, always do what is right for the patient and remember the rest is noise.”

I think of those words, every day, every policy, every patient I see.

The noise is the metrics, and the policies, and the anger. The noise is the fear of change, of breaking out of our silos. The noise is the anger and hurt of feeling betrayed by your profession, your hospital, your patient, your colleagues, and the system. The noise is the fear of taking that leap of faith to create something better.

But beyond the noise is the patient. That is our true north.

And we have hope. In Alaska we now have an IT system, developed by Collective Medical, that can connect every emergency department, social service, primary-care provider, and subspecialist. A tool which, like the center of a snowflake, can create a system of change around it if we make the conditions right. A tool that helped support Mat-Su’s high-utilizer program, on track to save $16 million over 2 years. Five percent of the patients constitute 50 percent of the cost to the system and we now have a tool to see and communicate with those patients. And that is only one low-hanging branch. There is so much redundancy, so many systems creating cost and not helping our patients. There are so many possibilities for a better tomorrow.

Let’s use that tool. Let's find new ones. Let’s break down our silos, speak each other’s languages, bend the cost curve and jump to a better system.

Here in Alaska, let’s figuratively skip the land lines and put in cell towers. Let’s build systems that work instead of blaming each other.

Let’s build a system where we do what is right for the patient, and remember the rest is noise.

Anne Zink, MD, FACEP is the emergency medicine medical director for Mat-Su Regional Medical Center in Palmer, Alaska, and immediate past president for the Alaska chapter of the American College of Emergency Physicians.

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