Dirty White Coat
Mel Herbert, MD, and the creators of EM:RAP, UCMAX, CorePendium, and the collaborators on "The Pitt" and many of the most influential medical education series present a new free podcast: “Dirty White Coat.” Join us twice a month as we dive into all things medicine—from AI to venture capital, long COVID to ketamine, RFK Jr. to Ozempic, and so much more. Created by doctors for clinicians of all levels and anyone interested in medicine, this show delivers expert insights, engaging discussions, and the humor we all desperately need more of!
Dirty White Coat
The Real Crisis in the ER: Systemic Dysfunction vs Financial Concerns
Interview with David Schriger, Peter Viccellio, and Al Sacchetti, MD's
Four decades of emergency medicine experience reveals how the specialty continues to normalize dysfunction while failing to articulate what emergency care should look like. Veterans explore solutions to the systemic problems that have kept emergency departments "at the breaking point" for over 30 years.
• Emergency physician compensation ranks around 16th among medical specialties—not the financial crisis some portray
• Working conditions, not compensation, represent the true crisis in emergency medicine today
• Emergency departments generate 33-50% of hospital revenue, but this value is rarely recognized by administration
• Physicians have accepted and normalized dysfunctional practices like hallway medicine instead of demanding change
• Simple solutions like elective scheduling smoothing and enhanced discharge programs work but aren't widely adopted
• Emergency medicine needs to define and demand what optimal practice should look like
• The healthcare system tries to solve 7-day-a-week problems with 5-day-a-week solutions
• Hospitals contain chaos in emergency departments to maintain predictability on inpatient floors
• Emergency physicians increasingly moving into hospital leadership roles where they can implement systemic improvements
Listen to our next episode where we'll explore how new emergency physicians can advocate for better workplace conditions despite institutional resistance.
it's a little. It's a little out of beer.
Speaker 3:He has hair. The rand corporation and asap came out with strategies for sustaining emergency care in the united states. Too much fanfare. It was all about what's wrong with emergency medicine and how do we fix it. And at the same time, there was a study that came out that showed that emergency medicine compensation is about midway between all the specialties. We're not right at the top, we're not right at the bottom. And also at the same time, we found that this problem with how many people are matching emergency medicine is starting to go away again. It was really great for 25 years, the best and the brightest, and then people stopped matching in emergency medicine and then they are again.
Speaker 3:So I got together, these crotchety old guys, to talk about this stuff from a historical perspective, to talk about this RAND report and to talk about what's wrong with emergency medicine and how we can fix it. And what you're going to have here is a group of people who've been doing this for over 40 years that can tell you what's new and what's not new. And when I think about the RAND Corporation and the ACIP report, I'm thinking of that quote. I think it was from Charlie Munger that said show me the incentives and I'll show you the outcomes. Let's talk about it from that point of view. What are the incentives here? What are the outcomes we're looking for? Are the two aligned?
Speaker 4:It's a good summary, but it's tricky.
Speaker 3:That's Peter Fajelio from Stony Brook in New York.
Speaker 4:Emergency physicians are paid in very different ways, and the one thing that's been clear in the last few years is that the emergency physicians that are at greatest risk are physicians that work for private equity firms, a number of which have gone bankrupt. I love one of them that they took out a one point five billion dollar loan. They awarded the board five hundred million of that and then declared bankruptcy and left their physicians hanging. But the what is it? The Becker Hospital report. I just got it in the email today. It ranked the 29 top physician salaries and we were number 16. We were better than obstetrics and just below pulmonary.
Speaker 4:So in terms of a public message, of life is terrible. It sucks. So the solution is to pay us more is a message that I don't think carries, but I think it is a Look. I think absolutely. Should we get paid more? Yes, I should be paid twice as much, three times as much, but that's a separate issue than what's going on in the emergency department.
Speaker 4:And what I found about the Rand report is it's almost identical to reports from three years ago, six years ago, nine years ago, 12 years ago, ASEP sort of promoted this as the emergency department at the breaking point. The first time there was ever an article that I'm aware of that I recall, of emergency departments being at the breaking point was in 1987, Time Magazine, and then in 1991, and then in 1995. So we're constantly at the breaking point and our response has been I think the world needs to be fixed. Emergency departments need to be better, Public health needs to be better, Primary care needs to be better, Mental health needs to be better. Everything needs to be better. We need to pour a lot more money into it, and that all may be well and true, but in terms of emergency medicine, it would be nice to focus on what it is exactly that's broken, both structurally and financially, and what specific things need to be done to fix it, Because I think that this report in many ways buries the lead.
Speaker 3:Right, thanks, dr Vecchile. Okay, al Cicchetti, what do you get to say?
Speaker 5:I think you bring up something that struck me about the report, which was I mean I admit you bring up something that struck me about the report, which was I mean I admit the report was more financially based. But from my perspective, going to work I find most difficult is not what I'm being paid per hour. You know where I work. I'm expected I'm going to see a large number of people who aren't going to be able to afford their care, and that's fine. I mean I made that selection.
Speaker 5:What bothers me the most is the biggest problem with emergency medicine is really not that financial. You put it in now, peter, we're doing okay. Everybody would like to be paid more, I agree. But the biggest problem for me is the conditions under which we are practicing our specialty. I mean, you know the boarded patients, the lack of consultant support these days. You know the increase in the violence against health care providers. I think the bigger thing is, aside from the violence, is the lack of respect. I mean I don't have to be hit by a patient to recognize the fact that they hurt me when they tell me I don't know what I'm doing because they read something about some holistic medicine that I should know about. The biggest problem with emergency medicine is not necessarily what was featured in that RAND report, but all the other ancillary things that go into what happens when you walk into the department for your shift.
Speaker 4:But, al, let's go back to the inciting event Emergency medicine. What was the evolution of emergency medicine? We were always the adolescents at the table of medicine when I first started out and emergency departments were crowded. We were boarding patients in 1980. What did we do? What did we say about it? We blamed it on the unnecessary visits. Did it help us? No, what did it do? It told insurance companies oh, you have unnecessary visits, okay, we won't pay for them anymore.
Speaker 4:Imagine surgery instead had taken over emergency medicine. Now the surgeons I know they don't do two cases in the same operating room. The cardiologists don't put two patients in the same room. Nobody does this except for us.
Speaker 4:We have never defined what our workplace should look like. You know, if we have 75 beds and we can double up some rooms and put people in hallways so we can maybe take care of 100 at once and we have 150 patients total there. I think if surgeons had taken over this because surgeons get their way instead of a 75 bed emergency department they have a 200 bed emergency department and they'd have three CAT scans in there. They'd have two operating rooms and they would have more nursing staff than you could think of. We have a tradition of accepting mediocrity. We have a tradition of trying to solve problems by seeing patients in hallways and in waiting rooms, and we have done what Patrick Moynihan very clearly described as defining deviancy down. We have accepted this as our fate. There's not one single structural article out of our organizations that say this is what emergency medicine should look like. We don't have any pride ourselves in what we're doing.
Speaker 5:But you're making my point. I mean that is the whole point. Here's a report that focuses strictly on the finances of it and missed out completely on all those things that you mentioned that those of us have been advocating for for years Now. Part of the reason you get your way and if you're a surgeon you get your way is you generate more money for the hospital.
Speaker 5:I think we've done a very bad job of selling the amount of money that we generate for the hospital.
Speaker 5:I mean, when they look at the income from the emergency department, they look at the income of patients you saw in discharge, anybody you admit gets, I guess, credited to the upstream people, so that MI you admit gets credited to cardiology when they go to the cath lab. Well, you know what, if you take the money that you generate off your admitted patients, turns out that you generate and we've done this a couple of times you generate at least a third to a half of the revenue for the hospital. But we've done a very big job of selling that to the hospital. We did it at our institution and it opened a lot of eyes. But nationally we don't, which is why, exactly what you said, we don't have all the things that the surgeons would have if they were running the emergency department, because the hospital has traditionally bought into. The surgeons generate money. They don't buy into the amount of money that we generate and we've done a bad job of selling that.
Speaker 3:Right, let's bring in Dave Schrager, professor of Immunosuppressant Medicine at UCLA, who has some very interesting ideas about how we should fix this.
Speaker 2:I mean, I think there is. But again, I think it's bigger than all of this, which is, you know, first of all, this is not a national problem in the sense that every state's a little bit different. You know, you go to Maryland and seeing a Medicaid patient is not a problem because they pay the same as private insurance. You go to California, it's a very different kettle of fish. You know, at our hospital, which is a quaternary care hospital, they lose money on almost every patient we admit from the emergency department, unlike what Al was saying, because they make money only when they're high profit margins, which means the right patients with the right insurance but, most importantly, with the right diseases. So they can't make money on a straight Medicare DRG. Now, that may be their problem in terms of efficiency and other things, but they lose money and that patient. So what they figured out is the best thing to do is to keep that patient in the emergency department for their entire stay while a more lucrative patient is admitted electively to take the bed. So I don't care if your ER has 75 beds, 150 beds or 400 beds. If they're all filled with borders, you're not practicing emergency medicine.
Speaker 2:But my point would be two points, one of which is this is larger than emergency medicine, and I agree with both of you in terms of some of the ways that you argue that we have framed ourselves to a disadvantage over time. You know, either not behaving like surgeons or, on the flip side right now, saying we are not primary care doctors, we're specialists, which at times during this cycle would have had an advantage that we haven't taken care of. But the bigger point for me is that everything we're talking about is symptomatic of a larger problem, so that right now, management, which is an evil in itself, is constantly trying to optimize what we do, given the situation, rather than saying we need to blow up this whole situation. Seeing patients in the hallway, seeing patients in the waiting room, seeing patients that aren't properly undressed all of those things are not good medicine and we shouldn't practice them. Until we're willing to throw down the gauntlet and say we're not going to do that anymore, let the waiting room back up, let the press come and let the C-suite deal with that. Until we're willing to do that, nothing's going to change.
Speaker 2:And my final point would be simply that the billing analytics of this are simplistic, because the fact is, most people are practicing emergency medicine in a way that it shouldn't be practiced.
Speaker 2:So ordering a troponin, a D-dimer and a CAT scan on every patient who walks in the door and then saying you're not paying us for adequate complexity is a bunch of BS, because what they should be paying us for is to think and to not order those tests which would save the system money. And instead everyone's in this race to front order everything in quote, unquote the name of efficiency. So when the patient does finally get to see a doctor, everything is done, but it coincidentally works out that that's what makes the most money for the hospital. And so we are doing a bad job on all counts. We're not sticking up for patient rights and saying we're not going to see patients in suboptimal conditions. We're not willing to bear the heat of that, and we also are practicing in a way which is not good medicine and is just convenient. So I think a lot of this falls back to us.
Speaker 5:Yeah, but you wind up cutting off your nose to spite your face if you say I'm not going to see patients in the hallways, I'm going to let the waiting room back up. Well, you know what? I went into medicine to help people, and I'm not helping somebody if I let them sit in the waiting room long enough for them to leave and not get their problem treated.
Speaker 2:So yeah, we. Let me just disagree with that for a second, which is that may be true for a small cohort of patients, but do that for a little while and the total number of people you will help by changing the system is far greater than the few that are hurt on the days when you go on strike.
Speaker 5:essentially, yeah, but I don't see that happening. I see that the hospital just saying look you guys, they're just incredibly inefficient, we're going to get rid of you and get somebody else in. It just doesn't, it doesn't float that they're going to respond to that. All we're going to do is tick off the patients.
Speaker 2:Well, as a one-off that may be true, but if we actually unionized and did this together, we would be in much different circumstances and we might push the healthcare systems to larger solutions. So that kind of incremental thinking that got us exactly where we are right now.
Speaker 4:Al, I have tracked what we say publicly for now 40 years, and what we say is things are terrible. But what we don't say is this is exactly what we need to do to fix it. We just say it's terrible. Oh, woe is me and pay me more.
Speaker 4:Now I think a lot of our conclusions are driven by our premises, so I think that there are a few myths out there that are premises that I don't think are true. The first is, as I mentioned, the unnecessary visits. I don't think that that is our issue at all in emergency medicine. Our emergency department is not being brought to its knees by having too many sprained ankles there. The second is in terms of money.
Speaker 4:Now, in the 80s there was literature that, oh, every emergency department admission is a money loser. But one thing changed, and it changed in a big way. It was with documentation. I no longer was admitting a patient with pneumonia, I was admitting a patient with low-bar pneumonia and lactic acid doses and septic shock, et cetera, so forth. And guess what? The payment for that is fantastic. And the third idea here is that we leave admissions in the emergency department because the C-suite has it together so well that they have figured out that they are going to leave admissions in the emergency department for financial benefit. I don't think that's true to begin with and I don't think you're given that.
Speaker 3:I think you're given let me say that may be true at a quaternary place.
Speaker 4:I think what drives our boarding in the emergency department is they simply just don't know what to do to fix it and it's not strategic. It's not like they have empty beds upstairs while we're boarding 30 patients, there are no beds upstairs to send the people up. So I think that to credit them with this very clever strategy I think given too much credit Now again at a given particular institution, this may be so. We fill the hospital with admissions. They make money off these admissions. I think that starting that as a fundamental premise is that the reason we have boarding and crowding in the emergency department is because it's financially beneficial to the hospital is. I think there's objective data to argue that. If that's what they think, they are wrong, Because when you get people upstairs, they have a shorter length of stay. If you discharge them early, they get a shorter length of stay. If you get discharged on weekends, they have a shorter length of stay, and shorter length of stays correlate with a lot more money for the hospital.
Speaker 5:I think, dave, you are right at your institution but at our shop we're much more like what Peter alluded to, which is, you know, when we did these studies at our shop, what we found was that you know even the non-s a little bit more of a mindset of, yeah, we do have to pay attention to the emergency department.
Speaker 5:I think one of the things that we fight against a lot is just history. I mean, it's been tradition that's been drilled into a lot of as Peter alluded to misinformed administrators that the way you make money is you ignore the emergency department and pay attention to the elective admissions. I don't think that's the case. I think you know, when we look at it, the vast majority of our really sick acute patients are coming in through the emergency departments and they're the ones that you know generate a lot of income off of procedures. We are an urban emergency department in the poorest city in the nation, but yet we can pull in from some of the suburbs you know for our tertiary care and we do okay. So I think you know solving the problems, the logistical problems in the emergency department, is a much bigger goal for, I guess, the leadership in emergency medicine than simply looking at the RAND report and saying we don't have enough money because it goes back to what Peter said we're number 16 on the hip parade. That's not so bad.
Speaker 4:But I think the correct answer to electives versus emergency patients is not pitting them against each other. Institutions have to figure out how to take care of both, and if there are certain patients you don't make much money on, like, for instance, people that can't pay you offset that with other patients, but you have to figure out how to take care of everybody that shows up. There's a right way to do it and a wrong way to do it, but we have not defined or laid out a roadmap, an architectural drawing of what emergency departments need to look like. We incorporate dysfunction into our architectural drawings when designing a new emergency department. There was one thing in the Rand Corporation report where they said well, emergency departments should build extra areas so that they can have a place to put their admissions. That's been looked at. If you build 10 beds to put admissions, then by the time you're done building, you're boarding 20 admissions. This is not the solution to the problem.
Speaker 2:Well, I would just say that these two highly respected gentlemen, I believe, are doing exactly what they both suggested we shouldn't do, which is trying to fix an impossible problem, and that's in the spirit of emergency medicine to do that, and I admire both of them. But the fact is this is a non-solvable problem in our current health care system. All of this is symptomatic of a disease which permeates the entire health care system. And so until you are willing, as I said before, to throw down the gauntlet and say stop, we are not going to try to optimize crap, we are not trying to perform alchemy. We are going to point out what the problems are in the system at a larger level than just ED care, and blow the system up. Nothing will change except in the most incremental ways.
Speaker 5:Right, but you're going to need buy-in, and I agree with you 100%. The system sucks, but in order to fix it you're going to need buy-in from every specialty. I mean, everybody's got to buy into it. In the interim we still have to, you know, take care of of um, the people who come to us, and I, I I like to see someone come up with that, that universal model that incorporates every aspect of medicine, and and apply it. But I don't see it. I see, you know people say, oh, um, you know we should solve it this way. I think Peter's got one of the best success stories ever where his institution was going to build a big new tower and Peter said wait a minute, just, you know, extend your operating room hours, move your critical cases to not just Monday, tuesday, wednesday but to the rest of the week, and all of a sudden it, you know, eliminated the need for the tower. That's a classic example of of the thinking that that would work.
Speaker 2:I have nothing wrong with that thinking. But let's look at it this way the average person in this country is lucky to be making 30 bucks an hour. Okay, at that wage, the society cannot afford the product that is currently being delivered as medicine in this country. Ok, and until you get those two things on par with each other, you might optimize one little locus over here or one little locus over here, but when you are delivering a product that the society cannot afford, you are not going to find a solution. You're just going to move the pieces around and hurt somebody or somebody else, and that's what needs to be addressed.
Speaker 4:Well, this was one thing lacking in the Rand report. In most places there actually are solutions to this without building towers, without having to triple the size of your emergency department or whatever else, and there's a handful of solutions. One is elective smoothing. That was the example that Al was talking about at Cincinnati Children's is once they smooth their elective schedule. This was just over five days. This was not a seven-day-a-week exercise schedule. This was just over five days. This was not a seven-day-a-week exercise.
Speaker 4:They canceled the building of a 100-bed tower because they didn't need it and the amount of volume they were able to increase through their operating room without adding operating rooms was to the tune of $130 million a year. Nyu did an early discharge program. They went from single digits to 40% out by noon and they did it for financial reasons. Their CFO said if patients don't get upstairs until afternoon, their length of stay is a half a day longer. Well, their O to E dropped by 0.8. That creates a huge amount of space. The guy at Montefiore weekend discharges. He enhanced weekend discharges. They went from boarding 30 patients a day to closing a 30-bed unit because they didn't need it. That can benefit boarding, can benefit the emergency department, can benefit the staff and inpatient services and dramatically improve the financial bottom line of the hospital.
Speaker 4:So why don't we do that? Because that's just not the way we do things. I mean, it's just inane as to why these sort of actions don't take because there's so much benefit to so many people. That's not outlined in the RAND Corporation. The RAND Corporation reports mostly things are horrible. Things are terrible and we need a roadmap for these are the specific solutions that you could do.
Speaker 4:How many people are still in the hospital after they no longer need it because they're sick? A lot of people are because they're waiting for PT, they're waiting for an echo, they're waiting for this, that and the other. It's very costly to the system to do that and very short-sighted to not address that. And it can be addressed without additional staff, without additional cost. It's just shifting things around. If you have 10 echo techs that come in from 8 to 4, if you just shift some of those up to 8 or 9 pm, you clear the queue for that day and the patients can get out the next morning.
Speaker 4:But we are not doing appropriate systems interventions to do it and so our solution is always as typical we need more money, we need more space, we need more staff, we need more everything. We need to change from the 1960s hospital of a nine to five, monday through Friday, with the skeleton crew on evenings, nights and weekends. We just never. We're like the frog that was sitting in the water that's slowly heating up. We never changed, and so now we're still trying to solve a seven day a week problem with a five day a week solution.
Speaker 2:I don't disagree in the sense that I think there are all kinds of inefficiencies in the system that could be improved.
Speaker 2:I think non-medical managers are probably the worst people to do that, and I do have a bias against management. I think that physicians are the ones who understand patient care and need to solve these problems many of them. But fundamentally, if you add up, I believe, peter, even if you did everything you said everywhere, you still have the problem that, at a median income of $40,000 to $50,000, we are delivering a product that the populace cannot afford, and that's because we're ordering too many tests, we're doing too many unnecessary procedures, both diagnostically and therapeutically, and we're not practicing optimal medicine. We need to clean up the medicine too. We're also not training Mel you put in the match stuff. I mean, we're not training doctors to be doctors anymore, we're training doctors to be kind of widget movers in the emergency room. You know, show me all the lab results and maybe I'll get around to this. Following a patient, no history, no physical examination, no thought. So create a system which pays us to think rather than to do, and maybe we can make some headway.
Speaker 5:I was going to say one of the things is, dave, what you're saying, some headway.
Speaker 5:I was going to say one of the things is, dave, what you're saying? All those changes also have to take place in the background of keeping people, I guess, being paid for their jobs. I mean, when you look at that, I am amazed when I see a patient who was discharged from our hospital about you know, last week or two weeks ago, a month ago and I go to the discharge summary and I can't figure out what the hell happened to that patient. There's all little categories that are blocked off, like you know, I asked this and I did that and I did this, and it's all the checkoff boxes for reimbursement, but you can't figure out what the hell happened. There's no little paragraph that tells you what the hell happened.
Speaker 5:And what you're advocating is great, but any hospital or whatnot's going to say I can't make those changes until you make changes in the payers to reimburse me for doing it differently. Otherwise, I'm going to write these discharge summaries. I'm going. I'm going to write these discharge summaries. I'm going to have my staff write these discharge summaries and just check off a whole lot of boxes to maximize our reimbursement.
Speaker 2:But if physicians let the managers whether they're financial managers or other managers drive the ship, we will get nowhere. And until we're willing to say no, we are not going to document for the purpose of billing. We're going to document for the patient, for the purpose of optimal patient care. We're not going to order tests for the purpose of optimizing income. We're going to order practice good medicine. Until we're willing to do that, nothing will change.
Speaker 5:Depends on the doc. I mean, it's funny, from from day one, my incentive was keep the waiting room empty. It just was. And you know, as, as a result, you don't document, as well, as a result, that the other doc, who doesn't pay attention to the waiting room but it's meticulous in their docking documentation, um, their, their incentive works out great. Um, so it's a, it's a wonderful statement and I agree. But if your incentive is patient care and keep the waiting room empty and do all those other things, yeah, your reimbursement is going to suffer.
Speaker 4:I could not disagree more. I don't order 65 things before I see the patient. That's just, and our department does it. Now we do have an area where patients are preliminary seen and orders are started if they can't get into a bed. But, Dave, I have complained, for instance, about radiology turnaround times and what's the response? Well, you would not have a problem if you didn't order so many tests, and I guess that's true. If I didn't order a single CAT scan, then there'd never be a wait for a CAT scan.
Speaker 4:But I think, Mel, you asked what's the incentive of the system and I think there is a large incentive in the system as a whole is to contain the chaos in the emergency department so that the inpatient floors can be methodical and rational and predictable. So you know, you're on an inpatient ward, there's only a certain number of beds and a certain number of nurses, and that's predictable and it's not chaotic. They can get rid of one patient before they take on a new patient. And how does that happen? That happens because the chaos is contained on this side of the line in the emergency department, and so we reap the unfortunate consequences of that need for the inpatient services to not have the chaos move upstairs.
Speaker 5:I've often been told that we are our worst own enemies and we enable the rest of the hospital to function inefficiently because we take care of them. So if interventional radiology, you know, is not efficient, we'll do the paracentesis for them in the emergency department. You know, if our outpatient pediatrics just can't seem to get their act together to see a kid, well, we'll bring that three-month-old with a fever back to see us and we'll take care of them. So what Peter has said is very accurate. You know, the more that we are really good at what we do, the easier we make it for the rest of the hospital to be really bad at what they do.
Speaker 4:Well, I've been fortunate enough in my career I'm a PGY 48 now I've been fortunate enough in my career to always work in a dysfunctional environment. So I never got to see the change from a functional place to a dysfunctional place. From the start we were boarding, crowding people in the waiting room. I think what changed in emergency medicine honestly was that culturally when I started it was fine to let people wait eight, 12 hours and you just didn't really give a damn. And culturally we have changed in that we don't feel that that's right to those human beings. So we have adapted in a very dysfunctional way.
Speaker 4:You know, build me a tent, I'll see somebody in a hallway do a rectal exam in a closet. I'll do whatever I can to help the patient. But what Dave is suggesting can't be done at a local level. If you do it in your own institution, then you're going to be replaced, but nationally we need to define what we look like. Look at what medicine is now.
Speaker 4:I work in a 600-bed hospital. If they knocked it down and they put me in charge of building it, I would take those 600 beds and 200 of them would belong to the emergency department, because if we expanded our scope of care, we'd be able to get a lot of those people out of the emergency department and then we could even minimize critical care admissions by taking care of them and then distribute people out to the other areas. If the inpatient services ran like the emergency department services do meaning I want the test now, I want the results now and I'm going to take action now that would transform in hospital medicine and it would transform the length of stay, it would transform the number of beds available so that you wouldn't have this issue with boarding.
Speaker 2:Well, I think that local level can lead to the kind of problems that these other distinguished gentlemen have identified, which is they could just fire you and it won't be noticed. So I think that we need to band together, that ASEP, for example, could articulate that have never been clearly articulated before, because each of those principles may have negative consequences to some part of the constituency. So I don't think we've been very bold in terms of articulating a future. That would be a better future and I think we could do a better job of doing that, certainly. But I think you know look what's happening in this country everywhere. You know, to all aspects of the country at this particular moment, and I think you know to some extent we need to get outside of our local problems.
Speaker 2:And I was kind of surprised that you sent over the match results, because you'll see all kinds of publicity within emergency medicine that oh, there were 60 unmatched spots instead of 90 unmatched spots or 200 unmatched spots, and people will focus on that and that's really taking their eye off the prize which we are heading collectively as a society. And it's not just the US, I mean, there's boarding in plenty of other countries. But you know we need to fundamentally rethink some of these things about how societies work, how health care is delivered and how the health care system is organized, before any of this will be solved. Sure there'll be some success stories I'm not quibbling with that and sure there's lots of inefficiencies in the ED and at the hospital level that could be fixed. But the fact is that this is much larger than that. Until we address the larger issues coherently and collectively, we won't get any meaningful solution.
Speaker 4:But the boldness has to be preceded by a clear vision of what the world should look like. And I don't see that. I just see a cry of distress oh, the emergency department's at the breaking point, which has been a mantra for at least 30 years, and that clearly somebody should figure out that. That's that. That is not a battle cry, because you're telling the public it needs to be fixed. Well, who's the expert at fixing it? The public's not the expert at fixing it. Congressmen aren't the expert at fixing it. We should. We should be the experts, but we need to define a vision and then be bold about it.
Speaker 5:I think it's interesting that you know, at least in this area. What I'm seeing is more and more chief medical officers or whatever that you want to name the title for the hospital are becoming emergency physicians, because I think emergency physicians are the ones who understand every aspect of medicine. You know, if you've got an internist, who traditionally was that position, well you know the OB people could come to them and feed them whatever line they want and they would have to buy it. Same thing with pediatricians and everything else. But I'm seeing more and more of these high level executives being emergency physicians and when you begin to look at now, they can do it exactly what Dave said they can take a step back and look at the global picture, not just their little area.
Speaker 4:There's something I do want to say, mel is again, part of the adolescent nature of emergency medicine is to bash people beyond your walls either the patients in this direction or the C-suite or whatever else. I have to say the people I've worked with from other departments the people in the C-suite and the middle manager, administrators and whatnot everybody has a good heart about what they're trying to do. They really are trying. Nobody likes this. There's no one that's chuckling in their office saying ha ha ha, aren't we just doing great? Everybody wants this fixed, but they need, I think, some help in what is it that we need to do, in what order and with what priority, to address this and fix it in a systematic way.
Speaker 4:I've found the same thing with the health department. They've come out with some crazy stuff, but in working with them I've always found their hearts in the right place. They really want to do the right thing. Sometimes they misinterpret something or misunderstand something, but everybody in the system that I work with, they want to do the best that they can for the patient on an individual level and on a system level. We just are not getting around to figuring out what we need to do in order to make that happen.
Speaker 2:I want to go back to Munger's quote that Mill offered up a few minutes ago, which is I don't disagree with you, but if you incentivize the C-suite to maximize profit, they will behave logically to do that. If you incentivize them with a different goal, which is to treat all people equally and fairly and quickly, they will figure out ways to do that. And it all comes down to incentives, and the incentives are money and until we fix that on both sides, which is the demand and the supply, we will not get anywhere.
Speaker 4:I actually I wish that were true, because if it were true, every hospital would have smoothing of elective surgery, every hospital would have a program for early discharge, every hospital would figure out how to get people out on weekends, because all of those things result in a huge financial benefit to the institution. So they may be wanting to maximize income, but they're looking within the dysfunctional system as to how to maximizing it, rather than stepping back and saying how can we rearrange the chairs on the deck here so we can actually get better throughput, get more patients in, get them out quicker, and we'll all do better as a result.
Speaker 3:So there you have it. Thanks to Dave Schroeger, to Peter Vecelio, to Elsa Keddie for their thoughts, for their ideas and hopefully some inspiration that perhaps the people who are best equipped to fix our problem is actually us, and maybe we haven't been doing that and maybe it's time.
