Patient Safety: A Crazy Suggestion

Edwin Leap II, MD FAAEM

We practice medicine in a strange time. Things are in evolution. The science of what we do seems to get better and better, while the way we do it, the practice of it, the application of that science sometimes seems to get worse. This thought has been running through my mind for a couple of weeks. In particular I’ve been thinking about safety.

I remember a few years ago when all the best minds in medicine assured us that patients were in constant peril in the waiting room and that the only way to make things better was to “pull till full.” As long as there was an open room, or room for a chair in the cluttered hallway, our patients would be whisked straight back from the death-trap of said waiting room where they would be safely embraced by the loving arms of physicians and nurses who could watch them right across from our desks, 24/7. While they tapped on the plexiglass asking for water and blankets.

Fast forward and patients are treated, across the land, in the waiting room. From check-in to discharge, the less sick (and sometimes the unknown very sick) are triaged, evaluated, examined, tested, treated, and discharged without ever going into the vast interior of our departments. Oh, and also billed hefty fees for the privilege.

This is simply what we do now. The waiting area is considered plenty safe. I anticipate a time when we move from waiting room medicine to parking lot medicine. At which point we’re circling back to telemedicine. (The difficult question will just be how administrations can find a way to bill facility fees for home visits.)

Of course, this is a complex issue that has to do with higher acuities, lack of insurance, boarding and all the rest. And also a misunderstanding by the “powers that be” about what’s happening in the ED. Because all of it feels increasingly unsafe. So what have we done in response? Well, we have policies. We have tablet-laden coordinators to stalk us and keep us on track and send us emails about our inadequacies. We have metrics about time to physician, time to disposition, time to antibiotics, cath lab, thrombolytics, and all the rest.

We also have computer prompts. Based on what I see at work on our EMR, roughly 95% of the patients who check in probably have sepsis, or need substance abuse counseling, or might be vaguely suicidal. In addition, it seems that almost every medicine interacts with every other so I need to keep clicking “benefits outweigh risk” and hoping for the best. I mean, the EMR doesn’t lie, it’s there to keep people safe. Right?

More recently we’re hearing a lot about the wonders of AI. Artificial intelligence will help keep things moving and will also keep patients safe. It will help us collate and coordinate all of the data about our terribly sick patients and will help us find the patients that might have slipped through our brains or fingers. Obviously I can see some benefits. I’m hardly one to critique such a technology. I grew up with a rotary phone, after all.

However, the AI issue brings me back to a salient point. If one of us highly skilled emergency physicians is working in the future when AI has reached a high level of functionality, and if the AI makes a mistake and someone has a terrible outcome or dies, Skynet won’t be sued. The physician who used the AI will be sued. The AI won’t be deposed, a physician will. And the AI won’t be listed on the National Practitioner Databank. The physician will bear that scarlet letter for life.

What this says to me, ultimately, is that perhaps the most important key to patient safety is having adequate amounts of trained physicians in proximity to real, sick patients. This is an idea so anachronistic it just might work.

Sadly, what I have learned in my travels doing locums is that generally, staffing companies and hospital administrations don’t really see this as a priority. Understaffed emergency departments are everywhere. And if they aren’t understaffed in the daytime, they often are at night when the sense of being overwhelmed feels vastly worse, and approaches hopelessness as the night drags on to day.

Somehow the shiny glitz of computer prompts and policies is far more alluring to those in power than the mundane reality that human doctors are the way to keep people safe. But systems press on and add new departments, new outpatient procedure labs, new imaging centers, and all the rest. I get it. Those shiny things generate cash.

Nevertheless, particularly at the front door of the hospital, the public face of the hospital, the emergency department, we need physicians. And sometimes, excess physicians so that people don’t have to wait to be seen by an already overstressed doctor caring for three critically ill patients. (Obviously we need more space for the huddle masses yearning to breathe, but that’s another topic altogether.)

If we really want to keep our patients safe we also need other species of physicians. We need the specialists who do the things we aren’t trained to do, and honestly shouldn’t be expected to do. Unless one practices in a large urban center, every day at work is a mystery of specialist availability. In my job we have no ophthalmology, no oral surgery, no neurology on site, and perhaps most terrifying of all in terms of urgency, many days and nights we have no urology.

The paradigm of simply transferring what we don’t have works only until nobody else has those things either. And suddenly safety goes right out the window.

As our volumes explode and our patients implode, there’s simply no better way to keep them from crossing the River Styx than for us to have enough people doing the job. No amount of pizza parties, award certificates, ice-cream sundaes in the cafeteria, or photo opportunities will make things better. And none of that will help those physicians who are stressed to the breaking point by trying to do a hard job saving dying patients. Especially while being pressed to improve their metrics while administration considers bare-bones staffing adequate without asking the opinion of those seeing the patients.

Most important, when our hospitals hold themselves out as havens of safety for the citizens of the community, they owe it to those patients (or customers if they prefer) to truly make things safer. Especially when they bill them to the point of financial hemorrhage.

The only fair thing to do, the only proper thing to do, is staff the places with enough human physicians with the training, experience, dedication, and passion to do the job right. And to do it laying eyes and hands on the people who need them.