On the Verge of Collapse

A System on the Verge of Collapse

‘COVID-19 has laid bare medicine’s house of cards’

by Dr. Sharon Anoush Chekijian 

I

OFTEN FEEL like the proverbial canary in the coal mine, acutely aware of how broken medicine is in this country and wondering if anyone else has noticed. I’ve been an emergency physician for the last 19 years, but increasingly, my job has felt different from what I trained to do. Emergency physicians are self-described adrenaline junkies. Our world revolves around trauma, stroke, sepsis and heart attacks. Little by little, however, our world has changed.

Even before the pandemic, it felt like the emergency department was shouldering the lion’s share of primary care: We’d treat hypertension, refill prescriptions when calls to the doctor’s office went unanswered and manage chronically elevated blood sugar. Behavioral health patients with nowhere else to go would arrive one after the other by ambulance. Eager to help our patients, we started offering drug and alcohol treatment programs. Victims of our success, we find that primary care physicians now seem likelier to send patients to the ED than to try treating them in their office. And it’s understandable, given the inaccessibility of outpatient radiologic and lab testing for urgent issues.

In dire straits. The U.S. medical system has long been tenuous, with signs of malfunction everywhere. Despite exorbitant spending, this country lags behind peer nations in critical health indicators such as life expectancy and chronic disease burden.

When the Affordable Care Act was enacted in 2010, we were hopeful. The system was about to be overhauled and streamlined, with optimism that all patients eventually would have a primary care home with electronic records that would follow them everywhere and seamlessly interface with multiple systems. Except that quantum leap never came.

Now COVID-19 has laid bare medicine’s house of cards. We are on the brink of disaster.

In the ED where I work, days typically start with 120 patients – most of them “boarding,” or waiting for a bed upstairs in the hospital. Our ED only has 53 beds to begin with. This means having nowhere to see the new patients who start floating into the waiting room that, if we are lucky, has just been emptied from the day before. By the time the floodgates open at 11 a.m., we are bursting at the seams.

More recently, we’ve stationed physicians, physician assistants and nurses in the waiting room to see patients. We even see them in the ambulance bay. Sometimes patients stay there for hours, unable to move into the ED. Because there is little hope a room will open anywhere in the ED to afford them the care they need, we start caring for them wherever we can – hallways, triage bays and waiting rooms included.

We take chances when we send patients home, hoping their oxygen level will hold, that someone else can take a look at their skin infection the following day after starting antibiotics, that they understood our instructions on how to manage their high blood sugar.

It may sound like we have a local problem in our ED only. There must be a management issue, a quick fix that an astute

hospital administrator can improvise, and we will be back to normal, caring for patients at the standard to which we are all accustomed. The truth is: This has become a national problem. Our ED is not alone. On social media, colleagues from all over the country are bemoaning the same situation.

Medicine’s house of cards has already started its crashing descent into collapse. We didn’t go into emergency medicine to care for patients this way, and they certainly didn’t come to us expecting the care we are struggling to provide. So what are the solutions?

Sounding the alarm. Institutional leaders, insurers and lawmakers need to recognize emergency department crowding as a critical patient safety issue. Triggers that activate disaster protocols should be expanded to include indicators of crowding so resources can be directed toward minimizing boarding. Financial incentives must be aligned to encourage swift discharges with appropriate and timely follow-up. If the system is unable to accommodate adequate, timely outpatient testing for urgent complaints that are not life-threatening, then we need to find the pain points and create solutions. Capacity and turnaround times for outpatient labs and radiology must be examined and improved.

In addition, both public and private insurers must incentivize every one of their patients to have a primary care physician. In turn, primary care doctors’ offices must increase capacity and access for urgent cases. Primaries and specialists should consider judiciously whether to urge their patients to seek care in the emergency department for imaging and testing that could be accomplished on an outpatient basis. Patients themselves need to consider responsible use of the ED, though it’s not simple, especially for those without easy access to medical care.

Our fundamental system must change, or the penalty will be the collapse of not only the system but the doctors, physician assistants and nurses who have been waging this Sisyphean battle as well. Instead of waiting for someone to sound the alarm, I am doing it now. Consider yourselves warned. l

Dr. Sharon Anoush Chekijian is an assistant professor of emergency medicine in the Yale School of Medicine and a Public Voices Fellow with The OpEd Project.