Sunday, 7 a.m.: On any given Sunday morning, I expect to arrive for my emergency department (ED) shift to a department in disarray. There’s a certain colliding of worlds that happens — the wreckage of Saturday night debauchery gone awry; the well-meaning offspring who visited an elderly parent only to notice that something is a bit off; the recognition that the weekend is ending and a sore throat hasn’t improved. This has always been the modus operandi of EDs. ED staff take pride in their fly-by-the-seat-of-their-pants, MacGyver-esque ability to flex with whatever walks or rolls through the door.
Lately, however, something is different. Go to any ED and you will find it bursting at the seams. The waiting room will be filled with languishing patients, and the wait will be long. This contrasts with the physician encounter, which is likely to be brief. You may have to cut off your patient mid-sentence; your speech is pressured and you move quickly.
The days when all patients were evaluated in a room wearing a gown are gone; they’re just as likely to be examined fully clothed in a hallway. The service is rushed and prioritizes rapid customer turnover; the quality is hit-or-miss; it doesn’t feel like an investment in long-term health and, given the beleaguered staff, it doesn’t seem invested in its employees either. It feels like a fast-food version of emergency medicine.
And yet, for anyone inclined to chuckle or raise their eyebrows, I should point out that the fast-food industry evolved as a direct counterpoint to more traditional high-end restaurants, and it has some distinct advantages over its sit-down alternative. It’s extremely convenient — it doesn’t require reservations and it might even be open all night. It’s more economical.
Interaction with fast-food staff might be more transactional or even automated, but there’s generally efficient delivery of a highly standardized product and experience. You get exactly what you’re expecting when you walk into a fast food place. Of course, all of this is accomplished at a price — speed over quality, consumption of a product that really isn’t good for you.
The Problematic Evolution of Care
For most of human history, healthcare has followed a fine-dining model, with a highly personalized, curated experience. A century ago, physicians visited patients in their homes. Medicine subsequently became more specialized, but the essence of the patient-physician contract remained unchanged — until someone rightly became concerned that the fine-dining approach to healthcare was exorbitantly expensive and quite inequitable.
What followed was an era of countless fixes aimed at achieving the affordability, efficiency, and consistency of a fast-food joint while maintaining the quality of a fine dining establishment: standardized guidelines, outcomes tracking, cost analyses, virtual visits, the electronic medical record, integrated care delivery, specialty centralization, fast tracks for low-acuity patients, value-based medicine, and patient-centric care. Even the legendary Atul Gawande, MD, MPH, jumped into the fray with a vision of fast-casual medicine.
Unfortunately, this decades-long, well-intended effort to fix healthcare somehow saddled our EDs with the worst of both dining options: long waits, limited or strained interaction with staff, an experience that is neither consistent nor highly personalized. It’s not the kind of experience most patients want, and it’s exceedingly frustrating for staff.
I might arrive for a shift and be asked to evaluate four patients in various states of distress within the first 30 minutes — only to be interrupted by an ambulance arriving with a patient in respiratory failure — only to be interrupted again by multiple texts from staff asking if I know four patients are waiting for me (for the record, I am always aware when there are patients waiting for me. It’s part of the job). Not to mention it’s also one of the most expensive locations in healthcare to receive medical services.
In an ideal world, accessing healthcare — emergency or routine — would be convenient. It would yield high-quality results. Patients would feel validated and supported. Healthcare organizations would invest in their people, with an emphasis on long-term well-being. This, in turn, might yield thriving, plentiful healthcare workers. We might even see medicine join the fight to combat climate change and other social injustices, given their devastating health effects. But at the moment, we are struggling with all of these objectives. And caught in the middle is a rapidly dwindling healthcare workforce.
Over the past decade, attrition among healthcare workers has sharply accelerated, and there is now a severe shortage of physicians across the nation. Older physicians, scarred by burnout and moral outrage, are hastening their retirements and cutting back their hours. Younger physicians are increasingly poached by other industries, such as research, marketing, or business consultancy. In a recent survey, 25% of U.S. medical students were considering dropping out of school, and globally, 54% envisioned a career that did not involve directly treating patients.
None of this is helped by the fact that entry into the profession remains highly limited due to small medical classes and arduous licensing requirements. Unlike the restaurant industry, healthcare does not have a vast labor pool to recruit from: the average training time for a physician is nearly a decade. With emergency medicine consistently ranking #1 in burnout, it’s hard not to worry about the future of my specialty.
EDs Can’t Do It All
I have no visionary solutions for how to fix our EDs, or how to right this ship that has listed so badly. I can only offer my perspective as someone caught in the middle of it for two decades. I wish I knew how to convince young physicians it is just as fulfilling to work at the bedside as in the tech industry. I wish I could spend more time with each of my patients and care for them in a manner that supports their dignity as well as my own. Just as I wish that I didn’t see some patients — the frequent flyers — in my ED every other week. I wish I could do more to ease the despair reflected in my patients’ faces as they line up in our waiting room.
What I do know is that emergency medicine can’t be both a high-end restaurant and a fast-food joint. We can’t do it all.
Here is the inconvenient truth: providing a version of emergency medicine that is satisfying to customers, staunches healthcare worker attrition, and fulfills the basic requirement of promoting long-term well-being is going to mean making some difficult choices instead of trying to have it all. It’s going to require compromise — something Americans are not used to accepting when it comes to their healthcare. It’s going to require a revision of what many of us consider the definition of “emergencies” and the purpose of EDs.
It may mean that each of us will have to forego some fast-food convenience, including longer waits than we might hope for, physician extenders and other non-physician clinicians, or technology solutions that might not be our first choice but add bandwidth to the system. Perhaps it means that the various specialties and silos in medicine come together to use their collective voice to foster a vision of high quality, sustainable healthcare. It will almost certainly mean that the right hand begins talking to the left.
And it may be that if we start prioritizing what we really care about, we just might wind up with something that everyone can live with. Because fast-food medicine doesn’t work.
Sunday, 8 a.m.: I pull up a chair next to a woman and lean in, trying to create a cozy atmosphere that ignores the crowded waiting room surrounding us. “I’m sorry you’ve been waiting a while,” I say. “It’s been a bit hectic this morning.” I am gratified when she cracks a smile. Then I get down to business. “I’m also sorry you haven’t been feeling well. I’d like to hear more about what’s going on and see if we can find a way to help you feel better…”
Mary C. Meyer, MD, MPH, is an emergency medicine physician and the former director of emergency management for The Permanente Medical Group, Kaiser Permanente Northern California. This perspective is the author’s alone and does not necessarily reflect that of any institutions or companies with which she is affiliated.
Please enable JavaScript to view the