Wu’s Views: What Are the Greatest Obstacles Facing EM Educators and Administrators?

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Drs. Teresa and Tina Wu are sisters who both went into emergency medicine. Now, one is a teacher while the other is an administrator. Here they share their candid discussion about the challenges of the emergency physician life. 


Dr. Teresa Wu is an associate professor in emergency medicine and the simulation curriculum director at The University of Arizona, College of Medicine-Phoenix

Dr. Tina Wu is the associate chief of service and the director of quality improvement at the Perelman Center for Emergency Services at New York University’s Langone Medical Center.


What are the great obstacles currently facing educators and administrators? 

Teresa Wu: As educators, we are faced with the same pressures, metrics, and expectations as our colleagues who are working in clinical practice without residents and medical students. We are running a department and serving as the captain of the ship, but we have to hit the pause button regularly throughout the day to teach, supervise, and mentor.

Gone are the days of in-depth bedside teaching and white board rounds with the department. As we are teaching, we are fully cognizant of the fact that patients are continuing to come in and the waiting room is filling up. Do we take the time to teach our resident how to do an ultrasound guided paracentesis when it is much faster to send the patient to IR and open up a bed for the next patient? Do we send the patient up to the ICU immediately or do we make the time to teach the medical student their first ultrasound guided central line? It is always much faster to click the button to order the CT scan of the abdomen and pelvis versus walking a resident through a good physical exam and history to determine if the patient actually needs the CT. Having good senior residents on the team can help expedite patient care, but more junior residents and medical students can also slow down the departmental flow. It takes time, energy, and patience to teach.

In clinical practice, it is easier to establish a good rapport with your patients if you are the only physician caring for the patient. Throw in medical students and residents, and just because of the pure increase in the number of people delivering a message, we increase the chance of misinterpretation or miscommunication. As educators, we are held accountable for our patient satisfaction scores, but we can’t control the interpersonal interactions between our trainees and our patients. That being said, sometimes having multiple providers deliver the same message has more impact. Patients get to hear their care plan in various ways from different providers and have the opportunity to digest and ask additional questions on subsequent re-evaluations from different members of the team.

As an educator, I know that the end result is worth all of the effort and time it takes to overcome these obstacles. It is an investment into the future of our patients, our community, and the health care delivery system we have been entrusted to grow.

Tina Wu: Outstanding teaching and efficiency aren’t mutually exclusive, Teresa. In this new era, some of the best educators are those who have learned just how important it is to impart knowledge effectively. After working a clinical shift, I acutely feel the frustrations of the other providers. Why does the volume fluctuate so much and why are we understaffed? Why are admitted patients boarding for days in the ED? Why do I have to tick off a hundred compulsory boxes to write one note about a patient’s cold? I used to blame the administrators for these inefficiencies. Now, I’m one of them.

Historically, the relationship between clinicians and administrators has been contentious, an “us versus them” mentality. “They” sat in their ivory tower, passing along edicts that didn’t take into account the practicalities of everyday clinical practice. When I accepted a position as a hospital administrator, I wanted to be empowered to fix the inefficiencies in the department for “us.” But balancing opposing priorities is a constant obstacle. It is difficult—perhaps impossible—to reconcile quantity with quality, patient satisfaction with safety, and thorough documentation with patient contact. Operational improvements are constantly stymied by mandatory tasks, like CME, paperwork, and credentialing. I became an administrator to create long term improvements and to be a patient and staff advocate; instead, the hospital pressures me to hound attendings about completing online HIPAA modules. Every distraction from my core responsibilities makes me inefficient and ineffective.

But framing and aligning incentives is a divisive responsibility that I welcome. “Metrics” has become a dirty word. Clinicians resent administrators constantly monitoring their every decision, tabulating their mistakes. But I believe in critically analyzing our department and withstanding the uncomfortable scrutiny of a high performing hospital. If I take my dad to a surgeon, I want to know the surgeon’s “metrics”: morbidity, mortality, hospital length of stay, pending lawsuits, and resident satisfaction scores. We all agree that there is a bell curve of medical student and resident performance. Yet some deny the extreme variability among attendings; we mask mistakes with “individual practice variability.” While Medical Directors should not be considered the Program Directors of attendings, we do manage complaints, bouncebacks, and missed diagnoses, collating the data into meaningful, specific feedback. As an administrator, I want to transform the perception of “metrics” from punishment to opportunities for improvement.

I still instinctively cringe when people call me an administrator. I consider myself an educator, a clinician, and an operational aficionado who answers to the leadership of the department and hospital. But if that title is a mouthful, I can be called a relationship counselor. At its core, my job is to prevent differences from ever becoming irreconcilable, whether that’s facilitating the relationship between administrators and clinicians or balancing operational efficiencies with compulsory duties. By bridging the gap between “us” and “them,” I can create objectives that align with both parties’ interests.

Teresa: Tina, as they say, it’s complicated. Take patient satisfaction, for example. In clinical practice, it is easier to establish a good rapport with your patients if you are the only physician caring for the patient. Throw in medical students and residents, and just because of the pure increase in the number of people delivering a message, we increase the chance of misinterpretation or miscommunication. As educators, we are held accountable for our patient satisfaction scores, but we can’t control the interpersonal interactions between our trainees and our patients. That being said, sometimes having multiple providers deliver the same message has more impact. Patients get to hear their care plan in various ways from different providers, and have the opportunity to digest and ask additional questions on subsequent re-evaluations from different members of the team. As an educator, we know that the end result is worth all of the effort and time it takes to overcome these obstacles. It is an investment in the future of our patients, our community, and the health care delivery system.

Tina: I disagree that “we can’t control the interpersonal interactions between our trainees and our patients.” Professionalism is a core dictum of our specialty and we fail as physicians if we cannot improve our interpersonal interactions with patient. We shouldn’t be sprinkling benzos and opioids on our patients – adequate communication cannot be over-emphasized. I used to blame certain inefficiencies on leadership. Now, I’m one of them.

ABOUT THE AUTHORS

EMERGENCY ULTRASOUND SECTION EDITOR
Dr. Wu is an Associate Professor and the Simulation Curriculum Director at the University of Arizona College of Medicine-Phoenix. She is the Director of the Emergency Ultrasound Program and Fellowships for Banner University Medical Center-Phoenix and the creator of the app SonoSupport. Dr. Wu is the Emergency Ultrasound Section Editor for EPM.

Dr. Wu is the associate chief of service and the director of quality improvement at the Perelman Center for Emergency Services at New York University's Langone Medical Center.

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