The Pin Factory: Rethink Your Staffing Models

Licking old wounds is what you do at my age. This issue of EP Monthly explores the question of workforce, like it was a “terra incognita”. We have discovered a new problem! Eureka! This is like Christopher Columbus claiming he discovered America.

Emergency medicine needs to take bold moves in experimenting with new, more efficient staffing models.

Licking old wounds is what you do at my age. This issue of EP Monthly explores the question of workforce, like it was a “terra incognita”. We have discovered a new problem! Eureka! This is like Christopher Columbus claiming he discovered America. Sorry, Chris, there were seven million people living in the Americas who felt that they didn’t need discovering. The workforce issue is not new territory. Since the time when one man decided to concentrate on making the spokes while another one would make the rims for wheels, people have been debating the divisions of labor. Adam Smith taught us everything we need to know about this with his pin factory example in the Wealth of Nations.

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Like most other stiltified power structures, American medicine is 70 percent tradition and 30 percent productive output. After discussing this with many of my friends in multiple other disciplines, it appears that emergency medicine lies somewhere between the most tradition-bound institutions in the United States (i.e. the U.S. Navy) and those with no tradition and no common sense (i.e. social media).

I gave a talk 20 years ago just before becoming president of ACEP in which I committed the effrontery of suggesting that not all ED visits needed a nursing exam and diagnosis. You would have thought I had executed every listener’s first child. When I challenged tradition by saying that we should do real research on this issue I was considered un-American. Hello America, you can’t have it both ways. If there is a nursing shortage, then move nurses to where they would be utilized best, which is in the monitoring and management of critically ill and injured patients.

Let’s just try things. Let’s not be afraid of experimentation. In most emergency departments the workforce must change. The day of the technician is dawning. Ambulatory patients can be put in rooms and properly prepared for examination by techs. EKGs, splints, dressing applications, transportation and basic comfort care do not require an RN degree. If you think I am strong on this issue, I haven’t even started on physicians. Why a physician would be sitting at a computer baffles me. Why a physician would be getting equipment, looking at wound rechecks or anything that can be easily passed down the line is an embarrassment to the system. We can only afford so much and we need to use the resources better.

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I am convinced that 90 percent of what we do requires about 10 percent of a doctor’s knowledge. The only problem is deciding when that 10 percent is really needed. If I am wrong on this issue, bring forth that data for examination. Show me the literature which defends what we are currently doing. If we don’t have this literature, then we need to get it. Eighty percent of the cost of emergency department care is in the personnel that are involved in giving that care. Our selfish interests should not supersede the legitimate interests of the citizens of the United States in finding viable, sustainable and financially supportable methods of obtaining healthcare. We need to look dispassionately at the care so as not to be tainted with the aura of making money off the backs of the infirmed.

To not ask such questions is intellectual and moral cowardice. It reeks of self-serving doctor/nurse featherbedding of the worst sort. Much of the disease we see and the impossible social situations we are asked to resolve are tragic; there is no reason they should be unduly expensive as well. The human tragedy, I admit, is both our raison d’etre and our entertainment. Since Homer told us of Achilles mourning the death of his beloved Patroclus at the walls of Troy, we have both empathized and wallowed in the pain and suffering of others. Now we get to charge for it. America, what a country!

Human life is still tragic. Death remains omnipresent and inevitable. But the real question is: Shall medicine so control our passage and our journey through life that its existence should bankrupt the nation and enslave future generations? Do you need a doctor to close most wounds? Can we deliver a sensible, similar product for one-third the cost? We have made the process, not the outcome, the center of our attention and the focus of our desire. We have elevated what we do to the quintessential example of ‘noblesse oblige.’ The cost be damned as long as we take our share off the top.

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This vertiginal crisis is treated as if it was a scene from Aristotle’s “Poetics”. Too much drama for no change in quality. We have become slaves to mindless ritual instead of stewards of the societal resources. We believe, or have told ourselves the lie, that only the top of the tree can do anything in medicine. If this is the case, why don’t we have a headache fellowship-trained neurologist see every headache in the emergency department? You know why. The department would come to a screeching halt. It would stop. It would never move. And the outcomes would be no different.

So what is the right level of expertise and how much is the outcome really affected? We seem to be caught in an ego-based power struggle in which we defend our current rules and positions without asking any hard questions. Immanuel Kant contended that struggle is the motivational force for the human condition and the basis of all past and present civilizations. This high German myth of survival of the fittest – vulgarized by Hegel in his oxymoronic metaphor of combat – has forced us to obfuscate the true purposes of medicine, that is to cure occasionally, to manage mostly, but to care always without reference to who the caregiver might be.

The efficient utilization of talent should be our goal. Professional evolution – the idea that professional organizations succeed by defending turf – has taken us to the edge of an intellectual cliff. The barbican of the system has become detrimental to the system’s examining itself. Since cost and ultimate resources represent the 900-pound guerilla in the room, I propose some steps we should take to address problems head on.

First, emergency medicine organizations need to support experimental hospitals where alternative staffing models can be tested and employed. We publish literally hundreds of papers each month which have to do with mediocre science and very little change in healthcare. And yet the biggest problem in medicine today (i.e. its affordability and availability) lies before us totally untouched. These questions, like a land of dreams, are set to be explored if we have the courage to do so. But nobody seems to be able to find a way to fund it, and there seems to be no heart in such exploratory journeys. As an example, the current triage models in the country are out of control. I am certain there are hospital systems that have made triage work correctly, but these people aren’t publishing. Then there is the emergency medical patient record which has taken on a life of its own, without much benefit to the patient or to the greater system. We know these new charts can improve billing, but can they actually improve outcomes? We just don’t know yet.

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Secondly, we need to find cooperation between our academic institutions and the myriad of physician groups who are already extensively using PAs, NPs, scribes and techs. By working together we can accurately assess the quality standards, patient satisfaction, liability risks and outcomes within these staffing arrangement. I am asking us to not be afraid to ask questions when we don’t know the answers. If we are really interested in reasonable care for reasonable cost, it is the only way forward. If we don’t do the work and produce the data, someone else will, and I promise you will not like the answer.

But beware, there are forces abroad in the land who are already at work asking their own set of questions about these issues. The Walmarts and CVS’s of the world are looking at the question of where accountable care organizations may want to spend their money. If we believe we have a lock on this system, we have deluded ourselves. There may be huge amounts of funding at stake.

Emergency medicine has for too long spoken out of both sides of its mouth on the volume issue. We cry ED overcrowding, forgetting that we are a volume-driven business. Most hospital EDs in the country could not live on major emergencies. You need the “small potatoes” to pay the bills. At a recent visit to a residency, one of the “children” commented to me that he only wanted to see the big stuff, (i.e. gunshot wounds, major traumas, MIs) and let other people see the “old ladies who are weak and dizzy.” He asked where he might find such a job. I suggested he try another planet. Except for the handful of legendary hellhole hospitals in the country, most shops need to do it all. Most emergency doctors see less than five gunshot wounds a year in people who are salvageable. Most of us will need to live on small potatoes. If we do it right, we can make rather tasty meals out of those small potatoes. But it will only work if we actively use the time and talent of others to extend our reach and spend our time with those cases which have a crying need for physician-level expertise.

Emergency medicine started out as rebels with a cause. Over time we have established ourselves as a patient-based specialty. But do we still believe in this? Is the patient still the center? Is getting them proper care for a reasonable fee still a laudable goal? We should be leading this pursuit of excellence rather than waiting to see what scraps fall from the table of healthcare. If we are wise, we will be going to the government, hospital administrators and third party payers to propose change. The results of any other strategy will not be in our favor.

“Fortuna favet fortibus”
Fortune favors the bold