Perhaps the greatest influence on the practice of emergency medicine will be how, where, and to some extent when, we fit into the emergency medicine system. Beyond the doors of the emergency department there are many influences related to the organisation, commissioning and expectations of the emergency service. Some of these can be influenced by the emergency physician, but for others the influence of societal and political factors will be significant drivers to practice in the coming decades.
How do we define what an emergency physician does?
Virchester is an ECNO centre, we don’t do ECMO and in truth I think we are typical in that regard. Despite a feeling of inadequacy when trawling through #FOAMed twitter feeds where it may seem that every ED has a full ECMO service we don’t. Recently we decided to explore whether ECMO is something that we want to pursue, we are a trauma centre and cardiac centre with a large catchment area and so there it seems likely that this is something that we should explore. In days gone by a group of clinicians would come together to make this happen, but these days it’s different. The financial repercussions are now much more closely scrutinised, tariffs are calculated and the impact on this on other services are considered before any orders are placed. The project remains stalled despite the enthusiasm of clinicians.
This is a really important question for the future as we look to define and visualise the scope of practice for the future emergency physician. The work that we do, the type of patients we see and the length of time that we look after them is only partially controlled by the emergency department and the clinicians within it. Take RSI for example, it appears to be a standard of practice in the US, Australia and Canada, but remains controversial in other parts of the world where that skill set is ‘owned’ by other specialities. Such variance extends between and within health systems. Taking the RSI example further it’s evident in the UK that practice varies dependent on the skills mix and local politics evident within and between specialities.
Multiple factors affect what we do. The way that we are trained, the interaction with other specialities and the organisation of health care services have a profound impact on the scope of practice, and in many ways explain the variability in experience and exposure that we experience. An inevitability perhaps, based on the history and organic growth in practice scope over time.
What of the future though. In recent years the local variance has been challenged as better systems to compare and contrast services have developed. In developed systems metrics linked to health outcomes and payment schemes are defining and in some cases limiting the scope of practice that we undertake.
Ultimately the work we do is driven by the targets, funding, society and finance of the health economy we inhabit.
Organisations, targets and outputs.
Emergency medicine is increasingly confined by time based process targets, with the UK being the most familiar with this concept through the 4-hour target. Now don’t get me wrong the 4-hour target was arguably one of the best things that ever happened to emergency care in the UK. In a non-fee paying system the target allowed a link to be made between resource availability and performance and as a result the investment in staff and facilities has been very welcome. It has also led to the increase in senior emergency physicians and thus the scope of what can be delivered within the emergency department. Advanced techniques, decisions and technologies require a more senior and stable workforce and this has certainly been a feature of UK practice. The sustainabilityof the workforce is challenged worldwide. In the UK, as workload and complexity have increased retention has been a problem both for trainees and for senior doctors and nurses. Similarly rates of burnout the UK and other nations is on the rise as the challenge of maintaining a satisfying career in emergency medicine appears to rise through a career.
It’s the economy, stupid.
When Bill Clinton’s campaign strategist coined this phrase in the 1992 US presidential election it struck a chord and helped push him to the White House. In just a few words the underlying driving force for all that we do is clear. In emergency medicine, like everything else is based on the appetite and ability to pay for it.
As an aside Bill Clinton’s campaign had three themes. 1. Change vs. the Same, 2. The Economy, stupid, 3. Don’t forget Health Care. It seems little has changed in 24 years!
In many health care systems emergency care can be seen as a direct or indirect income generator. Even in the UK where much emergency care is funded at a loss then there are still financial incentives for conditions such as major trauma (current tariff for a major trauma patient in the UK is about £1000), yet in order to be a trauma centre a hospital must have the required associated speciality and the lack of trauma specialists in the UK means that these clinicians are similarly engaged in more lucrative elective work. Yet such links are tenuous and they may easily be broken at the whim of political
In the UK we clearly have problems, but similarly the US, Canada, Australia and others are experiencing changes to treatment and investigation tariffs (in some form or another) with this being perceived as threat to the provision, scope, capacity and most importantly the quality of emergency care.
At a disease level we have seen the development specific therapies that divert patients away from the door of the emergency department. In cardiac disease the role of PCI is now well established in many health economies. More recently the more controversial but seemingly now well established use of hyper acute stroke centres combined with prehospital triage is streamlining patients with obvious pathology to the door of definitive care. We may see this trend continuing as other conditions and specialities seek to develop condition specific services. It has already been proposed that centres for sepsis, cardiac arrest and geriatrics should concentrate work with patients directed from the prehospital setting direct to specialist units. Perhaps the most obvious redistribution in large cities has been the development of both the speciality and geography of paediatric medicine which is actively distancing itself from the core of emergency medicine practice.
A new breed of clinicians, the so-called resuscitationists are similarly carving a niche out for themselves. Is this driven by a clinical need, an economic reality or a clinician preference? Reminiscent of the phrase ‘I’d rather be in resus this approach is understandable, linking back to the reasons why many of us chose a career in emergency medicine, but is it a sustainable reality?
It is in the nature of clinicians to restrict their practice as they mature. With emergency medicine being a relatively young speciality, and with the majority of clinicians only now approaching their senior years this sub specialisation trend is likely to continue as they pull back from the enormity of the widespread curriculum of emergency medicine into more limited areas of expertise. This trend to sub-specialisation may be driven by personal insecurity, aspiration or even limitation as much as clinical or economic requirement.
Whatever the reasons the likelihood is that, within large centres of population, emergency medicine will fragment into sub-speciality units and scope of practice. The implications for training and revalidation are clear. In 5 years time the concept of what an emergency physician does may be very different to that which exists today.
It’s about the money stupid.
Ultimately care follows the cash. The demographic effects of an increasingly complex elderly population combined with a diminishing clinical workforce will challenge our ability to deliver the scope of care that we might aspire to.
Although investment in emergency care has been substantial in recent years, the rise in attendances has outstripped and financial uplift. Hospital based emergency care is increasingly viewed as a bottomless pit for which alternative providers could deliver better, safer and cheaper care. Sadly, there is very little evidence regarding the effectiveness of alternatives to the emergency department.
The public expectation
To date we have largely acceded to the wishes of patients and families in the extent and cost of care but this is unsustainable. A wider and more public conversation is required to define the limitations of care, not just for individual patients but also for the population at large. If we are to aspire to equity in a resource limited society then such equity exists at both ends of the spectrum. If we are to ensure that everyone achieves the basics then that does mean that a minority will not get the best. Can we fund ECMO services at the expense of basic sepsis care? Such conversations are politically challenging, but they must come soon.
SMACC has excelled in addressing the questions of limitations of are around critical care, but a wider conversation is required for all of us in the emergency system.
There is some debate about why the characteristics of EM practice is changing and I have argued that fragmentation, scope of practice and alternative providers are significant influences. This will vary between different health care systems but there is no doubt that increasing complex health care systems may lead to unintended consequences and behaviours.
In the UK the King’s fund’s video on the current issues regarding performance, access and patient volume is interesting and although I’d argue with the data (there really has been an increase in attendances), it’s a useful overview to the way a complex system is struggling to meet the requirements of the population.
The key messages are in the video, complex systems are confusing for patients, have inherent inefficiencies and simply increasing capacity may not result in increased performance.
Funding Emergency Departments in England – why the current system is failing our patients and what needs to be done about it (July 2013). Royal College of Emergency Medicine.
What’s going on in A&E? King’s Fund. UK. 2016
An alternative guide to the urgent and emergency care system in England. King’s Fund. UK. 2016
The mind of the Resuscitationist. Scott Weingart. SMACC 2013.
Paediatric emergency medicine: Do we need George Clooney? Ffion Davies
Emerg Med J 2001;18:157-158 doi:10.1136/emj.18.3.157