EM Mindset – Beyond the ED

Author: Anton Helman, MD, CCFP (EM), FCFP (@EMCases, EM Attending Physician, North York General) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

When I started practicing EM 16 years ago my mindset was a simple one: look for the most life-threatening diagnoses, settle on the most probable diagnosis, band aid the most urgent problems, and move the patient through the ED quickly. This approach seemed to work well most of the time. My chief was happy, and no one complained. But I soon found myself becoming unsatisfied with work and seeing many of the same patients return to the ED with the same issues again and again.

As I dedicated more time to EM education, I shifted my mindset to a more holistic one in which an open mind, better communication, and a longer view of how we can ensure better help for the patient after they leave the ED means a better experience for the patient – and staff, too.

The problem

Emergency Medicine has grown at an incredible pace as a specialty and we, the EM community, should be proud of what we have achieved. Nonetheless, we remain a “reactive” specialty in which fixing the most urgent acute illness or injury in the most efficient way possible, all too often trumps holistic patient care. This is understandable. Patient volumes have been increasing in Canada at a rate of 2-5% annually, and hospitals are under an enormous amount of pressure to minimize costs and resources. So our goal in treating an ED patient is often limited to returning them to their baseline status, moving them on, and getting to the next patient. We are very good at this, but we all know that returning the patient to their baseline will not necessarily prevent them from bouncing back with the same problem. Our research and education reflect this attitude: we focus on “hard” outcomes like short-term mortality and 30 day “serious event” rate. I often hear EM physicians teaching residents about the outcomes that “really matter”. We all too often neglect the important functional and mental outcomes: ability to perform ADLs, getting back to work, maintaining healthy relationships, etc.

I think it’s important to realize that it’s the most vulnerable populations who end up in the ED and who need the holistic care that we can provide most. As the population ages, older patients have accounted for an increasing proportion of the patients we see in the ED. Young adults with mental health crises and addiction issues are also on the rise. And with growing income inequality, we see poorer health outcomes for those with low incomes; this trend is unlikely to cease.

Proposal for an EM mindset: Enhanced communication, open minded compassionate care, and thinking beyond the walls of the ED

We are first and foremost doctors, and as doctors our job is to provide compassionate care for patients. In the face of some toxic work environments where specialties in their silos “push back” at each other to avoid having to take care of patients, we need to constantly remind ourselves that we have the privilege to work as doctors to improve the lives of our fellow humans. We should be working together for this common goal. The sooner the medical culture embraces this, the sooner we will be able to provide holistic care to our patients, not to mention developing improved work satisfaction for ourselves. In the U.S. EM has recently been ranked as the medical specialty with the highest burnout rate, and I believe that with a change in mindset we can reverse this worrisome statistic. The ED is the hub of the hospital and health care system where almost all specialties intersect. EM is perfectly situated to impact the general medical work culture positively.

Emergency medicine should be an outward facing discipline

The ED is the gateway into the health care system for millions of people and so literally plays a central role in the health of communities. One of the disadvantages of EM is that we rarely get to follow up with our patients. Seeing illness develop over time not only gives us a deeper understanding of pathologic processes, but helps us understand a patient’s needs more deeply. We need to be more aware of the circumstances leading up to and following an ED visit. Transitions of care need to be seamless, especially for vulnerable populations. We have an opportunity to extend the influence of EM beyond the walls of the ED and really impact important patient outcomes and efficiency of care, as well as improve population health in general.

Many EM residency programs have no training in communication and compassionate care, which is a major oversight in my opinion. Improved patient experience has been linked to improved patient outcomes in more than one hundred studies. Simply sitting down to interview patients, giving them time to tell their story, looking them in the eyes rather than at their chart or your computer screen, addressing their concerns and fears, and giving them a chance to ask questions make them feel like they are being taken care of as a human rather than a disease or illness. There are simple quick things we can do for our patients in the ED that could have lasting positive health effects like simply stating to all smokers who present with a smoking-related illness “your current illness is related to your smoking. Quitting smoking is the best thing you can do for your health, and we can offer you some resources to help you quit when you’re ready to do so”. Even if only 10% of the patients you say this to end up quitting smoking, you’ve probably prevented a whole lot of smoking-related illness that might end up back in your ED requiring huge resources. If we recognize the importance of patient experience (as opposed to patient satisfaction scores), our mindset will change from just fixing the most urgent problem to healing our patients.

I believe that we have a responsibility as doctors in general, and as EM specialists seeing patients at their most vulnerable moments in particular, to provide compassionate care and preventative advice and resources that can have positive effects beyond the walls of the ED. We can help motivate patients to take better care of themselves in a supportive manner and point them in the right direction.

Let’s grow EM as a specialty in which the art of medicine shines

We suffer from the delusion that near everything in medicine can be labeled, categorized, protocolized, and proven – that there is a “right” answer for everything. While there is certainly value to these attempts at making sense of all the data that we are bombarded with, emergency physicians need to embrace uncertainty; flex to new situations, issues, and problems that arise; and be open to alternate approaches, open to our patients’ points of views, open to the idea that one theory replaces another in science; and ultimately embrace that there is no such thing as “the right thing to do”. By adapting a mindset of enhancing our communication skills to improve the patient experience, keeping an open, flexible mind, and learning more about how we can help our patients after they leave the ED, we can provide true patient-centered care that will impact the overall health of our patients in the long run. Your patients will remember the positive impact you had on their health decades later. We have an opportunity in EM not only to impact morbidity and mortality in the traditional sense, but to have deep lasting positive impact to help our patients live their lives to the fullest, while setting an example for other specialties to work together instead of against each other, and enhance our satisfaction for the great work we do


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