Question: Our Hospitalists and Emergency Physicians are feuding over the appropriateness of admissions from the ER.  How can we get them to work together better?

Answer: As a consultant, I’m frequently asked to offer insight on improving the working relationships between these two practices. The nexus of their interaction is the phone call regarding a patient needing an admission.  An amusing example of their respective perspectives is contained in “dueling” videos produced by two physician bloggers.

• The hospitalist perspective is offered on this Hospitalist vs ER Medical Video.
• The ER perspective is offered as a reply by ER Stories: ERP tries to admit a patient.

As the videos confirm, there is ample opportunity for conflict between the two. They frequently interact and the actions of one will certainly impact the workload, productivity, and efficiency of the other.

Attitudes and Objections

In addition to the barriers and objections to admissions posed by the Hospitalist, Emergency Physicians’ have other frustrations with the process. Those include:

• The time required for the Hospitalist to respond to the ED
• The use of Emergency Department space, equipment and personnel by the Hospitalists to conclude an examination prior to admitting the patient

The Hospitalists’ respond that they have a duty and obligation to effectively conclude whatever tasks they may be already engaged with when that call from the ED comes in, as well as one to the patients they may be have previously committed to see/treat/admit/discharge. They also insist that if they are to be the final arbiter of an admission, they need to have the means and opportunity to conduct a thoroughly examine before the patient gets to an in-house bed.

Common History and Interests

As two specialties and practices that share considerable history and circumstance, the antipathy that can characterize their relationships still comes as a surprise. Both are relatively new specialties, both came about, at least in part, as a means of relieving existing medical staff of on-call duties and responsibilities, and both have had to work extremely hard to convince medicine’s old guard that they are deserving of professional respect and appreciation.

Because of those commonalities (assuming they’re aware of them), no one is likely to be more sensitive to the plight of the Hospitalist than the ED Physician and vice versa.  For example, getting multiple admissions dumped on a Hospitalist just before the end of shift will certainly resonate with Emergency Physicians who have the same challenge in trying to conclude their shifts when the “bus pulls up at the ER.”

Before the advent of Hospitalists, many Emergency Physicians were expected to routinely respond to in-house emergencies in addition to seeing patients in the ED. In their efforts to be relieved of that duty, ER doc’s rightly argued that the expectation obligated them to be in two places at once, creating a potential claim of patient abandonment.  If they’re listening, Emergency Physicians should hear that argument echo in the Hospitalists’ dilemma!

Emergency Medicine was a “commodity” sold by third-party vendors long before it became a clinical specialty. In-Patient Medicine has that same heritage. As result, the hard earned improvements in the relationships between Emergency Physicians and Contract Management Groups (CMGs) offers significant lessons for Hospitalists in their dealings with Contract Services, if they choose to learn from them.

No Contact

In almost every engagement, my first revelation is the lack of communication between the two groups, their leadership and the physician members. Other than that phone call regarding admission or the occasional passing in the halls, the physicians typically have little interaction. As result of the “isolation” and as confirmed by the two video portrayals, the two specialties are convinced that no one (not another physician and certainly not administration) appreciates the unique demands and situations they encounter.

Given that lack of communication, one of my frequent recommendations is to increase that contact; the two physician groups need to recognize that they have much more in common than they may realize. Their appreciation of this reality could set the stage for a much closer alignment.

Both the ER Doc and the Hospitalist experience a common practice complication—the difficulty in getting specialist physicians and surgeons to respond. The two groups need to work together if they’re to effectively overcome the considerable financial and political clout of the surgeons and subspecialists. To do this they need to be allies, something that won’t happen as long as they constantly in conflict with each other.

Establishing and expanding communication between the two groups remains one of the best ways to convey that message. A good starting point is with leadership—the two physician directors should establish a regular schedule of meetings.

Meetings and Interactions

These meetings should also include the VPMA or another representative of the Administrative Senior Leadership Team. Their presence is suggested as a means of demonstrating the institution’s belief in and commitment to improving the effectiveness and efficiency of the relationship. Their being there also affords a conduit to the CEO and Board because the discussions are likely to reveal the need for changes to hospital policy, procedure, resources or facilities.

For example, the discussions may identify the need for a Critical Decision Unit so borderline cases can be observed until the appropriate disposition can be determined. They may establish the need to find alternative exam space (out-patient exam rooms, etc.) that could be accessed during peak volume hours when the ED is saturated. With that space plus nursing and technical personnel drawn from in-patient staff, the Hospitalist could conduct their admission examinations and do so without compromising ED operations.

Addressing questions about the appropriateness and timeliness of admissions should be a standard element on the agenda of the meetings between the two Medical Directors. Documentation on specific cases should be included for discussion, not just an exchange of rumor or anecdote. If questions persist about the legitimacy of admission requests/response, both the Emergency Department Medical Director (EDMD) and Director of Hospitalist Services should carefully and objectively examine the records to determine if their staffs or colleagues require additional supervision, training or education.

Routine information exchanges between the two groups can be extremely effective in providing exposure to the circumstances and conditions that characterize the respective practices. Many Hospitalist Practices have mid-day “stand-ups” that allow for communication between multiple Hospitalists. Having an ED Physician in attendance could improve the individual physician relationships. It could also help coordinate manpower utilization and scheduling so both services are better able to react when demand is high.

The Emergency Medicine Practice typically has monthly meetings, either in conjunction with the Emergency Department Staff or as a function of the group practice. Having a Hospitalist participate during that meeting could dramatically change the attitude and impressions of ED personnel and the Emergency Physicians regarding the life and times of the working Hospitalist.

You may want to determine if the Emergency Physicians are aware of the Hospitalists coverage hours and shifts? Ask if the Hospitalists know about the coverage pattern in the ED? Have the two compared those schedules to see if they’re ways to rearrange coverage to better respond to the needs of the patients and the respective physician services?

Compensation Complications

In its early years, Emergency Medicine was an hourly wage specialty. While some ER docs continue to be paid that way, most have now migrated to some form of “productivity compensation.” Because their pay is tied to the number and acuity of patients they see, anything that reduces their productivity by delaying deposition of patients or by occupying ED space or resources is going to be problematic.

In contrast, compensation methodologies among Hospitalists appear to be less uniform. Some are salaried; some are paid by the shift, others by the patient or by RVU.

If the ER staff and physicians “believe” that the Hospitalists income is “fixed” (either salaried or paid by the shift) such a perspective (whether accurate or not) will lead to the view that the Hospitalist is non-responsive because there’s no incentive to see new patients. Conversely, salaried Hospitalists may view an Emergency Physicians demand for rapid response as motivated solely by money. Such opinions enable negative attitudes that then provide the justification for resentment, resistance, even sabotage.

Administration may want to examine the respective compensation methodologies to determine if such differences are a contributing factor in the dysfunctional relationships. If so, an effort to align the incentives could significantly improve cooperation and performance.