March 27, 2019

Expanding the Reach of Emergency Medicine

This is a piece on observation medicine as the expansion of our specialty. My oh my, have things changed since my days of training where I learned to care for all comers irrespective of their money, background, color or creed. I learned to stabilize, evaluate and treat, then admit or discharge. Clearly I’m simplifying, though historically our disposition decision was binary, patient in or out.

Then over time as I practiced emergency medicine and grew in my career, I became exposed to the business side. The business side is complex and includes payors, contracts, utilization reviews, denials, audits, and the often thin margin between making versus losing money for a hospital and healthcare system.

So how did this become my world? Well, I was given a unique opportunity to start an EM-run observation unit two years after finishing residency. This was a risk for me as I had no formal background as to what observation even was and I was still ‘young’ in my career. At that time, I was a new mom, newish wife, relocating to a new city. Perhaps because of all the change and ‘newness’ around me, the entrepreneurial bone in my body asked, why not? I would also like to give credit here to meeting an exceptional mentor who was supportive of me and she also exuded a ‘why not’ attitude.

Over the next years, I’ve gone through numerous observation service expansions and though there is an obvious business case for this, my passion has been creating a new space for education and application of evidence-based emergency medicine. These are our bread and butter patient presentations. We care for people with chest pain, syncope, asthma, COPD, cellulitis, dehydration, heart failure all the time and now can continue caring for them. Moreover, we have expanded to care for more complex presentations like atrial fibrillation, pulmonary embolism, gastrointestinal bleeding, sickle cell pain crisis, TIA. We apply rules and our EM gestalt for best practice patient outcomes.

Our observation unit is home to learners and teachers. We have EM interns, medical students, APP students, social work students, occasional IM seniors spend time in our unit learning to apply evidence-based care and assure safe transitions in addition to just making the diagnosis. Our teachers are also leaders in simulation, ultrasound, resident education, healthcare delivery research, performance and quality improvement, and community outreach. We talk about what’s next, does this patient need a test and why we coordinate care so people have safer transitions to their homes or elsewhere, get them to primary care, or a specialist or consult a specialty when it’s not possible. We even have a fellowship.

So seven years later, another job opportunity, another kid, another new observation unit, here is what I would like to share. The spectrum of emergency medicine is ever expanding. We truly care for patients in ANY setting; during disasters, overseas, in the wilderness, in urgent cares, through video interfaces, in your typical ED, AND in observation units.

We are unique and our reach is expansive. So no matter what your passion and what opportunities arise in this great field of ours, ask yourself – why not?

By Maria Aini, MD