In the March episode of ACEP Nowcast, I spoke with Luke LeBas, MD, FACEP, about our opposing viewpoints on waiting room medicine. The inevitable fallout of boarding is that now there are no beds in which to see patients. So, we deploy forward into the waiting room.
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ACEP Now: Vol 42 – No 04 – April 2023As a department administrator, I took a “pro” approach to waiting room medicine. I tried to convert waiting room medicine into a streamlined process so that our doctors could see more patients safely. Dr. LeBas—who lives in New Orleans and has worked at a Level I tertiary care, academic trauma center for over 11 years, recently transitioned to a 50,000 visit community hospital, and also moonlights at a rural access hospital—took the opposite viewpoint.
The following interview has been edited for clarity and space.
Dr. Amy Ho: What makes you so staunchly against waiting room medicine, knowing that you and I agree boarding is here and it’s a problem?
Dr. Luke LeBas: I’m against it, but I do it. As much as I don’t enjoy doing it, as much as I don’t think it’s good for the patient, it is absolutely a necessity. We’re not just abandoning people to flail out in the waiting room. I like to think that I do what all emergency medicine doctors do—we make the best of a bad situation. We bring care to the patients where it’s needed. We are problem solvers. We are MacGyver individuals, and anytime a system is broken, we will make it work. Now, that goes back to why I don’t like waiting room medicine. At least at places that I’ve worked, it’s always been the emergency department had to bend over backwards—bend and don’t break to make up for the shortcomings within the hospital. But the entire hospital’s problems shouldn’t be laid on the shoulders of the emergency doctors.
Dr. Amy Ho: I can appreciate that. I think I have a little bit of bias because my background is actually in administration. Most everyone knows me from my role with ACEP Now, but in my day job, I work for a medium size medical group that’s physician owned, physician led, and founded by a physician, which I think really slants how we approach these issues. I came up in administration fresh out of residency doing an administrative fellowship and then worked as an assistant medical director and kind of made my way up in day-to-day operations. But, we accepted that it was inevitable. We are literally the specialists at making things work, but we also know that holding patients as collateral as a way to ransom the hospital into trying to come up with solutions isn’t part of the narrative we want to put out there.
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5 Responses to “Pros and Cons: Waiting Room Medicine”
April 16, 2023
John Patrick MD FACEPI was disappointed that there was very little said in the discussion about what is best for our patients
April 16, 2023
Mark Melrose, DO, FACEPDear Dr. Ho-
I come from a similar background as you- EM trained, spent most of my 35 year career in ED Director roles- academic, urban community, suburban community, public hospital, and founder/owner/operator of urgent care practices. I am now back in a purely clinical practice in an urban academic, tertiary care, well resourced specialty hospital. The issues you describe are indeed real world EM concerns, however there is one thing you stated as the basis for your value proposition on WR medicine that is so off base that I had to write this reply. “…But we also know that holding patients as collateral as a way to ransom the hospital into trying to come up with solutions isn’t part of the narrative we want to put out there.” FALSE!!! Patients are indeed held ransom daily by our ED’s, because they have nowhere else to go. In my urgent care practice, people would walk in, and turn right around and go somewhere else if the wait time was too long. It was money out of my pocket, so we made sure people didn’t wait. Our ED’s and ED patients will always be hostages as long as inpatient capacity is a slave to surgical revenue stream, and boarding is an ED problem, not a hospital-wide problem. If WR medicine was “best practice”, inpatient hallway medicine would be a thing, and private rooms would be doubled up, everywhere, everyday.
Yours truly,
Mark Melrose, DO, FACEP
April 16, 2023
GW MDLet’s be honest. This conversation is like the choice of only eating fast food and people arguing whether McDonalds or Burger King is better. Sure, you don’t want to starve. But how about not eating fast food at all.
What are the current interests and motivations of hospital leadership?
Let’s take an auto factory. Imagine one part of the factory has workers and processes with set hours.
In another part of the factory, you can run the workers into the ground, force them to build extra cars at all hours of the night, and they can’t say no.
Would you overwork that other part of the factory? Of course you would.
Want to fix this problem overnight?
1. Claw back the past 5 years of bonuses for the CEO, CNO, CFO, COO if there are more than 5 boarders 30 days of the year.
2. Not allow the CEO, CNO, CFO, COO to leave the hospital if there are any boarders in the ED.
3. Forced firing of all 4 of the above if there are more than 5 boarders 60 days of the year.
I guarantee you, the boarding problem would get fixed very very quickly.
But currently, the financial incentives are to maximize boarding. It’s a win-win for admin whatever they may say.
Elon Musk and Spacex are building self landing rockets. Boarding is just not that difficult. It hasn’t been fixed because the motivations are not to fix it.
And then it’s left to us to have these discussions of whether we should be taking care of patients with +trop’s, appendicitis, and sub arachnoids in the waiting room (yes, we had a SAH we were managing in the waiting room in the recent past).
April 23, 2023
Kevin C Meyer, MD, FACEPYou’re both saying the same thing, one glass half full and the other half empty.
I’ve done both clinical and admin over the years within different systems. Some systems are definitely more metric focused and do a better job than others.
Bottom line is that waiting room medicine (hallways too) is terrible for us and the patients. Fundamentally, hospital CEOs are convinced that a shift from inpatient to outpatient care is the future. I would argue that patients don’t know that. We are the center of the medical universe. Physicians in the outpatient setting cannot keep increasingly complicated patients from the ED, but actually encourage them to go if they are concerned.
We need to focus more staff and money on EDs, observation/respite units, and social workers. Make specialty ED in person consultations normal. Let telehealth and AI be the main stays of outpatient care.
We’re doing it wrong and those in charge are thinking about the future of medicine wrong.
January 12, 2024
N. Newman, MD“I think waiting room medicine, if you do it efficiently, shows our partners that we’re here doing our best.”
The fact that “waiting room medicine” is necessary demonstrates that the ED is not efficient and they system as a whole is functions poorly.