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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.
I think waiting room medicine, if you do it efficiently, shows our partners that we’re here doing our best. And when I say partners, I mean our partners in hospital medicine, our partners in social work, our partners in the ICU, our partners in EMS, and our partners, obviously, in administration at the hospital level. But, I think playing nice makes it so that having finesse in waiting room medicine helps the overall problem. A lot of time that I spent was working on, how do you make waiting room medicine better? What is good patient selection? Obviously, you want to do probably lower acuity patients. You want emergency physicians that can be a little bit minimalist, that can churn patients. You might want to have dynamic staffing for both physicians and nurses so that you can handle day-to-day surges. You want to come with processes where there’s a nurse, tech, or phlebotomist resources or physical access resources, i.e., nearby Pyxis’s, having internal waiting rooms, having a process for doing “waiting room medicine,” but in a way that is … ensuring privacy for patients. Also what do you do with these patients if they need a consult or admission? How do you facilitate that?
Dr. Luke LeBas: You seem to be very lucky in that you’re working at a facility that has such strong physician leadership and physicians who are in the C-suite and who are being listened to. Unfortunately, some of the jobs that I’ve had in the past, people that have been removed from the bedside from decades or people with an MBA that have no clinical background whatsoever are trying to dictate to me best practices. And you can clearly see that they don’t know what they’re talking about. And that gets to be a little frustrating whenever Blue Cottage comes in or McKenzie comes in or different organizations like that and they don’t understand the world that I’m living in. You’re lucky that is you, you’re on both sides of that fence. You’re able to talk to both sides of that equation. And that is a plus for the practicing pit doctor to have somebody like you that’s on their side.
Dr. Amy Ho: I think I certainly was welcomed to have walked into a facility where physicians were already very well liked and very well listened to by administration.
Dr. Luke LeBas: The planning that you’ve discussed, the internal waiting rooms, the throughput issues and all of this, I like all of that. And whenever it’s instituted as a new change within a hospital setting, I think that you would get more buy-in from the practicing doctors based off of how you sell it to them. Have a practicing doctor pitch it to them. Don’t have an MBA pitch it to them, don’t have somebody from the C-suite that you’ve never met before. Have somebody that you’ve worked hand in hand with to sit down with you and explain how this new process is going to work. Also, give explanations to the ED doctors what the rest of the hospital is doing. Acknowledge the difficulties that are going on in the ED and show me that the hospitalist and the surgeons and the other folks that are upstream and upstairs understand what we’re dealing with. Show me what sacrifices they’re making to try to help the situation as well.
Dr. Amy Ho: In my current role in administration, it’s almost purely in data and analytics. We look at things like, what is the arrival-to-triage time? What is the arrival-to-room time? What is the disposition-to-departure time for discharge patients and also for admitted patients? So that has, in a lot of ways, allowed us go to our counterparts and say, “Hey guys, we’ve looked at the ICU patients admitted in the ED, what’s going on? Because your admit hold rates are four times what hospitalist medicine is!”
Dr. Luke LeBas: The emergency department is more likely to not be stuck in a silo. We can speak surgeon, we can speak ICU, we can speak medicine. I do understand some of the difficulties these other specialties have, and I hope that they would also understand some of the difficulties that I have. Again, if everybody’s on the same page and everybody is equal within the conversation, I think that would be a great way to work toward improving the situation. But again, boarding is a hospital-wide, very complex issue, and expanding the ED, expanding the capabilities of the ED providers, I don’t think is a good answer to a problem that’s upstairs.
Dr. Amy Ho: Boarding is a problem that trickles down to us, right?
Dr. Luke LeBas: Yeah. I’m willing to work hard and I’m willing to bend over backwards, but I also want to see that other folks are doing the same. Prove to me that the hospital is trying to help out. One problem that we occasionally run into is there’s going to be one housekeeper for the entire facility on an overnight shift. Well, you expect me to turn over beds. I can’t do it unless I’m mopping floors and changing sheets myself.
Dr. Amy Ho: Sometimes the multiple internal waiting rooms feels a little bit like Disneyland. You wait in the line and you’re like, “Oh boy, I’m about there.” Then you turn the corner and you’re like, “Nope. Another internal waiting room, another turn.” From the perspective of the pit doc, not every hospital tries to address this solution administratively. What is there to do if you are at a facility where there isn’t an answer?
Dr. Luke LeBas: We’re constantly being told to do more, do it faster, do it quicker, do it with less. See 20 people in the waiting room with one nurse. And even if there is an emergency, your best nurse already has four ICU patients, two of which are intubated. I mean, we are revving the engine so fast, and at some point we’re going to break the engine. There needs to be help to unload the system.
COVID accelerated everything. As did burnout and the nursing shortage. What can we do to help unload us in the emergency department instead of getting tasks added to us? Every time I open up my emails, I see, “Hey, here’s something else that we want y’all to do in the emergency department.”
And again, these might be good things, these might be helpful things, but you also got to show me how the hospital’s trying to, on the backend, unloading tasks instead of giving me new things to do.
Dr. Amy Ho: Are we here for emergencies? Are we the experts in being resuscitation? Or are we actually just availablists?
Dr. Luke LeBas: I like to work. I like medicine. I like taking care of patients. I love working with the ED team. I don’t believe that boarding is an ED problem. I believe it’s a hospital problem. And I think one of the ways to fix this is to get more practicing doctors at the higher levels of the hospital who are able to speak on even footing, that there’s no hierarchy, there’s no, “Well, this person is more important because they generate more money for the hospital.”
Those kinds of issues, I think, need to be put to bed. And there needs to be a hospital-wide response to all of this. And the answer can’t just be laying it on a few people in the emergency department and expect them to do more and more work.
Dr. Amy Ho: I think you touch on a couple really important things. I think one is the importance of physician leadership. Two is the importance of hospital-wide initiatives, which to me, I think someone’s got to take the first step. And a lot of times it is emergency physician leaders because it’s what we see, it’s what we know extremely well, the waiting room is right there. To me, a lot of times the onus can be on the emergency medicine to take those first steps because the hospitals are our collaborative partners.
They’re not really our adversary. No one wants boarding. No hospital administrator walked around saying, “Wow, I wish I had more boarding hours in my hospital.” And I think the takeaways that I have is to first talk to your administration in the ED about options in the ED, i.e., is there a flex area or kind of a vertical area that you could use to take care of the waiting room patients where it’s appropriate?
I’m reminded of one of our pit docs actually, who used to show up at 3:00 p.m. with 80 patients in the waiting room. He would grab a nurse, he would grab a tech, he would walk out to the waiting room, make a large announcement of like, “Hi, I’m Dr. so-and-so. I’m going to try to take care of some of you that I can just get it addressed and let go. Please don’t be offended if I pass over you.” And then he would just start pulling patients into what was functionally a closet to get them seen. That was the beginning of waiting room medicine and I think that starts at a local level.
We mentioned multiple times that both of us think that this is a hospital-wide initiative. If you’re at a place where discussing boarding at the hospital level is appropriate, I think you can start opening up conversations about hallway patients on the inpatient ward, doing things like patient discharge lounges to help inpatient throughput, admit hold areas to move patients out of the ED, increasing social work, mobilizing physical therapy, occupational therapy, and speech therapy to help with the inpatient boarders.
Dr. Lebas, I want to say thank you for taking the time to discuss this important topic to which I agree, I don’t know that there is a solution. But boy do we try.
Dr. Ho is assistant editor of ACEP Now.
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.