On Caring for the Neglected 20%: People With Disabilities

In last month’s Health Affairs, I wrote a personal perspective about unequal treatment for patients with disabilities. Nearly 20% of the population in the U.S. have a disability; yet, teaching about care for people with disabilities is not a mandated part of the medical curriculum.

This is a deeply personal issue to me. As someone who grew up with a speech impediment, I am acutely aware of the prejudices and disparities that result from lack of knowledge.

I’m grateful to Health Affairs for publishing this article and producing the associated podcast. This has been nearly10 years in the making—thanks to my mentors and colleagues Dr. Fitzhugh Mullan and Dr. Audrey Young, among others, for encouraging me to write about my experiences. 

And I will be forever indebted to Professor Vivian Sisskin: a friend, mentor, supporter, cheerleader, and best speech therapist ever. This essay is dedicated to all those who are fighting to ensure equitable and accessible healthcare.

Link to Health Affairs article:

Condensed version in the Washington Post:

A Month of Conferences & Inspiration

My blog entries have been light over the last month in large part because of significant travel. In between clinical shifts in the ED and co-leading a fantastic cohort of GWU’s Residency Fellowship in Health Policy, I was fortunate to be invited to speak at several conferences in October. Here are some highlights:

In early October, I was honored to keynote the Centra Health Foundation annual gala in Lynchburg, VA to celebrate the work of several hundred volunteers, all of whom were either breast cancer survivors or family members of survivors. The event was moving and powerful; I thought of how proud my mother would be to hear me share her story with so many courageous and inspiring women.

Next was the 12^th Annual UC Davis Pre-Health Professions Conference in Davis, CA. Ten years ago, when I was the national president of the American Medical Student Association, I was approached by a student from a community college named Joubin Afshar who told me that he had started a conference for community college students who wanted information about the health professions. I attended the conference then, and was blown away by the drive and passion of these students. Nearly all were first generation college students, and for many, this was their first and only exposure to medical professionals.

Having been such a student myself, I vowed to return whenever possible. Last year and this year, I gave a keynote and led four workshops on leadership in medicine. Nearly 8,000 students attended the conference—many took overnight buses across California and even from the East Coast. It’s remarkable to see the work done by a small group of committed students. I wonder how many health professionals are where they are now because of the work of Joubin and his colleagues. (I also had the opportunity to see a friend and colleague, Dr. Davis Liu: an exceptional leader, thinker, and physician.)

My former Rhodes colleague who is now Chief Resident at Einstein Hospital in Philadelphia, Dr. Gary Huang, invited me to give Grand Rounds to the Departments of Internal Medicine and Emergency Medicine (pictured here with fellow Chief Resident and very kind physician Dr. Carlos Davila). I received many questions on what physician trainees can do to avoid burnout and deliver true patient-centered care. 

No answer I gave could have been as telling as the actions of Dr. Huang. As we were coming down the elevator, a woman in her fifties stopped us to ask directions to a particular surgeon’s office. I watched as Gary helped her figure out the name of the surgeon, led her to identify his location, then navigate her there. So many other people would have simply said, “I don’t know” and implied that it’s not their job to know, but not Gary. He took the time to help this woman in need, going far out of his way to do so. He didn’t do it to impress her or me (and I suspect he and his equally humble and caring wife Sherry would both be embarrassed by this blog post), but because it was the right thing to do. This action speaks volumes about the type of doctor he is, and answers the question that the residents asked: there may be many factors that make us disconnected from our patients, but it is within our abilities to treat patients as people, to value each person’s humanity, and to exemplify basic dignity and respect.

At the Urgent Matters Conference during the American College of Emergency Physicians meeting in Chicago, Dr. Jesse Pines expanded upon these themes. The other presenters (including my former attending at Brigham and now MGH Vice Chair, Dr. Ali Raja) and I spoke about how patient-centeredness and better communication can reduce overtreatment, improve patient safety, and transform care. The response was much better than expected, in no little part due to the amazing tweeting capabilities of one Dr. Seth Trueger (aka @MDAware).

Then it was on to Nijmegen, the Netherlands, where Corine Jansen (pictured), Jennie Grau, and their team organized the first-ever listening conference in healthcare. Initially, when my husband heard that I was speaking at listening conference, he laughed—isn’t it an oxymoron? And I have to say that I didn’t initially understand what a listening conference was really about (though the International Listening Association has a long history of hosting these conferences, and cosponsored this one).

The moment I showed up, though, I got it. Patients, family members, doctors, nurses—they shared their stories. They were powerful and unforgettable; indeed, as one participant commented, “the shortest distance between people is a story.” I heard a doctor speak about how he and his fellow neurologists assumed that their patients with Parkinson’s disease cared most about memory and managing their tremors. But when they listened—really listened—to their patients, they heard that what mattered most to them was sleep and sex. So they changed the entire medical encounter so that it wasn’t just about medication management, but also hired a sex and sleep therapist. Corine, Jennie, your team at REShape (where I took the photo with the best message ever): hats off to you for a fantastic conference and to the tremendous individuals I had the pleasure of meeting there.

This week, it is off to Grantmakers in Health Conference in DC then American Cancer Society in San Jose, CA. I hope to contribute more substantive blog posts soon; please write if there are particular topics you would like to see.

Care for the Neglected 20%

In this week’s “Shots” on NPR, I wrote about the barriers to care faced by patients with disabilities. Some of these barriers can be directly attributed to the lack of education healthcare providers receive about caring for people with disabilities.

Doctors' Ignorance Stands In the Way of Care For the Disabled

I was shocked to learn that though nearly 20% of the American population have a physical or mental disability that causes significant life impairment, studies show that less than 20% of medical schools have curriculum that discuss the needs of patients with disabilities. More than half of medical school deans report that their students are not competent to treat people with disabilities.

As someone who grew up with a severe and often debilitating stutter (see TEDxFoggyBottom talk where I discussed this in depth), caring for people with disabilities is a topic very personal to me. As a child, I had to visit the doctor several times a month for asthma attacks. When I had trouble getting out my words, doctors would ask my parents if I were mentally retarded. Sometimes, they initiated far more aggressive treatment because they thought my stutter was from difficulty breathing.

When I was a medical student, I recall an attending physician ordering a head CT on a patient who had a severe stutter just to make sure he wasn’t having a stroke. Had he listened to the patient for a few more minutes, he would have found out that this was how the patient always spoke, and that he was there for a completely unrelated issue. This is just one of many examples of how lack of understanding and training present a significant barrier to care.

In response to the NPR article, some readers have written about the burgeoning field of Physical Medicine and Rehabilitation. This is a much-needed specialty in medicine—but all doctors, nurses, and other healthcare providers need to be educated about how to take care of 20% of our patients.

I’d love to hear from you. What can we do to better educate healthcare professionals? Are there other areas that are neglected in medical training?

What I Learned—1 Year After When Doctors Don’t Listen

One year ago today, my book, When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests, was published. My goal in this last year has been to travel around the country and talk about the book and its message of advocating to improve your health. I planned a 48-city itinerary where I’d crisscross the U.S. from Massachusetts to California and back. I’d speak at bookstores, libraries, nursing homes, universities, and community centers.

What I didn’t anticipate was that this “speaking tour” would turn into a “listening tour”. 

From Boston to Los Angeles to Lexington to Cincinnati, people told me about their experiences with healthcare. Some, like 62-year old Annie from San Francisco, thought of themselves to be “e-patients”, or empowered patients. “I have a rare rheumatological illness that very few doctors have encountered,” she told me. “I bring research articles and educate my doctors.”

Others avoid doctors, like Janet, a 48-year woman from St. Louis who believes in “prevention, prevention, and prevention.” However, like many others I met, she sees healthcare providers nearly every week because she’s a caregiver to her elderly parents and her three children.

Over 2,000 people shared with me their frustrations with doctors, insurance companies, hospitals, and the healthcare system. I listened and learned.

Here are 10 themes that emerged: 

People don’t know that they have options, especially when it comes to saying no. They are used to doctors telling them what they need; they are surprised when I mentioned that patients always have a choice to NOT get a test or NOT take medications. Few interventions are so emergent that patients need to obtain them immediately. Watching and waiting, discussing it further with the doctor, and obtaining a second opinion are reasonable alternative. 

People want to please their doctors. In general, people like their doctors. Many feel they have to do what the doctor wants out of fear of displeasing them. “I lie and say I take medications I can’t afford,” 75-year Tony from San Antonio said. Others expressed their need for doctors to support their decisions. “Give me real choices and mean it,” says 38-year old Teresa. “Don’t judge me as being noncompliant just because I have a different value system.” 

People don’t want more care—they want right care. People recognize the harms of overtesting and overtreatment, and know that more care isn’t always better. They know to be wary of industries with ulterior motives. “Drug companies and insurance companies aren’t operating out of the goodness of their hearts,” says Joseph, a 55-year from Providence. “There’s a lot of money to be made money from healthcare.” They also fear rationing, and caution that less isn’t more either. What they want is the right care, without personal or commercial interests getting in the way. 

People don’t expect perfection, but they demand transparency. They know that doctors aren’t omniscient; they just want them to share what they know. Uncertainty is fine, as long as they are told the truth. Also, people accept that doctors are human and that medical errors occur. They don’t aim for retribution, but they do want disclosure of the mistake and to know that the doctor is committed to addressing it. 

People want more information to choose doctors and hospitals. “It’s disgraceful that I can find all types of information on choosing a coffee shop but I know next to nothing about my doctor,” 35-year old Jenny from Cincinnati says. People want to know about their doctors, not only their credentials, but also any financial conflicts of interests, their values, and who they are. 

People know that hospitals aren’t hotels. They don’t expect valet parking and 3-course meals, but they do want to be treated with respect. If they’re cold, they want a blanket. If they’re thirsty, they want some water. Without compassion and addressing basic human needs, marble staircases and fancy MRIs are worthless. The same goes for doctors’ offices. Forget the fancy carpeting, but find staff who treat people with humanity and dignity. 

People will wait if they get what they need. The dogma based on patient satisfaction survey results is that higher wait times leads to unhappy patients. However, the people I spoke with are unhappy not because they had to wait, but because they did not get what they expected despite the wait. “I waited two hours, and the doctor just spent five minutes with me,” said 49-year Sophie from Plymouth. Studies show that patients are interrupted in about 12 seconds; it’s no wonder people feel ignored and not listened to! 

People aren’t lazy when it comes to their health, and don’t always want the quick fix. Most people don’t want to go to their doctor at all, and prefer to find ways to improve their lifestyle and prevent disease. The popularity of diet and fitness books is case in point. Many do not want “the easy way out” in the form of drugs or surgery, but would rather discuss fitness, diet, and use of alternative therapies with their doctor. “It’s my doctor who doesn’t want to discuss these therapies with me,” says 22-year old Sandra.

With Dr. Jocelyn Elders and advocate Patty Skolnik

People know that the current system is unsustainable. No matter the politics, people saw the healthcare system as being broken, and all of them as victims—and future change agents. “It’s just like the environment: there are finite resources,” I heard over and over. Since “free” and “cheap” weren’t synonymous with good care, people are willing to pay out of pocket for better value (as long as it doesn’t bankrupt their family). They are willing to share in the cost to society, because they recognize they already are.

People crave connection and caring. They want face-to-face interaction with “their” doctor. They want to be listened to and heard. Knowing their medical history is only the start; they also want their doctors to understand and connect with them emotionally, physically, and spiritually. This requires a sustained relationship; people do not want to go to “minute clinics” or use smartphone apps to access their doctor, but rather long for a long-standing relationship with an accessible, trustworthy provider.

By no means is this list meant to be exhaustive or intended to represent every one of the individuals I met. The very nature of healthcare is that it is personal and individual. These findings represent the thoughts and wishes of a broad spectrum of people across the U.S. They challenge conventional wisdom when it comes to what is needed in healthcare. For example, the rise of urgent-care centers and smartphone apps should be seen as failure, not progress. Similarly, reducing wait times or adding fancy office furniture is not the fix for patient dissatisfaction.

Reform proposals tend to target policy changes that become mired in rhetoric and statistics. What people want is more basic, and more achievable. Doctors need to be transparency and honest with patients. They need to move away sick care towards healthcare. 

In the words of the great humanist and cardiologist Dr. Bernard Lown, we need to “do as much as possible for the patient, as little as possible to the patient.” Medical students need to learn shared decision-making and integrated care. Patients—people—should be part of every healthcare debate. Ultimately, we must restore medicine to being a caring partnership that prioritizes basic human dignity and respect. 

My listening tour continues. Please share your thoughts below. I look forward to listening and learning.

When More Isn’t Better

It was the beginning of my third year of medical school. I had just started my first clinical rotation. My very first patient was Ray, a middle-aged man with pancreatitis.

I presented his case to the team. “What are Ranson’s criteria?” the attending physician asked.

My mind went blank. “Uh, I’m not sure,” I said.

“Next time, you’d better be sure,” the attending said. He turned to my colleague, who promptly gave the correct answer.

On that first day of medical training, I learned that “I don’t know” is not an acceptable answer. If you don’t know, look it up. Make it up you have to. Whatever you do, never admit that you don’t know.

Not surprisingly, doctors end up not tolerating uncertainty. In our high-tech era, this means more is done. A patient has seemingly vague symptoms, so the doctor orders some laboratory tests “just to get a baseline”. A doctor doesn’t know what’s causing the headache, so she orders a CT or MRI “just to see”. Medical students are rewarded for pursuing obscure diagnoses, so they order increasingly esoteric tests “just in case”.

This insidious practice has resulted in a culture of overtesting and overtreatment. Studies show that 30% of all medical care—at the tune of $700 million per year—is waste. Not only does this impose a heavy financial burden on society and on patients, it also results in avoidable harm. Every test has risks and potential side effects. A CT scan has a risk of radiation, for example, that may lead to cancer later in life. And one test often leads to another, even riskier, test.

Recently, my husband had an itchy rash on his arms. He mentioned this to a dermatologist friend, who recommended that he come into the office for a skin biopsy. I asked how the biopsy would change my husband’s management: regardless of what it showed, wouldn't he still use a steroid cream? Sure, the dermatologist said, but at least we’d have more information.

Nothing against our well-intentioned friend, but this is a case where more information isn’t better. Why get a biopsy—an invasive procedure with risks including bleeding and infection—when it wouldn’t change the management or the outcome? Yet, tests are done all the time to quench the insatiable curiosity inherent in medicine: we just have to know.

Here’s another common scenario. A young woman comes in with abdominal pain. She’s able to eat and drink and looks well, but has a pain in her belly that’s bothering her. Many doctors would order a CT scan of her abdomen to make sure there’s not something bad going on. But what is this bad thing—how likely is it? How does the patient feel about the risks of the test, versus the risks of watchful waiting? If she’s fine waiting, then why expose this young person to unnecessary radiation, when it would be just as reasonable to wait to see if she gets better the next day?

More tests and better technologies are not the solution to improving clinical care. In fact, we know that 80% of diagnoses can be made without any tests at all, but by carefully listening to the patient’s story. I’m an emergency physician, yet even in the emergency setting, it is rare that a patient requires one particular test, and that test must be done right now.

Here’s what to do instead. Doctors: talk to your patients. If you’re not sure, tell them. Patients prefer honesty to false reassurance. Instead of reflexively ordering a test, discuss the benefit of the tincture of time. Remember that our first principle is to “Do no harm”. I just met two doctors, Tanner Caverly and Brandon Combs, who started an educational initiative to encourage doctors-in-training to write vignettes of medical overuse. To them, and to a growing number of physicians including the Lown Institute’s Right Care Alliance (of which I'm a proud member), preventing overuse is an ethical imperative.

Patients: insist on being an equal and active partner in your care. Ask “why” and “how”. Why is this test ordered? How will this test change my management? Make sure you know your diagnosis. Assure your doctor that it’s OK if she is not 100% sure; you don’t demand certainty, but you do expect transparency.

It’s taken me nearly ten years to unlearn the bravado I acquired in medical training and to learn that uncertainty isn’t bad; more isn’t always better; and less can be more. As the great cardiologist and humanist Dr. Bernard Lown says, you should always feel better after having gone to your doctor. We need to focus on healing by teaching and practicing the art of listening, compassion, and kindness.

Four Years Later: Reflections From the Last Day of Residency

On July 1^st, four years ago, I walked through Mass General and Brigham & Women’s Hospitals with an odd mixture of fear, relief, and excitement. Now, as I leave the hospital after my last shift of emergency medicine residency training, I am filled with a similar hodgepodge of emotions and reflections.

#1. “You were terrified of being a doctor!” I mentioned this article to the attending who oversaw my first shift as a newly-minted doctor. That day is forever etched in my mind; did he remember it? Much to my great embarrassment, he chuckled and said, of course. “I kept telling you not to worry if you don’t know something, but you were scared of everything!”

Though I knew that I was there to learn, it took me a while to get over my insecurities about not knowing so that I could focus on learning. And the learning was everywhere—on every single shift, I learned from great clinicians not just about diagnosis and treatment, but also important lessons on how to lead a team, how to teach, and, most importantly, how to help people who come to us in their time of need. I’ve been incredibly fortunate to have learned from many colleagues along the way, including the amazingly skillful and compassionate nurses at Brigham & Mass General. As my mentors say, it is called the practice of medicine for a reason, and we should embrace, rather than fear, the learning.

#2. “Mistakes will happen.” Every doctor has made a mistake some time in her life. Whether it’s a technical error (i.e. inserting a long IV into an artery rather than a vein), a systems error (i.e. ordering a medication for the wrong patient), or a communication error (i.e. angering a patient or colleague), all of us graduating residents will have made some kind of error. I myself made all three of these errors, and more.

With the volume of patients we will see throughout our careers, being the cause of medical error and interpersonal conflict is a terrifying and humbling thought. A wise physician said to me that just as residency is the time to learn how to practice medicine right, it’s also the time to learn skills like how to disclose mistakes to patients, and how to deal with conflict. “Don’t shy away from difficult situations,” he told me. “Put yourself in the middle of them to see what others do, and then develop your own style.”

#3. “That man has a name, and it’s not ‘the chest pain in room 8.’” As busy residents with long to-do lists, we often fall prey to the tendency to dehumanize our patients and brand them as chief complaints to quickly decide their disposition. On the surface, this might appear to save time, but dig a little deeper, and such algorithmic, depersonalized medicine results in unnecessary tests, misdiagnosis, and worse patient experience.

Furthermore, practicing cookbook medicine is not why we chose to become doctors. My work became much more meaningful when I made a commitment to connect with each patient, no matter how busy I am. I learned that the “old guy with dementia” was a world-renowned philosopher, that the “the onc patient with fever and neutropenia” had ten children with her preschool sweetheart. As physicians, we are privileged to hear so many stories from so many people. Cherish this gift we’re given to share in our patients’ rich lives. Our healthcare system isolates patients and disenfranchises families; we have the power to practice real patient- and family-centered medicine.

#4. “Residency is hard, and you have to take care of yourself.” My best friend from medical school, who had just completed his pediatric residency, warned me about this before I started intern year. How right he was. Work hours may have improved since our forefathers trained, but residents still work a lot and are exposed to high-stress situations with life-and-death consequences. Studies have shown that rates of depression and burnout increase sharply during training, yet the “hidden curriculum” of medical training still favors bravado over openness. Residents are taught to “suck it up” instead of talking about difficult situations and taking care of ourselves.

This is not the way it has to be! I learned this lesson the hard way during second year of residency, when my mother died. I suppressed my emotions rather than seek help, and saw how easy it is to feel isolated. Fight this impulse and stay connected. Find peers you can reflect with and openly speak about your experiences. Nourish the other people in your life and recognize their critical role in helping you through this process. For me, it was my wonderfully supportive husband and my friends who sustained me and kept me grounded. Make time for these people in your life. I cannot think of anyone who regrets the time spent with our loved ones and laments, “if only I spent that day reading one more research article!”

#5. “Emergency medicine is a phenomenal field.” The first grand rounds lecture I heard as an intern was by Dr. Larry Weiss, then President of AAEM. He spoke about how emergency medicine is an ideal specialty for advocacy: as the frontlines of medical care who interact with every aspect of the healthcare system, we are the most well-positioned physicians to advocate for our patients, our communities, and our society. We see the problems with public health—smoking, obesity, gun violence, etc. We see the problems with under-, over-, and misutilization of healthcare. And we have the ability and power to act on these problems every day.

In my fourth year of medical school, I selected emergency medicine as a specialty because I wanted the ability to treat any patient, anywhere. Being one of the emergency providers who took of care victims of the Boston bombings made me grateful for my training and for the skills I’ve learned along the way. We in emergency medicine have the incredible opportunity to utilize our training to do what we love while making a difference to improve care for our patients and to transform our healthcare system.

What else can I say about these last four years? It’s been a rollercoaster ride. Now that I’m about to embark on the next journey as an emergency medicine attending physician, health policy professor, and Director of Patient-Centered Care Research at the George Washington University in D.C., I am filled with exactly the same emotions of fear, relief, and excitement that I came to Boston with. I have learned so much from so many incredible people along the way, and will forever be indebted to the amazing attendings, residents, nurses, physician assistants, and other colleagues at Brigham & Mass General Hospitals.

Now, what will the next years bring? I’ll be on leave for the next month, but stay tuned for more dispatches and reflections, soon to be from the nation’s capitol.

What the U.S. Can Learn from China’s Health Care Reform

Wang Li is a 48-year old farmer from Dalian, China. After a two-day trip to the major provincial hospital, he’s heading home to his village to die. Wang has lung cancer, and even with insurance, his surgery will cost him 20,000RMB—$3,000, which is twice his annual salary. The surgery would be curative, but it doesn’t matter. “I cannot burden my family,” he said.

I am a Chinese-born, American physician who just returned from a two-month research trip spanning twelve cities and nine provinces in China, where many of the healthcare reforms in contention in the U.S. have already been tried. As Americans contemplate the decisions ahead, consider China’s cautionary tale.

Today’s China is one of great disparity. The wealthy minority receives top-notch care, while the poor majority suffers from little access to care and no way to pay for it. Stories abound of patients like Wang Li who sign out of hospitals when they run out of savings, knowing they will die without treatment.

It wasn’t always this way. In the mid-twentieth century, China had universal healthcare with a robust primary care system. Millions of “barefoot doctors” provided basic medical services in villages, and attention to prevention ensured significant gains in life expectancy.

The reforms of the 1980s changed healthcare from being a social good to a commodity. Universal insurance was dismantled, and 900 million people lost coverage overnight. Healthcare was decentralized to provincial governments, who allowed the market to operate with few restrictions.

What’s emerged is a fragmented system fraught with inefficiencies and perverse incentives. In Beijing, if a doctor diagnoses someone with a common cold and sends the patient home, she gets paid, 4.5 RMB, less than a dollar. But if she orders tests and administers IV antibiotics, she gets paid 400RMB, 100 times more.

There are additional ethical concerns. Because local governments have ultimate responsibility for service provision, poor provinces can afford to pay their doctors little more than manual workers. Doctors are expected to “top up” their salary through other means. Some earn up to 5 times their salary through kickbacks from pharmaceutical companies by prescribing new, expensive medications; others accept direct bribes from patients (“hong bao”) as promise for better care.

The commoditization of healthcare has caused direct harm to the patient-physician relationship. Patients question whether doctors are acting in their best interest. Threats against doctors occur daily, and doctors have become terrified of the people they serve.

Understandably, the attrition rate among doctors is multiplying. The lack of doctors is particularly acute in rural areas. With low pay and few opportunities there, doctors flock to cities, leaving many villages without any doctor. The high reimbursement for treatments has resulted in a huge pay differential in favor of specialists, and China has gone from a model primary care system to having virtually no general practitioners.

To its credit, the Chinese government has recognized the inadequacies of its healthcare reform, and is making amends including a nationalized health insurance system and a code of conduct for doctors. For the U.S. in considering similar reforms, China’s failures offer three important lessons:

First, health insurance does not equate access or coverage. In China, those with insurance still have to pay 60-70% out of pocket, leaving many without actual health coverage. Taking “personal responsibility” for our health may be important, but we should not price people out of life-saving treatments. 

Second, fee-for-service should be abolished in favor of fee-for-diagnosis, with a specific illness billed a fixed amount regardless of the tests and procedures performed. Not only does such “bundled payments” require accurate diagnoses, they reduce cost and the potential for inefficiency and corruption.

Third, healthcare regulations need to be national decisions. Given the variability among states and our mobile healthcare workforce, decentralized policies don’t make sense and will exacerbate inequalities. Market-based innovation can still be encouraged with pilot projects starting at the state level, but the U.S. needs national consensus on overriding principles.

This year, America has a once-in-a-generation chance to fix our broken healthcare system. As policy-makers discuss implementation of the Accountable Care Act, they should learn from China’s experience and decide whether they see medical care as a commodity or social provision, and what are the responsibilities of the government to ensure the health and well-being of its citizens.

A Young Emergency Physician Appreciates the History of U.S. Emergency Medicine Through the Lens of China’s ERs

I’m a young emergency physician, part of the “new breed” that’s always known emergency physicians to be residency-trained and emergency medicine (EM) as a well-respected field. Being a leader in the American Academy of Emergency Medicine, I often hear of our organization’s leaders speak about the struggles they had in establishing our specialty, but I didn’t have a sense of what they actually went through. Why is that they so dislike the term “emergency room” and cringe at the reference to “ER doctors”?

It took a visit to China for me to even begin to understand the reasons. In August-September 2012, I traveled back to the country of my birth to study the current state of medical education here. My trip traversed 9 provinces and involved visits to 14 medical schools and over 50 hospitals.

Being an emergency physician who is interested in healthcare systems, I was particularly curious to visit the Emergency Departments there (we prefer this term and the abbreviation “ED”s to ERs for reasons I’ll speak about later). What I found is quite far from the EDs I know. In fact, everywhere I visited, from rural provincial hospitals in Inner Mongolia to major inner-city teaching hospitals in Beijing, had an emergency ROOM. That’s because patients were literally seen in a giant room, with beds pushed against walls and (if they are lucky) a curtain to divide the rooms. Extra patients were lined up along hallways, often six-deep.

Many places had triage to service, meaning that patients were triaged to a specific area to be seen by specialists who came through the ER. So internists would see patients designated as having medical problems, surgeons would see patients thought to have surgical problems, etc. If the patient turned out to a different problem than was initially decided, a long discussion would take place before the patient was transferred to the correct part of the ER.

Since China is a densely populated country, many hospitals had serious issues with overcrowding. Not surprisingly, the biggest problem seems to be with patients waiting for a hospital bed—basically, boarding.

“Do you often see patients waiting for a bed for 24 hours?” I asked a doctor in a major Beijing hospital.

“24 hours? We are lucky if there’s a bed in 72 hours!” He went on to describe the difficulties he had with admitting an elderly woman with heart failure, diabetes, kidney problems, and liver cancer who came in with difficulty breathing. The cardiologists refused the patient, saying the problem was the kidney. The nephrologists declined, saying diabetes or cancer was the underlying problem. Oncology and endocrine stated the chief complaint was not mainly their issue. General internal medicine said the patient was too complicated. As a result, the patient stayed in the ED for the entirety of her care—a total of 30 days.

The emergency physicians I met attributed the problem of boarding to the lack of respect for the specialty. Though EM is a specialty in China, and there are EM residency programs in some cities, it is considered to be a specialty of last resort—for those physicians cannot make it in other fields. Most EDs are divisions that exist only under the auspices of “real” departments such as surgery and medicine. Attendings working in the ED are scorned by others, and fights over airway, chest tubes, and other procedures are frequent occurrences.

Hopefully, my fellow young American physicians are wondering what kind of backwards environment I’m describing, but many reading this column are probably thinking that this description is not too far from the reality they knew. Indeed, the road to becoming a specialty involves predictable stages. My generation takes it for granted that we are part of excellent training programs and will be specialists in a well-respected medical field. But it wasn’t long ago that our predecessors fought the same battles that China faces now, of specialty recognition, admission privileges, scope of practice, etc.

We young emergency physicians need to thank those who came before us for making our specialty what it is and paving the way for us. For creating the emergency DEPARTMENT (rather than the ER) staffed by emergency physicians (rather than ER docs). For ensuring safer and better care for our patients.

We must also recognize that while many problems have been resolved, many remain. Overcrowding and boarding continue to be problems in EDs across the U.S. There are continuing challenges to our scope of practice, and other specialties still question our abilities. Vocal groups still insist that there are other ways to become “certified” emergency physicians through alternative boards. The corporate practice of medicine remains a real issue for practicing physicians.

It’s imperative for young emergency physicians like myself to continue to find value for our specialty. China’s EM leaders have found creative solutions around their overcrowding and scope of practice by starting “E-ICUs” (emergency ICUs) and transitional care units (transition from E-ICU to home) and staffing “emergency inpatient” and observation units. As we look to the future of EM, we should be aware of our history, work to overcome ongoing problems, and continue to advance our specialty and improve healthcare, in the U.S. and internationally.

This article was initially published in AAEM’s Common Sense magazine. I welcome your comments!