If the ED tone is too friendly,
accommodating and conflict-averse, patients risk being stacking up, denied
access to any specialty guarded by a territorial, overstressed or inflexible registrar.
Such patients may then end up in poor old Gen Med for days longer than
necessary, awaiting the specialty input it was obvious they required from the
start, or worse, inappropriately discharged and coming to harm. However, if the
ED tone is too stroppy, hectoring and directive, patients risk being hurriedly bundled
into pressurised specialty beds causing stress, animosity and unseen down
stream pressures for that service - not least the admitting registrar being castigated
on the post take round for being “too soft”. Indeed, such is the nature of the
balance between collegiality and high-handed siege mentality for the duty ED
consultant, that if during the course of a busy shift in the emergency
department there is not at least one annoying w*nker from the in-patient
services to patiently manage, the annoying w*nker might indeed be yourself.
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| Emergency registrar slain for absent CRP |
The whole referral game can sometimes deteriorate into
competitive set pieces, in which move and counter move is anticipated and
blocked. ED docs playing the game with experience and seniority roll out their
moves with skill and confidence, playing key bits of information like ace cards
to force the opposing player to fold early. Juniors, new to the arena,
apologise and squirm as the weary specialist dances round their rambling
referral like a matador, weakening it with a series of well practised weary
requests for irrelevant absent information. More tests and the gathering of
multiple other opinions are suggested.
It is intimated that the referrer has lost either their faculties or
their bollocks, and thus any ability to make a reasonable decision. The overall
quality of referrals of this nature from the ED in general is questioned.
Finally the killer blow of “no beds anyway” may finally finish off the sorry
spectacle, and leave the referrer thinking twice before re-entering that arena
for the rest of the shift.
Of course, most of the time those on shift in the hospital
realise they are working to a common purpose and co-operate together seamlessly
and good-naturedly to the patient’s benefit.
But if referral were always dead easy for the ED, would we fall into the
trap of not earning our corn as a specialty ourselves? Emergency Medicine’s
greatest contributions to health outcomes and economics are generally the early
input of time-sensitive treatments to minimise morbidity and mortality (e.g.
antibiotics in sepsis), and the safe discharge of patients who do not require
in-patient care (e.g. PERC negative patients with pleuritic pain). Once an ED
referral is accepted by an admitting team though, the EM doc is relieved of the
responsibility of finessing the diagnosis and the worry of discharging the
patient home. This creates a very strong temptation to glibly, even sloppily, “buff
and turf”. This behaviour becomes closer and closer to routine operating
practice when the department is overrun with new patients, overcrowded due to
access block or staffed by inexperienced or burnt-out docs. Such practice may then
undermine the value the specialty adds to those most important of health
indicators: outcomes and costs.
 |
| Chilean Mine Rescue: no w*nkers |
It may just be possible however, to have a highly
functioning referral system that utilises both co-operation and competition to
produce great results. How? Give the ED direct admitting rights to all
specialties, selecting the most cost-effective and safe disposition for their
patient using evidence-based practice, senior supervision on the floor and clear
pre-agreed referral points (e.g. pre or post CT for stroke). Then
simultaneously exploit the competitive egos of the ED consultants by presenting
them with detailed performance feedback benchmarked against colleagues from
both within and outside their department. Furnish them with a list of not only admission
percentages, did not waits, critical incident and lengths of ED stay on their
watch, but also collated in-patient mortality, length of stay, and regular feedback
from all specialties on patients they admit.
Arguably human behaviour is equally influenced by the desire
to co-operate and the urge to compete. Facilitating co-operation and trust on
the shop floor, but yet encouraging healthy competition for excellence between
senior practitioners may tap into this very effectively. Then nobody has to be
a w*nker at work.
