Competition, Co-operation and the W*nker Theory.

The pervading wisdom is that public health services, designed on co-operative interaction, need to be exposed to “market realities” by introducing competitive forces to make them more efficient. In fact, we already have this tension of ideas on the trading floor of the emergency department.

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.

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.