ED Staffing for Success: An Economics-Based Approach for Improving Throughput

By Eric Bachenheimer, MBA, MHSA, FACHE 78463699_15

It has been about three years since CMS enacted its first emergency department-specific metrics that would become part of the mandatory reporting for U.S. hospitals. Since that time, hospitals have increasingly focused on initiatives designed to improve these public-facing metrics, such as arrival-to-provider, arrival-to-departure times and patients’ leaving the ED without being seen by a provider. Many approaches entail improving provider productivity or perhaps introducing new processes to help improve the length of stay in the ED. However, one of the key items often overlooked is the staffing of the ED itself (physicians, nurses and ED techs).

Variability is the nature of the ED – at any moment there could be 15 patients who present for treatment – or none! The number of patients coming to the ED at any given time is based upon hundreds of variables, from the temperature, rain/snow, day of week and traffic or community events. No two days are alike, and yet many emergency departments staff their departments the same way, 7 days a week! Appropriate staffing of the ED may not be easy, but it is critical to ensure appropriate coverage to adequately treat patients who seek care. So, how can we consider the best way to staff the ED?

Analyzing Supply and Demand in the ED

Many may be familiar with the concept of “supply and demand,” which stems from the principles of economics to determine market pricing for a particular good or service. When our ED consulting team evaluates the efficiency of an ED’s operations, one of the first things reviewed is the supply and demand, but in a different way than in economics, to consider if the emergency department is properly equipped. Here’s where the math comes into play.

Queuing theory tells us that if the customer arrival rates within an operation is greater than the ability to service customers, then there will be a queue, or waiting within the system. In an ED, this means patients experience wait times to be seen, and some may even walk out or elope. It is thus important to understand the numbers — how many patients are arriving by hour of the day and day of the week, and how long are they staying in the ED?

In addition to this, we also need to understand the patient population a bit more to consider the patient acuity of these arrivals. Are the patients coming in during the day presenting with sore throats and sprained ankles or are they coming in with chest pain and respiratory distress? The greater the patient acuity is, the greater the level of care that is needed to be provided by ED staff.

Once there is an understanding of the arrival rates by hour of day and day of the week and the patient acuity, the next item to evaluate is the efficiency of the operation by noting the ED cycle times (time it takes from ED patient arrival until the time they depart). Those EDs with longer patient cycle times will need to ensure there is enough staff to care for those patients. This explains why minimizing cycle times by making the ED a more efficient operation will lessen the staffing requirement.

After this information has been obtained, one can identify the “demand” side of the equation, which illustrates what we need to provide care to our patients.

The final step is making sure that the proper ED “supply” of physicians and nurses is available by hour of day and day of the week to address these needs efficiently. Physician staffing can be evaluated in terms of patients per physician or patient per provider hour to ensure there are adequate levels of staff. Nurse staffing can be evaluated to ensure that there are enough nursing hours worked in the day to provide the nursing function for patients in the ED. ED techs can be considered an extension of the nursing function to help offload the nurse, so long as there are no duties being performed by the techs that require a clinical license.

It’s important to note that it’s not possible to develop a staffing strategy using a pure mathematical approach because the ED may see a 4-hour surge, but workforce planning realistically prevents us from having a shift that lasts only 4 hours (although some ED staff would like that!). So, there needs to be a combination of mathematical logic combined with the pragmatic realities of ED shifts.

Robert Wood Johnson – Somerset employed the aforementioned approach towards evaluating the provider staffing of its ED Fast Track area and discovered that the number of associate practitioners was correct but that the shifts were not aligned with the patient arrival rates. Several of the morning shifts were shifted to begin 1-3 hours earlier than the current state in order to adjust for the patient demand. The results were that the Fast Track was able to achieve and sustain a median turnaround time of less than the 2 hour goal, and on many days, better than 90 minutes. Just as one should never seek to drive 500 miles with a quarter tank of gas in the car, ED leaders should be cognizant of their current staffing levels to ensure they have the right staffing levels and mix to address the patient demand for their services.

Eric Bachenheimer, MBA, MHSA, FACHE joined Emergency Medical Associates in 2004 and is the Director of Client Solutions for the ED Solutions team which advises and assists clients with achieving operational efficiencies, process redesign, enhancing patient satisfaction, and ensuring regulatory compliance. He has more than 10 years of experience in the emergency department industry. He holds a master’s degree in health services administration from the University of Michigan, a master’s degree in business administration from New York University, and a bachelor’s degree from the University of Massachusetts at Amherst. He is a certified emergency medical technician and has worked in EMS for nearly 15 years. He is a Fellow in the American College of Healthcare Executives, and serves on the editorial advisory board of ED Overcrowding Solutions. Bachenheimer also is an active member of the American Association of Healthcare Consultants and the Healthcare Financial Management Association. If you’d like to contact the author, Eric can be reached at bachenheimere@alpha-apr.com.

Emotional Intelligence: Getting to Know Your Stress

By Marc Milano, MD, FACEP EI

As you may recall, my last post discussed how to start building one’s emotional intelligence. Over the next few posts, I will address each of the major skills you will need to master:

  1. Quickly reducing stress on the fly
  2. Conquering relationship stress with emotional awareness
  3. Using nonverbal communication and humor to deal with challenges
  4. Resolving conflicts

Let’s look at the first skill:

The ability to quickly reduce the stress of the moment.

Think about this quote: “Stress can hijack your best intentions.” We’ve all seen this in action. The usually pleasant and compassionate individual becomes curt and snappy. You’ve probably justified his actions by saying to yourself, “he (or she) is just having a bad day.” More than likely this is a result of unrecognized or poorly managed stress.

Thus, we must first learn to recognize when we’re stressed. Sounds simple, but with the level of distraction and focus we have in the emergency department, or even with our administrative duties, it’s easy to overlook the presence and effects of stress upon us. Emotional awareness is the first step. If we are to meaningfully change behavior in ways that are consistent and reliable, we must learn how to overcome stress in the moment by becoming emotionally aware.

To accurately assess a situation, comprehend what another person is saying, be aware of our own feelings and communicate clearly, we must first mitigate high levels of stress. The ability to rapidly calm ourselves and reduce stress can help us stay balanced, focused and in control, regardless of the situation.

Conquering Stress: Functioning Well in the Heat of the Moment

Develop your stress-busting skills by working through the following steps:

  • Recognize when you’re stressed – The first step to reducing stress is recognizing what stress feels like. How does your body feel when you’re stressed? Are your muscles or stomach tight or sore? Are your hands clenched? Is your breath shallow? Being aware of your physical response to stress will help you regulate tension when it occurs. It’s different for everyone, but the key is to get in touch with that physical sensation. I personally have been able to “feel” my stress via a sensation of numbness in my cheeks. This is the critical first step.
  • Identify your stress response – Everyone reacts differently to stress. If you tend to become angry or agitated under stress, you’ll respond best to stress-relieving activities that quiet you down (Close your eyes, sit or lie down, turn off the lights). If you tend to become depressed or withdrawn, you will respond best to stress-relieving activities that are stimulating (Exercise, listen to upbeat music). If you tend to freeze—speeding up in some ways while slowing down in others—you need stress-relieving activities that provide both comfort and stimulation (Movies, reading).
  • Discover the stress-busting techniques that work for you – The best way to reduce stress quickly is by engaging one or more of your senses: sight, sound, smell, taste and touch. Each person responds differently to sensory input, so you need to find things that are soothing and/or energizing to you. For example, if you’re a visual person you can relieve stress by surrounding yourself with uplifting images. And if you respond more to sound, you may find a wind chime, a favorite piece of music, or the sound of a water fountain helps to quickly reduce your stress levels.

We will journey together through the other four skills in successive entries. Take the first steps today – get to know your signs of stress so you can better control it.

Marc A. Milano, MD, FACEP, is chief of the department of emergency medicine at Bayshore Community Hospital in Holmdel, N.J. He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

Innumeracy & its Consequences in Emergency Medicine

Employing the Rules of Statistics – Not Mathematics – Will Provide More Accurate Metric Measurement in Emergency healthcare59Medicine

By Phillip Stephens, DHSc, PA-C

“Math” and “fun” rarely appear in the same sentence, and bridging math and medicine is especially challenging. With that said, understanding numeracy is essential to emergency medicine. So let’s attempt to have some fun with math to understand these challenges and see if we can bridge the gap.

Do you ever wonder why the numbers that guide emergency medicine practice never seem to equate to reality? After all, we need emergency department metrics to guide our practice. Numbers are assigned to productivity, length of stay and wait times to measure and accomplish important goals. These models are a good thing.

But emergency physicians, managers and hospital administrators intuitively feel something isn’t quite right. We are continually chasing numbers but never seem to master many.

Other industries have mastery over their metrics. NASCAR has precise measures of fuel usage, tire wear and even track temperature that create accurate projections down to the millisecond. The metrics have utility. From NASA to restaurants, there are dozens of industries that maximize mathematical potential with precision. Why can’t emergency medicine?

Mathematical and critical thought is a beautiful thing, yet it’s often quite deceptive in practice. There are times in many industries when the numbers can’t be relied upon, especially if used incorrectly. If there is anything worse than no data, it’s bad data, and that is the very issue.

Harvard professor of biology Stephen Jay Gould alluded to this problem by pointing out that our culture tends to ignore variation. Instead, we focus on central tendency. The result is that if you plan based on average assumptions, on average you will be wrong. Let’s do a simple math problem to illustrate this based on Stanford University’s Sam Savage’s attempt to describe Gould’s observation. It’s fun and illuminating. And math.

According to Savage’s model, let’s say you and your wife work in different parts of the city. The commute from work for each of you is 30 minutes. You both leave work at 5 p.m., meaning you should both arrive home at the same time of 5:30 p.m.

On one particular evening, you both must attend a reception at 6 p.m. The reception is 30 minutes from your home in the opposite direction of your places of employment. The plan for this evening is for each of you to leave work at 5, meet at home at 5:30, and drive together to the reception, arriving at 6.You figure that mathematically, it works out. But intuitively something doesn’t seem quite right. Will you be late? Or more realistically, do you have any chance at all of being on time?

Although mathematical concepts are used in statistics, there is a difference between the two. We won’t examine the differences in detail so you’ll have to trust me on that one. The point is that when viewed mathematically, the trip certainly should work. However, statistically it won’t. Here’s why:

Savage’s classic model assumes you have a 50/50 chance that each of you will make it home by 5:30. That way each trip home is like a statistical coin toss where heads equals arriving by 5:30, and tails equals arriving after 5:30. Four combinations are possible about the trip home for the two of you (a coin toss for you and a coin toss for your spouse on whether you make it on time):

  • Heads / Tails = You are home by 5:30, but your spouse isn’t.
  • Tails / Heads = Your spouse is home by 5:30, but you aren’t.
  • Heads / Heads = Both of you are home by 5:30
  • Tails / Tails = Neither of you makes it home by 5:30 .

The only way you both arrive home by 5:30 p.m. is if you both flip heads. Your chance of arriving on time at the reception is not 100 percent just because the commutes work out mathematically. In fact, it isn’t even 50 percent. Statistically, there is only one chance in four that you both arrive at home on time. Mathematics deals with numbers, relationships and patterns. Statistics is systematic and analyzes data. There is a distinct difference in the limitations and utility of each.

Now suppose grandma is going to ride with you and must drive 30 minutes to meet at your home by 5:30 as well. Your chances of leaving on time just dropped to one in eight. Then imagine you are going to take a van with a half dozen friends who are going to join you, and each of them has a trip averaging 30 minutes. That is now like flipping heads 9 times in a row. You have dropped the odds of leaving on time to less than 1 in 500–and once you leave, you still have only a 50/50 chance that your drive to the reception will take only 30 minutes!

Doing simple math correctly resulted in an expected value. But professors like Gould and Savage understand this is a mistake. It’s a mistake that permeates business activities — including medicine. Savage calls it the Flaw of Averages.

Cartoonist Jeff Danziger illustrates the concept by depicting a man who drowns crossing a stream that is supposed to be, on average, only 3-feet deep. In actuality, the stream is 1-foot deep with a 6-foot hole mid-stream. Mathematically, it is on average only 3 feet deep. Now you see the problem. Let’s apply these concepts to emergency medicine flow now that we have a bit of understanding regarding the power of statistical analysis.

Consider a hypothetical meeting of representatives from registration, nursing, triage, radiology, lab, ancillary services such as ECG, blood gas, IV teams and physicians who sit to work on a project. It’s a single flow project, but up to a dozen subroutines or processes must be developed in parallel. It could be patient flow, throughput or anything requiring parallel tasks.

The leader asks each participant how long it will take each to conduct his or her part. Each provides a range, like 10 to 20 minutes to complete their individual function. But a range will not suffice, as the leader needs a specific goal. Math is a precise thing and so are management functions. So each provides the average or reasonable time it takes to complete their task.

The durations of all of these subroutines are not fixed like an assembly line. Each is uncertain and independent. But with an average time for each, the leader feels he can mathematically come up with an expected value of how long the patient care experience will take based on these calculations. Do you see where this is going? You’d think if you added up these processes or averaged them out you’d come up with an accurate projection, right?

Just like our statistical coin toss, the more parallel processes involved, the more times you must flip heads in a row. If more than 10 processes must simultaneously occur, you may have a 1 in 1,000 chance that your calculated projection will occur as calculated. And we wonder why we never hit our metrics!

Focusing on simple math and central tendency is irresistible, but it can be disastrous. And we haven’t even begun to inject uncertainties such as margins of error or probability ranges that create even more misjudgments.

Statisticians refer to uncertain levels of demand as input probability distributions. We don’t know how to generate these equations in medicine nor do we know what to do with them. Generating them can be terribly complex even in a static environment, and emergency medicine is far from static. Our industry is clearly unpredictable, dynamic and more biologic, defying inorganic methodologies.

Consider an emergency department that on two independent days had a volume of 200 patients. Mathematically, it’s enticing to assume central tendencies for each day. In other words, the two days are comparable, as the same number of patients was seen both days. It’s a seductive thought.

Mathematically we try to discern why the wait times, throughput, walkout rates or productivity differed, perhaps dramatically, on days when the volume was identical. But we forget Gould’s admonition that our culture fails to account for variation.

We don’t consider variations of patient acuity, arrival times, resources, staffing, productivity potential, turnover, boarding, space limitations or even weather conditions that account for myriad input probability distributions that occur independently each day with uncertain and unpredictable variability. We simply fail to take into account statistical variation.

To properly understand and describe the complexity of things from productivity to patient flow requires the order of differential equations (dx/dt = m sin t + nt3) not simple math (1+1=2). It’s simply the nature of our industry.

Managers are doing the math correctly. But have you ever looked at physician productivity, throughput times or any other calculated models and said to yourself, “The numbers look right, but that sure doesn’t seem to be how it actually works.” The math and reality just don’t seem to match, and we wonder why.

Our culture tends to ignore variation, so we do mathematics instead of statistics. It’s that simple… and that’s the reason why.

Phillip Stephens, DHSc, PA-C,is the associate practitioner site director for Emergency Medical Associates at Southeastern Regional Medical Center, Lumberton, N.C. He is adjunct faculty at A.T. Still University in Mesa, Ariz., where he teaches Research Methodology and has practiced as an emergency medicine physician assistant for 25 years.

How Being a Scribe Will Prepare Me for a Career in Healthcare Administration

By CarolAnn Sudia CIM

As a recent college graduate, I’m often asked, “What do you do?” I reply with pride, “I’m a clinical information manager.” Ordinarily, I get one of two reactions: a simple nod, where clearly the person is pretending to know what that means, or they delve deeper and ask, “OK, but what is it that you do?” And though I’ve been working as a clinical information manager (CIM™) for a little more than six months, I haven’t quite perfected my elevator pitch yet.

What I Do

In short, I transcribe doctors’ notes; they tell me what’s happening with the patient, and I enter the information into the computer. But really there’s much more to it than that. I’m responsible for obtaining clarifications, which means I have to have the wherewithal to understand that in the world of medical documentation and billing, a simple diagnosis – say congestive heart failure – isn’t going to be sufficient; there are a multitude of questions that run rapidly through my brain to ensure accurate and thorough documentation.

It isn’t often that a doctor forgets to tell me one of the layers in a diagnosis, but if he or she does, I am responsible to ask. I am also responsible for freeing up the doctor’s time by calling in consults with other medical practitioners and for checking the progress of lab and radiology results so the next step in the patient’s care can occur as quickly and efficiently as possible.

The CIM Position  

The CIM position, also known as a scribe, is a multifaceted and complex position that doesn’t lend itself to a quick, three-sentence answer to the question “What do you do,” but it’s a rewarding position with a fast-paced learning environment. Even though my great Aunt Marge may never fully understand what it is that I actually do, I know that what I do makes a difference in the lives of the doctors I work with and the patients they treat – and that’s a pretty wonderful thing.

Medical School vs. Healthcare Administration

After I give the person who asked the follow-up question the lengthy speech on what it is I do, the next question is always, and without fail, “So you want to go to med school?” And to that question I can give a quick and definite answer: “No!” I can understand their confusion; I graduated top of my class with a science degree and now I work in a hospital, but the truth is, I never wanted to be a doctor, so no, medical school is not in my future.

I’m more interested in business and how I can apply what I’ve learned as a scribe to advance my career at Emergency Medical Associates or to move into hospital administration. Prior to being hired as a scribe, I had a rough time bridging the gap between science and business, but as a clinical information manager, I’m able to merge my love of science with my interest in building on my business skills in a position that allows me to constantly learn and grow.

What I’ve Learned

I’ve learned how to work quickly while maintaining the highest quality of work, and because to err is human, I’ve learned to how take criticism, grow from it, and make sure it doesn’t happen again. All of these skills will make me more marketable to any business job I apply for in the future; add to that my insider knowledge of which administrative operations frustrate and impede doctors more than help them, and I have an edge over most others applying for a hospital administration position.

Working as a scribe is an obvious choice for anyone who wants to go to medical school, but for those of us who’d rather operate Excel than operate on a human, it provides an incredible opportunity to blend the worlds of science and business and acts as a jumping point for a career in the business side of a scientific world.

CarolAnn Sudia is a Clinical Information Manager for Inpatient Medical Associates, an affiliate of Emergency Medical Associates, at Newton Medical Center, Newton, N.J.  Sudia received her undergraduate degree from Rutgers University, New Brunswick, N.J.

How to Tap Into Your Emotional Intelligence in the ED and at Home

By Marc Milano, MD, FACEP

Our last discussion left off defining the key aspects of emotional intelligence (EI). It should be clear that a strong supply of emotional intelligence can make one’s interactions better, one’s relationships stronger, and one’s quality of life higher.

I have long been fascinated by the lack of correlation between intellectual intelligence and success. In fact, many of the most intelligent people I have known have struggled in many ways, both personally and professionally. I’m sure that you have known these same individuals – brilliant but socially inept, highly intelligent but frequently unfulfilled.

During medical school and residency, I was lucky to have a great deal of emotional intelligence instilled in me by my teachers. I have had some good fortune in life as a result of those great influences. I don’t define my success financially, or by status, but rather by how others see me and relate to me, as well as by how I impact others. Many people have asked me how I have navigated my career and my life, as they would like to achieve a certain goal or reach a higher level. I always respond by telling them that it’s not raw intelligence that matters; rather, it’s emotional intelligence that has helped me most.

The Benefits of Using Emotional Intelligence

Several years ago, my wife and I decided that it was time to move to a larger home in a suburban setting to raise our growing family. We found the perfect place. One problem – it would have been a 90-minute commute from my job. As I looked around at possible places of employment that were closer to the new house, I found one – six miles away! I cold-called the director and explained the situation. He politely told me that the site was fully staffed and he was not looking for anyone. Thinking in an emotionally intelligent way, I told him that I would be glad to wait, but I could possibly help by covering parties, meetings, etc. This was music to his ears. He offered me an interview. During the interview, I explained my philosophy as an employee. I told him that every day when I walk into work, I’m thinking about how I will strive not to create headaches for my boss. Two months later, I had a full-time offer from him. He actually moved staffing around to accommodate me. I appealed to what mattered to him – covering difficult shifts and helping him avoid stress.

Intellectual intelligence can get you only so far in life. If you can’t use that intelligence in a way that helps you control yourself and interact positively with others, it may be largely wasted.

Emotional Intelligence touches every aspect of our lives. A few examples:*

  • Relationships: If you understand your emotions and how to manage them, you will be more effective in expressing your feelings. More importantly, you will understand how others are feeling. It will improve communication and help you build stronger relationships both professionally and personally.
  • Mental Health: Understanding and managing your emotions, and looking deeply into what causes you to respond a certain way will decrease your stress. Stress makes us vulnerable to anxiety and depression.
  • Physical Health: If you can’t successfully manage your stress levels, your health will suffer. Stress can raise your blood pressure, impair your immune system, increase the risk of heart disease and stroke and speed up aging.

Work Performance: Emotional Intelligence can assist you in smoothly navigating the social and political complexities at work. It can help you lead and motivate others and propel you toward excellence. Emotional Intelligence is now being viewed by many employers as being as important as your technical ability, and they may seek to assess your EQ as part of the hiring process.

How to Raise Your Emotional Intelligence

Remember: The brain receives all of its information via the senses, and if this information is highly stressful or emotional, primal forces take over and our ability to act is then reduced to fight, flight or freeze. If we keep our emotions in balance, we have access to a wider range of reactions and responses. This will result in better decisions and better outcomes. Stress impairs memory. Memory is linked to emotion. One must stay connected to the emotional brain while also tapping into the rational brain. By using both, you will have more choices in responding to an event, but you will factor emotional memory into the process. Doing so will help prevent you from making recurrent mistakes in the future.

To achieve Emotional Intelligence, you must work to reduce stress, remain focused, and stay connected to yourself and others. This is done by learning key skills. The first two relate to controlling and managing stress, and the last three skills greatly improve communication.**

  • The ability to quickly reduce stress in the moment in a variety of settings
  • The ability to recognize your emotions and keep them from overwhelming you
  • The ability to connect emotionally with others by using nonverbal communication
  • The ability to use humor and play to stay connected in challenging situations
  • The ability to resolve conflicts positively and with confidence
  • We will expand on these five skills in future discussions. Please continue to follow me on this journey. You can become a better you, and make your world a better place.

Marc A. Milano, MD, FACEP, is chief of the department of emergency medicine at Bayshore Community Hospital in Holmdel, N.J. He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

* Daniel Goleman, Working with Emotional Intelligence
** Daniel Goleman, Emotional Intelligence

How to Better Understand the Needs of Your Patients

By Anthony J. Brutico, DO  78463795_15

One of the most important things we can do as emergency department providers is to always be aware of “the show.” Dr. Greg Henry describes the emergency department as “show business for ugly people.” And he’s right; sometimes the perception of the care we provide is just as important as the quality of the medicine.

There are two types of patients: those who use the emergency department as a place to get quick care and fast answers as a means of bypassing their primary care physician and those who believe they have a true emergency. Although the patients without a true emergency often are less ill than many of the other patients we see on regular basis, they also can be the most vocal and demanding.

They often are “well enough” to take careful notice of what we do, how we behave, and how long everything takes.  When a person is waiting for an ankle X-ray, they don’t have much else to do than to look and listen.  They hear gossip and staff complaints and can pay close attention to how our processes work.  They also usually have an expectation of their visit.  It is up to you as the provider to figure out what that expectation is–and to moderate it if you must, and to meet it if you can.

Is the patient with hematuria here for a urinalysis, or to see if he has cancer?  Is the person with a cough here because it’s hard for her to breathe, or to see if she has Enterovirus D68?  This may not always be apparent based on the complaint, but satisfaction for these patients can pivot on finding the answers to these questions. Patients often have, consciously or not, agendas.

Patients also like to see that they are getting something for their money.  Emergency department bills are often in the four to five figure price range.  And for that money, patients have expectations–including getting answers to specific questions.  Sure, you’ve determined the patient with foot pain for a week doesn’t have a fracture.  “Take ibuprofen, and follow up with your doctor.”  Realize a patient may have paid $3,000 for that “I could have done that myself” piece of medical advice.  Sure, our medical exam and opinion are highly valuable, but let’s face it, it’s not like they’re coming to see the Dalai Lama.  Remember the show – what else can you do?

Your goal is to have each patient leave the department feeling better than when he or she arrived. Ask what concerns the patient has.  Allay the fear; it’s very real, even if unrealistic. Ask if they need a work or school note.  Offer crutches and an ACE wrap.  Think, “What can we do?” instead of “There’s nothing to do.”  In my decade of treating patients in the emergency department, by far the most complaints have to do with:

  • Pain
  • Waiting
  • Getting what they came for

This by no means implies that you always should do what the patient wants.  I wouldn’t hand them a menu of tests and ask them what they would like.  I would, however, suggest that you always try to ascertain what specific concerns they have, address them, and do what you can to give the maximum attention to their issues, no matter how non-emergent they may be.  Patient satisfaction depends on it.

Anthony Brutico, DO, is the interim director of the emergency department at Newton Medical Center, Newton, N.J. Dr. Brutico received his medical degree from Lake Erie College of Osteopathic Medicine, and completed his residency at Memorial Hospital of York.

4 Qualities for Practicing Emotional Intelligence in Emergency Medicine

By Marc Milano, MD EQ

We meet new people and interact with those we already know in varied situations every day. And as emergency department providers, we encounter more new people in more diverse and stressful situations than most others do.

It should be clear that managing these interactions successfully will result in positive outcomes by creating the environment and experience of care that we want for our patients and colleagues.

A concept that helps to both define and inform us about good interactions is that of Emotional Intelligence. I define emotional intelligence as the ability to accurately, and in our case rapidly, discern what matters to another individual or group and use that information to provide mutual benefit.

Many authorities on the subject have suggested that emotional intelligence (EI or sometimes referred to as EQ – emotional quotient) is as important, if not more important, than IQ when it comes to success and happiness in life and work. I completely agree, as I have seen some highly intelligent people (high IQ) fail due to having a low EQ.

There are for basic qualities that embody emotional intelligence:

  1. Self Awareness – Recognizing your own emotions and how they affect your thoughts and behavior, knowing your strengths and weaknesses, and having self-confidence
  2. Self Management – The ability to control impulsive feelings and behaviors, manage your emotions in healthy ways, take initiative, follow through on commitments, and adapt to changing circumstances
  3. Social Awareness – The ability to understand the emotions, needs and concerns of other people, pick up on emotional cues, feel comfortable socially, and recognize the power dynamics in a group or organization. Empathy is a key here.
  4. Relationship Management – Recognizing how to develop and maintain good relationships, communicate clearly, inspire and influence others, work well in a team, and manage conflict

A new manager recently came to meet her new staff for the first time. She arrived late to the meeting. She began the introduction with a list of her accomplishments and then launched into her expectations of those she will supervise. She asked no questions of the staff and didn’t encourage their input or feedback. I can tell you for certain that after the meeting, the staff was not only intimidated, but worse yet, they were NOT engaged. That manager knew going into the meeting that this staff was facing great organizational change and uncertainty, coupled with being confronted with having to acclimate to a new leader.

How could she have done this better by applying emotional intelligence?

  1. She could have shown more respect for the group by coming 5 minutes early, not 5 minutes late. Having the forethought and consideration of how crucial this first interaction would be might have prevented that error.
  2. She could have done better by making a brief introduction and explaining why her prior experience would help her lead them to success.
  3. She could have, instead of laying down a set of expectations and changes without getting feedback, accomplished more by simply asking, “How can I help you achieve your goals?” or asking “What tools do you need from me to do an even better job?” Once she learned the needs of the group, she could use that knowledge to align the group with her goals and those of the organization.

This primer on emotional intelligence will serve as our first foray into a fascinating and important way of changing the way we interact with each other and the world around us. Please visit the blog in the future for additional posts on this topic. I encourage you to use the “Comment” feature to let me know your thoughts as well.

Marc A. Milano, MD, FACEP, is chief of the department of emergency medicine at Bayshore Community Hospital in Holmdel, N.J. He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

My Experience Filming ‘Untold Stories of the ER’

By Anthony Brutico, DO Untold Stories of the Er

From the emergency room to television, it certainly was an interesting journey. As an emergency physician, I have a lot of patient stories. Some are sad, some will bring a smile to your face and others leave you wondering what the patient was thinking. “Untold Stories of the ER” is a TV show that highlights all of the stories that make you ask “what was the patient thinking?” I must say that I had never watched the show before, and I assumed, like most ED physicians, that we tend to shy away from medical drama because we live and breathe it every day.

The First Stages

I submitted three cases. They liked the cases I provided, and one in particular made the cut for the show. One of the show’s scouts called me and asked me to do a quick interview via Skype. The producers wanted to see how animated I was and to see if I had “radio face.”

After completing the interview, they turned my two-page case summary into a script for the show. The process took roughly two weeks to finish and I was mailed multiple versions of the script to check for medical appropriateness. To make the case entertaining for television, they spiced up the drama. The patients were younger and were trying to go on a second honeymoon, and what the patient took for his aliments also was altered. The main points of the case, however, remained the same, and the show wanted to stay true to the medicine of the case. Unfortunately the amount of “medicine” seen for a dissecting aortic aneurysm is limited from the ER perspective, but the case had some excitement, drama, and twists and turns that made it into the ninth season. You’ll have to watch the episode to see what happens, but here’s a preview – the husband initially was my patient, but then his wife also needed medical attention when she heard his diagnosis!

Filming in Canada

One of the perks of being chosen to appear on the show was they arranged all travel and flew me to Vancouver. They even worked around my schedule as they understand the demands of emergency medicine.

It was a great trip, and Vancouver was beautiful. I got to spend some time in the Gastown region of Vancouver, which has interesting restaurants, bars and shops. I didn’t appreciate the time change much, which I assume is due to the reality of emergency medicine work schedules.

The next day, we arrived onsite to see the set and practice a “table read” with the actors and director. The set is actually an abandoned psychiatric hospital that the show rents from the government. The 3rd floor is renovated to look like an ER, complete with fake computer terminals, phones, tracking board and other props. It’s a convincing set. The production crew films in different sections of the set and moves props around to make it look like a different hospital on each episode.

My director was Allan Harmon, who has worked on directing and assistant directing movies such as “Police Academy” and “American Pie Presents: The Book of Love.” He was a lot of fun to work with and was patient with physicians who never acted a day in their lives.

Lights, Camera, Action!

After the table read and the set walkthrough, it was back to the hotel for a night of good sleep and an early start at 7 a.m. for filming. We arrived and received a miniature version of the script for reference. Then it was off to hair and makeup and wardrobe. I brought my own scrubs, so they just pressed them, and the makeup girls prettied me up as much as they could, but they respected their limitations.

The shoot took 13 hours! We did scenes in an order different from the normal show progression, mainly due to the use of paid actors and set setup. We started in the CT scan room, which threw me off because as far as the script goes, we were starting on page 14. Each scene had required 2-5 takes, usually starting with a practice take and then filmed ones afterward. I remember them taking the script away from me because I wanted to bring it in the scene.

“Action!” the director yelled after the clack of the clapperboard in my face. And we were off. I had to be convincing, show a feel of urgency and concern, and never look at the camera. The hired medic and I were on hand to make sure the IVs, EKG leads and other small props looked authentic and were used properly. Makeup artists kept touching up my face and production assistants handed out water and pieces of candy bars to keep us hydrated and alert. It was definitely not a bad way to spend a day!

The Final Product

After it was all over, I got to see some of the takes that were recorded, got some food and headed back home. I got a few promo shots and as of the time I wrote this blog, I still haven’t seen the show! As far as some PR for the show, I also agreed to do “The Juice,” a morning TV talk show in New Jersey, to discuss some ER stories and mistake that ED patients make.

Interested in Being on the Show?

Untold Stories of the ER is a docudrama that airs on Discovery Fit Health and TLC. The show features real emergency doctors telling their most bizarre and puzzling case. All cases are based on actual events, but are highly dramatized. Barring exceptional cases where the patient themselves are involved, specifics regarding the hospital and the patient and the case are changed to protect everyone’s privacy, so consent from the hospital or the patients is not required.

To submit a case for consideration, email a short description of each story you’d like to share to Ann Hassett at ahassett@mac.com.

Anthony Brutico, DO, is the assistant director of the emergency department at Newton Medical Center, Newton, N.J. Dr. Brutico received his medical degree from Lake Erie College of Osteopathic Medicine, and completed his residency at Memorial Hospital of York.

The show airs August 29 on Discovery Fit Health at and Mid-October on TLC.

Mindful Solutions to Dealing with Patients

By Megan McGrane, PA  mcgrane
What do you know about mindfulness? Jon Kabat-Zinn, the father of the modern mindfulness practice, is a professor at the University of Massachusetts Medical School.  He describes mindfulness as the practice of being fully present in each moment, clear from distraction (1). Best put, mindfulness is paying attention “on purpose.” So why am I telling you this? And what does it have to do with your day-to-day in the emergency department?

Mindfulness is certainly not a concept broached by most medical training programs.  However, mindfulness is a practice that has been in my life for almost a decade and is integral in my interactions with patients in the emergency department.

I understand you may be thinking, “So, what does this mindfulness thing have to do with helping sick patients?” Let me tell you how this practice has everything to do with emergency medicine and how I believe it can revolutionize the way you interact with patients and families.

We have all been there. It is Monday at 5 p.m., a patient has been waiting for a few hours and now you are telling them they need a study that could take an additional two to three hours to complete. Maybe you have a patient in a hallway bed that is constantly being shuffled past and bumped into as stretchers round the bend in the busy part of the department.

Perhaps a patient’s blood draw was lost or misplaced and never made it to the lab. Frustration can ensue in any of these scenarios, and they are far from ideal for all parties involved. Let me give you a few techniques that use mindfulness to help you “pay attention on purpose” and ease your interaction with patients.


It is easy to take shallow, rapid breaths when we get angry, anxious or stressed. Often we are so unaware of this habit that it never even occurs to us.  In a frustrated moment, taking a deep breath in through your nose, holding for four counts, and then breathing out again is a great technique to slow everything down. I often do this when a patient is raising his voice with me or is becoming increasingly frustrated. It helps me to slow down and respond rather than react.

Listen. And then Pause

The empty spaces in conversations can be uncomfortable. That is, until you get used to them! Practice allowing a few seconds to pass before speaking or responding when a patient is voicing concerns; this practice can make a huge difference in how the conversation goes. It allows you time to process what has been said, take a breath, and then respond. It also gives patients a chance to know they are being heard. Sometimes they also may take this space to continue their thoughts if needed.  Allowing a pause in conversation tells patients you are taking time to think about what they said, not just give an instant reply.

Allow Room For the Patient to Ask Questions

Asking at the end of each interaction if the patient has any questions for you and then PAUSING (as in #2) gives the patient time to think of anything he or she might not understand about what you have said or what is happening during the visit. “What is a CT?” “How long do I have to take this medicine?” “What happens when you do this procedure?” This is a simple tip taught in the early stages of medical education that’s easy to skip over in the fast-paced emergency department.

Remember, It is Not About You

The ER is a familiar place to us as healthcare providers. We spend many days (and nights) in these halls. The dinging of monitors and overhead pages are like white noise in our day. However, for our patients it may be their first time in a hospital, not to mention a busy emergency department.  The patient or a family member may be experiencing a health crisis.  Often anger, frustration and irritation are multifaceted, and in the ER setting, they are inextricably linked to fear and pain. Using mindfulness and breathing strategies during a tough interaction can help remind you of this: it is not about you.

(1) Mindful Medical Practice: Just another fad? Can Fam Physician. Aug 2009; 55(8): 778–779.

Megan McGrane, PA,  is a full-time emergency department physician assistant at Saint Barnabas Medical Center in Livingston, N.J. She received a bachelor’s degree and a master’s degree in exercise physiology from the University of Pittsburgh and holds a second master’s degree from University of Medicine and Dentistry of New Jersey (UMDNJ/Rutgers), Piscataway, N.J. She is a member of the American Academy of Physician Assistants.

Quick Tips with Dr. Marc Milano

By Marc Milano, MD, FACEP Marc Milano, MD

Topic: Patient Satisfaction

As emergency physicians, we find each day different from the last. We are constantly faced with new patients, new illnesses and new challenges.

But regardless of the day, our focus always is on providing the best care for the patient. And while situations inevitably arise in which patients and their family or friends can become aggressive and outwardly frustrated, there are tips to remaining calm, alleviating frustrations and improving patient satisfaction.

Treat Everyone in the Room

In the emergency department, patients are often accompanied by friends and family members. This is especially true with the very young and the elderly. They need support during times of stress and uncertainty. You can use this fact to your advantage if you follow some simple guidelines.

  • When you enter the room, introduce yourself to the patient, then to their family members and friends.
  • Find out how the guests are related to the patient.
  • Address both the patient and the guests but keep your primary focus on the patient.
  • Don’t show that you are frustrated by questions from the group. Simply let them know that you will answer them when you are done evaluating the patient.
  • Show empathy toward caregivers and acknowledge their hard work in caring for a sick loved one.

When you’re done with the evaluation, explain your plan, how long you expect the visit to take (OVERESTIMATE!), and then ask the group if they understand. Doctors sometimes are afraid to ask “Do you have any questions,” as it might open the flood gates. However, I’m frequently shocked that the patient and companions have none. Another way of addressing is to ask the family “Does all of this information make sense to you? I know it can be overwhelming.”

You can then get them involved in the patient’s care plan by asking them to help the patient with things like drinking contrast, using the call bell for help or letting you know right away if something changes with the patient.

When you master these concepts and incorporate them routinely into your practice, you’ll rarely have to do “damage control” with an angry family member.

Keep Calm and Treat the Patient

It’s not uncommon to be confronted with an angry or aggressive patient in the emergency department. This is one of our biggest challenges, but handling it well can result in a good outcome, not to mention that it’s a really rewarding feeling to be able to turn a patient’s frown upside down! Be nice, and show compassion and a strong desire to make things right.

First, do not ignore the elephant in the room. If you know what the problem is, confront it directly. Saying things like “lower your voice” or “calm down” almost never help the situation – and in fact generally inflame it. I use phrases like, “I’m Dr. Milano, and I’m here to help understand the problem and do everything I can to fix it.” Sometimes this alone can turn the tide.

Often the anger is about waiting time, so I will offer something like, “I will do everything in my power to expedite your care, without compromising the quality of it.” You must then be prepared to deliver on that promise; however, as failing them again will just cause a re-escalation. Get on the phone with the lab/radiology, etc., and explain the situation. Let the other staff members know what’s happening and reassure them that you have already calmed the patient, but you need their help the keep things that way.

Occasionally, the anger or frustration is due to an unrealistic expectation (think MRI of the finger on a Saturday at 3 a.m.). This is an opportunity to educate the patient as to why a particular treatment or test is not warranted, and maybe explain how it might be harmful or could waste even more of their valuable time. Explain that you will treat the pain, stabilize the problem and provide appropriate referral and guidance to get the problem solved. I will say things like, “My main goal is to rule out the serious things, treat your pain, and then point you in the right direction.”

The ED is full of challenging medical situations. We are on the front lines of the war against death and disease every day. We occasionally make the seemingly miraculous happen. It seems like that should be enough, but our pledge is to treat the whole patient, the whole situation and always to give our best effort.

Marc A. Milano, MD, FACEP, is chief of the department of emergency medicine at Bayshore Community Hospital in Holmdel, N.J. He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.


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