Private Practice Environment Presents Change, Challenge

Larry L. Alexander, MD, FACEP Private Practice Physician, Columbia Medical Center of Plano; Director of Risk Management; Assistant Director for Recruiting; Chair, Health Information Management/ Utilization Review Committee; EMRA Academic Affairs Representative 1991-93; Editor, EM Resident, 1990-93; Founder, EMRA Medical Student Committee

As emergency physicians, you and I hold unique positions in the scheme of health care. This puts us into situations that may be viewed as exciting and glamorous by the general public and engenders a "Better you than me!" out of colleagues. While I like E.R. (and yes, I do watch it and freely admit it), my life is not exactly like a TV show. If it is, it’s more like a dry documentary than a titillating soap opera. I definitely don’t get the benefits that George Clooney seems to get! Oh well, it’s real life that makes us mere mortals and not superhuman.

Emergency medicine is real life. All of us who work in emergency departments realize it, but we may get jaded views because we seldom get to see much of what could be called "normal." We see slices of others lives, the minor incidents and the major, even life-threatening, crises. The stress of constantly dealing with other people’s lives can make us frustrated, angry, or even, at least to appearance, uncaring. I do not think this latter to be true, but our workplace is unlike any other in the world. We choose it for many reasons, but ultimately it comes down to one—patients.

Patient care is the life blood of emergency medicine. As emergency physicians, we have no office, no set group of patients. We see any and all people who enter the doors of the emergency department. That means we do all that is needed for everyone who comes in, regardless of sex, age, race, employment status, religious or sexual preference, or ability to pay.

Private Practice
The practice of emergency medicine after residency training sheds a whole new light on medical practice. Many of us choose the private sector as opposed to the academic arena in which to practice medicine. This is a whole different world. Gone are the days when you always have a staff or more senior resident looking over your shoulder. It’s just you—making the decisions and living with the consequences. You are dealing with a totally different patient population than the one you saw during residency. They are usually more educated, are usually financially well off, and definitely have a different attitude about you and what they want from you. These demands can be very trying and give you many headaches. Welcome to the real world, the private sector.

The variety of patients that come to the ED provides a constant challenge to emergency physicians. We must be more than just "proficient" in all areas of medicine. Not only must we have the knowledge, we have to know how to use it fast and effectively. The key to success is being able to shift from one area to another in a heartbeat, without losing your concentration.

Since we take care of all types of patients, it is not uncommon to have a cross-section of them in the ED at any given time. It is very satisfying to complete a shift where you have successfully managed a ruptured ectopic, given TPA to a patient having an MI, helped arrange shelter for a homeless person, seen a young man with the first presentation of schizophrenia and managed a child abuse case, all without losing your cool or your mind.

The Business of Emergency Medicine
The practice of medicine is no longer a science or an art. It has become a business. This is, and probably always has been, especially true for emergency care. Patients present with a complaint or problem, it is "fixed" and they go home. As such, emergency physicians are providing a customer service and not just practicing medicine.

This concept of medicine as a business is fairly new to most physicians and must be learned and used effectively by the emergency physician. It may mean that your whole mindset for practicing medicine must be modified. In doing so, you will have to not only keep in mind what is medically best for the patient, but also what the patient expects, desires, and requires in the way of medical care. This can sometimes be very frustrating when you have patients who "know everything" about their "illness." It only takes a few complaints to administration to help you understand the importance of customer service and customer satisfaction in the provision of medical care today.

Another factor that has impacted the practice of medicine is managed care. Managed care is, at its best and worst, cost containment for medicine. This drive to lower the cost of health care, something we all desire, has changed the way most of us think about and, to some extent, practice medicine. If it hasn’t yet, it will.

With contracts being awarded to groups/hospitals based on cost per diagnosis, patient, or procedure, we as emergency physicians have had to reconsider the way we evaluate illnesses. We may have to reduce or limit the number and types of tests and procedures ordered in the ED because it is not covered in the contract. This may or may not be in the best interest of the patient from a medical standpoint. We have to weigh what is best for the patient using the least amount dollars against the contract and the need to support it or we and/or the hospital may lose the contract.

Social Services
I think one of the hardest issues that I have had to deal with has been in the arena of social services. We are all conscientious when it comes to using our medical skills, but the increasing social needs of patients and the constantly decreasing availability of services to meet those needs puts us in an awkward position. I feel very uncomfortable prescribing medication for someone when I know they have no job, no money, and no means to get the medicine, especially when it is really needed. This is many times a very important part of a visit to the emergency department. I think it is vital that your emergency department have at least social services access for referral for patients if not a social worker devoted to the ED.

Difficult Patients
One of the most frustrating patient populations that we deal with in the ED is the intoxicated and/or abusive patient. Many of these will require you to consider the legal implications as well as medical ones when evaluating and providing care to the patient. Do you let intoxicated persons drive home if they drove themselves to the ED? Do you need to do a serum alcohol level for your work-up, or not? Is the patient too intoxicated to make decisions about personal health care if no one else is around to do so? Is the intoxication part of a suicide attempt? These and many more questions make evaluating and caring for the intoxicated patient very difficult.

The abusive patient also strikes a sensitive chord in emergency care. Why is the patient abusive? Is it alcohol or some other substance? Or is it just an obnoxious personality showing true colors? Is there an underlying psychiatric disorder? Is the patient verbally or physically abusive? Is the abuse self-oriented or directed towards others? Does the patient require physical restraint to prevent self-injury or injury to others? If restraint is necessary in order to provide care, such as for lavage in an overdose or a self-mutilation injury, you should follow strict guidelines/protocols about the placement, timing, and re-evaluation of the restraints. Good documentation of need, placement, and re-evaluation can provide you with some legal protection if and when the need arises.

While we all try our best to evaluate and provide the care needed for each patient, we cannot make a patient accept our care. Even if a patient is of sound mind (and sometimes we all wonder about some of our patients), the patient may still choose to leave AMA. This can be an extremely infuriating situation for a physician. The patient may cite financial, physical, cultural, social, or religious reasons for leaving—none of which sound good to you and your scientific/medical thinking. You worry not only about the medical needs of the patient, but the legal implications of possible outcome. The best you can do in this situation is to ex-plain the situation clearly, the possible outcomes, and your position in a calm, cool, and professional manner, using plain English. Then you allow the patient to sign out AMA or document that the information was given and patient refused to sign AMA.

Other Issues
Your ability to practice emergency medicine hinges on several things—-your training experience, proficiency/skill with procedures, and the privileges granted you by the hospital to exercise the above. This can run the gamut from simple sutures to fracture reduction and splinting/casting to conscious sedation for procedures. You should have protocols for your group/ED that are based on the standards of emergency medicine practice.

One of the more controversial issues of the past for emergency physicians has been the authority to admit and the writing of admission orders. This may vary from hospital to hospital, but one important fact remains—the admitting physician (the attending or whomever will provide care for the patient in the hospital) has responsibility for the patient once the patient leaves the ED. This should be sanctioned and enforced by the medical staff and hospital.

Relating to Other Physicians
Vital to the practice of emergency medicine is the back-up support provided by physicians representing the other specialities of medicine. You need good back-up as well as good rapport with these physicians in order to provide the best possible care for your patient. Showing interest in follow-up care and working with your back-ups when they need you will help develop better relationships and make your job a lot easier.

Support from your colleagues, whether from your group or the medical staff, is very important. Friendship and camaraderie go a long way towards making a stressful shift better and a bad shift at least bearable. Get to know the people with whom you work. Participate in hospital committees and medical staff meetings. These are the people who will support you when you run into difficulty or will need your support if they get into difficulty.

Conclusion
Practicing emergency medicine in the private setting presents many challenges. You must learn the business of medicine, meet the demands of your patients, maintain a good working relationship with other specialists and social services, and represent your group on hospital committees. The private practice emergency physician must wear many hats to serve patients and meet the demands of the business of medicine.

Published in EM Resident, February 1997.

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