Overcrowding: Harming the Patients of Tomorrow?

It is 3 am on August 1st, 2018, in a busy hospital when a 47-year-old male presents with chest pain. The emergency physician on duty, who is a new residency graduate, performs a history and physical, orders an ECG, chest x-ray, and blood work. After reviewing the data, the patient is given aspirin, nitroglycerin, and heparin and admitted to observation for a rule-out with serial enzymes. At 7 am, the patient’s chest pain worsens and he suffers a cardiac arrest. An autopsy reveals cardiac tamponade and a large thoracic aortic dissection. As physicians and educators, we are products of our environment. In emergency departments (EDs) throughout the world, we were taught by our mentors to provide the most compassionate and best care possible, no matter what the circumstance. In turn, many of us try to repay our mentors by teaching the doctors of tomorrow. However, our “classroom” is changing. It is becoming increasingly overcrowded. As we spend more time discussing diversion with charge nurses, and less time teaching students and residents, we wonder if we are doing a disservice to the doctors (and patients) of tomorrow. Am I really supervising the residents adequately and giving the necessary feedback? When I barked in frustration at the family member who asked me for the fifth time when her mother would be admitted to the hospital, was I really modeling professional behavior? Could I really teach the student the subtleties of the abdominal exam on that fully clothed patient in the hallway? Who can be expected to teach under such difficult conditions? With so many competing interests and interruptions, who can possibly address the needs of students and residents? With constant pressure to perform clinically, despite limited resources, who has the time or energy to teach? Well . . . emergency physicians (EPs), that is who, it is what we do—adapt and overcome; create order from chaos. In fact, there are those among us that do it very well. Sometimes even the most clinically productive physicians somehow manage to be the best educators as well. How do they do it? What are the methods they use? What are the tricks of the trade that allow someone to manage an overcrowded ED and use all that extra learning substrate to their (and the learners’) advantage rather than to their detriment? The ED is a high stakes environment, both clinically and educationally. It is ripe with risk, but also full of potential reward. The stakes have never been higher, for today’s teachers and tomorrow’s physicians. While overcrowding is an evil that most EPs would rather do without, it does present emergency medicine (EM) with a unique opportunity. From doctors and patients to administrators and politicians, the rest of the world is starting to take notice of overcrowding as a major issue in patient care and medical education. Now that people are paying attention, it is time for EPs to act. No one is more qualified to lead this charge than the EM community. We have grown up on the front lines of the overcrowding battle and know the issues intimately. Furthermore, we are well poised to take on the challenge of conducting research, formulating solutions, and testing results. Our specialty naturally selects physicians and educators who are flexible, adaptable, quick-thinking, team-oriented, multitasking, and pragmatic— the very qualities necessary to approach the task at hand. EDs across the country and the world are becoming increasingly crowded. The numbers and the complexity of patients presenting to the ED are increasing.1,2 At the same time, there has been a decrease in the number of EDs to care for these patients. ED crowding is not just an ED problem, but often a product of a lack of hospital capacity. As the patient population continues to grow and age, the demand for primary care outstrips the resources available in their communities. The inpatient bed capacity in most hospitals lags behind ED needs, so the problem of ED overcrowding is expected to worsen further. ED crowding is a public health crisis.3,4 It is becoming increasingly prevalent in all types of EDs in all locations: urban, suburban, rural, teaching hospitals, and community centers.5 It has been shown to be associated with increased patient mortality,6–8 decreased quality of care,9–12 and decreased patient satisfaction.13 It is associated with higher rates of patients leaving without being seen by a physician,14–17 ambulance diversion,18,19 and ED lengths of stay. In response to the growing concern about the impact of ED crowding on education, the Society for Academic Emergency Medicine (SAEM) brought together a group of overcrowding and educational experts to study the issue. In this issue, an article is presented that is the product of these deliberations discusses the impact of overcrowding and education.20 Shayne et al.20 review the current literature and provide an excellent overview of the current state of EM education, particularly focusing on the Accreditation Council for Graduate Medical Education (ACGME) core competencies. While there is a growing body of literature on the negative impacts on ED overcrowding on patient care, there is a noticeable dearth of research on the effect of overcrowding on education. A truly novel conceptual model of ED crowding and education was proposed as a Starling-like curve, where initial increases in crowding may actually increase education, but as crowding increases, eventually education will peak and ultimately crash. Just as the real Starling curve can be shifted, this crowding–education curve provides a useful framework to conceptualize the fact that the impact on crowding may vary for different teachers, learners, skill sets, and educational settings. For example, senior residents may learn better in a busier high-acuity setting where they are learning to fine tune their skills. An intern in that same environment may become so overwhelmed that learning ceases to occur. Shayne et al. go on to review the unique opportunities and challenges that ED crowding provides to education. Despite the importance of the topic and the prevalence of overcrowding, it has been difficult to define and measure it properly. ED crowding is a complicated phenomenon with multifactorial causes and many varied effects. Some of these causes and effects are universal and some system- or site-specific. Multiple attempts have been made to measure crowding using various crowding scores.10,21–25 A recent study advocates using a simpler measure, ED occupancy rates, as a measure for overcrowding, because its reliability and validity are similar to the most accepted crowding score index.10 Some researchers advocate using the number of patients who left without being seen and ambulance diversion rates as surrogate measures of overcrowding. Work is ongoing to further define the most accurate tools and methods for measuring overcrowding, but it is a complicated problem, and some tools and methods that work well at one site may not be as accurate in others. Owing to the many confounding influences and variables involved in most teaching ventures, it is difficult to objectively measure the results of education and learning in any environment, especially that of a crowded ED. While there is no single perfect educational outcome measure, there are ways to evaluate educational interventions that involve triangulating data from several sources or methods to give the most valuable data possible. One could envision using Kirkpatrick’s hierarchy of learning to explore the effects of overcrowding on education in the ED.20 While we consider the problem of studying the effects of crowding on education, we also need to figure out better ways to teach in the current environment. It is important to remember that the everyday business of patient care and bedside teaching goes on, regardless of our long-term plans to effect change. In fact, some of the early studies into the topic of crowding and education reinforce this point—that any research should be grounded in the real-life limitations of the environment, for these very qualities (the fast pace, the multitasking required, the constant interruptions, and less-than-ideal circumstances) are at the heart of the issue. Rather than ignore them, we must embrace them as the very qualities that make the environment unique, in both positive and negative ways, and accept that these conditions will dictate the best methods to use in researching the subject and teaching while we research. Several authors have used various parts of Kirkpatrick’s hierarchy to evaluate the effects of overcrowding on education in the ED, but much more work needs to be done.26 Berger et al.27 and Kelly et al.28 used learner satisfaction tools (the first level of the hierarchy) to investigate the effect of overcrowding and clinical workload on learner satisfaction with ED faculty teaching. The study by Kelly et al. found that teacher attributes had a significant effect on learner reaction, independent of clinical volume. These findings reinforce the fact that ED learners value the teaching principles described by Thurgur et al.,29 Bandiera et al.,30 and Atzema et al.,31 which stress adaptability, practicality, and the ability to tailor teaching to the learner and situation. In short, it seems certain that teaching methods and characteristics may allow teachers and learners to adjust to a crowded environment. Along these lines, Aldeen and Gisondi32 proposed several practical strategies to improve bedside teaching in a crowded ED. More research is indicated to further evaluate the validity of these and other methods in crowded conditions. Ongoing research into the effects of crowding on education is beginning to offer clues on what types of teaching ED learners (and teachers) prefer in busy learning environments. However, most of the existing studies have been predicated on the lower level of Kirkpatrick’s hierarchy and depend on learner and teacher reaction tools. Much more work is needed, especially with regard to the higher levels of Kirkpatrick’s hierarchy.26 It would be useful to investigate the effect of crowding on objective measures of teaching and learning (the second level of the hierarchy), such as scores on tests or objective structured clinical examinations, or actual time spent teaching, especially given the findings by Chisholm et al.,33 who demonstrated a paucity of actual time spent by faculty directly observing residents. Several authors have begun to investigate the validity of standardized bedside observation tools.34 While this work does not directly examine crowding effects, validated direct observation tools could be used to study the effects of overcrowding on learned behaviors at the bedside (Kirkpatrick’s third level). Several authors have investigated the effects of teaching interventions on patient care outcomes (Kirkpatrick’s fourth level), with mixed results.35–38 Again, these studies were not directly related to crowding, but one could envision an investigation along the same lines with a crowded and noncrowded control arm. More research is needed to develop a better understanding of crowding and its effect on education in the ED. In addition to developing better teaching and research methods, EPs who are involved with teaching health care providers need to stand up and advocate for our students. In addition to being the place where clinical care is delivered, EDs are our classrooms. None of us would accept having an inadequate number of desks or textbooks for our children, nor would we accept having our children trying to learn in a classroom with a leaking ceiling. When our ED beds are full, we have no desks. When our flow of patients is slowed, we have no textbooks. When we are trying to teach in crowded hallways, we have the equivalent of leaking ceilings. Academic EPs need to rally to the cause of our students in the same way that other teachers have done. We need to visit our legislators and share our insight regarding the effects of ED overcrowding on both patient care and education. We should also serve as role models to our students and involve them in advocacy efforts, so that they will add their voices to our common cause. Emergency department crowding presents a challenge to EM, and for many, it has become a fact of life that is not likely to change. While there are some unique opportunities that ED crowding provides, there are many reasons to believe that ED crowding has a negative impact on both patient care and the education of future physicians. While ED crowding may lead to an increased number of patients and higher acuity, this educational “bonus” created by overcrowding is offset by compromised patient care and faculty teaching. In many cases, excessive ED crowding results from a lack of inpatient hospital capacity. In this gridlock situation when the ED is full but there is a decreased volume of new patient encounters, medical education is compromised as well. More discussion and research is needed to understand the true impact of crowding on education, and EPs are uniquely suited to the task. It is time we took a leadership position in the academic and research communities to determine what educational approaches are necessary to minimize damage and maximize learning in a crowded environment. SAEM, the Council of Emergency Medicine Residency Directors (CORD), and the Clerkship Directors in Emergency Medicine (CDEM) are ideally suited to foster the solutions to the education-crowding crisis. Just as we have adapted our clinical practice to maximize quality of care in the face of crowding, we need to change our teaching methods in a similar fashion. We cannot fail, for the true challenge of overcrowding in academic EDs is this: as we struggle in our busy EDs to avoid harming patients today, we cannot sacrifice teaching the doctors of tomorrow, for the effects of today’s teaching will be felt for many years into the future, by teachers, students, and patients alike. SAEM Crowding Taskforce Education Workgroup: Philip Shayne, MD, Department of Emergency Medicine, Emory University, Atlanta, GA Michelle Lin, MD, Division of Emergency Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA Jacob W. Ufberg, MD, Department of Emergency Medicine, Temple University, Philadelphia, PA Felix Ankel, MD, Department of Emergency Medicine, Regions Hospital, St. Paul, MN Kelly Barringer, MD, Department of Emergency Medicine, Regions Hospital, St. Paul, MN Sarah Morgan-Edwards, MD, Department of Emergency Medicine, University of New Mexico, Albuquerque, NM Nicole DeIorio, MD, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR Brent Asplin, MPH, MD, Department of Emergency Medicine, Regions Hospital, St. Paul, MN Michelle Lin, MD, Division of Emergency Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA Susan E. Farrell, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA Jonathan Fisher, MD, MPH, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA Benjamin White, MD, Harvard Affiliated Emergency Medicine Residency Program, Boston, MA Louis Binder, MD, Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH