American Academy of Emergency Medicine

“Metric Madness”: The Dying of the Light

I would like to thank the author of “Metric Madness” for clarity and courage, and the editors of Common Sense for sharing it and safeguarding its source. May simple words spark a fire of frank talk about serious issues.

The following perspectives come from 33 years as a single coverage ER Doc (one strand of our so-called Safety Net). Work means prioritizing urgent needs, juggling information, clinical status, and a Gatling-gun of communications. An array of problems and drama converge on the
ED: threating trauma and illness, minor trauma and complaints, chronic recurrent symptoms, the indigent and uninsured, those with no other timely access to medical care, the intoxicated, the drug-seeking, the worried well, those plagued by voices or suicidal thoughts, the frail elderly, unmanageable teenagers and foster kids, and anyone dragged in by police, handcuffed and cursing.

Applying door-to-doc metrics is an unreasonable approach. Stable presentations and non-urgent issues fall into a different category. Human dynamics are complicated, often disorderly. It’s not a question of how fast you get your burger or the oil changed.

Length of Stay (LOS) is only partially (and inconsistently) under an ER Doc’s control. Want my metrics to shine? Give me a shift with evenlypaced, straightforward encounters and a savvy, hustling team for support. Entangle me with intractable system problems, spotty specialty coverage, nursing shortages, inefficient inpatient limits, and an overwhelmed hospitalist; and the admissions — the sickest patients — will linger for hours and hours on uncomfortable ED beds.

The electronic medical record has improved access to information, but the EMR’s cost/benefit ratio was never seriously studied. Computers were touted as safer and more efficient when they are neither. They’ve only changed the form of hectic-shift errors. They are less efficient: ask any veteran ER doc or nurse if triage and flow were better before or after. The system of software, upgrades, training, and IT handlers is also very, very expensive. Policymakers banking on EMRs saving health care dollars are in for a rude awakening.

Here’s more uncomfortable truth: navigating an EMR’s various fields, checkpoints, detours, glitches, and obstacles fragments attention, scrambles clear thinking, and drains mental energy. Critical analysis is a physician’s most important asset. Since time is a closed system, every minute struggling with a machine (entering data, orders, prescriptions, discharge instructions) is time siphoned away from good patient care (such as a detailed history and a thorough exam), from answering questions and alleviating concerns, from comforting someone in distress.

EMRs control the data that feed metric madness and support belief in false accomplishment and misunderstanding of what quality really means. This foolishness is destroying morale by adding more stress to an already stressful job. Caregiver health suffers under its impact. All this in the context of a growing physician shortage! A sizeable percentage of ED groups are already under-staffed, meaning overtime for the harried few carrying the load. Requests for locum tenens help are drastically increasing.

Those who took an oath to serve humanity need to take a hard look at what is at stake. Then, putting aside labels and political affiliations, we must join forces and command the high ground of what is truly best for patient care — enlisting strong voices and fearless leadership. Maybe we need a march on Washington, crying out, “Unshackle our EDs, support hard-working doctors & nurses, supply them with adequate resources!” As an endangered canary in the mine, I sing the words of the poet Dylan Thomas: “Rage, rage against the dying of the light.”

- Tom Moskalewicz, MD

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