Report to the Maimonides Board on Stepping Down as Chair of EM

Thank you for the opportunity to address you once again. Last September 2009 when I presented a status report on the Department of Emergency Medicine, little did I expect to find myself here again so soon.

15 years ago at a board meeting very much like this one you created a new Department of Emergency Medicine for Maimonides. I was fortunate to be selected as the Founding Chairman of that new department. I’d like to spend a few moments recounting a chronology of the department’s physical and program development and then share another aspect of the department’s development--one perhaps less apparent to you, yet a facet of the department’s development I hope you’ll come to view as significant as facilities and program.

The first step towards the construction of the Weinberg Emergency Department took place in May 1996 with the move of the Ambulance Department from a trailer on the corner of 49^th and Ft. Hamilton parking area to a garage on 39^th Street. Maimonides operated 6 tours daily in the NYC EMS System. At about the same time, the Department moved into its administrative home at 965 48^th St.

June 1997 brought the opening of the adult ED in the newly constructed Weinberg Emergency Department and the following month, residents from the Kings County/Downstate Emergency Medicine Residency began rotating with faculty in our ED.

March 1998 brought the opening of the Sephardic Friends Pediatric ED and the Bruce Birnbaum Administrative Suite where our department leadership was housed through 2001 until the Cardiac Cath lab expanded in 2002. In 2000 we had our own CT scanner installed in the suite on the main hallway.

In late 2000 we began developing an application for our own Emergency Medicine Residency, an application that was approved in 2002, leading to the graduation of our first class of EM residents in 2005. In February 2004, the MMC Ambulance department moved to its present location on 38th Street operating 12 (8ALS/4BLS) tours daily in the FDNY EMS System.

The Department initiated both a 3-year Pediatric Emergency Medicine Fellowship and a 1-year Emergency Ultrasound fellowship training program in 2008. Our sixth class of EM Residents graduates tomorrow evening.

As a capstone, the hospital opened the new ED in January 2009 and installed a 64-detector/dual-source CT scanner in August of 2009.

I’d like to turn to the other development that I mentioned earlier. Over the past 15 years the staff of the Department of Emergency Medicine have truly incorporated the many communities we serve as partners in improvement and incorporated improvement into the daily work of patient care.

The staff of the department, whose roles as clinician, technician, administrative and operational support are centered on individual patient care, have also incorporated into their core work improving how patient care is delivered at the bedside. Particularly in this latter role, the hospital’s community partners have been invaluable for their ready advice. Partnering with community representatives hasn’t always been easy and neither we nor our community partners have always gotten it right in our initial efforts, yet much of the improvements accomplished can be attributed to the interdisciplinary team in the department of EM and to effective collaboration with the community and its representatives.

I’ve experienced a thrilling and challenging 15 years.  As your steward for the department of emergency medicine I’ve done my utmost to fulfill your vision for program development supported by the facilities and resources you’ve invested. I trust you can equally value the extant culture of the department of EM which fully engages the necessity of continuous improvement in caring for patients as a fundamental element of daily work. The creation and existence of this culture is a source of considerable satisfaction to me.

Trust and the Serendipity Engine: Twitter

In this wonderful, 10 minute video done at the NYC Web 2.0 Conference in mid-November 2009, Chris Brogan opines on the value of Twitter, especially search on Twitter. He tells of his experience with discovering the Roger Smith Hotel, just down the way from the Four Seasons which is losing business to the Roger Smith. Why? Because colleagues responded to his twittered question about where to stay and then so did a live communicating voice (through Twitter) from the Roger Smith.

However, don't be distracted by the forgoing narrative as it's the deeper message that Brogan speaks to a commercial world using the web for commercial business that resonated for me. I've written about Brogan before, elsewhere, and urge you to read that post and Brogan's Trust Manifesto, for it is the loss of trust that so many clinicians experience--perhaps not so much with their patients--in working with all of the components of the health care system that support clinicians in the care of their patients. Brogan in this video, once again speaks to building trust, using the contemporary tool of relationship development: Twitter.

Brogan recommends using your @replies much more than most users do to this point. 80% of his tweets are replies--he suggests that users reply to others 12 times for every one original tweet and addresses many other aspects of using Twitter.

He goes on to raise a series of questions:

How do we share?
How do we extend experiences and relationships?
How do we collaborate?
How do we make new distribution?
How do we develop relationships that yield?

"The difference between an audience and a community is which way we turn the chairs."

Brogan closes with this quote from Ralph Waldo Emerson, "Do not go wherever the road may lead, but go where there is no road and leave a trail."

I'm proud to have done that in my work in Emergency Medicine; I'm just warming up for the next act.

Giving thanks for the sacrifice of those we've lost and powerful writer of "The Lost"

Moving and powerful remembrance from a leader and survivor of the Afghanistan war. Soon to learn of plans for expansion of this war, "How do you ask a man to be the last man to die for a mistake?" J. Kerry, 1971.

Engage with Grace at your Family Thanksgiving

Engage with  Grace and help your loved ones understand and act on your purpose at the end of your life even as today all celebrate and give thanks together.

HealthCamp Philadelphia--Less than a month to go

HealthCamp Philadelphia

The BarCamp movement of self-produced intense conferences reminds me of the charrettes I'd hear about from my close friend and college roommate when he was in architecture school. HealthCamp has grown out of BarCamp and on Saturday, March 28, 2009 HealthCamp Philadelphia begins at 8:00 AM in the Hamilton Building on the Thomas Jefferson University at 11th and Locust Streets. The slide show summarizes the day and its goals.

Comparative Effectiveness Research--The View from Wachter's World

Bob Wachter discusses the challenges of implementing the comparative effectiveness research results we have in hand. From the perspective of leading physicians and frequent contacts with a diverse range of specialists and sub-specialists in my tertiary care providing community, teaching hospital I find myself nodding in agreement with Wachter's observations.

Everyone but the citizen's ox gets gored by comparative effectiveness research implementations. I use the term citizen advisedly, taking my cue from Obama; for some number of patients may well feel that they lose out as individuals, even as the polity benefits.

Tough implementation ahead with lots of squabbling before we're done accomplishing a fraction of the result the policymakers are seeking.

Customer-Consumer Confusion and now Patients, too

EP Monthly's "WhiteCoat's Call Room" posts two links and discusses "Patients or Customers"?

Patient, customer and consumer have specific meanings, not accurately used in the posts from Aggravated DocSurg and Detroit Receiving's EM Blog.While I'm in general agreement with many (not all) of the sentiments expressed in the two posts, it's important to get the correct meaning of the terms.

Customer= he who pays
Consumer= he who uses

The definitions are from Princeton Wordnet, but they're the same as what I was taught at Wharton 20+ years ago.

Part of our challenge in forming relationships in the ostensible business (good or service exchanged for value) is that for many users of physician services (i.e., patients) both the patient and physician experience customer-consumer confusion with consequent misalignment of incentives.

Patients will be increasingly demanding of receiving value in their care for value given directly (fee-for-service) or through employer and tax-based services. They will find the employers holding them accountable for "smart shopping" or the government steering in other ways--or both.

My father was a proud physician, he cared only for patients. Were I to view the world as he did, I would be struggling to feed my family. In this year of the 200th anniversary of Charles Darwin's birth, let's remember that it is not only individuals, but also entire species and perhaps professions for whom survival is not guaranteed; one must adapt or die.