In the March episode of ACEP Nowcast, I spoke with Luke LeBas, MD, FACEP, about our opposing viewpoints on waiting room medicine. The inevitable fallout of boarding is that now there are no beds in which to see patients. So, we deploy forward into the waiting room.
As a department administrator, I took a “pro” approach to waiting room medicine. I tried to convert waiting room medicine into a streamlined process so that our doctors could see more patients safely. Dr. LeBas—who lives in New Orleans and has worked at a Level I tertiary care, academic trauma center for over 11 years, recently transitioned to a 50,000 visit community hospital, and also moonlights at a rural access hospital—took the opposite viewpoint.
The following interview has been edited for clarity and space.
Dr. Amy Ho: What makes you so staunchly against waiting room medicine, knowing that you and I agree boarding is here and it’s a problem?
Dr. Luke LeBas: I’m against it, but I do it. As much as I don’t enjoy doing it, as much as I don’t think it’s good for the patient, it is absolutely a necessity. We’re not just abandoning people to flail out in the waiting room. I like to think that I do what all emergency medicine doctors do—we make the best of a bad situation. We bring care to the patients where it’s needed. We are problem solvers. We are MacGyver individuals, and anytime a system is broken, we will make it work. Now, that goes back to why I don’t like waiting room medicine. At least at places that I’ve worked, it’s always been the emergency department had to bend over backwards—bend and don’t break to make up for the shortcomings within the hospital. But the entire hospital’s problems shouldn’t be laid on the shoulders of the emergency doctors.
Dr. Amy Ho: I can appreciate that. I think I have a little bit of bias because my background is actually in administration. Most everyone knows me from my role with ACEP Now, but in my day job, I work for a medium size medical group that’s physician owned, physician led, and founded by a physician, which I think really slants how we approach these issues. I came up in administration fresh out of residency doing an administrative fellowship and then worked as an assistant medical director and kind of made my way up in day-to-day operations. But, we accepted that it was inevitable. We are literally the specialists at making things work, but we also know that holding patients as collateral as a way to ransom the hospital into trying to come up with solutions isn’t part of the narrative we want to put out there.
I think waiting room medicine, if you do it efficiently, shows our partners that we’re here doing our best. And when I say partners, I mean our partners in hospital medicine, our partners in social work, our partners in the ICU, our partners in EMS, and our partners, obviously, in administration at the hospital level. But, I think playing nice makes it so that having finesse in waiting room medicine helps the overall problem. A lot of time that I spent was working on, how do you make waiting room medicine better? What is good patient selection? Obviously, you want to do probably lower acuity patients. You want emergency physicians that can be a little bit minimalist, that can churn patients. You might want to have dynamic staffing for both physicians and nurses so that you can handle day-to-day surges. You want to come with processes where there’s a nurse, tech, or phlebotomist resources or physical access resources, i.e., nearby Pyxis’s, having internal waiting rooms, having a process for doing “waiting room medicine,” but in a way that is … ensuring privacy for patients. Also what do you do with these patients if they need a consult or admission? How do you facilitate that?
Dr. Luke LeBas: You seem to be very lucky in that you’re working at a facility that has such strong physician leadership and physicians who are in the C-suite and who are being listened to. Unfortunately, some of the jobs that I’ve had in the past, people that have been removed from the bedside from decades or people with an MBA that have no clinical background whatsoever are trying to dictate to me best practices. And you can clearly see that they don’t know what they’re talking about. And that gets to be a little frustrating whenever Blue Cottage comes in or McKenzie comes in or different organizations like that and they don’t understand the world that I’m living in. You’re lucky that is you, you’re on both sides of that fence. You’re able to talk to both sides of that equation. And that is a plus for the practicing pit doctor to have somebody like you that’s on their side.
Dr. Amy Ho: I think I certainly was welcomed to have walked into a facility where physicians were already very well liked and very well listened to by administration.
Dr. Luke LeBas: The planning that you’ve discussed, the internal waiting rooms, the throughput issues and all of this, I like all of that. And whenever it’s instituted as a new change within a hospital setting, I think that you would get more buy-in from the practicing doctors based off of how you sell it to them. Have a practicing doctor pitch it to them. Don’t have an MBA pitch it to them, don’t have somebody from the C-suite that you’ve never met before. Have somebody that you’ve worked hand in hand with to sit down with you and explain how this new process is going to work. Also, give explanations to the ED doctors what the rest of the hospital is doing. Acknowledge the difficulties that are going on in the ED and show me that the hospitalist and the surgeons and the other folks that are upstream and upstairs understand what we’re dealing with. Show me what sacrifices they’re making to try to help the situation as well.
Dr. Amy Ho: In my current role in administration, it’s almost purely in data and analytics. We look at things like, what is the arrival-to-triage time? What is the arrival-to-room time? What is the disposition-to-departure time for discharge patients and also for admitted patients? So that has, in a lot of ways, allowed us go to our counterparts and say, “Hey guys, we’ve looked at the ICU patients admitted in the ED, what’s going on? Because your admit hold rates are four times what hospitalist medicine is!”
Dr. Luke LeBas: The emergency department is more likely to not be stuck in a silo. We can speak surgeon, we can speak ICU, we can speak medicine. I do understand some of the difficulties these other specialties have, and I hope that they would also understand some of the difficulties that I have. Again, if everybody’s on the same page and everybody is equal within the conversation, I think that would be a great way to work toward improving the situation. But again, boarding is a hospital-wide, very complex issue, and expanding the ED, expanding the capabilities of the ED providers, I don’t think is a good answer to a problem that’s upstairs.
Dr. Amy Ho: Boarding is a problem that trickles down to us, right?
Dr. Luke LeBas: Yeah. I’m willing to work hard and I’m willing to bend over backwards, but I also want to see that other folks are doing the same. Prove to me that the hospital is trying to help out. One problem that we occasionally run into is there’s going to be one housekeeper for the entire facility on an overnight shift. Well, you expect me to turn over beds. I can’t do it unless I’m mopping floors and changing sheets myself.
Dr. Amy Ho: Sometimes the multiple internal waiting rooms feels a little bit like Disneyland. You wait in the line and you’re like, “Oh boy, I’m about there.” Then you turn the corner and you’re like, “Nope. Another internal waiting room, another turn.” From the perspective of the pit doc, not every hospital tries to address this solution administratively. What is there to do if you are at a facility where there isn’t an answer?
Dr. Luke LeBas: We’re constantly being told to do more, do it faster, do it quicker, do it with less. See 20 people in the waiting room with one nurse. And even if there is an emergency, your best nurse already has four ICU patients, two of which are intubated. I mean, we are revving the engine so fast, and at some point we’re going to break the engine. There needs to be help to unload the system.
COVID accelerated everything. As did burnout and the nursing shortage. What can we do to help unload us in the emergency department instead of getting tasks added to us? Every time I open up my emails, I see, “Hey, here’s something else that we want y’all to do in the emergency department.”
And again, these might be good things, these might be helpful things, but you also got to show me how the hospital’s trying to, on the backend, unloading tasks instead of giving me new things to do.
Dr. Amy Ho: Are we here for emergencies? Are we the experts in being resuscitation? Or are we actually just availablists?
Dr. Luke LeBas: I like to work. I like medicine. I like taking care of patients. I love working with the ED team. I don’t believe that boarding is an ED problem. I believe it’s a hospital problem. And I think one of the ways to fix this is to get more practicing doctors at the higher levels of the hospital who are able to speak on even footing, that there’s no hierarchy, there’s no, “Well, this person is more important because they generate more money for the hospital.”
Those kinds of issues, I think, need to be put to bed. And there needs to be a hospital-wide response to all of this. And the answer can’t just be laying it on a few people in the emergency department and expect them to do more and more work.
Listen to the full interview online. Click or scan the QR Code to access the podcast.
Dr. Amy Ho: I think you touch on a couple really important things. I think one is the importance of physician leadership. Two is the importance of hospital-wide initiatives, which to me, I think someone’s got to take the first step. And a lot of times it is emergency physician leaders because it’s what we see, it’s what we know extremely well, the waiting room is right there. To me, a lot of times the onus can be on the emergency medicine to take those first steps because the hospitals are our collaborative partners.
They’re not really our adversary. No one wants boarding. No hospital administrator walked around saying, “Wow, I wish I had more boarding hours in my hospital.” And I think the takeaways that I have is to first talk to your administration in the ED about options in the ED, i.e., is there a flex area or kind of a vertical area that you could use to take care of the waiting room patients where it’s appropriate?
I’m reminded of one of our pit docs actually, who used to show up at 3:00 p.m. with 80 patients in the waiting room. He would grab a nurse, he would grab a tech, he would walk out to the waiting room, make a large announcement of like, “Hi, I’m Dr. so-and-so. I’m going to try to take care of some of you that I can just get it addressed and let go. Please don’t be offended if I pass over you.” And then he would just start pulling patients into what was functionally a closet to get them seen. That was the beginning of waiting room medicine and I think that starts at a local level.
We mentioned multiple times that both of us think that this is a hospital-wide initiative. If you’re at a place where discussing boarding at the hospital level is appropriate, I think you can start opening up conversations about hallway patients on the inpatient ward, doing things like patient discharge lounges to help inpatient throughput, admit hold areas to move patients out of the ED, increasing social work, mobilizing physical therapy, occupational therapy, and speech therapy to help with the inpatient boarders.
Dr. Lebas, I want to say thank you for taking the time to discuss this important topic to which I agree, I don’t know that there is a solution. But boy do we try.
Dr. Ho is assistant editor of ACEP Now.
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