Much has been said and written about the challenges facing America's emergency departments (EDs). Experts (and not-so-experts) attribute crowding, delays and wait times to the unique quirks of our healthcare system. Common culprits include the primary care shortage
, lack of universal coverage and nonemergency utilization by patients
All of these explanations hold water to some degree. But in summer 2015, I had an experience in Santiago, Chile, that suggests the issues facing American EDs may be more universal than we think.
Emergency Medicine in Chile
The Chilean health system has achieved some excellent population outcomes on a relatively lean budget. Chile is on par with the United States in terms of life expectancy, preventable mortality and infant mortality. By contrast, Chile spends just 7.5 percent of its gross domestic product on healthcare, while the United States spends nearly 18 percent.
Chilean hospitals have been delivering emergency care for many years, but only recently has emergency medicine (EM) been treated as a distinct area of practice. In 2013, Chile's comptroller general officially recognized emergency medicine (urgencia
, in Spanish) as the nation's 38th medical specialty.
Newly minted Chilean emergency physicians face many of the same challenges that their American counterparts did in the 1970s. At present, few hospitals have a dedicated Emergency Medicine department. Instead, EM is usually considered a subdepartment of Medicine or Surgery.
Chilean EM is also coming of age in challenging times. For one, Chile has extremely high rates of ED utilization. A typical group of 1,000 Americans will make 400 ED visits in a year. By contrast, 1,000 Chileans will make 1,000 visits.
Chile's EDs are in need of leaders who can improve efficiency and strengthen the continuum of care. However, relatively little leadership and management training is available to Chilean physicians.
The leaders of Clínica Las Condes (CLC)
recognize the value of physician leadership.
CLC is a private 253-bed hospital in Santiago. Recognized as one of the capital's premier hospitals, it offers many advanced treatments and technologies. CLC's 50-bed ED is a receiving center for air and ground ambulances. In 2007, it became the first hospital in Chile to achieve accreditation from the Joint Commission International
CLC believes that physicians are in the best position to lead change and enhance care delivery. The hospital has partnered with Johns Hopkins University, the University of Southern California (USC) and others to provide professional development opportunities for its physicians. It also hosted Chile's first national emergency medicine conference in 2013.
Wes Fields, MD
, a member of CEP America's Board of Directors, became involved with CLC through his friend William "Billy" Mallon, MD
, Division Chief of International Emergency Medicine at Stony Brook University School of Medicine. (Dr. Mallon had spent a sabbatical year in Chile working alongside local physicians to establish EM as a recognized specialty.) Dr. Fields addressed the first EM conference, describing the challenges facing U.S. EDs and their implications for the Chilean system
The following year, Dr. Fields returned to Santiago, accompanied by CEP America Chief Medical Officer Prentice Tom, MD
. In a joint presentation, they described best practices for managing an emergency medicine program. Seeing that the Chilean emergency physicians were hungry for leadership training, they approached CLC about bringing CEP America's Medical Director Academy to the department.
And that's where I come into the story. Along with Dr. Fields, Dr. Tom and Partner Gregg Miller, MD
, I served as volunteer course director for our first-ever international Medical Director Academy. I was excited to meet our students and to hear about their experiences in a system so different from our own.
CEP America's Medical Director Academy is a three-day program designed to prepare high-performing physicians for leadership roles. Participants learn about the importance of culture
, teamwork, change management
and data-driven practice. Lectures also cover key job functions like recruiting, operations, peer review
, and physician evaluation and counseling.
The course directors worked with our counterparts in CLC to adapt the curriculum for a Chilean audience. During this process, I received valuable counsel from two Chilean friends who happened to be doctors. They assured me that when it comes to leadership and management, their struggles are very similar. Apparently, leading change — and even leading a meeting — can be challenging for physicians everywhere.
In the end, we were fairly confident that the same management tools and techniques would work in Chilean hospitals. So we made relatively few changes to the content, other than removing some items specific to CEP America and U.S. law.
An Academy Like No Other
The Medical Director Academy in Santiago ran from July 30 to Aug. 1, 2015. About 50 people formally registered, but over 90 attended the lectures. Most participants were emergency physicians, but surgeons, nurses and others also participated. CLC provided real-time Spanish language translation via headphones — similar to the process used in the United Nations.
One of the most popular talks of the program was on the history of U.S. emergency medicine. That might seem like a bit of an odd fit for a Chilean audience. But they loved hearing Dr. Fields talk about all the politics and policy wrangling that culminated in the recognition of the emergency medicine specialty. I think the stories appealed to them, because they were living many of the same events.
As we'd expected, the Chilean physicians' management struggles were not so different from our own. For example, Dr. Miller gave a lecture introducing the concept of Rapid Medical Evaluation® (RME), a parallel processing model that places a provider in triage to help improve turnaround times. As I listened to the ensuing discussion, I realized that the Chilean emergency physicians were already well along in their process improvement. Though most had never heard of RME, they'd already begun engineering similar solutions completely from scratch.
Not every subject we introduced was a perfect fit. Some participants were a bit leery of concepts like peer review and physician counseling. For the most part, these practices were new to them. There may also have been some cultural differences at play — though to be fair, plenty of American physicians find peer review uncomfortable, too.
Despite some reservations, the participants were genuinely interested. One asked, "If [peer review] is anonymous, can I just pick the same person's cases over and over?" This opened a great conversation about protecting the integrity of the process through the use of objective triggers. We also talked about the importance of transparency, and how it promotes feelings of trust and fairness among the medical staff involved.
Just the Beginning?
At the end of the Academy, I was left with a feeling of deep satisfaction. A lot of work had gone into the program, but I personally felt that I'd gained as much as I'd put in. It's always rewarding to teach people who are so hungry to learn. Most of all, I was left with a feeling of solidarity — that our experiences were more alike than different.
Overall, the Academy content was very well received. "Will we do this next year?" the participants asked during our final coffee break. "What will we cover?"
As of this writing, we're exploring the idea of future Medical Director Academies with CLC, perhaps every 12 to 24 months. In the meantime, we were excited to receive a visit from a CLC executive, who spent a week in California touring our EDs. I'm sure his curiosity and thirst for knowledge will pay huge dividends for his medical staff in Santiago.