The ED-Hospitalist Relationship: Friend or Foe?

One of the things that I love about my job as a hospitalist is the ease with which we can develop friendships with colleagues from other disciplines. Since I am an inpatient physician, it’s not surprising that some of my good friends are cardiologists, nurses, endocrinologists, physical therapists and, of course, other hospitalists. In fact, I met my neurosurgeon husband while co-managing his patients at the hospital. While thinking about this two years ago, I realized there were very few ED physicians on my list of friends. I was perplexed because while I interact with ED docs more than any other group of physicians, I didn’t seem to have many as close friends.

To better understand this discrepancy, I took a trip back in time and thought about how we learned to interact with our ED colleagues during residency. I realized that many of us unfortunately learn to perceive them as the enemy, and then start attending practice using only our negative experiences with the ED as a reference point. I clearly recall my interactions with the ED during my first year as a hospitalist attending, trying to triage admissions for our attending-staffed observation unit. I was dismayed by the number and variety of “inappropriate” admissions sent to our unit, like pregnant patients with no medical complaints or trauma patients for overnight observation. It was a frustrating experience to be the admitting and managing physician in these scenarios, and this only further reinforced my negative experiences from residency.

However, my view of my ED colleagues began to change as I matured as a physician. I realized that hospitals are intricately connected systems where very small problems always create large domino effects. I learned that the ED has to find a disposition for every patient they evaluate so that they can remain open without diverting incoming patients that require emergent care. When one service (often the appropriate one) refuses to admit, they have no choice but to contact another. Often, this defaults to the hospitalist service. In the bigger picture, we are both unfortunately in a difficult situation. The emergency physician and the hospitalist are truly two sides of the same coin then. ED docs manage the incoming flow and we hospitalists manage the outgoing flow. Understanding this concept and all that it entails has transformed my perception of the role of the ED physician.

As the hospitalist director of my group, this new perception has been reinforced by closely working with ED leadership. Last year, the hospital asked my team and the ED physicians to come together to improve throughput time. Led by a neutral third party, we attempted to dissect and understand the barriers to patient flow from the ED to the medical floors. We analyzed the complicated process of admission from the ED to the floors, and learned about struggles faced by our ED colleagues in efficiently triaging and admitting patients. To hospitalists this process sometimes appears to translate as a ”dump”; however, it was clear from our root cause analysis that there were many system inefficiencies driving admissions decisions that were not necessarily the actions of an individual physician. Likewise, they also learned about the difficulties we face managing certain admissions. This collaboration and greater understanding of the pressures each team faces has helped to improve the overall relationships and interactions between my team and the ED.

As we carve out our niche in our hospitals in quality and systems improvement, I remind everyone that it is important to develop respectful, collegial and strong relationships with our counterparts in the ED. Additionally, it’s also important to codify the goals and expectations that surround our interactions, like establishing the roles of each provider in an active co-management scenario. With clear understanding among providers in the hospital, this can be communicated to the ED to ensure smooth patient transitions. The ED-hospitalist relationship is one that, if nurtured and developed thoughtfully, will go a long away in proving that an ED physician is the closest friend that a hospitalist can have.