The PalliEM Podcast:
Episode 3 – Embeded Palliative Care in the Emergency Department
– with Dr. David Wang, MD.

EPISODE 3 SPEAKERS:
David Wang, MD, Justin Brooten, MD

PRODUCTION:
Audio Editing Assistant: William Park,  Transcription Editing Assistant: Ryan Hilton

Justin Brooten, MD  00:00

Today I’m joined by Dr. David Wang. Dr. Wang is a system director for palliative care with Scripps Health. He is board-certified in both emergency medicine and Hospice and Palliative Medicine. Dr. Wang holds integrative leadership roles within the American College of Emergency Physicians and the American Academy of Hospice and Palliative Medicine. He chairs national committees, lectures widely, and recently published his textbook on primary palliative skills for clinicians. Dr. Wang also has prior experience working in health policy at the World Health Organization. He is passionate about transforming the way Americans imagine, deliver, and receive care at their end of life. Dr. Wang, thank you so much for joining us,

David Wang, MD  00:36

Justin, thanks for having me, and thank you to all those taking time to listen to us today.

Justin Brooten, MD  00:40

So, my first question for you is because this is a unique field, what led to your interest in pursuing training in the combined field of emergency and palliative medicine?

David Wang, MD  00:51

Well, Justin, this is a combination of skills that has become surprisingly much more popular and common over the last 10 years. I remember having these conversations back then and would be met with puzzled looks, I would say for me, it arose from a very personal desire to be with people in a time of great need, which we get to do in both the ED and throughout the entire spectrum of palliative services. And on a professional scale, as healthcare has evolved over the last 10 years, we’re paying a lot more attention to giving people the right care at the right time, making sure that we’re not doing things to people that isn’t within their desires, that they have informed consent about what happens when they enter the four walls of a hospital, and that we also really give people the best experience with the serious illnesses that we can. And so, for all of my colleagues, and for all of you who are considering a union of these fields, I can’t think of a better way to deliver the best possible care to people.

Justin Brooten, MD  01:49

That’s well put and it’s very true. It’s very apropos right now, because so many things happen in the emergency room, and being able to combine both the patient’s goals with the resources that we have at our disposal. So how do you utilize your skills in both emergency medicine and palliative medicine in your current professional role?

David Wang, MD  02:08

I think for a lot of physicians and clinicians coming from an emergency department context, first, you’re by nature, each of you very gifted decision-makers and task switchers, you’re able to assimilate lots of information and very quickly drive through to what, what’s needed to be done in the moment. When you combine that with the palliative mindset and perspective of a bigger picture of what is possible for patients and families and taking the time to understand what they truly want and hope to achieve. It’s really a remarkable way to make the most of your time in front of another human being talking about what matters, sifting, filtering through all the technical jargon, and being able to hear and receive values from someone in their family, and deliver a recommendation based on truly what is best for them. For us here at Scripps, where I primarily work, it’s an incredible chance to bring together colleagues who are skilled in both of these fields, to create a service, unlike many others in this country, of putting our palliative consultants directly in the ED to meet with patients with serious illness and a time of crisis, and to be able to quickly drive right to the heart of what’s important, and how do we give you the care that you need to get that? And how do we avoid the things that either are unwanted or unhelpful?

Justin Brooten, MD  03:35

Excellent. And why do you think – and I’m going to start with – I’m gonna break this question up in a couple pieces. Why should EM physicians be interested in having palliative care integrated into the emergency room?

David Wang, MD  03:48

You know 10 years ago I think the answer to this question would look very different than it does now. 10 years ago, I remember when I was on a roadshow talking about this with various program chiefs, I was often met with puzzled looks, with responses being I suppose that makes sense, or I think I might know somebody who does something like that. And now go to any academic training program, excuse me, now go to any academic emergency program in the country and you’re guaranteed to find somebody who has an interest in this. And the question has really shifted from not why should I do this, but how? And why has that come about? Why that shift? Well, I think, one, that emergency physicians are realizing that well, a huge part of our work is very workflow-driven and automated. At the end of day, we want to go home and feel good about the care we deliver, and sometimes delivering aggressive amounts of care to patients who may not understand or may not appreciate what that means for them and their likely outcomes is unwanted. We don’t feel good about not being part of an informed process. And so doing the best we can to ameliorate symptoms and deliver goal concordant care has become something that is valuable to many emergency physicians coming into practice. But the bigger question here, I’m sorry, but the bigger question, Justin, that you asked is, how do we do this? And, and that is, I think one of the key challenges of our time, which is, you know, not only, I think the same is where there’s a will there’s a way and enough of a will has been created enough of a groundswell that we are now creating the way for emergency physicians. The most evolved ways to go and pursue fellowship training and emergency physicians as a cohort are the most rapidly growing subset within all fellowship certified palliative physicians. At the moment, there are about 170 of us, but that number is increasing rapidly every two years when the boards are offered. There’s also incredible advocacy and activity at the levels of the national organizations across ACEP, AAEM, AAEM, and of course with AAHPM everyone is taking what they’re learning and bringing it back to being ambassadors within their respective emergency departments in the community, at academic centers, trying to figure out a way to make this work feasible in the ED, not just doing what they do upstairs, but in a way that the average emergency physician can integrate into a shift and still be successful and the practice constraints they have with throughput and metrics and whatnot.

Justin Brooten, MD  06:31

Well, along those same lines, because you mentioned you’re trying to find ways to integrate that still works with EM practice, what do you think are the big ways an EM physician can integrate into practice while still thinking about the flow of the ED, what are some simple steps?

David Wang, MD  06:48

Well, I would say for the average emergency physician working independent listening to this, think about a series of steps. The first is probably just familiarizing yourself with some basic skill sets. The ACEP communities, and various online websites, such as Dr. Brooten and PalliEM, all contain content for how you can clinically improve your skills. The next step though, is if this is really a passion of yours, think about what it might mean to be a champion in your local emergency departments, to obtain additional training, whether it be through a program, such as vital talk, which will improve your communication, epic EM, which is a curriculum offered every couple years, or even more formally, through a part-time or full-time fellowship. Those are the skills that are hard to learn necessarily through online that can become invaluable to you and worth the investment in time. And then for those who want to go even one step further, thinking about what you would wish your career to look like after whether you’ll be – you’ll bring all those skills back to your local emergency department and continue to teach your colleagues locally, whether you want to become an educator, working both realms and teaching both how to work better with one another emergency medicine and palliative, or really to go on and build systems that might enable success for people trying to bridge these two clinical fields. As we all know, the practice and art of medicine can sometimes be very significantly affected by the constraints that are put on us by administrators and government and payroll day metrics. So, it’s important to be able to set ourselves up for success, ultimately, so that doing the right thing to the patients also means that we’re able to continue practicing and growing our work.

Justin Brooten, MD  08:37

Well stated. And one of the things that crosses my mind as a physician with both education in palliative care and emergency medicine, what are some of the unique challenges that palliative care providers face when they go down to the ED and they’re consulting a patient in the ED that you think they need to be cognizant of?

David Wang, MD  08:55

That’s a great question, Justin. As we know, medicine, for better or for worse, is still very tribal, even now into the 2020s. We operate in our silos, and we’re used to the things we’re used to. I think that disconnect can happen to either party. For instance, if a physician calls for a palliative consult in the emergency department and assuming that a service is available to go down there, a palliative physician may say to that person well, I’m just about to hop into a family meeting, I’ll come right after, to one person that means one hour to the other person, that means five minutes. So, setting expectations of availability is important. Who is the person that goes down to the emergency department that delivers the offering, it may not be a physician. The interdisciplinary nature of palliative care is not as well appreciated in other parts of the hospital or maybe is not as keenly understood in other parts of the hospital. A sense of ‘is the service available off hours’ sometimes introducing the emergency department is a place where additional consultations may be created, it can create a sense of hesitancy in some palliative teams. I had one palliative doc once ask me, does this mean I need to bring a sleeping bag to the office now? And so, understanding what you and your team can bear and being really clear about that with the ED is important. What I found talking to a lot of people about this in establishing services, is that any help is appreciated when you pick up the phone, and you’ll say we’d love to help in and of itself that is positively received by the ED. That being said, I think one of the key questions that palliative teams need to ask themselves when they’re thinking about expanding relationships into the ED is, before we even go through the nuts and bolts of how, you know, the hours of staffing and who’s going to do the consults. It’s really about where in their growth cycle, their services, are they still kind of a startup phase where it’s important just to get more consultations, establish the need in the hospital so that they can acquire additional resources for their team, or are they maybe a little bit later on in their growth. And they’re recognizing that we have more than enough consults, actually, we want to expand to the ED because we want to get involved early for these patients who are – who have very long length of stay in receiving care that’s congruent with their wishes. Or maybe the goal is completely for community-based care and that this mature palliative service in a broader healthcare system, realizing that inpatient work is sometimes too little too late, and what they love their ED relationship to be is one to actually identify patients, as a pipeline for their clinic, or perhaps for earlier consideration of hospice, being honest with yourselves and what your team can bear and where you’d like to grow. Is it a pivotal discussion to have before you start seeing patients in the ED and setting a new cultural expectation around that?

Justin Brooten, MD  11:51

I really appreciate how you highlighted several things. There’s multiple avenues of care opportunities that come through the ED and you’re absolutely right, you want to get the inpatient consults, especially the really, really sick patients who you’re worried about what’s going to happen in this hospitalization acutely. And you’re absolutely right, you want to address outpatient concerns, because that is ideal to get them earlier up in the stream of a serious illness, to be able to make plans get advanced directives start working on that process early as opposed to waiting until they have an acute hospitalization. And maybe they’ve lost capacity, or a bunch of other interventions have happened already. So that’s a good point is that there’s multiple avenues of care that can kind of be started through the ED. The other thing that’s interesting, you point out, is the timescale that we operate on in palliative care and in the emergency room are so starkly different. So, I like what you said about a family meeting, you know, to the ED doc, that could mean okay, I need five minutes, and to the palliative care person that’s easily 45 minutes to an hour because we have those meetings. And you’re right, you have to set those expectations because I’ve found when I’m on shift, and I’m seeing people in the ED, if I’ve got a really complicated conversation to have with someone, I’m calling my own team member to come have that conversation because I can’t supervise residents and maintain the flow of the emergency room while also having a 30 minute plus conversation with a patient or family. And I agree it’s – the ED wants help, so when there’s a situation that you need that skilled conversation, you want to make sure you’re doing the right thing for the patient, but you can’t take the time to do it the best you could while still running the emergency room. But if you’ve got that, that clinician there that’s skilled in that communication and can take that time, then it’s a huge asset. So, I really appreciate it what you pointed out about the multiple avenues that can take – one of the things that I’ve appreciated about your work is how you’ve really broken down the impact that palliative care ED integration can have across a health system. So, I’m curious, just in the big picture sets, what are some of the things that health systems need to recognize when they consider this integration process? Because it has a huge impact. Overall, what are the impacts of palliative care ED integration on health system?

David Wang, MD  14:11

I think both health systems are well versed with the concept of the Quadruple Aim that we want to deliver the right care to patients, improve their experience, be good stewards of our healthcare resources, and then be cognizant of the emotional impact of this work on our providers. Palliative care is one of the few things in medicine that is a winner in all these categories, and especially bring it into the ED only augments that impact. At Scripps, we’ve been very fortunate to be able to demonstrate that creating and embedding a palliative consult team within our ED has been well received and has generated a return on investment for all stakeholders. What we found was when we deliver an early palliative intervention and in the ED, it is truly the most early inpatient intervention possible, compared to the interventions that we deliver upstairs when we’re not normally called later in the hospital course on the floor in the ICU, those ED initiated consultations reduced the patient’s length of hospital length of stay by over three quarters. And likewise, their costs of care as well. Not only that, I’d like to think that those patients get more care and attention, symptom management, all throughout the process. They may also be referred to hospice and clinic earlier, so they may come back to the hospital less, live a higher quality of life at home rather than continue to visit us in our inpatient facilities. When we have compared that to the cost to launch a service like that, it shouldn’t be a surprise to anyone that the health care system benefits significantly from that, the return on investment financially is over 15 times the cost. And so with numbers like that, most people will pay attention and realize that even though this is a high-cost intervention to implement, the risk-reward tradeoff is significantly beneficial. Now, I have to recognize that it’s difficult to scale something like this, if you’re in a small health system, you may not have the headcount to put a palliative provider in the ED. I’m also a believer that given the nature of palliative work, doesn’t necessarily have to be a provider staffing this. And there are models in the country where even hospices, for instance, will fund a position in the ED instead to take care of their patients who come in, and extremists who probably might have had their needs taken care of at home, and provide a boon to the ED. I’ll also lastly point out for our emergency physician listeners. The thought of working elbow to elbow with a palliative person may seem strange, and what the key concern being, are they going to impede my workflows, are they going to slow me down? Are they going to make things more gray when I like things black and white? And I’m happy to say having been in our ED now for the last nine months, our satisfaction has been really high amongst our providers. Nearly 100% of them said that they were extremely satisfied with our services, that palliative was valuable to them and their patient, that we did not impede workflows. And that even by being there, just by hearing us talk and seeing our work, they themselves have felt more confident and identify patients who need palliative and their own skillset in preliminarily addressing some of those needs. So much so that they volunteered to tie our success into their own financial compensation. And so, we’re privileged that they would trust us with that. And we certainly want to make sure that they’re rewarded for doing the right thing by working hard ourselves.

Justin Brooten, MD  17:53

That is some – that is really impressive data. And there’s several things you mentioned that I really liked one, I mean, of course, as you know, the literature backs up what you said about the cost savings. But as far as the length of stay decrease, that’s impressive. If you’re knocked down by three quarters, I know that I’ve looked at the data on early ED consultation and outcomes, but that’s very impressive. And also I liked what you said about it not impeding workflows, is that something that I think comes up a lot is, it’s great, it’s great that we have these conversations downstairs and some people see the benefit and utility in it, if we avoid ICU hospitalizations or hospitalization altogether, it’s the alignment of goals with the patient and family is to try to attempt care at home. But that’s going to take extra time, it’s going to affect my workflow, it’s going to affect the ED flow. So, the fact that you’ve had such success in that is – it’s really impressive, and it’s encouraging. And the next question I had, you mentioned another type of model, you mentioned having hospice agencies provide someone and you mentioned what your system has been working with, with a dedicated ED provider. What are some other models that exist in trying to incorporate palliative care into the emergency setting?

David Wang, MD  19:06

There are models for triggers, triggers for consultation, that’s in our earlier iteration, that’s what we use, in another one of my hospitals, we found that to be similarly impactful, very similar length of stay in cost impact, however, the uptake was low. And really what that came down to is patient identification. The triggers are only useful if they’re actually implemented and what we found is up only about a third of the emergency physicians will go through that process. It’s hard to ask an emergency physician to do one more thing. Even if it’s as simple as if you see the patient look sick, call palliative, and leave a voicemail. And that’s really all of ours was it wasn’t a complex trigger system nor was it a significant ask of time, but I have to acknowledge that it was one more ask of time. That’s why we’re we were much more successful with this embedded service because we just turn around, tap the ED doc on the shoulder and say, hey, I’m going to, I’m going to go see this person who I think would benefit from our services, and they say go, go ahead, have a field day. And then we come back, we give them closed-ended recommendations, if-then statements, and we try to make things easy for them. And that I think is what’s needed to be successful, which is the ED does not need anybody coming in telling them how to do their job, to come in and create more asks of their already stretched days, and they’re limited mindspace, juggling 80 tasks at once, the easier we can make it for people to do the right thing, the better the results will be. And in this case, a significant benefit to the health care system altogether. You know, Justin, the one thing I didn’t really talk about was the importance of building relationships and getting something like this off the ground. And I can’t stress that enough, which is at the end of the day, these are all just ideas. But operationalizing idea is more complex and making sure that you get buy-in and acceptance from all your stakeholders, before jumping into something like this is really crucial. So just having the ED and administrators on board isn’t enough. I really want to make sure you discuss this with your hospitalists, or your admitting medicine teams, whatever they may look like, your intensivists letting your frequent community specialists, oncologists, and whatnot, cardiologists aware as well. And then, probably most importantly, is making sure that the inpatient palliative team understands what this would look like, that there is a clear boundary between what patients are handled by the ED team and who follows those patients next day, that there’s good open communication between both of those teams and it really feels like one service with two arms, rather than two separate teams in the hospital.

Justin Brooten, MD  21:52

What you said about relationships is so true. And it’s interesting, I like, as you mentioned before you have that initial iteration of a triggered console system. And while that’s effective, and it does help, you’re right asking anything out of the clinicians when they’re already strapped for their headspace their thought-space is a lot, but just having somebody next to you, it totally changes things. And I’ve had a similar experience. I do, I do inpatient consults on Wednesdays and I’m in the ED the rest of the time. And when I’m there Wednesdays, I’ll cruise down to the ED and we have our own system that we’re working on in process to, to generate consults from the ED for appropriate patients. But inevitably, I go down, you know, my colleagues see me and they’re like, there’s like, oh, there’s a, there’s a patient I should tell you about, you know because they know me. And it is it’s a relationship thing. So, we are working on some similar models that our system and you’re right, you have to have the right resources for it. But just having that relationship and having someone who trust the recommendations they’re going to get from someone, and they know that those recommendations are going to be helpful, and they’re not going to impede the workflows important. In addition, you mentioned this earlier, you have the benefit with that embedded provider of, you start to teach each other, you know, if the palliative provider doesn’t have as much ED experience, they get that sense for, okay, what does the ED need? What are the unique needs of the emergency room? And how can I best adapt to that? And the ED physician is going to pick up skills from the palliative care provider. I mean, we’ve all – we interact with so many other specialist clinicians, we start to learn, okay, well, well, GI here likes to do this for this problem, and cardiology likes to do this for this problem. And pretty soon they’re like to go, well, palliative would like to do this probably for this problem. And you know, this might be where I start if I’m managing pain, and I’m not calling them because I feel comfortable managing that now, in a way I didn’t before because I’ve had a chance to interact with another clinician that has expertise in that. So, I really like that. And the success that you’ve seen with that it’s not surprising, because of that, that model generating those kind of positive relationships. What would you say to someone who is thinking about pursuing training in both of these? What how would you advise them?

David Wang, MD  24:05

Gosh, I think I would encourage them. I think if you search your heart and you find this work to be meaningful, and then you spent some time in a palliative setting, be it a consult service or hospice or clinic or whatnot, and that the work feels acceptable to you and that the work feels exciting for you. I would say it’s worth the investment of time. I think everyone has to ask themselves, you know, what do I want out of my career? What do I want? What kind of legacy do I want to leave? And if being able to bring some of the palliative aspects of work into the ED is something that has a place in that, then I will say reach out and find a mentor and talk some more about what kind of shape that has to take. I want to be cognizant though that not everyone is in a position where they can go do a fellowship, be a full-time or part-time. And so, there are still ways to go acquire additional training, training that hopefully will become actually included in an AVM certification process. To be the best emergency physician, you can. I would say, I think probably 20 years ago, if you were doing this work, you are going above and beyond, you’re the cream of the crop of Emergency Physicians doing something that nobody else is doing. But now for everyday emergency physician to learn a little bit more about how to manage difficult symptoms, to be versed in their understanding of hospice, and to have a thoughtful approach to goals of care. Really, that just makes you a good emergency physician now, something I would hope that everyone would aspire to.

Justin Brooten, MD  25:47

Absolutely. What are the greatest obstacles to ED palliative care integration?

David Wang, MD  25:53

Hmm, that’s a really good question. There are certainly obstacles out there. I’ll give you maybe two answers on that. The first is, I think, at a personal level, we have to recognize, you know, medicine is an apprenticeship model. It sucks, in the beginning when you’re going through school, and residency and training, but then you become an attending and really, for the most part, nobody tells you what to do anymore, and you get very set in your way of doing things. And so, being able to innovate, to do, to adjust to workflows that don’t fit into how you’ve mastered a craft can be really hard. It can be hard for the person wanting to go into palliative, it can be hard for the person in the ED trying to implement palliative protocols and workflows. The second part of it is at the system’s level, which is it’s hard to align incentives these days, it’s getting easier, but it’s still hard to align incentives in a lot of healthcare systems to make it such that we can design a way of working that achieves the right thing for the patients. We’re lucky in palliative that we don’t really have a lot of turf wars with anybody any other service. And so the work that we offer often is usually well-received. Even still, I know there are plenty of health systems out there that see their EDs entirely as feeders into their inpatient beds. The ED exists to put heads to beds, and very little else. And so it can be hard to stimulate that conversation with the administrators to recognize that creating ways for ED palliative partnerships to be successful, is worth the financial ask and has a positive impact to patients, to our providers, and ultimately, to the financial bottom lines, which the administrators should be holding to. We want to keep the lights on, of course, we want to do the right things for patients. And we want to make it so that we enjoy going through the day doing those things. To the motivator listener, I asked you to consider these questions to ask of yourself and of your colleagues, which is what would success look like? And why is it that we haven’t reached that point yet? Have things been tried? Why haven’t they been tried? If they were tried? Why were they not successful? What would be important for me as somebody in both of these worlds to do or who would it be important for me to talk to, to try to bring this together? I think these are some of the things that are important to kind of think through first before jumping into designing what an initiative might look like.

Justin Brooten, MD  28:30

Thank you so much, Dr. Wang for joining us today. I appreciate your thoughtful responses and thank you for your time and the efforts that you’re making to integrate this into the way we do health care in this country.

David Wang, MD  28:42

Thank you, Justin, for having me.