EM:POWER: if not us, who? If not now, when?

Times are tough. As we prepare to turn the corner on the COVID-19 pandemic, the world faces serious, inter-dependent challenges to its environment, economy, geopolitical stability and health. All of these are inextricably linked, something to keep in mind as we contemplate the future of healthcare. By way of illustration, some experts believe that over the next 2 decades, over a billion climate refugees will relocate to cooler parts of the world, further stressing all our systems, challenging the notion of sovereignty over closed borders, compelling us to “shed some of our tribal identities and embrace a pan-species identity” [1]. This scenario poses an existential question: as evidence mounts that our global ecosystem is failing, how can humankind collaborate to make it through to the future and thrive as a species, especially when the pain and suffering are so unequally shared?

Looking at emergency care through a similar lens, we too face a clear and present existential threat and practice within an unstable ecosystem, in which it already feels like waves of medical refugees are landing on our shores. With the decline and fall of their primary care home, they present to EDs with more co-morbidities and in ever greater numbers. Those requiring admission often face siloed services, quotas, ‘closed borders’; so, they wait, and those behind them wait, with predictable results.

Commissioned by CAEP in 2021, the mandate of the EM:POWER* Task Force (*Emergency Medicine: Patient Care-Organizational-Workforce-Ecosystem Redesign) is to propose a systems-based approach to the future of emergency care, where integrated networks with multiple access points–not just emergency departments–are responsive to patient needs and adaptive to changing conditions. Commitment to a common purpose, a new approach to workforce planning, transition to a Learning Health System [2] and accountability from the top down will be required to enable systems-level change. The ‘caps’ in EM:POWER also speak to bottom-up, front-line ownership, imparting a sense of agency to emergency medicine to catalyze meaningful change. If not us, who? Be it the environment, the economy, or healthcare, leading large-scale change [3] is never easy. It differs from the processes we are familiar with and defies the easy “fixes” [4] that are so tempting to political leaders and bureaucrats. We cannot act alone, so our task force is consulting broadly, engaging with leaders and organizations within and beyond medicine. Thus far, the response has been extremely encouraging.

“We don’t rise to the level of our goals; we fall to the level of our systems”—James Clear

The late Mikhail Gorbachev saw a failing system in the USSR decades ago, and launched a program of reform, widely known as glasnost (openness) and perestroika (redesign). He believed the way to a better future for his country was through increasing transparency, new ideas and empowering organizations and individuals outside their secretive bureaucracy. That courageous approach won him a Nobel Prize but not many friends in the halls of power.

Here in Canada, our secret is out—our health care systems are failing and this is having an overwhelming impact on emergency departments and the patients they serve. We experience it up close every day—packed waiting rooms, ambulance offload delays, treatment delays resulting in unnecessary harm, frustrated patients leaving before they are seen, and moral injury to our team of providers. Experienced nurses are leaving for more sustainable lives; staff shortages are causing burnout and, ultimately, ED closures. It is a vicious cycle of demand, dysfunction and delay, system-wide. Canada is next to last among OECD countries for access to family physicians, near last in acute care beds, and worst in terms of waits for specialists, elective surgery, and advanced imaging. As a consequence, Canadians have the highest rate of ED use in the first world and visits are rising rapidly [5].

Critically, our healthcare system is not a system in any cohesive sense, but rather a disconnected set of programs with countless loci of decision-making, and dynamic, often unpredictable responses to simplistic or ill-conceived plans. Governments and health administrators struggle with understanding complex systems, and often make decisions based on narrow assumptions that may be harmful to other patients and the system as a whole. COVID-19 is not a root cause of system dysfunction; it is more the last straw and another call to action. Reports and commissions addressing health system dysfunction date back decades. Despite these, the system has continued its seemingly inexorable decline, leading some to question its viability and core values.

The Canada Health Act [6] expresses those values in five foundational principles, but the promise of “reasonable access” for all Canadians to health services “without…barriers” is a long-lost ideal. The Romanow Report [7], which also articulated a value-based future for health care, supported system modernization and recommended a sixth foundational principle—accountability—which we will strongly promote, at all levels of governance. But large numbers of health providers with a solitary focus on individual patients do not make for an effective, responsive or sustainable system. A formal curriculum on Health Systems Science must therefore be a key component of the next generation of health sciences education, to complement basic and clinical sciences [8].

A redesigned healthcare ecosystem must have a clear purpose, to provides direction, coherence, and an overarching WHY to all that we do. This is well articulated by the IHI’s triple aim: improving patient experience, improving population outcomes, and optimizing value (outcomes per dollar spent) [9]. We recommend the adoption of a quadruple aim, recognizing the vital importance of readiness and resilience. The two are linked–readiness is the preparedness to respond while resilience in the ability to recover. Both provider and system readiness/resilience are required to address the inevitable but unpredictable surges that occur during normal times, and to meet the unknown risks of the future. Without these, the other three aims are just empty words, and the system will be buckle under unmet demand/capacity mismatches and a burned-out workforce, as our experience with COVID-19 has illustrated.

“What if there was a different starting point–the intended function of the system–and planners worked backward to determine the most suitable form for that function?” [10]

The primary function of emergency medicine is the assessment and treatment of unexpected, time-dependent illness and injury. However, our present workplace is incompatible with our prime directive and the myriad other functions we undertake in the midst of intractable access block. Emergency care in the future will be defined less by bricks and mortar, or geography, and increasingly by the range of competencies we offer to patients and other caregivers, even at great distances. New technologies and national licensure will even the playing field for acute care in historically underserviced areas, allowing physically isolated providers to become part of a virtual team practice guided by emergency physicians, and patients to receive care by in their home environment, whenever possible.

But emergency medicine cannot achieve its present or future functions in the health system if it also must be the “safety net” for other specialties or sectors that are unable to fulfill their own mandates, be it through poor design, misunderstanding, or lack of accountability. Counterbalancing the paradigm of sovereignty over closed borders with a common good approach, in which resources are equitably allocated to those most in need–including those we have variously called boarders, orphans or refugees– will be a major step forward.

We all feel most comfortable and safe in a familiar environment. Physicians are very comfortable in the house of medicine, but it’s really a neighborhood of houses, each one home to a specialty with its own professional identity, evaluating its own set of discrete patients and problems, in the way we have all been taught. Do not look now, but just outside our neighborhood the temperature is rising and there are already medical refugees at our doors. The effects of wildfires, floods and hurricanes are now directly impacting the health of our patients; socioeconomic inequity fuels other fires, even as burnout spreads amongst our own colleagues. If we are to create a better future for ourselves and our patients, we must start by agreeing on core values, accepting the interlinked responsibilities for patient, population and system health, and supporting our workforce. We must be literate in health systems science, establish truly integrated networks of care, and expand collaborative health services research. Leaders within complex health systems must show they are competent in these essential concepts, nurture innovation, be comfortable with uncertainty, but still insist on accountability.

These are the some of the ideas that are driving the EM:POWER Task Force and could contribute to a future framework for emergency care, in a redesigned system. Ultimately, it is hoped that this project will be a catalyst for other disciplines and organizations within healthcare to join with us to help plan a better future. If not now, when?

Declaration

Conflict of interest

None of the authors has any conflict of interest to declare.