Clash over ER training could hurt Harborview

Harborview Medical Center's Emergency Department, despite its stellar reputation for trauma care, has been ordered to hire emergency-medicine specialists or lose its national accreditation to train emergency doctors.

Harborview has no board-certified emergency-medicine physicians teaching newly minted resident doctors working for certification in the specialty, a violation of training standards.

Harborview promises to begin hiring the specialists. But the 34 emergency-medicine residents rotating through Harborview told deans at the affiliated University of Washington School of Medicine last week the plan is a "superficial fix" and may force them to seek training elsewhere.

"They've got the best of everything, except emergency medicine," said Dr. Ben Betteridge, a chief resident in the three-year training program. "The dirty little secret is there are no emergency-medicine trained doctors in the ER."

In that, Harborview may be the last of a vanishing breed.

"Harborview would appear to be the last place in the country that emergency-medicine residents are supervised on an emergency-department rotation by non-emergency-medicine-trained faculty," said Dr. Robert Suter, president of the American College of Emergency Physicians.

The dispute lays bare a long-simmering clash between emergency-medicine specialists — including those at the UW — and Harborview doctors over how best to run an emergency department and train emergency-medicine residents. As part of the UW system, Harborview shares the medical school's mission to train doctors to serve the region.

"I know there are some people who believe that all emergency rooms should only be run by emergency-medicine-trained physicians," said Dr. Scott Barnhart, Harborview's medical director. "That is not the model that we have adopted here."

Barnhart said Harborview's system, which prides itself on quick access to an array of specialists, provides excellent care for patients and top-level training for residents.

"Who best to train any resident how to do an emergency surgical resuscitation — where they have to open the chest — than a trauma surgeon? That provides a high level of training," he said.

Losing the emergency-medicine residency program would be ironic, at least, and likely embarrassing for the UW School of Medicine. Harborview's busy Emergency Department also would lose about one-third of its resident work force, a loss Barnhart said the hospital could handle.

At any other hospital, this dispute would be dismissed as an academic turf war. But this is Harborview, the Northwest's only top-level trauma center, known nationally for superb care of patients with grave injuries.

Its Emergency Department is run by the legendary Dr. Michael Copass. Over the past three decades — since before emergency medicine became a recognized specialty in 1979 — he has built Harborview's Emergency Department into a model admired and studied by hospitals around the world.

So the notice of training-program deficiencies last year from the Accreditation Council for Graduate Medical Education caused a stir. As a result, Harborview agreed to hire "three to four" board-certified emergency doctors to supervise residents by mid-2006, Barnhart said.

But, he added, "I'm not sure it makes particularly good sense." He said that he wouldn't speculate about the "motives of the emergency-medicine specialty," but that as medical director he had to ask himself: "Is this about quality?"

"My answer — very comfortably — is no," Barnhart said.

For their part, the residents and UW emergency-medicine faculty said hiring a handful of emergency specialists won't solve deeper problems at Harborview.

Harborview's plan is "woefully inadequate and unacceptable," said Dr. Richard Cummins, a UW professor and emergency-medicine specialist. He said it would continue to subject residents to a "substandard training experience."

How Harborview works

Harborview's Emergency Department relies on highly trained specialists, from orthopedists to trauma surgeons, who provide care to seriously ill or injured people.

Internal-medicine specialists called attendings manage the ER day-to-day and supervise the emergency-medicine residents, who are licensed doctors receiving specialty training. The residents rotate through Harborview, the UW Medical Center and other hospitals as part of a joint residency program run by Madigan Army Medical Center.

Residents training in other specialties also staff the ER.

At most hospitals, doctors certified in emergency medicine provide initial care in the ER and then bring in specialists as needed. In other teaching hospitals, they supervise emergency-medicine residents who provide care.

The Harborview residents said they aren't learning the skills needed to work at smaller, often rural, hospitals where access to specialists may be limited.

"I can't consult a subspecialist for every patient I see; I have to be able to take care of these things myself," said Dr. Tony Billingsley, an emergency-medicine chief resident, "and I'm not getting the training to do that."

Consider Barnhart's example of an emergency surgical resuscitation. At Harborview, residents said, the surgeon and patient vanish to the operating room, and it's left to the internal-medicine supervisor to explain the procedure to the residents.

But most internists, the residents said, have little experience in many emergency-medicine procedures and can't teach them everything they need to know.

"There are experts in our field, too, and we'd like to learn from them," Billingsley said.

Added Betteridge: "We're required to learn from them. That's the standard across the country, one that Harborview chooses to ignore."

Residents said the care they deliver is dictated by a set of protocols and nominally supervised by the internists. Sometimes, residents receive no supervision at all, they said. And instead of real-time teaching, they face a rigorous, after-the-fact review of their work, often by Copass.

The residents also said some of Harborview's protocols are outdated.

Dr. Thomas Martin, a board-certified medical toxicologist, told residency leaders that Harborview clings to practices he considers a "gross deviation from the standard of care." For example: the ER's routine stomach-pumping for overdose patients. For more than a decade, Martin said, standard care has been to give activated charcoal by mouth or stomach tube.

Barnhart and Copass said they took complaints of outdated protocols seriously and looked carefully at results under the hospital's quality-improvement process, which isn't public.

"We don't follow some of the avant-garde guidelines," Copass said, but the hospital's review found patient outcomes were good. "We couldn't see that we've hurt anybody."

Nevertheless, said Cummins of UW, some residents are "quite concerned." On board-certification exams, they'll be asked about drug overdoses, for example, and the right answers aren't what they're learning at Harborview, he said.

An ER legend

The deficiency notice sharpened the debate between Copass, Harborview's emergency-department director, and those who have worked for a decade to bring emergency-medicine specialists into Harborview.

At nearly 67, Copass is a legendary figure.

There's his dogged commitment to patients and a workday that never seems to end. There's his tireless work on Medic I, the emergency-response system he helped fashion into the envy of cities around the world. And then there are his razor-sharp reviews and unforgettable scoldings of any trainee who didn't follow his rules.

In Copass' ER, residents learn by doing. "Nobody in this ER is didactically told what to do minute by minute, not even the medical students," he said.

"If [a resident] says, 'Gee, I want to be told moment to moment what to do by an attending,' that's — that's — fine," Copass said, "but this is not that. This is where you're given the privilege of acting on your own, without anybody saying 'Did you do this? Did you do that? Did you think of this?' "

Copass conceded there may be a "generational issue" with his insistence on "being accountable for an action."

Emergency residents want to be "told what to do" by an emergency physician, he said, but his way is better: "Here you have general surgeons, internists, neurologists, orthopedic surgeons all helping educate you at the same time."

Still, emergency-medicine leaders said it's time for Harborview to change.

"The fact that things have continued to work at Harborview to this point is testimony to the outstanding dedication of Dr. Copass and his just phenomenal work over the years," said Suter, the American College of Emergency Physicians president. "But one man in and of himself, no matter how great, cannot be there 24 hours a day to teach the residents and keep things on track."

The residents said they just want to keep the program in good standing, improve teaching and provide "evidence-based" care. They're talking publicly, they said, because Harborview's training program could be one of the best.

"I love taking care of patients at Harborview," Billingsley said. "I love the things I see at Harborview. I love the procedures I get to do at Harborview. I love the breadth of experience I get at Harborview. I'd just like somebody to give me a little direction along the way."

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com