Shirts, Skins, and Transitions of Care (Part 1 of 2)

Wesley Fields , MD, FACEP

Emergency Physician, Board Member

Published January 31, 2013

As Chief of Thoracic and Vascular Trauma at the Shock Trauma Center in Maryland, Dr. James O’Connor knows the difference between sick and well. With decades of experience at the leading statewide trauma program in America, Dr. O’Connor and his colleagues are actively engaged in expanding the critical care services for trauma patients to include Maryland’s sickest patients needing medical intensive care. As he recently explained to an expert panel gathered to assist the editors of Health Affairs to frame a special edition on ‘Reinventing Emergency Care,’ the reason is very simple. It is increasingly true that healthcare consumers have “one set of doctors when they are well, and another set when they are sick.”

Regardless of their specialty training, physicians are more and more likely to choose between practicing in office settings or hospitals. In some cases, full-time hospital practice for surgical subspecialists like Dr. O’Connor is a matter of necessity. Outside military theaters, no one would dream of doing an open-chest procedure outside the best equipped hospital available. Further, regionalization of advanced trauma care, speeding access to premier specialists like Jim and his colleagues at Shock Trauma, has been shown to save lives and improve medical outcomes.

In other cases, such as internal medicine, opting for full-time practice as a ‘hospitalist’ is more a matter of intellectual interest or professional lifestyle. Some physicians thrive on the predictability of seeing familiar patients in stable condition by appointments in their own office. Others prefer the challenge of the acutely ill, with complex or unknown problems to be sorted out during hospitalization, even if it means being available at three o’clock in the morning on call nights.

The rapid growth of the hospitalist movement over the last decade suggests that differentiation is a positive adaptation for both office and hospital-based practitioners of internal medicine. For reforming healthcare industries, specialization appears to increase the efficiency and productivity for both hospitalists [reducing hospital length of stay] and internists in full-time office practice [seeing more patients per hour].

In playgrounds and parks throughout America, the concept of ‘shirts and skins’ refers to ad hoc teams that rapidly form to facilitate competition in pickup games of basketball, touch football, even Frisbee. In healthcare markets, ‘shirts and skins’ can be applied to ad hoc teams that form to meet unmet needs of patients with time-sensitive demands. In the 1960s, a number of social trends converged in hospital emergency rooms, resulting in the first medical specialty driven by a US population demanding acute care 24/7. Within a few decades, the specialty of emergency medicine was recognized by the American Board of Medical Specialties, formalized by the American Board of Emergency Medicine, and standardized at more than 150 residency programs in teaching hospitals around the country. The hospitalist movement is well along in its own growth and evolution as well.

In the next few years, as the healthcare version of shirts and skins continues, best practices and new strategies will be needed as patients shuttle between the Acute Care Continuum and longitudinal screening and chronic care for stable conditions in office settings. For example, when patients require post-acute care after hospitalization, how can transitions between teams reduce the risk of re-admission in 30 days for the same condition, thus avoiding penalties in Medicare payments to hospitals? How can critical medical information on interventions and outcomes be shared with office-based providers who lack secure access to information systems in acute care facilities? When primary care providers refer patients to EDs for first contact care for conditions that may be time-sensitive or emergent, how can systems of care identify which ED visits are successful handoffs, and not failures of primary care?

Finally, in a sidebar, Dr. O’Connor also showed why residency and fellowship training are the beginning of physician specialization, rather than an end-point. As Shock Trauma expands into regionalized critical care for Maryland, they are looking for a director for the new division. Obviously, it will be someone from a top critical care fellowship. But residency graduates in both internal medicine and emergency medicine can specialize in critical care. And the linkage between trauma care and critical care is as apparent to Jim as the fact that emergency physicians manage both within Maryland’s Acute Care Continuum.

Next in Part II: Shirts and Skins, The Bump Rule.

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