Steve Davidson, MD, MBA is retired as an emergency physician and CMIO of Maimonides Medical Center in Brooklyn, NY and provides consulting services as EMedConcepts.
Tell me about yourself.
I was born in Philadelphia. My dad was an internist-gastroenterologist, doing endoscopies back in the era of rigid scopes. My grandfathers were home carpenters, so I grew up with the idea that you could use your brain and you could use your hands. I went to medical school because I had ambitions to be an academic. I discovered emergency medicine as a new field. I was impressed by David Wagner, who was one of the grandfathers of the field. He was a pediatric surgeon who worked in the ER so he could pay his kids’ tuition.
Since it was a new field and there were fewer people clambering around on the ladder, I thought I might get to the top quicker. I never really made it to the top, but did OK. As one of the earliest trainees, I got involved in academic emergency medicine and was a tenured full professor. I went to Wharton, got an MBA, and managed to land a really nifty job in Brooklyn, working for a guy who was doing a turnaround on a hospital there, Maimonides Medical Center.
He let me take the ER as an independent business unit. I ran the medical side and the business side of the ER. Everybody who worked in the ER worked for me, including nursing. If there were more than five people in a job title, they worked for me. I did that for 15 years, managed to piss off a few people, and got kicked upstairs to the CMIO gig. I discovered that my impatience and short attention span, which was an asset in the ER, was a contributor to a crash landing in the executive suite.
I went back to taking care of patients for a few years, sold my place in Brooklyn at the top of the market, and came back to Philly, where I had real connections beyond professional friends. I’ve spent the last 16 months renovating an old stone pile, a 100-year-old house, and working on Steve — going to the gym, eating right. I’ve gone to hear lots of live music. That’s enough.
Now that you’re somewhat of an outside observer of healthcare, what do you see?
If you’ve seen one ER, you’ve seen one ER. They are all different. I brought to that my experience with W. Edwards Deming and the idea of improvement processes, things like that.
Culture is an overwhelming force that is hard to overcome, and healthcare’s culture has been incredibly physician-centric. The nursing force was always there, but has gotten much stronger with the real administrative control that has gotten much, much stronger. It’s hard to see how, other than in small-scale improvement efforts, overall system improvement is going to happen without major legislative and financial flow change.
Your work in the ED was the ultimate episodic practice. Is it a marketing challenge to convince patients / consumers why they should value continuity of care when they are reasonably happy with the status quo other than price?
Middle-class folks who can afford the drop-in to the urgent care centers are eager to scratch that itch right away. In my experience in caring for the people who were not regularly doctored – for example, the folks who were on medical assistance in Brooklyn and had to make do with hospital clinics — would get very dejected when the internal medicine resident who had clinic once a week graduated after three years and was no longer their doctor.
I can’t tell you how many people I saw over my 15 years in the ER who would show up after not having been in the ER very much in the previous several years. They had been assigned to a new doc and clinic and they didn’t like that doc. Those people craved the continuity of care. My middle-class friends on Facebook, to all appearances, are glad for the networks of urgent care centers.
How should we apply social determinants of health to improve public health?
Many ERs, including where I used to work, have identified lists of frequent flyers. This goes back to the work of a guy at Cooper in Camden that was written up in the New Yorker, it might be 10 years ago now. He identified people who needed a new refrigerator, a new bed, or their roof repaired. Social determinants of health.
What’s happening in a place like Maimonides Medical Center is that the patients who were constantly in the emergency department, they are trying to get at the contributors to these visits. They get social work and community organizations engaged. At Maimonides – I’m not hawking what they’re doing as anything special because I know other places are doing it, I’m just telling you about the place where I know a little something — put together this community health network. They have integrated behavioral health with primary care for this patient population, for the broader group of patients with any serious behavioral health issues. It’s apparently having some impact on the frequency of utilization of the emergency department by individuals identified within this population.
As someone who ran medical services for a big-city fire department, how well have we integrated 911 services, pre-hospital care, and related technology into hospital practices?
There was a time when EMS developed as a medical service. If you go way back, ambulances were a secondary function of hearses. If you move a little bit past that, Frank Pantridge created heart ambulances in Belfast, Northern Ireland to save “hearts too good to die” with a defibrillator. Trauma surgeon David Boyd recognized that trauma care in Vietnam was better than it was for a motor vehicle crash victims.
Pre-hospital care developed as a medical service. Over the years, fire departments increasingly engaged it, initially for their own purposes to provide services to their own people who got injured at scenes. Over the years, as the number of structure fires began diminishing — both because older structures had burned out and because of better fire prevention practices — fire chiefs needed to maintain a reason for a handle on the public purse. Since they already had ambulance services for their own folks, they increasingly moved into EMS. Ultimately, what we’ve decided as a country by and large is that EMS pre-hospital care mostly resides in paid fire departments, at least in the urban and inner suburban areas.
Even as that was happening, Joe Ryan in Pinellas, Florida and others like him identified that a large number of people were calling for care. They were worried well or had something small and self-limiting that could be dealt with on the scene. In Brooklyn’s Orthodox Jewish community, you have Hatzolah, an all-male volunteer ambulance service that raises funds, does not bill, and hence has no requirement to transport. Without transport in EMS, nobody pays. You get paid for the transport, not for the care. Hatzolah is an example of doing this right within the community — responding to people’s needs, offering help at their bedside or in their home or workplace, and not necessarily transporting.
Emergency medical dispatch, created by Jeff Clawson, MD, is a discipline that has developed data-driven protocols to give telephone advice prior to arrival and to help select the requirements for urgency of response. The fire departments are overwhelmed and budgets everywhere are under such stress that they are interested in interventions that avoid transport and divert callers / patients into other means of care. That’s probably a good thing if it’s being done correctly. Joe Ryan, who now is in Reno, got money from CMS several years ago to look at an expanded role for paramedics to offer care in the community. I don’t know whether he was able to move forward with that based on issues with the local ambulance providers.
Doctors and nurses, by and large, have a charitable and helping impulse. With the public safety mindset — firefighters among them, who are rightly celebrated for running into the danger when everybody else is running away — there remains some question in my mind as to how suited the fire department is to be doing this work. But clearly fire chief leadership across the country has taken up this role throughout and is doing the best they can with it.
Jim Page was a fire chief, founder of the Journal of Emergency Medical Services, and a big booster of EMS on the fire side in California. Mr. Page has been dead for a decade or so, but there was a point at which he quite publicly said that doctors in EMS were bossy nuisances. To some degree, that’s part of the environment I worked in and why I decided to move on from the EMS leadership roles I’d had.
We first exchanged emails about the extent of misdiagnosis and how machine learning and artificial intelligence might have a role. As a doctor, how much value would you receive from technology helping you arrive at a diagnosis?
In the dim, dark past, I was a clinician working with John Clark, a surgeon. He was able to show that a junior resident using his software solution, running on an old Mac, was more accurate in diagnosing appendicitis than the most experienced surgeons by themselves. There was a period of time where John’s software was used on the orbiting space station. That was before we did a lot of bedside ultrasound and CT scanning of the abdomen. I’m telling you this story just to preface my response that in medicine, certainly emergency medicine, we are learning about our cognitive errors in reaching decisions for patients, including diagnostic decisions.
The heuristic is that you know what you know, and if you don’t think of something, it doesn’t end up on your differential diagnosis. If it’s not something you see very often, you may not think of it. Systematic ways of prompting consideration of reasonable possibilities — and who the hell knows what “reasonable” is? — can be of value.
I just saw a paper pointing to the three areas of most diagnostic error harm – vascular events, infections, and cancer. These are big categories, even in the emergency department. Patients have cancer that hasn’t yet been diagnosed or they’ve had previously diagnosed and treated cancers and present with a new set of symptoms. It’s easy to think in terms of the statistical probabilities rather than considering the possibility of other cancer stuff.
What advice would you offer to someone looking forward to retiring and not having to go to work every day?
I’m no great fan of Arthur Brooks, who just announced that he’s retiring as executive director of the American Enterprise Institute, but he had a spectacular essay in the Atlantic called “Your Professional Decline Is Coming (Much) Sooner Than You Think.” It basically says that you are already past the peak of your career. You just don’t know it.
He writes very broadly in terms of how you might think of the rest of your life. I have found it thought-provoking and well worth the read. For me, I am a reader. I am a curious person. I’m a big-time lover of acoustic music – bluegrass, old-timey Irish music, and all the mash-ups of that.
You must be more than your career. I’m extraordinarily fortunate that my folks introduced me to music while I was young. They didn’t give me a hard time when they found me reading the Encyclopedia Britannica under the bedclothes by flashlight in the middle of the night.
People are where it’s at. The residency that I was part of at Hahnemann Hospital is gone and the hospital is closing down. Before that, Medical College of Pennsylvania, where I spent 20 years. That’s gone, absorbed into Drexel. Places disappear, places change.
I’ll just close with one last thing. A man very close to me — we’ve been friends since we were 18 — had a terrible fall last week. He was horribly injured and is in an ICU of a big trauma center. I got to his bedside about 20 hours after he got to the hospital, but I got help by reaching out to the broader emergency medicine community. I was connected to the doctor who first cared for him when he hit the ER. That doctor was two degrees of separation from me, and I was connected to that doctor within about two to three hours of calling out for help to my network.
It’s people, it’s people, it’s people. Whatever you do in retirement, stay connected to people.