Code Black and the Changing Culture of Emergency Medicine

“The romance isn’t gone. But it’s definitely going.”

That was the verdict from Dr. Patsy McNeil, MEP Health’s Director of Patient Satisfaction, as we discussed the documentary film Code Black at a recent Leadership Academy meeting.

The film chronicles a handful of emergency medicine residents training at one of the busiest emergency departments in the country, Los Angeles County Hospital. More than anything, the film documents a changing culture in emergency medicine. At LA County, that change is embodied by a 2008 move from the old hospital building to a new one. 

As one of the residents says in the film, it’s not just a new building, it’s a new culture. And it’s a change that is being felt by emergency physicians all over the country, including those at US Acute Care Solutions.

At one point during a pause in the film, some of our newer physicians asked our more veteran ones – Dr. McNeil and Dr. Angelo Falcone included – whether the change in culture has really been as drastic from when they started out as it seems.

Dr. Falcone remembered his days training at George Washington, where there was a place where “the sickest of the sick” went, just like the “C-Booth” profiled in Code Black. “It was very romantic in some ways. It was raw,” Dr. Falcone recalled.

Emergency medicine is itself a rather new specialty, so many of its veteran practitioners remember the time of fewer rules, fewer protocols, and certainly less regulation. It was a time which one veteran ER doc in the film referred to as a time for cowboys. Then television caught wind, and shows like ER only further romanticized the life of the ER doc.

Young, ambitious, Type-A cowboy (and cowgirl) types flooded into the profession. They still do today, drawn by the unique culture, urgency, and mission of the emergency department. The opportunity to care for people at their worst time, under the most pressure-filled of circumstances.

At Los Angeles County Hospital that sense of purpose is only magnified, since it’s one of the few community hospitals in the country, attracting a disproportionate amount of the working poor, the uninsured, and anyone else without the means or ability to get care elsewhere. County hospitals are only 2 percent of the hospitals in the country, but handle 20 percent of all uncompensated care, according to the film.

One physician in the film likens the modern hospital to what a church was for the sick and poor hundreds of years ago: the one place they can go for care and comfort, when they’re most in need. The move from the old hospital building to the new one changed the culture of the place in large part simply because of the physical layout. In the old building, for example, it was literally impossible to abide by certain HIPPA regulations concerning patient privacy – so they just got waivers.

The confined space is part of what made the “C-Booth” so crazy, intense, and efficient all at once. The sickest of the sick were brought there, all next to each other. There, ER physicians cared for the five-year-old car crash victim right next to the gang member bleeding out from a gunshot. It wasn’t always dignified, said one doctor – but it did work. The space played a large part in creating the mentality.

The new building was built to abide by a slew of new healthcare regulations, and so it was inevitable that the culture would change as well. Suddenly physicians and residents alike who had been used to flaunting rules were expected to abide by them. The enormous bureaucracy that is now the American healthcare system suddenly showed itself in a way that hadn’t quite been apparent in the old building.

Of course, our physicians are more than aware of healthcare regulation. What Code Black seemed to crystalize though beyond the mind-numbingness of it all is that there is an entire generation of emergency physicians who signed up for one kind of environment, or were drawn to an image of it, and are instead faced with something different.

The documentary raised many important questions, but one which stood out for the MEP group was whether new healthcare regulation would stymie innovation in emergency medicine. “Some of the great innovations in the history of medicine were by cowboys, people who were breaking all sorts of rules. So, who will be able to take the next great leaps in medicine?” Dr. McNeil asked.

She predicted the innovations will be smaller, less audacious than in the past. As if to cement the point, one of our physicians pointed to hallway bedding. “That’s cowboy-ish,” Dr. McNeil said, emphasizing the “ish.”

Dr. Neil Roy suggested that regulations are actually an opportunity to innovate, and that innovations and improvements that he’s harped on for years are suddenly becoming easier to get buy-in for now that there are additional financial incentives and penalties for the hospital. It’s an opportunity for change,” Dr. Roy said.

Questions of bureaucracy aside, it’s clear that emergency physicians today have more to do than care for the sickest of the sick. A common sentiment in emergency medicine now is that caring for patients is the easy part. The really difficult work is the management (or, in some case, the “wrangling,” to borrow a cowboy term) of the hospital, the staff, and the bureaucracy to ensure that, though the culture is changing, the doctors are still able to do what they signed up for: effectively practice medicine.