Emergency Care and the Public's Health1st ed. By Jesse M.Pines, MD, MBA, MSCE, JameelAbualenain, MD, MPH, JamesScott, MD, and RobertShesser, MD, MPH. Hoboken, NJ: Wiley‐Blackwell, 2014; 232 pp; $99.95 (hardcover/available in electronic format).

Upon completing didactic and practical training, residents usually appear to be well prepared for the scientific challenges of clinical practice. In medical school, they received in-depth training in the biomedical sciences, and in residency, they spent extensive hours working with patients, learning the many nuances of emergency medicine (EM) and becoming familiar with the core curriculum. When they then enter the clinical work force, they are competent clinicians capable of evaluating their patients, making accurate diagnoses, and initiating appropriate treatment. However, currently there appears to be a lack of preparation and confidence in many of these young physicians when it comes to dealing with some of the problematic, everyday operations they confront in the emergency department (ED). Their training seems to lack sufficient exposure to the effect that sociological, psychological, environmental, and nutritional factors have on the successful delivery of health care. Their training also fails to sufficiently address the assessment of family dynamics, human factors/ergonomics, patient education, cultural differences among patients, personal dynamics in the workplace, and the use of computerized information technologies on the delivery of health care. This lack of training can lead to frustration when these young doctors have to deal with problems such as inefficient and fragmented health care, poor or incomplete communication between treating physicians, delays in patient evaluation and treatment, and overcrowding of the ED. As a result, this often precipitates an increase in the potential for medical errors, untoward patient outcomes, increased legal culpability, and decreasing patient satisfaction scores. This can lead to “burnout,” causing clinicians to seek other career venues. In addition, there appears to be a gap in providing new clinicians with sufficient exposure to telemedicine and the utility of simulation training. The current medical curriculum largely neglects the various health care payment systems and important medicolegal issues such as the implications and specifics of the Emergency Medical Treatment and Labor Act (EMTALA) and the effect of emergency medicine on public health. Emergency Care and the Public's Health addresses these issues. The cadre of 37 authors and four expert editors provides a concise, yet rather thorough overview of EM today. Although the authors claim this is book is a primer text and not a comprehensive review of the topics at hand, I believe the book includes and substantively reviews many pertinent issues that may be very useful to clinicians and a great asset in the armamentarium of ED directors and hospital administrators. The 214 pages of text are broken down into five parts, with several chapters within each section. The compendium of 37 contributing authors from seven countries provides a candid documentary style of prose in which they describe the various factors relevant to the current practice of EM. The authors describe how these factors developed and how they need to continue to undergo a metamorphosis in order to provide appropriate, efficient care to patients who will enter into the “system” of medicine in the future. Topics covered include the current status of the U.S. emergency care system, the relevance and utility of technology in emergency care, and the emergency care workforce. The text goes on to provide a comprehensive discussion about the nature of the U.S. emergency and disaster response, including lessons learned from the past, what is available currently, and what needs to be implemented in the future. Education and the incorporation of technology (i.e., computers, newly developed imaging modalities, simulation, the electronic medical record, and new diagnostic tools) are discussed within the current paradigm of EM and its effect on services available for the enhancement of public health and safety. In addition, the authors discuss the need for an appropriate level of adaptation and integration of emergency medicine to both current and future anticipated needs of the population served and how this will affect public health overall. The book is subdivided into five parts, with each part further expanded into anywhere from one to four chapters. Part 1, written by the first two listed editors of the text, is entitled “The Emergency Care System in the United States.” This section includes three chapters that provide a synopsis of the historical development of EM and a brief overview of topics to be addressed, such as the need to address myths and misconceptions regarding emergency care, a description of international emergency care, and the utility of the electronic health record. Of note, the authors also include a discussion of the “human factor” in emergency care. This section discusses the strengths and weaknesses of individuals in the workplace, the effects of fatigue on efficiency, multitasking ergonomics, and how this affects the process and outcome of health care delivery. The chapter also covers the use of technology for telemedicine and simulation and how these entities can enhance current emergency care and better integrate emergency care into overall patient care. The role of the ED in coordinating care, the role of emergency care in disaster preparedness, and how payment reform and legal issues affect emergency care are discussed. The second chapter addresses and attempts to dispel several misconceptions regarding emergency care. These include ED use by indigent patients, insurance coverage issues of ED patients, the relative cost of emergency care, the relationships patients do or do not have with primary health care provides, the presence of guidelines for “appropriate” ED visits, and the presence of standards for admission versus discharge of patients, as well as standards for reporting illness frequency and prevalence to the public. The authors also address why emergency physicians choose the profession and who employs them. Chapter 3, written by 13 international authors from various countries, describes emergency care in countries such as Australia, Canada, Denmark, France, Iran, Japan, Singapore, and the United Kingdom. This provides a basis for comparison and contrast to the current U.S. system and how health care delivery may be modified. In Part 2, the chapters cover the human factor in emergency care, i.e., human factors engineering. This includes issues regarding ergonomics, workflow, effects of overcrowding on work efficiency and safety, teamwork, health information, tasks interrupting clinical decision making, fatigue, memory impairment, and the potential for medical errors. The subsequent chapters in this section address the ED information system (EDIS), the electronic health record and how these can provide a solution to data exchange and patient flow, thus potentially decreasing medical errors and job stress. In addition, telehealth is addressed and placed in perspective as a tool for extending physician coverage and medical expertise to many facilities away from the “medical center.” This also can serve as a time-saving modality in patient evaluation and decrease the need for inefficient interfacility transfers. In an attempt to decrease medical errors and avoid injury to patients, the utility of implementing simulation using high-fidelity equipment is again presented. This may enhance the diagnostic and technical skills of future health care providers and decrease the potential exposure to harm that future patients may encounter. Part 3, emergency care workforce, addresses how the patient population and demographics of the patients are changing and how this does and may affect future ED encounters. The effects of the Affordable Care Act (ACA) of 2010 on emergency care are discussed. Another topic covered is how EDs are staffed and how an unexpected change in volume and patient presentation affects the ED. The authors also address the presence and effect of physician assistants, nurse practitioners, nurses, and emergency physicians and the mix of providers that works best. Part 4 discusses the role of emergency care in disaster preparedness and disaster management and mitigation. The last chapter of part 4 (chapter 10) drills down to the significance of preparedness and biosurveillance regarding disease incidence and prevalence in emergency care and public health. Part 5 covers the integration of these entities with coordination of future care of patients. Also of interest, payment for services rendered in the ED, fee-for-service, diagnosis related groups, capitation, Medicare/Medicaid, bundled payments, and accountable care organizations are presented. The need for accountability and the metrics involved in assessing the quality and value of emergency care are addressed. Chapter 13 addresses the legal aspects of emergency care, such as EMTALA, the Americans with Disabilities Act (ADA), and the Hill-Burton Act. In addition, the duties of the hospital and when, how, and what defines a medical screening examination is presented and clarified, as is the legal definition of what “come to a hospital” or being on hospital grounds, or in the hospital ambulance, really means. The last chapter presents the future of EM with regard to education, payment for services, future legal consideration, projected ED volume and appropriate ED staffing, and the future of emergency medical services (EMS) systems. As the scope of practice of and subspecialty of EMS grows, the role of EMS with respect to public health may increase. This topic should be considered in future editions of this book and may prove to be a significant entity in the enhancement of the future of public health. Emergency Care and the Public's Health provides useful and practical information to enhance the understanding of the state of emergency care in the United States today. The chapters address, identify, define, and clarify many issues that emergency physicians and other health care providers encounter or will encounter in their respective careers. This book will better prepare physicians for their career choices when seeking and working in future employment environments. In my opinion, physicians in training (including EM residents), emergency care providers, allied health care professionals, current and future ED directors, administrators, and even hospital leaders (CEOs, CFOs) should be exposed to this book.

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