References

1. 1. Gan NY, Lam WC. Retinal detachments in the pediatric population. Taiwan J Ophthalmology. 2018; 8(4):222-236.
   2. Haimann MH, Burton TC, Brown CK. Epidemiology of retinal detachment. Arch Ophthalmol. 1982; 100(2):289-292.
   3. Kim DJ, Francispragasam M, Docherty G, et al. Test characteristics of point-of-care ultrasound for the diagnosis of retinal detachment in the emergency department. Acad Emerg Med. 2019; 26(1):16-22.
   4. Read SP, Aziz HA, Kuriyan A, et al. Retinal detachment surgery in a pediatric population: visual and anatomic outcomes. Retina. 2018; 38(7):1393-1402.
   5. Lahham S, Shniter I, Thompson M, et al. Point-of-care ultrasonography in the diagnosis of retinal detachment, vitreous hemorrhage, and vitreous detachment in the emergency department. JAMA Netw Open. 2019; 2(4):e192162.
   6. Naik AU, Rishi E, Rishi P. Pediatric vitreous hemorrhage: a narrative review. Indian J Ophthalmol. 2019; 67(6):732-739.
   7. AIUM official statement for recommended maximum scanning times for displayed thermal index values. J Ultrasound Med. 2023; 42(12):E74-E75.

David Lobel, MD FAEMS FACEP
Clinical Assistant Professor of Emergency Medicine,
State University of New York  Downstate Medical Center
Medical Director, Prehospital Services
Department of Emergency Medicine, Maimonides Medical Center

Mackenzie Wilson, MD
PGY-2 Emergency Medicine
Maimonides Medical Center

Abbas Husain, MD FACEP
Associate Residency Director
Medical Education Fellowship Director
Staten Island University Hospital, Northwell Health

Amar Bukvic, DO
PGY-1
Staten Island University Hospital, Northwell Health

A Matter of Life and Death: The Role of the EM Physician in Goals of Care (GOC) Discussions

The ED: Where It Starts

As EM physicians, we are versatile— suturing with the precision of a plastic surgeon or interpreting images like a radiologist. We take pride in managing a broad range of critical conditions that demand proficiency in skills across multiple specialties. Yet, despite caring for some of the sickest patients in the hospital, there is one specialty we often overlook: palliative medicine.

Emergency departments are not designed for goals-of-life conversations. Between overcrowding from boarding and the constant pressure for productivity, it is nearly impossible to find the time or space for delicate discussions about life and death. In spite of these challenges, there is an undeniable need for end-of-life care to begin with us. More than 50% of patients in their final month of life will visit the ED, most of them are admitted and pass away in the hospital.¹

Our Role in Establishing, Guiding, and “Dispo-ing” Goals of Care

The role of the EM physician should not be to replace the palliative care team but to add components of palliative medicine that are within our scope. Just as we manage a shoulder dislocation in the absence of orthopedics, we should initiate palliative conversations when appropriate, understanding that deeper, ongoing management can later involve a specialized team.

The Who

From the healthy young adult that suffers a non-recoverable accident to the older patient having an acute exacerbation of a chronic disease, the people we see regularly are the ones that see us first, and sometimes, last.

EM physicians are exceptionally positioned to detect “sick” vs. “not sick”. A multitude of EM specific algorithms for palliative care discussion exists. One of the simplest ways to determine this is the “surprise question” which is “would you be surprised if this patient died in the next 12 months?” If the answer is no, the positive predictive value of death was 0.92 with a specificity and sensitivity of 79% and 68%.² This provides a very easy screening tool for a busy EM physician to use to stratify which patient would benefit from GOC discussions.

The Why

EM physicians are perfectly positioned to be the “first responder” of palliative care. GOC intervention in the ED has been shown to increase the quality of life for patients as measured by the FACT-G (Functional Assessment of Cancer Therapy-General Measure) score. ³ It also does not seem to shorten survival, increases overall patient satisfaction, and increases advanced directive documentation within the electronic medical record.⁴ The positive effect on the patient has been shown but there is also a positive effect on the system as a whole with a decrease in subsequent visits.⁴

Futile treatment also has an effect on us. The leading cause of burnout within EM physicians has been shown to be emotional exhaustion and depersonalization.⁵ A meta-analysis of ICU physicians and nurses showed that futile life-sustaining treatment had a profound effect on them emotionally causing negative emotions like anger, depression, and soul-destroying sentiments.⁶ Reducing the amount of futile care provided in the ED can help alleviate the emotional burden of intensive, non-sustainable resuscitation efforts.

The How

End of life conversations are never easy but can be standardized. The SPIKES model was developed by medical oncologists to provide a framework for sharing unfavorable medical information.⁷ It stands for setting, perception, invitation, knowledge, emotion, and strategy. Setting establishes a time and place. Perception is asking questions before telling information. Invitation is asking if the patient and family are ready to talk. Knowledge is providing your expertise on the situation in simple terms. Emotion is addressing emotion with empathy via naming, understanding, respecting, and supporting. Strategy is to formulate the next steps or providing the possible pathways the patient will go through.

Another aspect is understanding the acute symptomatic needs of a dying patient. This can be accomplished through further training in palliative medicine with your palliative colleagues. Briefly, we can discuss some important considerations here. Pain is present in nearly 40% of patients at the end of life.⁸ Pain can be managed with 2-5 mg IV morphine every 15 minutes as needed, which also relieves dyspnea without causing undue sedation.⁸ Lastly, the “death rattle”, terminal respiratory secretions, are usually managed by pharmaceutical agents like glycopyrrolate. However, it has been shown that addressing pain and dyspnea are superior as medications had no greater effect than placebo on reducing secretions.⁹

The ED: Where It Ends

The scope of emergency medicine continues to expand as we broaden the concept of emergency care and care delivery. Palliative care is an excellent addition to our arsenal of skills within the ED. Even a brief 2-hour educational intervention can increase EM physician comfort levels in discussing goals of care.¹⁰ Through quick stratification strategies like the “surprise question”, standardized conversations using the SPIKES framework, and proper symptomatic management, we have the potential to reduce the emotional toll on the patient, their family, and ourselves. As EM physicians, we are uniquely positioned not only to initiate life-saving interventions but also to ensure a dignified end when those interventions are no longer appropriate.

References

1. 1. Smith AK, McCarthy E, Weber E, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff. 2012;31(6): 1277-1285.
   2. Downar, J., Goldman, R., Pinto, R., Englesakis, M., & Adhikari, N. K. (2017). The “surprise question” for predicting death in seriously ill patients: a systematic review and meta-analysis. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 189(13), E484–E493. https://doi.org/10.1503/cmaj.160775
   3. Grudzen CR, Richardson LD, Johnson PN, et al. Emergency Department–Initiated Palliative Care in Advanced Cancer: A Randomized Clinical Trial. JAMA Oncol. 2016;2(5):591–598. doi:10.1001/jamaoncol.2015.5252
   4. Bigelow S, Medzon R, Siegel M, Jin R. Difficult Conversations: Outcomes of Emergency Department Nurse-Directed Goals-of-Care Discussions. J Palliat Care. 2024 Jan;39(1):3-12. doi: 10.1177/08258597221149402. Epub 2023 Jan 2. PMID: 36594209.
   5. Zhang Q, Mu MC, He Y, Cai ZL, Li ZC. Burnout in emergency medicine physicians: A meta-analysis and systematic review. Medicine (Baltimore). 2020 Aug 7;99(32):e21462. doi: 10.1097/MD.0000000000021462. PMID: 32769876; PMCID: PMC7593073.
   6. Choi HR, Ho MH, Lin CC. Futile life-sustaining treatment in the intensive care unit – nurse and physician experiences: meta-synthesis. BMJ Support Palliat Care. 2024 Feb 21;14(1):36-46. doi: 10.1136/spcare-2023-004640. PMID: 38050047.
   7. Bell, D., Ruttenberg, M. B., & Chai, E. (2018). Care of Geriatric Patients with Advanced Illnesses and End-of-Life Needs in the Emergency Department. Clinics in Geriatric Medicine, 34(3), 453–467. https://doi.org/10.1016/j.cger.2018.04.008
   8. Blinderman CD, Billings JA. Comfort care for patients dying in the hospital. N Engl J Med 2015;373(26):2549–61.
   9. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Co chrane Database Syst Rev 2008;(1):CD005177.
   10. Bowman, J. K., Aaronson, E. L., George, N. R., Cole, C. A., & Ouchi, K. (2018). Effect of Brief Educational Intervention on Emergency Medicine Resident Physicians’ Comfort with Goals-of-Care Conversations. Journal of Palliative Medicine, 21(10), 1378–1379. https://doi.org/10.1089/jpm.2018.0217

Laura Melville, MD MS
Associate Research Director
SAFE Medical Director
NewYork-Presbyterian Brooklyn Methodist Hospital
Chair, New York Research Committee

Kassem Michael Makki, DO
Chief Resident of Research
NewYork-Presbyterian Brooklyn Methodist Hospital

Christopher Mendoza, MD MA FACEP
Vice Chief of Clinical Services
Director of Quality and Patient Safety
Assistant Professor of Clinical Emergency Medicine
Department of Emergency Medicine
NewYork-Presbyterian Brooklyn Methodist Hospital

Introduction

High utilizers of the emergency department (ED) represent a small yet significant portion of the patient population. Despite them accounting for a small percentage of the over ED patient population, their frequent visits and high resource needs have a large impact on ED through put and the care of other patients. Also referred to as super-high utilizers (SHUs), these patients frequently return to the ED due to chronic medical conditions, complex social needs and other underlying factors¹. SHUs often experience fragmented care, which can result in inefficient resource use and suboptimal health outcomes. One approach to addressing these challenges is the development of longitudinal care plans (LCPs), which aim to provide continuous, coordinated care across healthcare settings¹. This article explores the development, implementation and outcomes of LCPs for managing SHUs in the ED setting.

Indications for Longitudinal Care Plans

Longitudinal care plans are particularly useful for patients who present to the ED frequently due to a combination of chronic health conditions, psychiatric disorders and unmet social needs. SHUs often suffer from complex conditions such as heart disease, diabetes, chronic obstructive pulmonary disease (COPD), psychiatric disorders and substance use disorders^1,2. Social determinants of health, such as housing instability and lack of access to primary care, exacerbate these issues and lead to recurrent ED visits. LCPs are designed to address both medical and social needs, creating a coordinated system of care that aims to reduce the frequency of ED visits².

Demographics of Super-High Utilizers

A retrospective cohort study of 1,515 super-utilizers admitted to an urban safety-net hospital provided insight into the demographic characteristics of this patient group³. The mean age was 53.8 years, with 44.2% of the population being homeless. In terms of race and ethnicity, 40.4% identified as Hispanic/Latino, 37.6% as White, 17.3% as Black and 1.5% as Asian. Males made up 54.9% of the population, while females comprised 45.1%. A large proportion of SHUs (56.6%) were covered by Medicaid and 21% were on Medicare, indicating a significant reliance on public health insurance programs. Understanding these demographic factors is essential for developing effective and tailored LCPs. The LCPs facilitate efficient up front communication to the care team, explaining the complicated nature of these patients care needs, allowing for more focused and expedited care.

Impact on Healthcare Utilization

The financial burden associated with SHUs is substantial, particularly in cases where patients have chronic conditions such as sickle cell disease (SCD). A study on healthcare expenditures found that super-utilizers with SCD had healthcare costs that were 13.37 to 43.46 times higher than those of low-utilizers, depending on their insurance type⁴. These patients incurred significant costs in both inpatient and outpatient settings, as well as through frequent ED visits. This pattern of high healthcare utilization underscores the importance of implementing LCPs to reduce unnecessary ED visits and hospital admissions. Moreover, SHUs are often readmitted multiple times per year, which places a strain on ED resources, increases wait times and contributes to the overcrowding of hospitals. LCPs aim to mitigate these issues by addressing the root causes of frequent ED use, such as unmanaged chronic diseases and lack of access to primary care.

Components of Longitudinal Care Plans

LCPs are comprehensive, patient-centered plans that span across various healthcare settings. They aim to reduce unnecessary ED visits, improve chronic disease management and enhance overall patient outcomes. The following components are essential in the development and implementation of LCPs:

1. Multidisciplinary Team Approach: LCPs require the collaboration of a diverse team of healthcare providers, including ED physicians, primary care providers, security personnel, social workers, case managers and psychiatrists¹. This team works together to assess the patient’s medical, social and psychiatric needs and create a plan that addresses these factors comprehensively.
2. Patient-Centered Goals: LCPs are designed around the patient’s individual health goals, focusing on improving their quality of life while managing chronic conditions. The care plan coordinates efforts between the ED, inpatient services, outpatient providers and primary care to ensure that all aspects of the patient’s health are addressed².
3. Ongoing Communication: Real-time updates and alerts during ED visits or hospital admissions are critical to keeping the care team informed about the patient’s status and any changes in their health¹. This continuous communication ensures that the care plan is updated and adjusted as needed, based on the patient’s evolving needs.
4. Social Support Integration: A key element of LCPs is addressing the social determinants of health that often drive SHU behaviors, such as homelessness, substance use disorders or lack of transportation. LCPs coordinate with community resources to help meet these needs, ultimately reducing the reliance on the ED for non-emergent care.
5. Combating implicit bias: Often these patients present secondary to exacerbation of chronic medical conditions. Often due to non-compliance and difficult access to care. This is a strain on the ED and often the ED provider. The care plans can serve as a way of explaining the social situation of the patient up front, ideally curbing some of the implicit bias felt by the provider. They aim to help the provider better understand the patient and his or her needs, which can help make for a productive initial interaction.

Steps in Developing a Longitudinal Care Plan

Creating an effective LCP involves several key steps that ensure the plan is comprehensive and tailored to the patient’s unique needs:

1. Identification: The first step is identifying patients who qualify for an LCP. This typically involves tracking patients with frequent ED visits and hospital admissions, who often have complex medical and social needs. Frontline ED providers will also be able to recommend patients who would benefit from a care plan.
2. Comprehensive Assessment: A thorough evaluation of the patient’s medical history, current health status, psychiatric conditions and social needs is conducted by the multidisciplinary team. This assessment helps to identify the factors contributing to frequent ED use.
3. Goal Setting: The patient is involved in setting realistic and achievable health goals. This might include improving management of chronic conditions, securing stable housing or reducing substance use.
4. Care Plan Development: The multidisciplinary team develops a detailed plan that outlines specific interventions across different healthcare settings. This includes coordinating primary care visits, connecting the patient with social services and providing ongoing psychiatric support.
5. Implementation and Monitoring: Once the care plan is in place, it is essential to monitor the patient’s progress. Real-time alerts and communication between providers allow for timely adjustments to the plan as the patient’s condition evolves.
6. Ongoing Adjustments: As the patient progresses, the LCP should be regularly updated to reflect any changes in the patient’s health or social circumstances. The care team remains in constant communication to ensure the plan remains effective.

Implementation and Management

Successful implementation of an LCP requires seamless communication between healthcare providers and the use of technology to track SHU visits in real-time. ED triage systems can flag SHU patients, ensuring that their LCP is activated and apparent at the initiation of the ED visit. This approach allows healthcare teams to follow established protocols, ensuring the patient receives consistent care. Over time, the coordinated care outlined in the LCP reduces the need for repeated ED visits, as patients receive more appropriate care in outpatient settings.

Case Study: SHU Program at NYP/WCM

At NewYork-Presbyterian/Weill Cornell Medicine, a program was developed to implement LCPs for 15 super-high utilizers⁵. The outcomes were remarkable: ED visits were reduced by 70%, hospital admissions decreased by 74%, and the healthcare system realized significant cost savings. Over a 2.5-year period, the program prevented 575 ED visits and 167 hospital admissions, resulting in a savings of $862,500 from reduced ED visits and $2.5 million from fewer hospital admissions⁵. This case study illustrates the potential of LCPs to significantly improve patient outcomes and reduce healthcare costs when applied effectively.

Challenges in Implementation

Despite the clear benefits of LCPs, several challenges remain in their widespread implementation. EHR interoperability is a major barrier, as inconsistent electronic health record systems between healthcare providers hinder the sharing of care plans. Patient noncompliance is another significant obstacle, particularly among SHUs who struggle with factors like homelessness, substance use or mental health disorders. Additionally, resource limitations within emergency departments, such as a lack of staffing or time to create individualized care plans, can make it difficult to sustain LCPs in the long term.

Conclusion

Longitudinal care plans are a highly effective strategy for managing super-high utilizers in the emergency department. By coordinating care across healthcare settings, LCPs reduce unnecessary ED visits, improve chronic disease management and lead to better outcomes for both patients and healthcare systems. However, addressing challenges such as EHR interoperability, patient compliance and resource allocation is critical for maximizing the potential of LCPs in emergency medicine.

Carlton C. Watson, MD MS
Chair, Emergency Medicine Resident Committee
PGY-3
Vassar Brothers Medical Center

Interviewers:

Joshua Schiller, MD
Director of Global Health/Social Emergency Medicine
Attending Physician
Maimonides Medical Center

Sophia Lin, MD FPD-AEMUS
Assistant Professor of Clinical Emergency Medicine and Clinical Pediatrics
Director of Emergency Ultrasound
Department of Emergency Medicine
Weill Cornell Medicine

Can you tell us about the MATTERS program, and how it is relevant to EM practice?

MATTERS was developed to serve as a “one-stop” solution to linking people with opioid use disorder (OUD) out of the emergency department.  We efficiently connect individuals with OUD to an outpatient treatment organization of their choice through our rapid referral platform.  Patients choose from over 2,500 weekly appointment slots that are offered by over 250 unique treatment organizations and can choose to follow up in-person, virtually, or in a hybrid model.  Individuals are also provided with several barrier-reducing resources and services at their time of referral to ease the minds of emergency medicine (EM) providers when sending patients for follow-up treatment.  EM providers can submit referrals in as little as three minutes, and we’ve ensured that the process is efficient and intuitive so that it doesn’t impose any unnecessary burden on their existing workflows.  This program is especially relevant to EM practice as emergency departments (ED) are typically the ‘first line of defense’ for individuals with OUD who present in acute withdrawal/post-overdose.  If this process can work in large tertiary care centers along with small critical access hospitals, it can work almost anywhere.

How is MATTERS able to provide for your patient communities?

We’ve expanded our platform and services through a patient-centered approach by listening to feedback from patients and network partners.  Patients choose where they want to follow up based on their geographic location, preferred treatment model (virtual, in-person, hybrid), and other services offered by each participating treatment organization. These treatment centers will accept any patient regardless of insurance status, polysubstance use, and previous treatment history. As part of the referral process, the MATTERS medication voucher is automatically issued to uninsured and underinsured individuals to cover the cost of up to 14 days of any combination buprenorphine/naloxone prescription that is issued at the time of referral – and we recommend this “bridge prescription” in our standardized protocol to ensure patients have flexibility when they’re following up to care.  MATTERS also automatically provides a free, round-trip ride to patients who need it for their first follow-up appointment, no questions asked.  Everyone referred through our program can opt-in to be contacted by a peer in recovery, offering an extra layer of support during the earlier stages of their recovery. Our staff also follows up with everyone within 72 hours of their referral to help navigate barriers to treatment and link patients to the support services they need to succeed. We then follow up again at 30, 60, and 90 days to ensure continuity of care.

ALL OF THIS is completed in as little as three minutes.  Individuals who are not linked to care can visit our website and get evaluated for substance use disorder through our telemedicine services.  In as little as an hour, people are connected via video with a prescriber, where they can receive a prescription for medications for OUD (MOUD) and receive a MATTERS referral with all of the wrap-around services we offer. This reduces barriers to treatment for many people with significant transportation barriers.

We also understand that not all patients are ready for treatment. For people who are unsure about seeking treatment, we distribute free harm reduction supplies to anyone across our networks. This not only helps prevent the risk of overdose, but also creates a relationship with people who use drugs so that if/when they are ready for treatment, they know we are here to help.

Are there certain demographics that are particularly affected by this programming?

For the first time in nearly a decade, national rates of opioid overdose deaths decreased in the U.S.; however, this is mainly applicable to Non-Hispanic White populations.  Black, Indigenous, and People of Color (BIPOC) communities are affected by opioid and substance use disorders at a disproportionately higher rate compared to their white counterparts.  We also know that people experiencing homelessness are disproportionately affected by substance use disorder due to the unique challenges they face. This calls for services to provide barrier-reducing support to engage marginalized communities.

We also know that there are inequities in the kinds of MOUD these communities receive. Unfortunately, Black and Brown communities are much less likely to be prescribed buprenorphine when compared to White individuals.  There are various reasons for this, but the leading “cause” is racial bias and systemic discrimination.  We focus on expanding access to buprenorphine across all communities through standardizing prescribing protocols for physicians new to providing MOUD treatment.

How did the development of MATTERS come about?

After years of working in the emergency department, there was a common theme: people with OUD were repeatedly coming back to the ED for treatment. We thought to ourselves: what isn’t working?  When we asked the patients this question, we often heard that they were discharged with a long list of phone numbers to call and schedule a follow-up appointment for treatment. When patients tried to call these numbers, they were either out of service or an appointment wasn’t available for weeks at a time.  This led to patients feeling like they were at yet another dead-end when seeking treatment and resulted in them returning to the ED.

The fact of the matter is that the experience would be much different if the patient presented with a cardiac concern.  Those patients are immediately prescribed medication and receive a follow-up appointment before they leave the hospital.  When we asked treatment organizations, they were eager to accept new patients. They needed some scheduling flexibility, but they were not as overwhelmed as we initially thought.

That is when the MATTERS concept was born: we wanted to streamline the process of linking people with OUD to outpatient treatment. In partnership with UBMD Emergency Medicine—the physician group affiliated with the University of Buffalo— we onboarded one major hospital and three community-based treatment organizations as a pilot to demonstrate proof of concept.  Each treatment organization chipped in weekly appointment availability so one single organization would not be overwhelmed.  We have put the patient first and allowed them to choose which location they wanted to follow up at, which helped build autonomy and empowerment in their recovery journey.

How important is collaboration with other healthcare institutions locally for the treatment of addiction? What specific institutions have you found instrumental in treatment?

Collaboration has been vital for our program’s success. We know that our healthcare system is siloed, and instead of re-creating the wheel, we wanted to connect pre-existing resources to provide the best receiving network for patients.  Local organizations are already committed to improving access to treatment for OUD because many of them know how pressing the issue is within their communities.  Partnering with local organizations is also key because most patients want to receive treatment and support from someone familiar, not someone from across the state.

Without the support from the Jacobs School of Medicine and Biological Sciences at the University of Buffalo, as well as UBMD Emergency Medicine, our program would not be possible.  Key stakeholders in expanding treatment include hospitals, insurance companies, law enforcement, EMS agencies, telemedicine agencies, EMS professionals, and peer organizations.  Statewide institutions, such as the New York State Office of Addiction Services and Supports and the NYS AIDS Institute, have been instrumental in expanding the MATTERS program.

How is MATTERS presented/taught to other staff in your department?

MATTERS focuses on reframing how we think about addiction. We define OUD as a severe, life-threatening disease that typically requires treatment with medication.  We try to use the term “medication for addiction treatment” rather than “medication-assisted treatment.”  Why? Because for OUD, the medication is the treatment.  It does the heavy lifting rather than assist in treating the condition.

When we present on the MATTERS program, we also focus on reducing the stigma associated with OUD. In medicine, we still refer to this disease as “abuse,” which can be stigmatizing and “othering” to patients.  Abuse is such a negative, powerful word that carries a negative connotation.  We draw attention to the fact that no one would choose to experience OUD, and OUD does not discriminate.  When we address common barriers to treatment or meet a patient’s basic needs, they are much more likely to follow up for treatment.  We also like to frame MATTERS as a one-stop solution for patients and providers alike.  We built this program to be simple and effective for busy EM physicians trying to link patients to treatment.

What are common challenges encountered with MATTERS? How are they overcome?

Even with all of the support services we offer, it is difficult to consistently reach marginalized communities, specifically homeless populations—without a phone, email, or consistent transportation; it can be difficult to stay linked to care for this demographic.  Another challenge is funding.  Initially, we received several pilot grants to build MATTERS (from the Blue Cross Blue Fund along with the Oishei Foundation in Buffalo, NY).  More recently as the program has grown, we have partnered with several New York State Agencies (primarily NYS Department of Health and OASAS) for support of the MATTERS program.  We are evaluating options for federal funding to assist in the ability to offer MATTERS services to additional states.

We have overcome these challenges by improving access to our services. In the summer of 2022, we launched the MATTERS Network mobile app to place our resources directly at the fingertips of folks who need them most.  We’ve also expanded to offer follow-up support services so that if someone is having a hard time staying linked to care, we can address those issues on an individual basis.

What advice can you offer to EM physicians interested in initiating a similar program to MATTERS but who have no background or training in this field?  What are the first steps they can take to pursue this interest?

The first step is assessing the resources already available in your region.   Recreating the wheel will always take longer and will be more complicated than building strategic partnerships with community-based organizations working toward the same goal as you.  Use MATTERS as a resource!  We’ve built this program with deliberate attention paid to the ability to replicate across the country in any emergency department (and beyond).  We strive to serve as a national model for linkage to treatment for complex disease processes including, but not limited to, OUD, hepatitis, HIV, and mental health.

We’ve done a lot to build this program, and we want it to serve as a model for innovative treatment for OUD.  Review our published research articles where we outline the development and results of the MATTERS program and other similar initiatives to better understand how you may start a similar program.

Sophia Lin, MD FPD-AEMUS
Assistant Professor of Clinical Emergency Medicine and Clinical Pediatrics
Director of Emergency Ultrasound
Department of Emergency Medicine
Weill Cornell Medicine

Jonathan St. George, MD
Assistant Professor of Emergency Medicine
Weill Cornell Medicine

The New Learning Space: Can Design Thinking Transform How We Learn?

The Learning Challenge

It’s no exaggeration to say that how we learn in healthcare can be demoralizing. Imagine another intense day of clinical care. The miles on the commute home feel longer than usual. You sink into the couch and use that last ounce of decision-making ability to settle on leftovers for dinner.

That is, until you check your email and realize you have several overdue compliance requirements. Now online, you click from one video to the next, reviewing low-yield content that requires just enough of your attention so you can answer the final quiz and get your credit for CME.

This scene plays out daily in clinicians’ lives at a time when how we learn has never been more critical. In a healthcare system undergoing rapid transformation and disruptive change, learning often becomes another checkbox requirement rather than what it could be – an antidote to complexity and burnout.

Our work in MedEd innovation shows that focusing on how we learn, not just what we learn, can be an effective way to address this problem. By creating better methods of delivering knowledge and skills, we can help clinicians be more adaptable and resilient and assist them in navigating complexity. We can address burnout by using education design to reconnect us with the heart of our profession. Great learning reminds us that what we do matters, connects us with our colleagues and patients, and inspires us to continue the journey of lifelong improvement.

Medical educators can lead this transformation by becoming design thinkers and innovators. They can create the next generation of learning systems that “meet us where we live,” integrate seamlessly into our workflow, merge digital and physical space to enhance our learning environment and make education more collaborative and engaging.

If what we learn is the fuel that powers our clinical judgment, how we deliver that learning is the pipeline through which that fuel flows. How well we build that pipeline will determine how effectively new ideas, knowledge, skills and technology flow to the bedside. This has consequences for both patient care and the well-being of the caregivers providing that care.

Our Work

Our education team at Weill Cornell Medicine took a collaborative design thinking approach to teaching high-quality airway management skills relevant to learners at all levels of experience, from medical students to experienced clinicians. We connected experts and physician educators with a diverse group of creative partners and deliberately searched for inspiration from outside traditional medical education sources to produce an innovative learning format to teach complex concepts and procedure skills in airway management. The result of these efforts is the Protected Airway Collaborative.

We first evaluated the strengths and weaknesses of current airway training methodologies and identified a core set of “built for humans” design principles. These principles focused on the learner and guided the development of our new learning delivery system.

Design Principles

• Focuses on how we learn
• Addresses human factors
• Applies adult learning theory
• Meets learners where they live
• Integrates seamlessly into the workflow
• Works for the environment in which it’s deployed
• Uses readily available “off the shelf” technology
• Merges digital and physical space
• Serves as a sandbox for further innovation
• Encourages collaboration
• Promotes diversity
• Seeks to inspire

The core team expanded its collaboration beyond the academic medical community by inviting artists, content creators, fabricators, graphic designers, storytellers and engineers to participate individually and through partnerships with educational institutions including the School of Visual Arts and Cornell Tech. This purposeful inclusion from outside the medical community provided skill sets currently unavailable within medical education and offered solutions arising from a diversity of perspectives.

Exhibits at New York City’s Museum of Modern Art (MoMA) served as our original design inspiration. MoMA’s exhibits create an immersive, interactive, self-directed learning experience through art, space, light, guided audio, graphic design and multimedia tools. This highly successful educational format engages millions of people every year with varied levels of subject matter expertise. We chose to model our educational framework after MoMA’s exhibits because of the numerous potential benefits of a more immersive and integrated teaching style.

Our design challenge was to leverage digital and physical space to recreate a museum-style experience in a low-cost and easily reproducible format using off-the-shelf technology.

The Digital Space

We evaluated multiple digital platforms for their ability to function as part of an immersive physical learning space. We developed an ecosystem of free digital tools, including Twitter, YouTube, Instagram and SoundCloud, to create a library of original content and a network of curated online resources. A low-cost website using WordPress (a user-friendly platform that allows medical educators with no web design experience) was used to organize this digital content into a theme-based curriculum similar to a series of online courses.

This online ecosystem stands independently as a valuable collection of educational resources. However, the intention was never to add to the crowded world of online courses or the growing number of social media “influencers” in medicine but to use these tools in a new way: through the seamless integration of digital content that is adapted to function in an immersive and interactive physical learning environment.

Our goal was to design education that operates both digitally and physically, enhancing the benefits of each.

The Bridge

The next challenge was creating a low-cost and reliable method of delivering this adapted digital content to learners in a physical space. We solved this digital/physical divide by applying graphic design principles to create a unique poster format as the basis for our immersive, interactive and exploratory museum-style experience.

Graphic design, as defined by the American Institute of Graphic Arts (AIGA), is “the art and practice of planning and projecting ideas and experiences with visual and textual content.” A ubiquitous feature of our daily lives, it is an overlooked and underutilized resource in medical education.

A well-designed poster is a workhorse of information delivery that captures attention, shares ideas and disseminates information. Until now, its use in medical education has been relegated to scientific poster presentations.

The interactive infographic posters prototyped for this project utilize the power of graphic design in several innovative ways: to deliver information, transform physical spaces and connect with multimedia content.

Each poster created for this project independently delivers important narratives, concepts, clinical pearls, memes, cognitive tools, practice-changing evidence or steps of clinical procedures. High-impact text and graphics are used to capture the eye, engage learners and draw them into the learning experience we developed.

Posters are grouped together in series. Each poster is an integral component of a layered theme-based narrative containing multiple voices and perspectives. In each series, various learning styles are incorporated to cover all the concepts and skills required to master a particular topic.

We applied graphic design principles to both transmit information in an engaging visual format and develop a “visual language” for the posters. This visual language provided a functional element to our immersive, interactive, museum-style learning space. Each poster in a thematic series uses color, a three-letter code and a numerical sequence that allows a series of posters to guide learners through the physical space created.

This graphic design-based schema originates from Massimo Vignelli’s iconic graphic design for the New York City transit system in the 1960s. Using color, circles, numbers and letters, his subway map transformed how people navigated the city’s subway system. Similarly, the poster prototype’s visual language guides learners through the physical learning space while still allowing them the freedom to travel within that space in any way that suits their learning objectives.

We embedded QR codes to connect learners with digital content. Upon snapping a QR code with their mobile device, learners see a digital copy of the poster, allowing them to feel and understand the connection between digital and physical space. An audio introduction recreates the museum tour experience and learners can then access all related multimedia content by scrolling down the web page.

These interactive infographic posters connect learners with relevant digital content within a physical space, allowing both to become more than the sum of their parts and creating the backbone of a learning experience that moves seamlessly between these previously divided domains.

The Physical Space

We grouped posters in theme-based series and utilized elements of simple pop-up exhibitions in defining our physical space, thereby solving a critical aspect of our design challenge. Our team focused on building an immersive, interactive, self-guided learning experience within this newly defined physical space. We focused on providing the hands-on training required to teach complex airway procedural skills in a format that existing digital content and online courses cannot deliver.

This required thinking about digital content creation with the physical environment in mind: integrating the digital content with laryngoscopes, airway trainers, fabricated models and other equipment to facilitate immersion into a sensory experience in which the digital space and physical space are complementary.

The Experience

These new learning spaces were designed to be self-directed, immersive and interactive. The theme-based interactive infographic posters are transportable and can thus transform any existing room into a museum-style experience.

Opportunities to develop core knowledge and skills occur in these spaces in a judgment-free zone. This allows learners to customize their learning, problem-solve and practice skills before receiving feedback. It encourages them to return to the self-directed portions of these spaces with more focused and refined learning objectives. The ability to rapidly cycle back and forth from coaches to self-directed portions of a learning space until mastery is achieved is a crucial design feature of the overall learning experience based on Kolb’s learning cycle.

A guide and point system gamifies the experience and functions as an assessment tool. After obtaining enough points, learners earn credit for completing the space. The assessment tool also allows the design team to see where learners are struggling and use this feedback for iterative improvements.

The Benefits

Traditionally, only online courses can run asynchronously. However, a major limitation of online courses is they cannot accommodate hands-on practice for procedure skills. Pop-up educational courses combining digital and physical content are different and can provide both asynchronous learning and hands-on experience. These courses are not limited by the time constraints of traditional courses and can be set up for days, weeks or even months to allow large numbers of learners to engage with the content and practice essential skills in pop-up spaces. The portability of the digital content and posters allows tremendous flexibility in the physical spaces that can be used. These spaces can include resident rooms, empty conference rooms or other common hospital spaces.

Our new learning model’s open-source and collaborative design complements other teaching approaches, including simulation. The flipped classroom element of our educational experience makes it ideal for integrating simulation as a capstone experience. Simulation cases are used to solidify the bridge between the digital and physical spaces by incorporating learning objectives drawn from the learning spaces themselves.

Another feature of this new learning model is the inclusion of diverse perspectives and even participants’ voices within the larger theme-based narrative. Participants are invited to record de-identified stories about challenging airways on video or in writing. Stories are then shared via the course’s website and the poster QR codes at relevant stations. Storytelling helps participants reflect upon difficult learning experiences. Interacting with others’ stories helps normalize anxiety around difficult airways so that the learners can focus on skill-building both during and after the course.

Our course design frees faculty from teaching in a one-size-fits-all format. The flipped classroom model enables learners to build confidence first before needing to demonstrate technique. As a result, an educator can work one-on-one with learners and tailor what they teach to a specific learner’s needs and skill level, making the process more enjoyable and efficient for both the educator and the learner.

Since the course’s backbone is a website designed to integrate digital and physical space, it is also infinitely scalable, allowing unlimited online and in-person learning. Through the printed posters, the website can run an endless number of our pop-up learning spaces across the globe without concern for geographic location or time. Remote coaching expands the potential of these new learning spaces, increasing the number of available educators and making the workflow for educators and learners more efficient. The course design also allows consistency to be built into the system. Providing a framework of instructional tools and materials means that many learners can be taught without significant variation or erosion in the quality of learning as the system grows.

We are particularly interested in evaluating this model as a low-cost teaching tool for healthcare systems in resource-limited communities. As most of the work is done on the front end with creation of digital content and posters for a physical pop-up space, the cost for others to implement the course is relatively low.

The collaborative and open framework of this course is fertile ground for further innovation. It provides a platform for studying and testing tools such as AI XR and attracts collaborations with fabricators, such as the Maker Lab at Cornell Tech, to design low-cost models that integrate into physical spaces. It also draws interest from illustrators, artists and content creators to develop engaging audio, video and graphic design features.

Next Steps

We have used this system to teach thousands of learners across our institution, the country, and internationally by deploying posters and equipment in break rooms, resident rooms, classrooms and other pop-up locations. From its inception as a small local project, it has morphed into a nationally and internationally recognized airway course.

A transformation in healthcare delivery can occur only if there is a similar transformation in learning delivery. We hope that our collaborative, low-cost approach, using available technology and existing resources, sparks further interest in medical education innovation, provides a roadmap for overcoming some of the barriers to learning in today’s healthcare environment and creates opportunities to develop new pathways toward viable solutions that inspire and teach physicians for generations to come.

Resources

The Protected Airway Collaborative

https://theprotectedairway.com/

Design Thinking

https://readings.design/PDF/Tim%20Brown,%20Design%20Thinking.pdf

Sandars J, Goh PS (2020). Design Thinking in Medical Education: The Key Features and Practical Application. J Med Educ Curric Dev. Published 2020 Jun 4.

Madson, M. J. (2021). Making sense of design thinking: A primer for medical teachers. Medical Teacher, 43(10), 1115–1121.

Graphic Design

https://icenet.blog/2020/09/22/presentation-design-for-medical-educators/

Maria Tama, MD
Co-Director of Emergency Ultrasound
Department of Emergency Medicine
Staten Island University Hospital

Christie Chen, MD
Clinical Assistant Professor of Emergency Medicine and Pediatrics
Division of Pediatric Emergency Medicine, Ronald O. Perelman Department of Emergency Medicine
NYU Grossman School of Medicine, NYU Langone Health

Thomas M. Kennedy, MD 
Assistant Professor of Pediatrics in Emergency Medicine
Columbia University Vagelos College of Physicians and Surgeons
Department of Emergency Medicine, Division of Emergency Ultrasound
NewYork-Presbyterian Morgan Stanley Children’s Hospital