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In recent years policy makers and medical experts have begun to understand that there is a fundamental requirement of physician’s to change their perceptions of support personnel.  Examples of support personnel include registered nurses, respiratory therapists, radiology technicians, paramedics, and computer technicians.  A specific example of a physician perception problem is in the emergency department.  There is often a disparity at the group level between emergency department physicians and paramedics.  Emergency Medical Services (EMS) and emergency departments have undertaken drastic measures to improve their organizational relationship when caring for an ill patient, however; there continues to be opportunity for improvement in the relationship between emergency department physician’s and their perceptions of a paramedic’s ability to diagnosis an ST-elevation myocardial infarction.  A paramedic’s diagnosis of an acute myocardial infarction is done by a methodical interpretation an electrocardiogram (EKG) of the heart.  Ideally, based upon the interpretation of the EKG by the paramedic a hospital wide alert should be enacted by the emergency department physician if the patient is having an ST-elevation myocardial infarction.  The hospital wide alert is to ensure that the individuals who will care for the infarcting patient will be ready for the rapid transport of the patient while anticipating the needs of the patient.  This is an especially difficult situation in that emergency room physicians have been under the perception that paramedics are improperly diagnosing ST-elevation myocardial infarctions therefore, causing an unnecessary use of vital staff resources.  Additionally emergency room physician’s perceptions are sealed in the belief that only they can properly diagnosis an infarcting patient.  The perception of emergency room physician needs to be addressed due to the fact that the diagnosis of ST-elevation myocardial infarction is associated with a higher that average morality.  Furthermore, hospitals are benchmarked according to their overall timing in the treatment of acute myocardial infarction which affects hospital reimbursement.

As the healthcare industry grows direct implications of reimbursement and quality are under extreme scrutiny.  Healthcare facilities are required to maintain quality while ensuring efficiency is improved.  Physician perceptions can ultimately hinder the expeditious care of a patient.  In healthcare organizations, patient trust in the physician-patient relationship is based on the idea that physicians have responsibility and control over medical decision-making and that the physicians prioritize the needs of patients over all other considerations (Carayon, 2007).  In the past decade, the issue of professionalism among physicians has been the central focus of numerous national and international medical conferences and public initiatives by professional organizations (Carayon, 2007).  All these efforts have been geared towards changing physician’s perception on healthcare organizations.  The main area of concern by the regulators of changing physician perception is for the delivery of expeditious of health care to patients.  This initiative delineates primary dedication to a patients needs and has spawned a call for renewed commitment to the principles of patient welfare, patient autonomy, and social welfare. 

Although physician perceptions affect all departments a specific area of concern is between the emergency department physician and the Emergency Medical Services (EMS).  The problem is at the group level.  Emergency room physicians specifically oversee the treatment of emergency department patients.  The emergency department physicians are ultimately responsible for the treatment course of the patient.  Therefore an emergency medicine physician’s perception of a paramedic’s electrocardiogram interpretation should be one of trust based upon a quantitative method steeped in accuracy.  Data will either prove or disprove the perception.  If the emergency department physician does not change their perception about the EMS paramedic they will not be providing quality or efficient care of ST-elevation myocardial infarction patient.  The organization must ensure that physician perceptions are modified to fulfill the patient’s best interest. Carayon  commented that “the need to change the perceptions of physicians has been motivated by perceived negative effects of the efforts by healthcare organizations to improve quality and decrease costs on the ability of physicians to serve as advocates for their patients” (p. 139). There is a need to reduce the perceived conflict between the goals of physicians as professionals and organizational management efforts which will help to explain why so many organizational attempts to change physician perception meet with failure (Carayon, 2007).

The healthcare facility must understand that there is a perception problem among the physician and EMS services.  Once the problem is diagnosed data will either prove or disprove the perception.  The national standard currently for the timing of treatment of the ST-elevation myocardial infarction patient is equal to or less than ninety minutes.  Currently of all healthcare facilities reporting to the American College of Cardiology only 77% of the time is this goal met.  Healthcare facilities must constantly benchmark their data to improve their outcomes.  Every ST-elevation myocardial infarction case is scrutinized by using a gap analysis method to determine if fallouts occur.  Furthermore, gap analysis is also used to accurately establish at what point of the treatment course the problem is occurring.  Most often the fall-out happens at the time of diagnosis in the field by the paramedic to the emergency department physician.  Valuable time is lost if the emergency department physician does not activate a STEMI alert at the time of diagnosis in the field.  With-out proper quality improvement data is it  evident that emergency room physician’s will not trust the paramedic’s accuracy therefore the STEMI process within the facility will not be instituted in a timely manner.

In order to change physicians’ perceptions on health care organizations, three challenges must be confronted (Manion, Lorimer, & Leander, 1996).  First, health care organizations must be well prepared through education and coaching to play their part. They must be ready to deal with the most volatile customer service situations.  Second, managers must steadfastly position physicians as the first line remedy for problem resolution.  Traditionally managers have been rewarded for fighting fires and resolving crises, forgetting to deal with the root of the problem.  The third challenge is in changing the perception of physicians which is the most daunting.  Physicians should not be rewarded for going straight to the top. They must learn to get the results they need directly through the other members in the organization.  Physicians must have regular dialogue with their peers about mutual expectations and responsibilities, not when problems arise but all the time (Manion, Lorimer, & Leander, 1996).

Healthcare organizations must align the physician’s goals in the same direction. Manion, Lorimer & Leander (1996) indicate that healthcare organizations must consider ‘going directly to the teams’ as the best way for physicians to get the results. For example, the nurse manager receiving a physician complaint completely understands a situation and arranges an immediate discussion with the physician. This approach accomplishes several objectives. First of all, it redirects problem resolution to the team and, second, it avoids giving the physician the perception that the manager is blowing them off or just does not want to be involved (Manion, Lorimer & Leander, 1996). By consistently handling these situations in such manner, it gradually changes behaviors because it becomes in physicians’ own self-interest to seek out the team. 

The organizational development model best to use in this position would be Lewin’s change model.  Lewin’s change model includes the unfreezing of the physician’s perception, changing the perception by physicians’, and then refreezing the new perception.  Nancy Borkowski asserted in her book Organizational Behavior in Healthcare, that in healthcare organizations, Lewin’s change model permits us to view change as a series of forces working in different directions and that for the implementation to take place there must be an increase in the strength of the force for change that is driving forces, the strength and position of opposing forces must as well be reduced or removed (Borkowski, 2009).  Research espoused that physicians’ non-acceptance of Clinical Practice Guidelines (CPGs) into their medical practice illustrates the application of Lewin’s Force Field Analysis in the change process.  In healthcare organizations, CPGs are seen as important tools to reduce variances of medical services received by patients and to improve the quality of care by establishing best practices. However, CPGs have been remarkably unsuccessful in influencing physicians’ perception and practice patterns. Borkowski further indicated that “the driving forces for perception change and implementation of CPGs represented knowledge and attitudinal change and were viewed positively by physicians” (p. 378). On the other hand, restraining forces represented changes being imposed by some external force that were viewed by physicians with resentment and negativity.

Lewin provides us with a three-step process for implementing planned change in a healthcare organization. The first step is unfreezing were by physicians involved in perpetuating resistance acquire an understanding of variances that exist between current practices and behavior and desired activities and behavior.  Borkowski  established that “unfreezing may occur when managers effectively communicate the need to change driving forces such as mortality or morbidity rates, hospital readmission data, and best practices benchmarks to physicians”  (Borkowski, 2009 p.378).  The second step is the change.  Borkowski reveals that on the basis of new objectives in the healthcare organization, a series of revised policies, procedures, and operating practices is implemented.  In this step, it is important that physicians understand the reasons for change and participate in the design of new approaches.  Physician’s involvement in the change design followed by appropriate training and reorientation presents each worker with the opportunity to buy into the new approaches (Borkowski, 2009). The third step in Lewin’s change model entails refreezing.  Refreezing according to Lewin stabilizes the organization at a new state of equilibrium.  It is frequently accomplished through the use of supporting mechanisms that reinforce the new organizational state, such as organizational culture rewards, and structures.  (Cummings & Worley, 2009 p.23). Therefore healthcare organizations must monitor daily activities to ensure objectives are operationally successful.  Audits and feedback of physician’s perceptions and practice patterns are the most common reinforcements used by the managers in healthcare organizations (Borkowski, 2009). 

Marquis’ & Huston state that “during this last phase, physicians should assist in stabilizing the system so that it becomes integrated into the status quo” (Leadership Roles and Managment Functions in Nursing: Theory and Application, 2008 p. 169).  For refreezing to occur, the change agent must be supportive and reinforce the individual adaptive efforts of those affected by the change.  In healthcare organizations, refreezing does not eliminate the possibility of further improvement to the change.  All the physicians should measure the impact of change and allow it to be a part of refreezing because without measurement, the capacity to achieve administrative and clinical outcomes remains an intuitive undertaking (Marquis’ & Huston, 2008).

In conclusion, Marquis’ & Huston contend that many forces are driving change in contemporary healthcare costs, declining reimbursement, workforce shortages, increasing technology needs, and a growing elderly population are just a few of the concerns.  All of these dynamic forces have led to the need to change physicians’ perceptions.  Moreover if perceptions are not changed destabilization within a healthcare organization may actually threaten the viability of both the patient and the organization.  Specifically a patient experiencing an ST-elevation must be provided an unbiased diagnosis based upon clinical methodology not perception.  In this context, Marquis’ & Huston emphasize that the reality today is healthcare organizations should continually institute change to upgrade their structure, promote greater quality, and change the physician perceptions.  To change physician perceptions, healthcare organizations should undergo dynamic changes directed at organizational restructuring and quality improvement. Change and quality improvement efforts that incorporate system redesign may are more successful in changing physician perceptions and maintaining physicians’ job satisfaction in healthcare organizations.  

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