COMMENTARY

Overcrowding: Harming the Patients ofTomorrow?Jonathan Fisher, MD, MPH, Peter E. Sokolove, MD, and Sean P. Kelly, MD, for the Society forAcademic Emergency Medicine (SAEM) Crowding Taskforce Education Workgroup*

ACADEMIC EMERGENCY MEDICINE 2009; 16:56–60 ª 2008 by the Society for Academic EmergencyMedicine

Keywords: crowding, overcrowding, education, educational research

It is 3 AM on August 1st, 2018, in a busy hospi-tal when a 47-year-old male presents withchest pain. The emergency physician on duty,who is a new residency graduate, performs ahistory and physical, orders an ECG, chestx-ray, and blood work. After reviewing thedata, the patient is given aspirin, nitroglycerin,and heparin and admitted to observation fora rule-out with serial enzymes. At 7 AM, thepatient’s chest pain worsens and he suffers acardiac arrest. An autopsy reveals cardiactamponade and a large thoracic aortic dissec-tion.

As physicians and educators, we are products of ourenvironment. In emergency departments (EDs) through-out the world, we were taught by our mentors to providethe most compassionate and best care possible, no mat-ter what the circumstance. In turn, many of us try torepay our mentors by teaching the doctors of tomorrow.However, our ‘‘classroom’’ is changing. It is becomingincreasingly overcrowded. As we spend more time dis-cussing diversion with charge nurses, and less timeteaching students and residents, we wonder if we aredoing a disservice to the doctors (and patients) of tomor-row. Am I really supervising the residents adequatelyand giving the necessary feedback? When I barked infrustration at the family member who asked me for thefifth time when her mother would be admitted to the hos-pital, was I really modeling professional behavior? CouldI really teach the student the subtleties of the abdominalexam on that fully clothed patient in the hallway?

Who can be expected to teach under such difficultconditions? With so many competing interests and

interruptions, who can possibly address the needs ofstudents and residents? With constant pressure to per-form clinically, despite limited resources, who has thetime or energy to teach?

Well . . . emergency physicians (EPs), that is who, it iswhat we do—adapt and overcome; create order fromchaos. In fact, there are those among us that do it verywell. Sometimes even the most clinically productivephysicians somehow manage to be the best educatorsas well. How do they do it? What are the methods theyuse? What are the tricks of the trade that allow some-one to manage an overcrowded ED and use all thatextra learning substrate to their (and the learners’)advantage rather than to their detriment? The ED is ahigh stakes environment, both clinically and education-ally. It is ripe with risk, but also full of potential reward.The stakes have never been higher, for today’s teachersand tomorrow’s physicians.

While overcrowding is an evil that most EPs wouldrather do without, it does present emergency medicine(EM) with a unique opportunity. From doctors andpatients to administrators and politicians, the rest ofthe world is starting to take notice of overcrowding asa major issue in patient care and medical education.Now that people are paying attention, it is time for EPsto act. No one is more qualified to lead this charge thanthe EM community. We have grown up on the frontlines of the overcrowding battle and know the issuesintimately. Furthermore, we are well poised to take onthe challenge of conducting research, formulating solu-tions, and testing results. Our specialty naturally selectsphysicians and educators who are flexible, adaptable,quick-thinking, team-oriented, multitasking, and prag-matic— the very qualities necessary to approach thetask at hand.

BRIEF BACKGROUND

ED CrowdingEDs across the country and the world are becomingincreasingly crowded. The numbers and the complexityof patients presenting to the ED are increasing.1,2 At

ISSN 1069-6563 ª 2008 by the Society for Academic Emergency Medicine56 PII ISSN 1069-6563583 doi: 10.1111/j.1553-2712.2008.00260.x

From the Departments of Emergency Medicine, Beth IsraelDeaconess Medical Center (JF, SPK), Boston, MA; and theUniversity of California, Davis (PES), Sacramento, CA.SAEM Crowding Taskforce Education Workgroup membersare listed in Appendix A.A related article appears on page 76.Received April 11, 2008; accepted July 24, 2008.

the same time, there has been a decrease in the numberof EDs to care for these patients. ED crowding is notjust an ED problem, but often a product of a lack ofhospital capacity. As the patient population continuesto grow and age, the demand for primary care outstripsthe resources available in their communities. The inpa-tient bed capacity in most hospitals lags behind EDneeds, so the problem of ED overcrowding is expectedto worsen further.

Size and ScopeED crowding is a public health crisis.3,4 It is becomingincreasingly prevalent in all types of EDs in all loca-tions: urban, suburban, rural, teaching hospitals, andcommunity centers.5 It has been shown to be associatedwith increased patient mortality,6–8 decreased quality ofcare,9–12 and decreased patient satisfaction.13 It is asso-ciated with higher rates of patients leaving withoutbeing seen by a physician,14–17 ambulance diversion,18,19

and ED lengths of stay.

CONSENSUS OF EXPERTS

In response to the growing concern about the impactof ED crowding on education, the Society for AcademicEmergency Medicine (SAEM) brought together a groupof overcrowding and educational experts to study theissue. In this issue, an article is presented that is theproduct of these deliberations discusses the impact ofovercrowding and education.20

Shayne et al.20 review the current literature and pro-vide an excellent overview of the current state of EMeducation, particularly focusing on the AccreditationCouncil for Graduate Medical Education (ACGME) corecompetencies. While there is a growing body of litera-ture on the negative impacts on ED overcrowding onpatient care, there is a noticeable dearth of research onthe effect of overcrowding on education. A truly novelconceptual model of ED crowding and education wasproposed as a Starling-like curve, where initialincreases in crowding may actually increase education,but as crowding increases, eventually education willpeak and ultimately crash. Just as the real Starlingcurve can be shifted, this crowding–education curveprovides a useful framework to conceptualize the factthat the impact on crowding may vary for differentteachers, learners, skill sets, and educational settings.For example, senior residents may learn better in a bus-ier high-acuity setting where they are learning to finetune their skills. An intern in that same environmentmay become so overwhelmed that learning ceases tooccur. Shayne et al. go on to review the unique oppor-tunities and challenges that ED crowding provides toeducation.

WHAT WE DO NOT KNOW

How to Measure CrowdingDespite the importance of the topic and the prevalenceof overcrowding, it has been difficult to define andmeasure it properly. ED crowding is a complicated phe-nomenon with multifactorial causes and many variedeffects. Some of these causes and effects are universal

and some system- or site-specific. Multiple attemptshave been made to measure crowding using variouscrowding scores.10,21–25 A recent study advocates usinga simpler measure, ED occupancy rates, as a measurefor overcrowding, because its reliability and validity aresimilar to the most accepted crowding score index.10

Some researchers advocate using the number ofpatients who left without being seen and ambulancediversion rates as surrogate measures of overcrowding.Work is ongoing to further define the most accuratetools and methods for measuring overcrowding, but itis a complicated problem, and some tools and methodsthat work well at one site may not be as accurate inothers.

How to Measure Education?Owing to the many confounding influences andvariables involved in most teaching ventures, it isdifficult to objectively measure the results of educationand learning in any environment, especially that of acrowded ED. While there is no single perfect educa-tional outcome measure, there are ways to evaluateeducational interventions that involve triangulating datafrom several sources or methods to give the most valu-able data possible. One could envision using Kirkpa-trick’s hierarchy of learning to explore the effects ofovercrowding on education in the ED.20

CALL TO DEVELOP BETTER TEACHING METHODSWHILE WE ASSESS CROWDING AND EDUCATION

While we consider the problem of studying the effectsof crowding on education, we also need to figure outbetter ways to teach in the current environment. It isimportant to remember that the everyday business ofpatient care and bedside teaching goes on, regardlessof our long-term plans to effect change. In fact, someof the early studies into the topic of crowding and edu-cation reinforce this point—that any research should begrounded in the real-life limitations of the environment,for these very qualities (the fast pace, the multitaskingrequired, the constant interruptions, and less-than-idealcircumstances) are at the heart of the issue. Rather thanignore them, we must embrace them as the very quali-ties that make the environment unique, in both positiveand negative ways, and accept that these conditionswill dictate the best methods to use in researching thesubject and teaching while we research.

Several authors have used various parts of Kirkpa-trick’s hierarchy to evaluate the effects of overcrowd-ing on education in the ED, but much more workneeds to be done.26 Berger et al.27 and Kelly et al.28

used learner satisfaction tools (the first level of thehierarchy) to investigate the effect of overcrowdingand clinical workload on learner satisfaction with EDfaculty teaching. The study by Kelly et al. found thatteacher attributes had a significant effect on learnerreaction, independent of clinical volume. These findingsreinforce the fact that ED learners value the teachingprinciples described by Thurgur et al.,29 Bandieraet al.,30 and Atzema et al.,31 which stress adaptability,practicality, and the ability to tailor teaching to thelearner and situation. In short, it seems certain that

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teaching methods and characteristics may allow teach-ers and learners to adjust to a crowded environment.Along these lines, Aldeen and Gisondi32 proposed sev-eral practical strategies to improve bedside teaching ina crowded ED. More research is indicated to furtherevaluate the validity of these and other methods incrowded conditions.

CALL TO DEVELOP BETTER RESEARCH METHODSTO ASSESS CROWDING AND EDUCATION

Ongoing research into the effects of crowding on edu-cation is beginning to offer clues on what types ofteaching ED learners (and teachers) prefer in busylearning environments. However, most of the existingstudies have been predicated on the lower level ofKirkpatrick’s hierarchy and depend on learner and tea-cher reaction tools. Much more work is needed, espe-cially with regard to the higher levels of Kirkpatrick’shierarchy.26 It would be useful to investigate the effectof crowding on objective measures of teaching andlearning (the second level of the hierarchy), such asscores on tests or objective structured clinical examin-ations, or actual time spent teaching, especially giventhe findings by Chisholm et al.,33 who demonstrated apaucity of actual time spent by faculty directly observ-ing residents. Several authors have begun to investi-gate the validity of standardized bedside observationtools.34 While this work does not directly examinecrowding effects, validated direct observation toolscould be used to study the effects of overcrowding onlearned behaviors at the bedside (Kirkpatrick’s thirdlevel). Several authors have investigated the effects ofteaching interventions on patient care outcomes (Kirk-patrick’s fourth level), with mixed results.35–38 Again,these studies were not directly related to crowding,but one could envision an investigation along the samelines with a crowded and noncrowded control arm.More research is needed to develop a better under-standing of crowding and its effect on education inthe ED.

CALL FOR ACADEMIC EPS TO ADVOCATE FORRELIEF OF ED CROWDING

In addition to developing better teaching and researchmethods, EPs who are involved with teaching healthcare providers need to stand up and advocate for ourstudents. In addition to being the place where clinicalcare is delivered, EDs are our classrooms. None of uswould accept having an inadequate number of desks ortextbooks for our children, nor would we accept havingour children trying to learn in a classroom with a leak-ing ceiling. When our ED beds are full, we have nodesks. When our flow of patients is slowed, we have notextbooks. When we are trying to teach in crowdedhallways, we have the equivalent of leaking ceilings.Academic EPs need to rally to the cause of our studentsin the same way that other teachers have done. Weneed to visit our legislators and share our insightregarding the effects of ED overcrowding on bothpatient care and education. We should also serve asrole models to our students and involve them in

advocacy efforts, so that they will add their voices toour common cause.

CONCLUSIONS

Emergency department crowding presents a challengeto EM, and for many, it has become a fact of life that isnot likely to change. While there are some unique oppor-tunities that ED crowding provides, there are many rea-sons to believe that ED crowding has a negative impacton both patient care and the education of future physi-cians. While ED crowding may lead to an increased num-ber of patients and higher acuity, this educational‘‘bonus’’ created by overcrowding is offset by compro-mised patient care and faculty teaching. In many cases,excessive ED crowding results from a lack of inpatienthospital capacity. In this gridlock situation when the EDis full but there is a decreased volume of new patientencounters, medical education is compromised as well.More discussion and research is needed to understandthe true impact of crowding on education, and EPs areuniquely suited to the task. It is time we took a leadershipposition in the academic and research communities todetermine what educational approaches are necessary tominimize damage and maximize learning in a crowdedenvironment. SAEM, the Council of Emergency Medi-cine Residency Directors (CORD), and the ClerkshipDirectors in Emergency Medicine (CDEM) are ideallysuited to foster the solutions to the education-crowdingcrisis. Just as we have adapted our clinical practice tomaximize quality of care in the face of crowding, we needto change our teaching methods in a similar fashion. Wecannot fail, for the true challenge of overcrowding inacademic EDs is this: as we struggle in our busy EDs toavoid harming patients today, we cannot sacrifice teach-ing the doctors of tomorrow, for the effects of today’steaching will be felt for many years into the future, byteachers, students, and patients alike.

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APPENDIX A

SAEM Crowding Taskforce Education Workgroup:Philip Shayne, MD, Department of Emergency Medi-

cine, Emory University, Atlanta, GAMichelle Lin, MD, Division of Emergency Medicine,

University of California San Francisco and San Fran-cisco General Hospital, San Francisco, CA

Jacob W. Ufberg, MD, Department of EmergencyMedicine, Temple University, Philadelphia, PA

Felix Ankel, MD, Department of Emergency Medi-cine, Regions Hospital, St. Paul, MN

Kelly Barringer, MD, Department of EmergencyMedicine, Regions Hospital, St. Paul, MN

Sarah Morgan-Edwards, MD, Department of Emer-gency Medicine, University of New Mexico, Albuquer-que, NM

Nicole DeIorio, MD, Department of Emergency Medi-cine, Oregon Health and Science University, Portland, OR

Brent Asplin, MPH, MD, Department of EmergencyMedicine, Regions Hospital, St. Paul, MN

Michelle Lin, MD, Division of Emergency Medicine,University of California San Francisco and SanFrancisco General Hospital, San Francisco, CA

Susan E. Farrell, MD, Department of EmergencyMedicine, Brigham and Women’s Hospital, Boston, MA

Jonathan Fisher, MD, MPH, Department of Emer-gency Medicine, Beth Israel Deaconess Medical Center,Boston, MA

Benjamin White, MD, Harvard Affiliated EmergencyMedicine Residency Program, Boston, MA

Louis Binder, MD, Department of EmergencyMedicine, MetroHealth Medical Center, Cleveland, OH

60 Fisher et al. • OVERCROWDING: HARMING THE PATIENTS OF TOMORROW?