 This is Think Tech Hawaii, Community Matters here, HGPS Association, yes, the Hawaii Emergency Physicians Association. Actually associated, we're a company. Associates. Yeah. And I'll tell you how that, what, it'll be part of the discussion of why groups like us exist. I'm Jay Fidel. That's Craig Thomas. We're having this pre-show conversation. He is the CEO, am I right? President, yeah. President, okay, of HEPA, which is the Hawaii Emergency Physicians Associates, yeah, yeah. And they staff emergency rooms all over the place. Yeah, we are sort of the staffing entity for community emergency departments across the state. Across the state. Yeah, we're on every island except Maui, every major island except Maui. And it's more efficient that way, isn't it? I mean, you can't have different emergency room organizations staffing different places. That's not efficient. Well, there are some different organizations staffing different hospitals. What you really don't want to have, and what the hospitals hate, is them having to staff their departments. So they find people like us to recruit, retain, mentor, and occasionally allow to share their talents with the community, a pool of physicians. You're different. You're different. An emergency room doctor is different. I always had a lot of admiration for emergency room doctors. They've got to be able to handle emergencies of all kinds, all across the spectrum. And they've got to be able to do it fast and they've got to save lives when necessary. So do you agree with me, Craig? Yes and no. Yes. And at some stage, not today, we could talk about the various mentalities of different specialties, which is honestly a fascinating topic. So yes, we are different. We have a tension span about that long. But and we are solution oriented. You know, in fact, one of the faculty I had was given a plaque. And the plaque from his students, his residents was occasionally wrong, never in doubt. Got to be that way now. Well, you have to make a decision. No, it's healthy, but it can't be paralyzed. So our real role is to manage the first hour of everything and actually to manage the whole thing of most things. And that's wonderful. We share important moments with the people who come to us. We occasionally are lifesaving. Often we can't change the arc of things, which is a different kind of importance. Occasionally we make mistakes. Of course, we're human. And sometimes we just make things a little better, like sell up a cut or give some reassurance. So it's honestly a wonderful job. Yeah, I was going to ask you, is there a special gratification in that because of the speed, the adrenaline, if you will, of that experience? Yeah, especially if you don't have a tension span long enough to measure. No, it's wonderful. It's, I don't know if it's weaving a bunch of threads or juggling a bunch of balls and keeping them in the air, but that's really what it is. You have the serious, the mundane, the, I don't know, the cycle social, the crying baby, all at once. And I'm not trying to inflate the job. It's not magic. It's, you learn how to do it. But it's wonderful. That's for training to be an emergency room doctor. Yeah, there's, of course, you go to medical school, then you do residency. Then you have to pass a written and oral exam. And then you take a test every year, do a few other things. And then every 10 years, you retake the big test. So, yeah, it's a specialty in its own right. And it's because we're often, depends on the size of the hospital, obviously. But at smaller hospitals, we're often the only doctor in the hospital a lot of the time. And some of our very small sites, well, over weekends. Or at our littlest sites, sometimes weekdays, too. We staff some fairly small places. And we may be really the only practicing doctor on the island in some places. So you might get drawn off from emergency work to something else? Well, we never leave the department. Well, that's not true. We may go somewhere else in the hospital, but we never leave the premises. On the other hand, yeah, we find ourselves doing a variety of kind of adventures. Because you are a jack of all expertise. At least for the acute stabilization. You know, I don't take out appendixes. I don't do lots of things. Hopefully, I identify the people who need those services and then connect them with both the individual but also the place that can provide it. And so in some places, you can think of us as the portal to the health system. So you need an entry and an emergency department. If you need healthcare, acutely, an emergency department is a great place to go because that's what we do. And it may well be that you don't need much service or the service that you need we can provide or it may be you need tertiary care, in which case we arrange that for you. And you will get transferred to whoever it is. And Hawaii is small enough that really there's only a couple of tertiary centers. What's tertiary? Oh! It's my apologies. So we're going to learn a lot with you, Greg. I'll do my best. So community hospitals offer a spectrum of services and it depends on their size, what they do and don't. But some things. So emergency doctor, you need one for every or more than one. You need one on duty for every emergency department. Neurosurgeon, oh, you may need one of those for every 100,000 residents. And so pretty clearly, you're not going to have the neurosurgeon at a small community hospital. And so the tertiary centers, they're the ones with the spectrum of specialty. So they're places like Queens, for example. Or if you're a child at Capulania Women's and Children's. And there are a few other centers with pretty wide capability. But those are really the two tertiary centers for respectively trauma and the biggest spectrum of medical services and, of course, children. Well this brings me to the question, which is inevitable, this question. We have a doctor shortage. It affects the neighbor islands more than Honolulu. And the question is how does that affect staffing of emergency rooms on the neighbor islands? Is there a problem? Is there a rotation? Do emergency physicians move around? Are you able to staff these remote places? Yes, we are able to staff. And if we didn't, we would be a failed entity. There is no tolerance for... We have a scheduling program. And until all the slots are filled, it's filled with a little red open. Well, there is no doctor open. So we have to get a name in there before the schedule is in effect. So and that's one of the reasons hospitals hire us. It is definitely true that staffing, Oahu is much easier than staffing a number of the other places. And actually I'd like to give a little shout out. HMSA helped us a couple years ago with some special support for staffing some outlying hospitals. And it was beneficial. We gave them some things in return, but that's the way this should work. How many of you guys have been in business for what, 40, 50 years? The group was founded not by me in 1971. I've been at it since 1983. So yeah, our group's been around quite a while. Yeah. Amazing. And the doctor thing is interesting. It's more of a maldistribution of both geographically and by specialty than overall a shortage. There's that too. And it's more, as I say, urban Honolulu, pretty easy. Even outlying areas on Oahu, not so easy. And when you get to outlying islands, it's tough. Yeah. So you have to go, there's a special recruitment. You have to approach somebody and say, look, we need somebody in Kohala. You know, how about it? You have to give them your combat pay or something. Well, that's one of the things we do. I mean, overall for recruiting, we have another challenge, and that is that there is no emergency medicine training program in the state. So even if you're a local person, I was about to say a local guy, but obviously it's local of either gender. There are a lot of women emergency physicians now, which is a tremendously good development. My doctor was a woman. That's a good sign. I don't think there's nearly as much difference between genders as a lot of people do, but some of the things that women bring to the specialty have really great, honestly. It's been an evolution in our group and in medicine in general, and it's all good. In any event, whether you're either a gender or a local person, you might even go to the jabs from here. If you're going to be an emergency medicine physician, you have to go to Mainland for three or four years to do your residency. A special residency just for this. There is. I don't know exactly. Somewhere around, I think, about 120 of these residencies, but there's not one. There are other residencies in Hawaii. Should we have one? You know, I would love to see that happen. It came fairly close a few years ago. It didn't happen. We definitely have the clinical experience available, and we have a number of talented providers in our group, but also a number of the other ones. We could provide a good experience. It would be really nice because then people who really wanted to stay here could stay here for residency, but also it would be a magnet for interested people wanting to move here, which would be great. In general, if you've worked with a resident, you have a really good idea whether you want to hire them or not. So I would love that. So that's basically how it works. How many doctors do you have, by the way, all together? Well, that's a good, yeah, roughly. No exactly. Well, what I didn't tell you is, well, so I'll tell you, we staffed nine different departments across the state, except Maui, as I said. We have about 80 FTE emergency physicians. That stands for? Oh, FTE is full-time equivalent, sorry, and the reason I use that jargon is we have a few people who work part-time, that kind of thing, but when we're actually just looking at the number of shifts to fill, it takes about 80-ish bodies to do it. We probably have... That's doctors. Doctors. You also have non-doctors staff. We actually have actually two kinds of doctors. We have emergency doctors. And then we provide hospitalist services at a number of our sites also. That's a relatively recent development, which I'm excited about because it's an opportunity to coordinate the care between the portal to the hospital and the healthcare system, the emergency department, and through their inpatient stay. And so in recent years, several of our sites, actually the majority of them, have asked us to provide hospitalist services too. So those doctors are generally internists or family practitioners. And we have about, using the FTE jargon again, 10 or 11 of those doctors plus some part-timers. And that's been a positive and interesting experience, which I'm excited about. And then we also have some mid-level providers, physicians, assistants, and nurse practitioners. So you staff the room, all the necessary people. Well we staff the department. The hospital provides the other staff. And so the nurses, the techs, the registrars, the x-ray techs, the laboratory services. And so sort of the contract is, if you're the hospital, you contract with us and we say we'll provide an appropriate number of doctors to cover the volume, et cetera. And they'll have these criteria and we'll collaborate on who should stay and who should go, that kind of thing. And in exchange, you will provide what we need, which is appropriate space, appropriate staff, also adjusted by volume, availability of services, that kind of thing. And it works together. We're going to take a short break. This is Craig Thomas. He's an MD, of course. He's an emergency room physician. And he's the president of HEPA, which is Hawaii Emergency room, Hawaii Emergency Physicians Associates. He's been doing business in Hawaii since 1971 and staffs the emergency rooms. And it's really wonderful to be able to talk to you because usually we get to talk to you in an emergency situation. Today we can schmooze. Yeah, it's true. Although, when it's slow in the emergency department, schmoozing sometimes happens there too. That's a wonderful story. So, thanks. We'll be right back for more. We can talk about some medicine now. This is Think Tech Hawaii, raising public awareness. I just walked by and I said, what's happening, guys? They told me they were making music. Aloha. My name is Mark Shklav. I am the host of Think Tech Hawaii's Law Across the Sea. Law Across the Sea comes on every other Monday at 11 a.m. Please join us. I like to bring in guests that talk about all types of things that come across the sea to Hawaii, not just law, love, people, ideas, history. Please join us for Law Across the Sea. Okay, we're back. We're live. I'm Jay Fidel. Much more on medicine with Craig Thomas and he's actually going to show a regular basis next week and thereafter. We're going to get much more on medicine. Today's show is about emergency room physicians. Why are they like the DMV? And I mean the Department of Motor Vehicles. Why are they like the DMV? Well, I was waiting in line at the DMV a few years ago looking around me and like, yeah, this looks just like my emergency department except I'm standing in the middle of it waiting in line. Everybody. Yeah, and it occurred to me and I honestly think it's really true that over time everybody goes to the DMV, some people more often than others, and same is true of emergency departments. It's like Times Square. If you stand at the corner of 42nd Street and set in Broadway for long enough you will meet everybody you ever knew. No, it's really true. It's definitely true of the emergency department. And we are, as we discussed earlier, sort of a portal to healthcare, but we're also a hub. And we sort out what to do and where to go next. Yeah, and I wanted to ask you about that. I wanted to get into your physician's brain for a minute. So I walk in. I decide that I need emergency room assistance, right or wrong, may or may not. I'm in some kind of stress to rest and I feel I need to come and see you. What's the physician's triage process at that point? Okay, so first of all, let me emphasize that it's often hard to figure out whether you need emergency services or not. But if you have an acute or feel like you have an acute health issue that needs evaluation, we will be delighted to see you. That's our job. And so you walk in, a little bit of an intake happens, hopefully not much, because the real goal is for me to see you almost immediately. And it used to be thought, and it's how I was taught in medical school, that there was sort of this process. You do the history, you do the past medical history, you do the review of systems, and you sort of progress through the thing and end up with the answer. But it's been learned that that's actually not at all how we do it. It's how we record the thing and you do need in the end to cover those steps. But that doesn't mean we do it sequentially. So what we're really trying to do, and over time, I actually think AI will ultimately... I was just going to ask you about it. Well, I beat you to do it. No, it is like AI. And so far the processes are not well enough understood that it's not very useful except in limited settings, but I'm not delusional. That's going to change, which is fine. Help is always good. So it's difficult because there are many factors. I don't know if you're a reliable narrator or not, or whether you're a underreporter or an overreporter, and all these things you try to take into account. And obviously we work subliminally also. I look at you, I already have a sense of your disposition, your age. If you were pale or sweating or in pain or things like that, this is not something recorded physically, but it's something I have. It's the way the patient presents, and it doesn't take very long to scan on all these possibilities. That's correct. I walk into the room. I know what your chief complaint is, which may or may not be your actual problem. I know what your vital signs are. I know what the nurse thought, which can be very helpful, and also can be a red herring. You mean when I talked to the nurse, she's going to tell you what I said? Well, of course. Okay, all right. Get that one out of here. Don't tell the doctor. Yeah, yeah, yeah. No, we work together, and it's like any difficult and collaborative effort. More insight is always helpful. What we end up doing, so my job really is to assess the diagnosable and treatable conditions, moderately in order of likelihood. Now, I'd like to find out other things too, but if you have an untreatable condition, yeah, we should try to figure that out. But truthfully, it doesn't matter. Whether it's self-limited and it will get better or it's going to get you. And if I miss it, that's bad, but truthfully, it didn't change your life. Does that make sense? Yes. So what we've learned about how doctors, emergency doctors think is we sort of have a after the initial look and the discussion, we have sort of four or five items that we've listed sort of in order of testability, treatability, and likelihood. So that's not necessarily in the order of likelihood, because let's say you potentially could have a rather uncommon, but treatable, lethal condition. Well, we want to find those. That's... And you have to be alert to that. We do. It's something that's really subtle. It needs to be part of the process. Now, having said that, those are the kinds of things we miss, which is life, unfortunately. But it is what our focus is. So we may look for something that's maybe there's only a 1% chance of it being present, but if it's treatable and bad, well, maybe that's the kind of thing we should look for. You really need to know about that. Yeah. And I actually want to also, I don't know if this is reassuring people. I think it is. We do not have certainty. Our ability to sort the probability. We have significant ability, and we have some new tools that help. But it's not perfect. It's differential diagnosis is another way of saying playing the odds. But in addition, our tests are not perfect. Differential diagnosis is when you have different possibilities, and you have to weigh and balance them. Yeah. So when I said you had four or five things you were kind of actively trying to establish to be the case or low likelihood of being the case. That's sort of your working differential diagnosis. And in the end, I'll say, you know, you had crushing chest pain, definitely a worrisome thing. But on the other hand, look, we found out that you have esophageitis, let's say, which is Yes. Yeah. A comparatively benign condition. Yeah. But there are certainly some bad things that that could have been. So we're making you happy. We're telling you don't have a heart attack. Good news for you. What I'm actually telling you is very low chance you have a heart attack and we have the tests we've done mean that you're down in the 1% range. And I could do way more tests and we wouldn't get any lower. So if it was me, I would stop. So you're talking about common sense. You're talking about, you know, finding the truth in a world of variables. That's our goal. And finding the probable truth. Probable truth. We call it shared decision making and it's a great concept and we need to do it. It's also tricky because I guess what I have to tell you is what am I thinking? What am I worried about? What are our options? Are you going to tell me this stuff? Are you going to say here's my differential possibilities? Yeah, it's awesome. Or are you going to wait until later when you know more? Well, it's an ongoing dialogue and of course I have half a dozen other patients. So I'm in and out. So as we get information, oh, your EKG's back. You know, you'll be glad to know it looks really good. That greatly lowers the chance of this being your heart. Who are you starting? It sounds like house. Remember house? So, you know, it's funny about house. I never saw a whole show, but I had more than one patient tell me, oh, you remind me of Dr. House. And I'm like, well, tell me about Dr. House. And they're like, oh, he's just a grumpy guy who lives around the ER stoned on Vicodin. And I'm like, oh, I don't know if I want to be reminded of Dr. House. First, we're not grumpy. Yeah, that's good. And I don't limp very often and no narks, but anyway. But I think that the nice thing about Dr. House, I saw it got kind of curious. I looked it up and he did talk with his patients and he did explore the differentials and kind of share the various possibilities and that's our job. What I get out of this though is that, you know, if I go to my Zorch doctor, that's an organ just between the kidney and the petunia. Got it. Do you have to fertilize it? I suppose. Yeah. And I say to my Zorch doctor, you know, my Zorch is bothering me, he's going to focus on my Zorch. Yep. He's not going to look at my left ear. Emergency room physicians, they look at the whole thing. Well, we hope we do. And so you've actually picked on a couple interesting things. The first is if you go to your Zorch doctor, you're absolutely right. That doctor is likely to focus on your Zorch. And it's pretty much guaranteed that that will be what gets worked up and treated. Now a good Zorch doctor could also notice your eyes are yellow. Oops, maybe it's not the Zorch. But still, you go to a specialist, you will get what that specialist does almost for sure. Right. Hopefully look at you in an undifferentiated manner. And that's why I said we certainly listen to the nurse. Let's hope he or she was right because it can be very helpful. It can also be a red herring. Oh, you know, oh, that guy, he was here yesterday. It was nothing. Well, you are back. That means whatever we did didn't work. So maybe we better start over again. Welcome back for step two. Yeah, exactly. So yeah, we attempt to diagnose and manage the beginnings of everything. So this comprehensive actually takes us to, you know, the medicine. And it seems to me that if you're looking at the whole person, you're looking at them, you're getting all these vital signs and readouts and taking tests all on a kind of stat basis, that means quick. Then you have to know a lot, okay? So the question is, post that special training residency and emergency medicine, how do emergency room doctors stay current because, you know, you'll agree with me, things move pretty quickly in medicine. There's a new, you know, invention, you know, like every day the medical journals are filled with new ideas, new possibilities, new obligations for physicians. How do you keep current on all these things? Well, as a friend of mine once said, the specialty literature is written in English. So you're right though, there's an enormous amount of information coming out all the time. Honestly, most of it is not practice changing. But you need to know that too, because you may have just heard about, oh, I don't know, the fact that they've done this sham study on stents. And guess what? For stable angina, that's people with chest pain, but it's pretty stable. Contrary to what we believe, stents don't help. Well, I need to know that. I don't do stents, but it could certainly be direct my referral, and it could also direct my conversation with you. So I have a variety of ways of keeping current, and they test us, as I told you, annually. The biggest method I use is I use a literature aggregator and reviewer. And so every morning in my inbox are, oh, I don't know, six or eight studies with a critique. I can obviously look up the real study if I choose to. And mostly I look at it and think, that's not practice changing, or I think, oh really, that's different from the pattern of the previous studies I've seen. We need to learn more about this. You don't want to be on the bleeding edge, and you don't want to be the last one to the party. Many of the bleeding edge things don't turn out to be progress, and some are harmful. On the other hand, you certainly want to adopt the things that are practice changing. You have to find your key. You do. And for emergency doctors, it's particularly difficult, because we cover the spectrum of specialties. But we all do some variant of what I just said. Well, so we're going forward now. Much more on medicine. We'll be doing next week, the week after and so forth. You'll host. I'm really looking forward to seeing the guests you bring in, doctors and otherwise, to explore medicine so people can understand those frontiers and which of these reports you know you take very seriously and which not as seriously. Lots of journals, lots of threads, lots of science. I love that. So my question to you actually, Craig, is how do you see this show going forward? How do you see it unfolding? Well, that's a really interesting question. And we need to visit about what kind of people we should bring in. And obviously, whoever that is will shape the individual show. I thought in general it would be nice to spend a small amount of time on what headlines I view as affecting health in the past week. And maybe a study or two that I think are interesting to share. And then I think depending on the guest, we will focus on pre-hospital care or health insurance. Well, health insurance is interesting. So a big headline over the weekend, you probably saw it, was that it's projected and in the next eight years premiums will double and in fact, looks like a little more than that because they were talking about $14,000 for an individual plan. So brings to mind Stein's law. Stein's law is something to the, he's an economist, something to the effect of things that won't last forever don't. So that is not going to, I don't know what's capped in health insurance premiums but if they double in the next eight years, something's going to blow up. That's going to affect health insurance, health and our society. Absolutely. And so we have to be mindful of all of that. And maybe that should be the focus of next week. It's honestly, it's a big deal. And the cost of medicine is going to be a recurrent theme because part of value is cost. And if we cost 18% of GDP, I don't think our value is as high as that. Certainly, most of the rest of the world spends half that and they do in many instances is better than we do. Very important question, you know, because ultimately it's life, it's health, it's our society and how we live. Yep. So it's a tremendous topic and I'm so glad you're embracing it. This will be an enjoyable experience. Thank you Craig. So looking forward. Craig Thomas, physician par excellence.