Emily Aaronson, MD: Designing Better Systems of Care

Q:  Dr. Emily Aaronson, emergency medicine physicians and associate chief quality officer at Mass General, believes that strong communication between patients and their care teams can greatly improve the quality of patient care. Particularly in the care of patients with serious illnesses, she knows that conversation is critical to ensuring that doctors fully understand their patients' unique values and goals in relation to their health. In her work, Emily has helped to lead Mass General's efforts to improve patient safety in every corner of the hospital. In addition to her work in quality and safety, she has spearheaded improvements in the quality of care for patients with serious illness in the emergency department. Most recently, during the peak of the COVID-19 pandemic, Emily was part of the core team responsible for the integration of palliative care in the emergency department. Emily believes that pairing the emergency and palliative specialties results in compassionate, thoughtful care that is tailored to the individual. 

So welcome, Emily. Thank you so much for being here today.

A:  Thank you for having me.

Q:  So I know that your role at Mass General is split between this administrative side focused on quality and safety and sort of this clinical side in emergency medicine. I'm wondering if we can start at the beginning, talking a little bit about your entry into medicine.

A:  I took a little bit of a circuitous path into medicine. I was not the pre-med that was slated for med school. And I actually started my career in healthcare consulting, and so, it was actually during that time that I was working in healthcare consulting and spent a lot of time with these often physician leaders, these healthcare administrators who had brought us on as consultants into their organization. 

And I remember distinctly working with a physician leader at one of the largest hospitals in the country and spending the morning with this leader, who would spend the morning with us really thinking about these large, complex problems throughout the system that he was leading and then would go, in the afternoon be providing direct bedside care to individual patients. And that was really the moment for me, where I thought, wow, you can do that for a living? Like, I didn't even know that was a job you could have. And that was really the impetus for me to really shift my career at that point and pursue a career in medicine.

Q:  What was the shift like from being a healthcare consultant to being a practitioner?

A:  I sort of started my career working in healthcare consulting for a firm that really partnered with some of the country's largest hospitals to help them think through some of their most vexing systems issues. And that exposure to the sort of complexity and that profound impact of both the healthcare system and the individual clinicians within it was really what drove me to want to make that shift. Always really envisioning my career as both serving patients individually as a physician, and then also collectively as a healthcare administrator. 

With all that said, I think the sort of toughest piece of that transition was really going from thinking almost exclusively about the systems that surround care and sort of all the ways that we can reengineer these systems to facilitate the provision of better care to becoming a med student, and then an intern and a resident, and recognizing just how little time in training – and frankly in clinical practice in general – is really dedicated to thinking about these really important issues. 

I actually, I remember, rounding on a patient as a med student and this was an older gentleman that had been on a blood-thinning medication called Coumadin. And he also had a really complicated medical history. And the result was that he had a handful of different specialists caring for him. On one occasion two of them wrote for his Coumadin prescription. And instead of recognizing the error, he got them both filled at the pharmacy. So, he ended up coming into the hospital after he started bleeding, which was really undoubtedly a result of this incredibly high Coumadin level. And so, we all stood around his bedside and spent, like, 45 minutes talking about the pharmacokinetics of Coumadin, about how it thins the blood, about the other medications it sort of interacts with. And then we talked a whole lot about his anemia and all the things about that that made us worry. And then at length about our options for reversing the bleeding. But we never talked about how the error happened. And we never talked about the drivers of the system problem that led to all of that, or even how to think about identifying them, and certainly not about how we would begin to think about solving them.

I was really struck by that, about how far the pendulum swung from, as a consultant, this sort of complete immersion in the system, to this really relative absence of it once I was on this side of medicine. And so, that was actually a big driver for me, to learn more about safety and quality and to really want to carve out a career in that space.

Q:  Can you talk a little bit more about healthcare systems and what that means.

A:  Yeah. So sort of the infrastructure that surrounds care. And so, all of the many different things which are carefully designed within the healthcare system, or within sort of the patient's experience of their care, that all contribute to the ultimate outcome. That can be everything from the electronic medical record, the way that that's set up, the flow and throughput through the hospital, the process from the time medications are ordered, how they're ordered, how there are doublechecked, through to the way they're delivered. I mean, it's really sort of every aspect of medicine outside of the clinical knowledge.

Q: I wonder if you maybe could talk a little bit more about your role. And it sounds like a lot of it might be educating people in the hospital. Maybe you could share a little bit more about the approach to quality and safety in the work that you do.

A:  So at MGH, I'm the associate chief quality officer, and so work within the Center for Quality and Safety. And within the Center, we touch on all different aspects of really quality and patient safety. And so, there is certainly a piece related to education, and that's education for our trainees, for all of our staff, our clinicians and all of our staff. But it's also a lot about analyzing errors, about trying to proactively identify where there may be potential fallibilities within the system, and how we can make the system safer, again, ways to sort of prevent errors from happening. Once an error happens, within the Center, we help facilitate the bringing together of teams to try to analyze errors, understand what the drivers were, what the causes of the errors were. And then come up with, hopefully, really airtight solutions that can help prevent them from ever happening again.

Q:  Yeah, I'm intrigued about the very first part, which is proactively identifying a potential error. What goes into identifying an error?

A:  There are so many different ways that we are able to identify where there may be the risk of errors. And so, one way is we actually have a safety reporting system where anybody in the hospital could open up our safety reporting system and put in a safety report. And a big piece of what we try to help people understand is that this reporting system is not just supposed to be used once an error has already occurred.

 It can be used for things like what we call near misses. So when you appreciate that, boy, that could have led to an error and it didn't, but it was really maybe just chance. And so there's something about that system that could probably be made better or stronger. And so, a lot of the proactive, sort of identification of risk comes from folks working on the front lines, who identify different areas, either processes or systems, that they let us know seem like high-risk areas.

Q: When you think back to when you first began the role and where you are now, what are the different sort of challenges or goals that you have now versus when you began?

A:  I think some of the challenges within patient safety and quality improvement within medicine are perennial and we are always working on. And some of them we've made huge strides in and have sort of, I think, phased the work out as other new, emerging risks have arrived. So you know, right now, I think there's a tremendous focus on improving outcomes for patients with sepsis and recognizing all of the different systems that we can create to help improve that care. 

So new ways to identify these patients early, to alert the whole care team to the fact that we're caring for a patient that has an illness where time really matters; figuring out how the dispensation of medications can happen quickly and in a really tailored way; making sure that all of the orders for the right diagnostic tests are ordered every time; when I started this work, sepsis, wasn't something that we were as focused on, and has become sort of this emerging area that we really recognize there's a huge opportunity to make a difference by just designing better, smarter systems.

Q:  Interesting. And I'd love to hear a little bit about how you've managed these quality and safety responsibilities along with the work that you're doing as an emergency medicine doctor.

A: I think they're actually really complementary. In my role as an emergency physician, I'm really sort of in the mix, seeing first hand where we are doing really well and the systems that we want to spread and where there may be opportunities for us to do better. And then I'm able to sort of bring that clinical perspective back to the Center for Quality and Safety as we try to understand the root causes of problems or design systems that have the clinicians that will be interacting with them in mind. And so, I think it's actually a really nice balance to be able to have a foot in both of those.

Q: I'd love to hear a little bit more about what your work as an emergency medicine physician entails.

A:  The beauty of emergency medicine in my mind is that every day looks completely different. We provide care in a very busy, fast-paced emergency department, one in which we sort of say, anything, any time, anywhere. 

Unlike many of my colleagues in the ambulatory space, I do not get to look at the list of patients that I will see at the beginning of the day. And so, you hear about the patients from the team that is leaving their shift and sort of understand who those patients are. Some patients arrived 15 minutes before you got there and are still very undifferentiated; some of them have been in the emergency department for several hours and are just waiting for tests or results.

Q:  I'm wondering, you know, if you could share more about what keeps you motivated, what keeps you energized in the work that you're doing?

A:  So I think really that opportunity to walk with people at time in their life of such intense need, and often really significant distress, just seems like such a sacred space that I really find so motivating. I think the idea that we can do what we can to alleviate their suffering through our diagnostic abilities, our facility with treatment and through our compassion. The ability to really be present with patients and families in the ER is, I think, so important and so impactful. 

Q:  Yeah. And you mentioned being present with your patients. I'm wondering, in the time that you've been doing this, is there a way that you've found really, effective for you in sort of carving out that time to be present with your patients?

A:  I think presence has been something that I personally worked on in all aspects of my life – in the emergency department and outside of it. And something that I think is a skill that we are all increasingly recognizing we can bring to these interactions and that they just have the potential to make a tremendous impact.

Q:  Can you tell me a little bit about how your work changed with COVID-19?

A: So it certainly changed a lot. I think the uncertainty though about exactly what we should be doing for these patients medically was really a huge piece of what was so different. 

I think we're really used to having a solid, broad base of medical knowledge, which we then overlay with these nuanced presentations of different patients and then ultimately come up with what we believe is the right treatment plan. But in this situation, the sort of medical knowledge hadn't been established yet. You know, is intubating these patients early best, or should we try to stave that off? Should we give steroids? Antivirals? Antibiotics? And there was just a lot we didn't know, and we didn't know it actually worked. 

Q: What was the approach to sort of filling in some of those gaps of understanding?

A:  So we had several different approaches. All of them hinged on just really close communication and a commitment to this rapid acquisition of knowledge as it became available as sort of quickly as we could. And so, we stood up a couple different forums for our group of emergency attendings to connect with each other, really several times a week, to share knowledge. And it was not the type of knowledge that we were used to really thinking about. 

You know, we're used to sharing knowledge from large, multisite studies with thousands of patients. But in this situation, we were really getting on the phone and just talking about, these are the four patients that I saw yesterday with severe COVID-19, and this is what happened, and this is how they did. And then we would all try to digest that information together, learn what we could, and keep moving forward. People would bring to those conversations anything that had been published in the literature, anything that we had learned from other sites, and really just trying to use what we ended up calling our sort of COVID case conference as the place where we could come together to be sure that everybody in the group was rapidly advancing their own knowledge as it became available.

Q:  That's incredible. That experience and that new type of collaboration, what was that like for you in the moment?

A:  I think there were aspects of it that were incredibly scary. I think the not knowing, although we are very used to working in environments with uncertainty, we were not used to having uncertainty about the actual knowledge related to diseases. And so, I think there were aspects of that that were a bit unsettling. I think the infrastructure that we were able to create within our group to come together really felt incredibly strengthening and I think really allowed us all to feel really connected and really supported as we went through it. So it was in some ways really empowering. 

Q:  And I know that you were part of the team that spearheaded the integration of palliative care in the emergency department. Can you tell me a little bit about how your team identified that need in the very beginning?

A:  Yeah, so this was a big undertaking and really, I think, in many ways, what I'm most proud of when I reflect on the work that we did in the ED during the peak of the pandemic. The idea of integrating palliative care into the ED is one that's been around for a while, but for sort of a whole variety of reasons we just hadn't been able to really figure out how to make it happen; really, no one in the country had cracked the nut on this. 

The premise of palliative care in the ED is that emergency clinicians providing care in crisis really just don't have the dedicated time and often the skill or training to provide palliative care in the ED. And yet, these patients arrive sometimes with underlying serious illness and often with acute life-threatening illness.

And the reflex is for us to really do everything. We treat intensely and intensively in a very time-pressured way. And the gap, of course, ends up being a clear understanding of what patients' goals and values are, and a recognition that two different patients arriving with the same disease may not make the same choices for their treatment based on their own goals and values. And so, with that all said, when the first wave of COVID patients arrived, there was really this like immediate recognition of the need to integrate palliative care into the ED and to do it really rapidly. The gap, I think, has always really been there, but was really highlighted as this volume of very sick patients arriving really increased. 

We were sort of able to create a model that embedded a palliative care provider into the ED where they were able to do that really critical work of making sure that patients and families had the space and time to really reflect on and communicate their goals and values, and then really be a bridge to the medical team to help us then construct a care plan that was tailored to reflect their wishes.

And the team, of course, ended up doing much more than that. They were providing support and information to families and to patients. They were supporting their spiritual needs, connecting them with resources to support that. They were tending to the mental and psychological health of patients and families. And during COVID, often, because of the visitor restrictions, we're also virtually connecting patients with their families. 

But the impact was just amazing. Ultimately, with palliative care in the ED, we could just feel so much more secure that the care we were providing was right by the patient. You know, when we were providing incredibly invasive, aggressive therapy, we feel more at ease that this is what patients wanted. And when we weren't, we could feel confident that it was because it wasn't what the patient wanted. It just all felt really patient-centered. 

Q:  So Emily, I'm just wondering, for anyone who might now know, if you could tell us what palliative care is.

A:  Sure. So palliative care is a specialty that really aims to relieve suffering in all stages of disease for patients with serious illness. And I think it's important to understand that it is not limited to end-of-life care. It can really be offered to patients at any time along the trajectory of any type of serious illness. And patients can be engaged in palliative care at the same time that they're pursuing curative treatment. And so, it's really aiming to sort of improve the quality of life providing emotional, spiritual, physical, social support and to think about trying to really effectively manage patient symptoms.

Q:  And you had mentioned earlier that this had been a tough nut to crack historically. 

Can you talk a little bit about the challenges and the barriers of integrating palliative care in the emergency department?

A:  Yeah, so this had been something that people had been sort of opining about for over a decade across the country, and again, nobody had really been able to figure out how to do it. And I think it's because although there were some people that had this hypothesis that these two things really did live naturally together, there were lots of people that weren't fully bought in to the idea yet. 

And I think I get it; I think from the outside looking in to a hectic, chaotic, fast-paced emergency department, where people are in critical distress, and then trying to understand how a specialty like palliative care that really tries to create space and time for thoughtful conversations about these really important issues, like how those two could live together I think was really challenging for people to envision. And it wasn't until we were at this place where we thought, you know, we've just got to give it a try, that we were able to sort of do this experiment and coming away from it realize that actually these two specialties are a perfect marriage and in so many ways really belong together.

When I think about the patients that specifically were affected by this, you know, one that really stays with me was this much older patient – she was in her late 90s – who came in quite sick from COVID. And she was still quite engaged when she arrived and palliative care was able to have this lengthy discussion with her about what mattered to her most. 

And she was really, like, crystal clear about what she wanted, which was a peaceful passing without any invasive therapies. She did not want to be intubated. She didn't want chest compressions. She was really focused on peace and comfort. And she was clear that she had thought about that a lot, but she was also clear that she hadn't really discussed it with her family or any other doctors. 

And you know, it was interesting. When the family was called, they were really clear that she was a fighter and they thought that she would want everything done. And palliative care was able to close the gap between the two. And within a few hours of arriving in the ED, her breathing started to deteriorate and she became quite confused. And by the time she went to the medical floor, there's no way she would have been able to participate in a conversation like that. 

And it was just so powerful for us to feel like we were able to do right by this patient by focusing on making her comfortable and by focusing on her peace at the end of life. Which was the word she kept using. And then supporting her family to really understand that these were her wishes. 

I think if that conversation hadn't happened in the ED, the team upstairs would have had probably very little choice but to lean on the family for the patient's wishes. And she would have had a very different end-of-life experience, one that I think really wasn't aligned with her goals.

Q:  That's really interesting to think about that disconnect sometimes between what a family thinks their loved one might want and what the loved one actually wants. 

A: I think that many of us over the decade that we've been talking about this anticipated it being a lot more of a struggle. But I think we were just so struck when this started happening at just how appreciative and grateful and excited the emergency medicine team was to have this be a part of the care that they were able to provide. 

I think that everybody really understands that this is higher quality care, and so to feel like we could provide that, even with all of the environmental challenges of the emergency department, even with the chaos and with, you know, the tremendous number of patients coming through the door and the very high acuity, the fact that because we had this additional team member who only had that of their focus, allowed everybody to feel like we were able to give better care. 

Q:  And has this been a permanent change? Or how is this carrying forward?

A:  So we're now in the process of figuring out that very, you know, that very challenging piece around sustainability. And so, the model that we had at the peak of the COVID surge isn't one that we were able to sustain. We had two physicians, palliative care physicians embedded in the emergency department for 12-plus hours a day, but we are really excited that what we've been able to do is try to distill the learning from the experience and then create a model that we can sustain. And so, we're very close to launching an embedded palliative care provider back into the emergency department during our peak hours to begin this work again in earnest. 

Q:  So we've talked a lot about the fast-paced environment of the ER, having to make quick decisions. It sounds like it can at times be quite a lot. How do you manage your own personal wellness?

A:  Yeah, so I lean a lot on family and friends. I have two young daughters; I have a one-year-old and a three-year-old. And am very lucky to have just a super supportive spouse. And so, I really try hard to leave work at work and come home and be present. I find the ability to leave my phone at the front door and just be really present with all of the silliness that they bring just really restorative and really helps contribute to my own wellness.

And it's not easy, of course, and so I also have made a really dedicated effort to sort of work on that skill. I have a daily meditation practice that's really important to me, and a yoga practice that I've leaned on for years as a source of wellness. But I've really come to understand that things like being present are really a skill, and I think like any other, I really have to practice them if I want to keep it current and keep it sharp.

Q:  So and one thing that I wanted to ask, you'd mentioned earlier that, you know, the privilege of what you're able to do and how that impacts you. Can you talk about how maybe your work, whether it's in recent experiences during COVID or just in general, has really influenced your own outlook on life.

A: I think there's no question that being an emergency physician, you are very acutely aware of your own mortality.

And so many of the things we see, you feel, when you, you know, meet these patients and are a part of these care teams, that it is just luck, that it, that you are not in that situation; I think the sort of "by the grace of God go I," is one that's sort of a refrain that I think many of us feel very connected to in that specialty. And so I think that, you know, as much as we can, try to carry that sense with us closely in all that we do to try to live as well as we can, feels real.

Q:  Great. Thank you so much, Emily. This was wonderful. I really appreciate your time. Typically at the end of every episode I love to ask our guests a few questions that are the same for everybody. 

Q:  So thank you so much, Emily. It was, it's so wonderful to have you. 

A:  Thanks so much for having me.

Q:  Okay, my first question: What's the best advice you've ever gotten?

A:  One good piece of advice I got related to academics and training, was early on as an undergrad when I came home for Thanksgiving and I was talking to a family friend about how much I was enjoying my art history classes.

And she said, "Well, have you thought about majoring in art history?" And I said, "Well, no, that's ridiculous, you know, I don't plan to be an art historian, I'm not going to have a job in a gallery. I really want to go into strategy consulting. Why would I do that?" And she said that, "You know, look, you have the rest of your life to learn the business of whatever business it is you are going to do, or the content of whatever it is you are going to do. 

But that at this early stage in your education, find something that is interesting to you that can be a lifelong hobby and passion, and that it will so enrich your life, which will otherwise be so focused on something entirely different that you will be better off for having that balance." 

Q:  That's great. My next question, and you mentioned this a little bit earlier, but what rituals help you have a successful day?

A:  So yeah, we did talk a little bit about that I have a morning meditation practice and a very brief morning yoga practice. And I think more recently, you know, when I think about rituals, a neat one that I've learned from the Benson-Henry Institute is when they talk about trying to sort of center in a moment to sort of bring yourself into being present. 

And so, they taught this method of when you go to Cal Stat your hands, just take one focused breath; like, in through the nose, out through the mouth. And I have found that has become a ritual for me as I go into a patient room to really, as ridiculous as it sounds, be present with the Cal Stat, to really sort of Cal Stat my hands and take that opportunity to just come back to this moment to then enter the room. And that's a ritual that I've really appreciated.

Q:  That's great advice, and a great ritual. Two in one. If you weren't a doctor, what would you be?

A: We are famous in emergency medicine for being the people that like every single specialty during med school, couldn't decide, and so ended up in emergency medicine. And I think with careers I'm sort of the same. I'm like, what would I be? There's so many things I want to be! I want to have a bakery. I'd love to run a yoga studio. I could have a gallery. Right, I mean, the list goes on. So I think the emergency medicine provider in me probably acknowledges there are a lot of different things I would love to do.

Q:  You're speaking my language. I love it. That's great. What advice would you give to your younger self?

A: So I think that the advice that I would give my younger self would probably be to just lean in to mentorship.

A: If you meet somebody that you think is inspiring, that you think is impressive, that you think you can learn from, reach out to them and try to glean whatever wisdom you can from everybody around you. 

Q:  What's the best decision that you've ever made?

A: I think the best decision for me personally has been related to having a family. It wasn't something I was always that excited about. I wasn't honestly all that sure I wanted kids, and now I have two little ones and I'm like so pleasantly surprised by the experience. 

Q:  Do you have any guilty pleasures?

A:  Everything bagel, plain cream cheese, and a tomato. The best! 

Q:  Classic, I love it.

A:  So good.

Q: So thank you so much, Emily, for being here today. 

A:  Thanks so much for having me.