Breaking the Partnership Barrier

Getting the Most Out of Academic-Industry Collaborations

“The real world” versus “the ivory tower.” “Town” versus “gown.” “Applied” research versus “pure.” There are a lot of names for the gap between the academic researchers in a discipline and the practitioners who work in the field, and almost all of them reflect the distrust and even animosity that can exist between these two groups.

As many fields move toward “evidence-based” practice in one form or another, however, both sides are making increasing attempts to narrow that gap. One of the most effective methods is to build collaborations between researchers and practitioners—but even with the best of intentions, mismatched objectives, unclear expectations, and a host of other problems lead most of these collaborations to fall short of their goals. In some cases, they actually widen the breach.

Fortunately, recent studies of such collaborations indicate that there are a few ways to help increase the likelihood of their success—and reduce the chances that your carefully-developed research partnership will devolve into a screaming match over intellectual property, applications of the findings, or the order of the authors’ names on the final report.

Why Collaborate?

Given the inherent philosophical and cultural differences between university researchers and field practitioners, what reasons are there for attempting to build collaborations in the first place?

Very briefly, there are at least two: theory testing and research uptake.

Theory testing is a benefit primarily for the researchers. While it is certainly possible to develop viable, logical, and relevant theories using data alone, proper interpretation of that data often requires practical experience from the field.

For example, if you were studying the importance of officer communication in barricaded suspect situations, you could develop useful theories and new communicative approaches just by listening to recordings of officer interactions. Without the input of officers themselves, however, your interpretation of those interactions could be skewed. What the researcher hears as an interruption, the officer might point out was actually just a technical problem—the second officer’s radio didn’t pick up the first officer’s message. Without the field context, in other words, many theories cannot be fully validated.

On the other side, research uptake is a benefit primarily for practitioners in the field. Research uptake refers to the extent to which practitioners actually use—bring into their daily work—new ideas and understandings developed by researchers. This is an area that lags in almost every field, from management to medicine, with one medical researcher finding that it takes as much as 17 years for new practices to be adopted by doctors and surgeons.

If practitioners want to improve what they do and to make use of the most up-to-date knowledge about their field, they must be informed about that new knowledge and its benefits to themselves and those they serve. Research collaborations have been shown to improve this kind of research uptake significantly.

How to Make it Work

Although our understanding of what really goes on within any individual research collaboration is necessarily limited, a number of recent studies have shown that there are a few things researchers and practitioners can do to make their collaborations successful.

1—Set Clear Expectations

Perhaps the most important thing to do before the collaboration gets underway is to clearly outline what each side wants from the experience. One study, for example, found that while researchers are most interested in getting published papers, practitioners were most interested in seeing physical or organizational changes (new technologies, better management structures, etc.). In other words, academics tend to see the research as an end in itself, while practitioners want to go a step further and see the results implemented or applied in some way.

Understanding what each side wants or needs, and setting specific goals to achieve at least some of everyone’s expectations, can help guide the collaboration to success and head off the inevitable arguments that will result if one side is seen to be benefiting at the expense of the other.

2—Be Explicit About Value

Collaborations sometimes end in fights and even lawsuits, but more often they simply wane. Busy schedules, unclear goals, and competing projects all contribute to this. The antidote to this kind of slow death by neglect is to explicitly set out, in terms that matter to all the parties involved, the value of the project and the value of each participant.

Consider the example of the study to improve officer communications at high-intensity crime scenes. What is the value of the project overall—and what is its value for each of the stakeholders involved? Clearly, improved officer communication could lead to improved officer safety and more efficient scene operations: that’s the value for the officers. These improvements could in turn lead to better outcomes for victims and, potentially, higher apprehension rates or lower property damage costs: that’s a value not only for officers but for the community. Furthermore, this research could lead to a better overall understanding of communication problems in high-stakes, high-emotion situations: a benefit for the communication researchers.

In addition to this high-level value description, also make sure you lay out the value of each participant. Otherwise, each group may begin to feel that they don’t need the others and can go back to working alone. In our example, the researchers should be given a brief introduction to the work the officers do, their experiential understanding of their own communications practices, and what they can bring to the data collection and analysis portion of the research. On the flip side, officers should be trained on the background of the research, the potential benefits to themselves, and the already-existing studies that show how improved communication can improve officer safety.

3—Build Goal-Oriented Teams

One of the main reasons many researcher-practitioner collaborations fail is that their make-up is ambiguous, shifting, or too broad.
Imagine a researcher wanted a better understanding of the effects of shift work on employee sleep cycles. In many cases, the researcher contacts an agency and gains approval to do the research. Then what? Who is in charge? Does the researcher work directly with the employees, or through a supervisor? Will the researcher have one point of contact in the agency, or will she simply deal with whoever is there when she shows up—even if that person has never been informed about the research in the first place?

The better approach is for one or more researchers to establish a research team, including one or more supervisory personnel and one or more line-level personnel. This team will decide on the expectations together, inform other personnel about the research and its purpose, and conduct the study. All communications about the research will go through this team, and decisions will be made by them, jointly. If this central team can be kept to five or six persons, all the better.

Build Your Own

Of course we can only scratch the surface of researcher-practitioner collaborations here. The key point is this: research benefits from practitioner involvement, practice benefits from research—and both benefit when “the ivory tower” and “the real world” meet in the middle. So reach out and make a research connection today!

 

I Heart Research. But Why?

A few weeks ago, I requested from our design department, as a give-away for our conference booth, pins that read, “I {heart} research.” I thought they’d be a little trendy, a little offbeat for a research organization—a little fun. What I didn’t expect was the response I got from the designers.

“You love research? Why?”

They didn’t understand why a person would love research—much less admit to it. On the spur of the moment, I’m afraid I didn’t give a terribly coherent answer. In fact, I was taken aback. Why would you not love research?

Thinking about it over the next few days, I realized that in that moment of disconnect, there was a possibility for greater understanding. Why do we love research? What’s so great about it? What keeps some of us coming back to it again and again, whether it’s part of our job description or not? What do we see in all those “numbers and data,” as one designer put it?

I’d like to take this opportunity to answer some of those questions and hopefully explain what there is to love about research—and how you can love it, too.

Pushing the Edge

Probably the most exciting, “lovable” thing about research is the feeling that you’re working on the very edge of human knowledge. It’s true that some research questions are edgier than others, but in any good research project, you should be answering a question we don’t yet know the answer to.

Imagine this: you are sitting in a lab, or in your office, or at a computer in your den, and you realize something. You realize you have just discovered an event, a tiny event but an event nonetheless, that simply cannot be explained by any existing theory. You, alone in the entire world or perhaps together with a few colleagues, know something that no one else in the world knows.

Then comes the task of proving your idea, of putting it to test after test, and then demonstrating those proofs to others so that they are compelled to see what you’ve seen.

Perhaps as little as five percent of a working researcher’s life is made up of these moments, but they are worth the years of work it takes to achieve them. It may be that no one outside your field will ever even hear of your discovery, but you will know that you have moved human knowledge forward a vital half-inch. That is an awe-inspiring feeling.

Efficiency, Efficiency, Efficiency

Another reason to love research is that it offers one way to have confidence in your actions and to find out how to do them better.

What is the best way to identify over the phone whether a patient is having a heart attack? How can we best manage the communication center so that calltakers and dispatchers are at their best when calls for help come in? What placements of equipment and personnel around a particular geographical area reduce response times most? These are questions that we can best answer by doing the research—gathering data, analyzing it, and changing our actions accordingly.

If pushing the edge of human knowledge is the best reason for loving “basic” research (research that attempts to answer fundamental questions about what the world is really like), then achieving better, more efficient results is the best reason for loving “applied” research (research that helps us understand the world so that we can alter it).

Need To Know

All this aside, though, the reason most of us who do research get into it, and stay with it, is that we simply need to know. In many cases, this applies not only to our work but to our lives as well.

If we want to lose weight, we need to know everything that has been learned about nutrition, exercise, short term and long term weight loss outcomes, and anything else we can find out about the science behind the body’s reactions to food and movement.

If we are going to buy a house, we need to know every possible type of mortgage, every type of home construction, the ups and downs of the housing market over various time periods, the growth potential of the area, the low-down on termites and asbestos and mold.

The same is true in our research work. If we encounter a situation in which we don’t know the answer—or, even better, in which the answer isn’t known—we must find out.

And that, in a nutshell, is why we heart research. Because we need to know.

You Can, Too

If you see something of yourself in any of these descriptions, then you, too, are a researcher or a potential researcher. What is it that you need to know? How are you going to find out?

What better time than now?

The Common Frontier

Managing Conflict in the Comm Center

While there are some among us who seem to thrive on conflict, they are (fortunately) few and far between.

On the other hand, comm centers—and emergency services more generally—tend to attract hard-charging, ambitious, high-energy, “type A” personalities. Add to that the stress and emotion of the job and long hours, and you’ve got a recipe for explosions.

Conflict drains energy from your real work.

Although they may seem very different, comm center personnel and research scientists have this in common. A single lab may be home to dozens of highly-ambitious, stressed-out scientists and graduate students, all of whom are competing for limited and dwindling resources. Some are obsessively dedicated to their work, while others are burnt-out and cynical.

Sound familiar?

In both cases, conflict is inevitable. The question is, how can we deal with interpersonal conflicts in these high-pressure environments without damaging the work that is important to us or the people we are there to help?

What Doesn’t Work

According to Managing Scientists: Leadership Strategies in Scientific Research, there are four typical responses to conflict. Of these, three have limited value.

Avoidance is self-explanatory: those who respond to conflict by avoiding it simply refuse to deal with either the conflict itself or with the issues or people that caused it. As the authors of Managing Scientists put it, “The problem with avoidance is simple: ‘Avoiding a conflict neither effectively resolves it nor eliminates it.’” In other words, you can only avoid a conflict for so long; eventually, it will blow up in your face.

Smoothing is an approach in which a person “minimizes the differences between individuals or groups and emphasizes the commonalities.” This can be useful “if the issue is minor,” or if the people involve generally get along very well. If the issues are important, though—especially if they involve seniority, shift selection, processes and procedures, rules, or hierarchies—smoothing is really just another method of avoiding the conflict by pretending the issues aren’t as serious as they are.

Finally, compromise can be effective, but less often than you might think. In a compromise, “each party gives up something or shares a resource equally.” The problem here is that a compromise is often not ideal for any of the parties involved, meaning that the same questions and issues are likely to come up again—and again, and again—until a real decision about the relative merits of each side is made.

Bringing Heads Together

What has been found to work is confrontation. This may come as a surprise, since many of us think of confrontation as synonymous with battles, clashes, and other forms of fighting. Yet as the Managing Scientists authors point out, the term is derived from “the old French term for sharing a common frontier.” Other sources cite the origin of the term as referring to adjoining territories or look back to the original Latin word, which combined com (“together”) and frontem (“forehead”)—so that “confrontation” essentially refers to bringing heads together.

In this early sense, confrontation is about sitting face to face—fronting each other.

More specifically, you may want to try to use confrontation to determine or achieve superordinate goals, or the “’common set of goals and objectives that can’t be attained without the cooperation of the [parties] involved.’” The best way to deal with conflict, in other words, is to try to determine what it is that cannot be done by one person or group acting alone.

In the comm center, this means keeping the focus on (and perhaps reminding the feuding parties about) what’s important about what you do—serving the public—and why no one person can do it alone. That can make a good starting point to confront the issues under dispute and how to resolve them, not only for the people involved, but for the good of the larger mission.

Find the Common Frontier

The concept of the “common frontier” can also be useful in a directly practical way. Think about two people having a fight. The tension and energy are directed at one another, escalating and being reinforced by the direct interaction. That’s why we call it “facing off.”

What frontiers can we reach if we work in common?

If the fighters’ attention can be directed to something else, even for a short period, the tension often dissipates.

The same is true of professional conflicts. The people involved become so focused on the conflict and each other that they lose sight of everything else. Simply redirecting their attention, especially toward something that they have in common (such as the larger goal of the center or of emergency services), can allow them to redirect their energies. It may also give them an excuse to “back out” of the fight without losing face.

How about you? How do you deal with conflict? What can you do to turn conflict into confrontation in your center and realign your people to your common frontier?

Managing Disaster: The Dispatcher and Emergent Response Groups

Over the holiday vacation, one of the things I did was catch up on reading. I had a pile of books on my bedside table that I’d been meaning to read for ages, and I finally got to most of them. One of the best was Erik Auf der Heide’s classic Disaster Response: Principles of Preparation and Coordination. From his insightful analysis of some of the largest disasters in American history to his still-relevant suggestions for improvement in the disaster planning process, Auf der Heide’s book is definitely worth reading.

What I noticed as I read, though, was the almost total absence of references to dispatch and communications. Auf der Heide does discuss inter-agency communications, communication with the media, and communication with the public, but of the dispatchers—the glue that holds a disaster response together—he says almost nothing.

Disasters can require new roles and responsibilities from dispatchers.

This omission is all too typical of the many books and articles I’ve read on disaster response, planning, and preparation. Dispatchers are seldom mentioned, and when they are it’s mostly in the context of something that’s “also important,” a side note. I’d like to expand on the whole complex role of dispatch in disaster response, but that’s a book, not a blog post. So instead, I thought I’d reflect on a concept that’s growing in acceptance in the disaster planning community—the “emergent response group”—and the role dispatch can play in forming and managing such groups.

Unlike the pre-planned teams we often think of when we imagine disaster response (such as EMS teams of ambulances and fire trucks or hospital teams of nurses and doctors), emergent response groups are teams that form on the spur of the moment in response to specific needs.

For example, just after Hurricane Katrina, civilian boat owners stepped forward to rescue those stranded by the flood waters because the Coast Guard was overwhelmed with requests for help. In other disasters, local volunteers have formed emergent response groups to care for stranded pets until their owners could claim them, offer housing to displaced victims, or provide First Aid.

These groups are different from typical, pre-planned teams in a few ways. They’ve never worked together before and are often total strangers. They don’t know each other’s strengths, weaknesses, and areas of expertise. They have not had the chance to build trust or rapport. At the same time, they don’t plan to work together long; they come together to solve a specific problem or achieve a particular task, and when that’s done, they disband. (Learn more about emergent response groups here.)

Dispatchers could help organize and manage impromptu groups of volunteers.

So what is the dispatcher’s role in such groups? If you have worked in emergency communications for any period of time, you can probably guess: the dispatcher may be called upon to act as manager, director, or coordinator for such teams, perhaps at just those moments when the communication center is already at its absolute busiest.

Dispatchers are obvious candidates for this role. From the console in the communication center, the dispatcher has a high-level view of the disaster. The calls coming in help her see where victims are, while reports from police and ambulance responders let her know where the worst-hit areas are or where particular kinds of help are needed. This information is often not available to spontaneous, usually volunteer emergent teams, but if made available by the dispatcher, it could help direct such teams to where their skills and energy will be of most use.

In addition, dispatchers are experienced in managing teams from a distance, visualizing an emergency or disaster scene and allocating resources where they’re needed. This is important even when dealing with pre-planned teams of responders who have worked together for years, trust each other, and know each other’s plans. For emergent teams that don’t have these advantages, dispatch can provide an even more valuable service—organizing a spontaneous grouping of a few people who want to help into a unit with a clear goal, access to needed resources and information, and a de facto leader.

What amazes me most, in fact, about the many articles that discuss the concept of emergent response groups, is how few of them even mention dispatch. Here is a large organization of trained professionals with a high-level view of the situation, experience managing emergency scenes from off-site, and the ability to direct services and volunteers where needed, and yet almost no one thinks of using them.

So what can be done? Next time your agency, city, or medical control gets together to discuss disaster response planning, speak up! Let administrators know what a valuable resource they have in their dispatchers. And if possible, ask for dispatch to be included not only in the planning process but in the training.

Emergent response groups are made up of willing volunteers from the community—people with skills, resources, and energy and the desire to use them to help others. Dispatch could support this huge potential work force and put it to its best use. For the best outcome, though, dispatchers need to be prepped and trained, so get yourself a seat at that planning table. If the moment comes when your community is in crisis, such preparation may well mean lives saved.

War Stories: What Are They Good For?

It’s a proud tradition in EMS and public safety, the war story. The really good ones don’t need to be embellished, but some of the best are those that have grown increasingly impossible over years of telling and retelling. Some are gory; others are heartwarming. Many involve the kind of gallows humor that keeps paramedics, surgeons, and police officers able to face their jobs every day but makes the uninitiated turn white and go quiet. I am one of those, I admit, who gets a little queasy when the talk turns to spurting aortas and impaled torsos.

In fact, it was my own somewhat reluctant fascination with the war stories of coworkers who have been on the front lines that made me want to find out—why are they so popular? What are they good for? Do we really need them, or do they just satisfy the morbid curiosity of the listener and the macho pride of the teller?

It’s a tough job–someone’s got to talk about it!

A number of writers in the EMS world have tackled this question in the past few years. Mike Rubin takes a humorous approach in his not-to-be-missed blog post, “How to Tell a Good War Story,” while Carl J. Post, a professor at New York Medical College and EMS historian, takes on the question of historical narrative and what it tells us about ourselves. The blog Medic Madness, meanwhile, takes old-school back-room boasting public, providing a forum for all the goriest, funniest, and most revealing EMS stories its writer, Sean Eddy, can put on the page.

But what does EMS get from all this story-telling? Some claim that the purpose of a good war story is educational, that it’s a way to prepare the “new guy” or “new gal” for life in a difficult and sometimes terrifying job. It’s hard to know, though, exactly what the newbies are supposed to be learning from such stories—except how to tell a few of their own, that is. I think there’s actually more to it than that. What public safety and emergency medicine people get out of a good war story is recognition.

Not Exactly Millionaire Celebrities

The reality of EMS is that, no matter how vital to the community, it tends to be invisible except when there’s a problem. Most people’s interaction with emergency responders on any given day is likely to be a grumbled complaint about getting out of the way while a fire engine runs through a red light. And unfortunately, most citizens don’t hear about the work of EMS until there’s a lawsuit. Add all that to the fact that EMS isn’t exactly making anyone a millionaire, and you can understand why there can be a feeling among some emergency personnel that they are not being appropriately recognized for their hard, sometimes boring, sometimes dangerous work.

Of course, that goes double for dispatchers, who often feel overlooked even within their own agencies.

A war story is a way to push back against that invisibility, to get some credit for what they do. Even the grossed-out or shocked look on a listener’s face can feel like a recognition that the work you’re doing is hard, that it’s not something just anyone can do. That goes a long way to making the long shifts of saving lives invisibly, behind the scenes, often in unpleasant circumstances.

As Benjamin Gilmour puts it in his new book Paramedico (essentially one long string of international war stories—and really good ones at that), he wrote the book not so much to talk about the “sick and injured” as to bring the spotlight onto the ambulance workers he’s worked with, “the men and women who have remained a mystery to the world for long enough.” A good war story, in other words, is a (semi-) acceptable way to make your work a little less of a mystery, to get the spotlight on it for a moment.

Dying to Help

There’s another, slightly touchier, aspect to the war story as well. EMS workers—including dispatchers—tend to be dedicated, often “type-A” individuals. They work odd, often changing shifts. They see bad things and enter stressful situations, then sit for hours waiting for something to happen. It’s no surprise that the heart attack, chronic illness, mental health, and addiction statistics for emergency workers can be so abysmal. And that’s not including the inherent dangers of the job, especially emergency vehicle accidents.

In the past decade or so, the resources available to EMS workers and dispatchers, and the level of acceptance for actually using those services, have increased substantially. This is great news. Stress debriefings, support and therapy, and other official means of addressing the mental and physical challenges of the job are critically important.

But the war story has something to offer here, as well. We all know the feeling: something terrible has happened, or you’ve seen something gross, and you must tell someone about it or burst. It doesn’t matter whether the other person wants to hear; you have to tell. The war story functions in this way, giving emergency responders a way to talk about and decompress from difficult and terrible scenes.

I know that some of you will scoff at this. Many want to be seen as asbestos-coated, impervious to the stresses and dangers of their work. That’s fine. In fact, that’s precisely why the war story works sometimes when therapy won’t. The telling of a war story doesn’t force you to be vulnerable or talk about how you feel. The teller gets to maintain, or even boost, that sense of power and imperviousness that keeps him or her going, while still getting the benefits of sharing and validation.

And So Much More

These are really just a couple of the many ways war stories function in a high-stress occupation like emergency response. And what do I know? I’ve never done the job—just talked to a lot of people who have.

That’s why I’d love to hear from you. Join the conversation below and let us know: what is the real purpose of war stories? Do you tell them? What do they do for you?

Investigation vs. Instinct: The Role of Evidence-Based Practice in Emergency Dispatch

You don’t have to be a professor to make good use of research.

A dispatcher’s job is incredibly complex. Most dispatchers are constantly doing at least five things at the same time: answering phones and gathering information about what’s happening on the scene, tracking units through both linear time-sequence software and two-dimensional maps, communicating with responders via the radio, keeping track of hold times for non-emergency calls, and simultaneously ignoring and keeping an ear open to the sounds of the dispatch center itself. And that doesn’t even include the split-second decisions they have to make at every turn.

It’s no wonder that so much of the dispatcher’s work relies on instinct—the tacit knowledge built up through years of experience.

At the same time, it’s pretty clear that it would be inefficient and costly to expect every dispatcher to start from scratch and learn the profession through the painstaking work of experience. Moreover, it’s possible for even the most experienced professional in any field to develop some bad habits as well as many effective ones—and there are some interactions that need to go right the first time, such as dealing with an abuse victim who is trying to communicate with the dispatcher without letting her abuser know what’s going on. Finally, we all know that some of the things we say are based on experience are actually just based on tradition—doing things the way we’ve always done them.

For these reasons, the experience that guides dispatchers and administrators in so many situations needs to be supplemented and supported with research.

What is Evidence-Based Practice?

Evidence-based practice got its start in medicine when clinicians and researchers began to insist that treatments should not only work—have some positive effect on patient outcomes—but actually be demonstrated to work.

The same concept has been extended to many other fields. Teachers, for example, study their teaching practices to determine what actually helps students learn. Businesses conduct internal research to find out the best ways to locate and support talented employees. Sports trainers incorporate research in anatomy, nutrition, and biology to improve their athletes’ performance.

In this larger context, the definition of evidence-based practice has expanded as well. Rather than referring only to patient outcomes or treatment types, evidence-based practice now refers to any process of incorporating scientific evidence into everyday practice.
In short, evidence-based practice brings together three things: scientific evidence generated by researchers, expert knowledge based on experience, and user and customer perspectives.

Combining these three things effectively is not always easy, but doing so can help ensure that our practice meets both the current standards in the field and the expectations of those we serve. (You can find more detailed information and definitions here, here, and here.)

Evidence-Based Practice at Dispatch

Emergency dispatching has been moving toward evidence-based practice for the past thirty years, but progress is still slow and piecemeal. There are several reasons for this: the scientific research itself has been lacking, dispatchers and administrators are not likely to read the research, and administrative and political realities sometimes make adopting new practices difficult.

I’m not going to go into all three of these issues here. Instead, I’m going to leave you with a claim and a challenge.

The claim is this: incorporating some element of evidence-based practice into your work as a dispatcher or administrator (or, even better, into the running of your agency as a whole) can improve job satisfaction, customer service, and situation outcomes. Staying aware of the most recent research in your field and adopting best practices certainly aids in these outcomes, and conducting your own research studies and sharing your findings with others may do so even more.

And so we come to the challenge: make evidence-based practice part of your work, in some small way, starting today.

Find and read some of the increasingly available research on dispatching, telephone triage, next-gen 911, communications center administration, business management, policing, fire operations, emergency medicine, or whatever other field is relevant to your agency. Challenge yourself to change a bad phone habit based on research about customer service and patient outcomes. Start your own small research study to find out the causes of turnover in your agency or areas of confusion in your center. Do something to start integrating your years of experience with evidence that can support and refine your practice.

Challenge yourself to do this for a few weeks, and you’ll find areas of interest in your work that you didn’t even know existed—and perhaps improve the vital services you provide to your community in the process.

Increased Health Literacy Reduces ED Visits—Except When it Doesn’t

Health literacy is generally considered to have two components: the ability understand health information and the ability to use that information to make good decisions about your own health (see here and here for definitions). Health literacy has been found to be a key indicator of all kinds of healthy behaviors, including eating nutritious foods, exercising, and scheduling regular physicals. It just makes sense that higher health literacy would also have some impact on whether patients end up in the emergency room or ambulance.

Interestingly, though, there appears to be something of a paradox in the relationship between health literacy and emergency services use. Health literacy appears to significantly reduce the number of potentially preventable hospital admissions and overall use of emergency services–except when it does the exact opposite.

More Health Literacy, More Health

One of the most consistent findings about the relationship between health literacy and emergency services or emergency department use is that limited health literacy leads to fewer doctor visits, which in the end translates to more “potentially preventable hospital admissions,” as one study put it. It makes sense: if you go to the doctor less often, you’re less likely to catch chronic or terminal diseases in their early stages. Diabetes, cancer, and heart disease–three of the biggest killers in all Western countries–are much more likely to require emergency care if not properly managed through regular doctor visits.

Overall, those with lower health literacy have also been found to have higher risk of death, according to the U.S. Agency for Healthcare Research and Quality (AHRQ). Those with low health literacy have difficulty reading medication labels, are less likely to get screened for major diseases, and are less likely to seek out preventive interventions such as flu shots. Compounding the issue is that minorities and those in poverty, groups with poorer health outcomes on average, tend to have lower health literacy as well (although of course this is not universal).

Fortunately, a number of programs exist to help patients improve their health literacy, even in the ED. One such program, for example, educated parents who came to the ED about mild health complaints and where to take their children first when they got sick. The program was highly effective, reducing the study group’s visits to the ED by 30% (an outcome that not only reduces ED overcrowding but saves the parents money as well).

Except . . .

At least one study, though, has found that some education programs can have exactly the opposite effect. The Keep Well at Home Project, initiated in West London, screened older adults and provided them with at-home care and health education to reduce hospital admissions—an intervention that makes total intuitive sense.

What happened? “There was an increase of 51%” in emergency admissions among patients involved in the program. As the authors put it in a wonderful phrasing, “the KWAH Project reveals that there can be a major gap between what seems to be a sensible national initiative and what actually occurs when attempts are made to apply the policy.”

Why?

To be fair, the KWAH Project may have done its patients more good than if it had reduced their emergency admissions as planned. The screening may well have identified serious problems that would otherwise have gone unnoticed or helped patients better recognized changes in their own symptoms. The outcomes of their hospital visits aren’t known, so it’s hard to tell whether those visits were necessary.

What is important to remember about all of these studies, though, is that the effects of educational interventions to change health behaviors—especially the often rushed, emotional choices that patients make about seeking emergency care—are not straightforward cause-and-effect. Interventions to increase health literacy in our communities clearly lead to improved health outcomes. Whether they lead to reduced emergency services use is less clear.

And perhaps most complicated of all is the question of whether we want them to. If increased health literacy means, for example, that patients recognize a heart attack or stroke earlier, then we should be happy to see more of these patients in the emergency room. The key, in future research, will be to tease out which patients (like the parents of children with minor concerns) can be safely educated out of the ED, and which should be educated in.

The Future on Wheels: EMS and Health Information Technology

In the aftermath of Hurricane Katrina, so many things went wrong that thousands of damaged or destroyed medical records became, for a while at least, a secondary story. As the long-term effects of that massive loss have become more obvious, however, the missing records have become a rallying point for proponents of improved healthcare information technologies, especially electronic patient records.

Such records are particularly advantageous in emergency care settings. As one study in Academic Emergency Medicine put it, emergency departments are “highly variable, evanescent, contingent, uncertain, poorly bounded, resource constrained, and beholden to many external influences.” In other words, emergency settings are always in flux, resources are scarce, and new incoming emergencies can disrupt an entire system in a moment. The need to find out who patients are, their medical histories, and any comorbidities that might influence their current condition only adds to the chaos.

In such settings, electronic patient records, which gather together information from all the patient’s providers and present it in electronic form, can save precious minutes and help prevent medication reactions, incorrect diagnoses, and repetitions of expensive and time-consuming tests.

All of these concerns are compounded further for EMS providers. Riding in an ambulance to a patient, paramedics have available to them only the information provided by the dispatcher—information, in other words, about the immediate cause of the call for help. They have no access to patient records, limited diagnostic and treatment options, and very limited time. Moreover, they often arrive at the hospital and hand off the patient before their patient report is complete. This means that

Preparing for the Coming Wave of Older Patients

It is no secret that the population of the United States is aging. According to the Department of Health and Human Services’ Administration of Aging, the number of persons over 65 in the U.S. will be about 72.1 million in 2030—more than twice their number in 2000. By that point, seniors will make up nearly 20% of the entire American population.

Hospitals have begun to respond to this reality, even in the emergency room. A number of hospital emergency departments have developed special processes or teams for handling seniors, while some have actually opened separate, focused emergency departments that will only take geriatric patients.

The reason for implementing such sweeping reforms is that older patients present unique problems. Seniors are more at risk for adverse effects from medical care. Many find themselves with limited mobility and function after an emergency incident, meaning that return visits to the emergency room are very high for this population. In addition, older patients are more likely to have unusual conditions, suffer from multiple different conditions that can confound diagnosis and treatment, and already take multiple medications that can interact with new prescriptions.

In part, the changes happening in emergency rooms are also the result of perceived problems with previously available care. In 2005, for example, the Society for Academic Emergency Medicine found six areas in which emergency medicine was failing to meet the minimum standard of care for seniors. These included cognitive assessment and pain and medication management, key indicators of return visits.

How does all of this affect emergency medical services, prehospital providers, and dispatch? One recent study identified three areas in which EMS needed more study and improved response.

First, they found that the complex presentations of disease in older patients was confounding diagnosis and treatment in the prehospital setting and that more research is needed to determine the best methods for diagnosis, and the most valuable interventions, for seniors before they arrive at the hospital.

Second, they suggested the importance of alternate care methods for seniors. Because the stress of an ambulance ride, the chaos of the emergency room, and the limited time for treatment all pose risks for older adults, the possibility of instead transporting them to geriatric care centers, treating them at home, or otherwise providing them with alternate care options is particularly important.

Finally, the study argued that EMS could be more effectively involved in screening older patients for conditions that might indicate future problems. Because EMS providers are already interacting with the patient—who may not be receiving regular care—they are in a position to screen the patient for cognitive and physical declines that may pose more serious problems in the future. They could then provide that information to the emergency room staff, the patient’s doctor, or the patient, hopefully leading to better preventive care rather than another trip to the ER for an unidentified, and thus untreated, condition.

Prehospital care providers, both in the dispatch center and on scene, have the potential to substantially improve the quality of care older patients are receiving—and also to reduce the potential harms they may experience from traditional emergency care. As the population ages, EMS will be increasingly involved in such patients’ lives, and we should prepare for this involvement soon—before one in every five of us is over 65.

When Your Schedule Goes Sideways: How to Handle Shift-Work Stress

If you work the graveyard shift, or if your day-night schedule changes every week, take heart: you’re not alone. According to the Bureau of Labor Statistics, almost 15 million American workers work nights on a permanent or rotating basis. From nurses, ER doctors, and medical interns to tow truck drivers, janitors, and air traffic controllers, millions of Americans–and many millions more worldwide–work through the hours when most people are asleep.

Those of you who do shift work, especially if it includes night shifts, know the stresses that come with sleeping in the day and never having a regular sleep schedule. And if you’re the spouse or child of a shift worker, you know the different stresses that brings: creeping around the house while your spouse sleeps, never being able to make plans more than a few days in advance. Such a schedule can definitely take its toll. Fortunately, research suggests there’s a lot you can do to combat the effects–and what’s more, they may not be as bad as you’ve been told.

The Shift Work Blues

The overriding problem with shift-work, especially night-shift work, is that it messes with what is called your circadian rhythm: your natural sleeping-and-waking cycle that also includes broader patterns of energy and tiredness. People are pretty adaptable, and by setting a strict sleeping schedule during the day, you could adjust fully to night work over time . . . except that life keeps going on. As the American Psychological Association puts it, adapting perfectly would put you “out of phase with regular day-working people,” including your family and friends, banks and other businesses, and anyone you wanted to, say, meet for lunch.

Night shifts can shift your mood

In other words, it’s really the variation in schedules that causes the biggest issues. Well–that and not having control. One study in the American Behavioral Scientist found that it was lack of autonomy over one’s own schedule (not being able to set your own hours, in other words) that caused the most stress among shift workers. Similarly, a study of nurses found that the more experienced the nurse, the less shift-related stress they experienced, suggesting that workers with more authority (and, as a result, more autonomy and choice and probably more say in their own schedules) suffer fewer ill effects from shift work.

Finally, there is some evidence that there are personality types more suited to night work. In particular, if you find you’re able to sleep easily wherever you are, or if you don’t need a lot of sleep in the first place, you may be better fitted for night work or shifting schedules.

Interestingly, these differences in autonomy, experience, and personality can override what have long been considered inevitable responses to shift work, including weight gain, loss of sleep, inattention, and safety issues. It turns out that choosing when you work, having some autonomy over your own schedule while at work (which allows you to better fit your activities to your shifting energy levels), and being suited to the work personally can make a big difference.

Self-Care for Shift Work Stress

The good news is, there are a lot of ways to reduce the stressful effects of shift work in your life. Regular exercise and healthy eating habits have been shown to reduce sleepiness and increase energy in night-shift workers. In particular, moving around whenever you can while you’re at work and not eating big, heavy meals at night can keep you from hitting the sleep wall in the wee hours of the morning.

Caffeine, too, can be useful but also has the potential to increase your stress in the long term. Although it may make you more energetic in the moment, it’s draining over the course of days and weeks. If you do drink coffee or soda, making sure you don’t drink any within four to five hours before you plan to go to sleep can reduce sleeplessness and increase the quality of your sleep in the long run.

And quality of sleep, it turns out, is really important–every bit as important as quantity. Not getting fully into the deep-sleep cycle can lead to jitters and anxiety, agitation, fatigue, and irritability, as well as difficulty concentrating.

Help yourself achieve this kind of deep sleep, even during the day, by setting up bedtime routines, including turning off lights and lighted devices (such as the TV or iPad) at least half an hour before getting in bed, having a sleep-transition activity such as meditation or reading to help you relax, and using heavy curtains to keep your bedroom as dark as possible. Enlist your family’s help in keeping the bedroom as quiet as possible, and try sleeping immediately when you get home from a night shift, then taking a nap before going back.

If you can, also try to take more control over your own schedule. Ask your supervisor to give you some more say in your shifts. Or, if that’s not possible, at least take control of your schedule at home, finding one or more activities you can do at the same time every day–a midday meal, a workout, a family activity–to give you some stability and routine.

Sanity First

A lot of shift workers, dispatchers included, are people who are doing very important, even life-saving work and have a strong dedication to doing it well. Whether it’s keeping planes from hitting each other over a runway, managing an Intensive Care Unit, or taking 911 calls, night shift workers are busy protecting us, keeping services available, and preparing the world for another day, all while we sleep. If you’re one of the millions who do this work, remember that your first obligation is to yourself. The more you can reduce your stress and exhaustion, the better you’ll be at what you do, both at work and at home.