This episode focuses on career opportunities for people who want to concentrate on the business aspects of medicine.
Dr. Lindsey Spiegelman is an Emergency Medicine Physician and Clinical Faculty at the University of California Irvine Medical Center. She double majored in neuroscience and psychology at the University of Southern California and then went to medical school at UC Irvine. She completed a clinical informatics fellowship and MBA at UC Irvine as well. She is the lead medical informaticist for the UCI Emergency Department and a member of the ED Clinical Operations team. She is particularly interested in projects related to ED throughput, hospital efficiency, and leveraging technology for effective patient care.
Today, join Alaina Rajagopal as she talks to Dr. Lindsey Spiegelman about her experiences and how physicians can work to improve efficiency in their systems.
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The Business Of Medicine With Dr. Lindsey Spiegelman
Welcome to another episode. Please keep in mind that the content of this episode does not constitute medical advice but is purely for the purpose of education. This episode was sponsored by the National Geographic Society's Emergency Fund for Journalists. Our guest is Dr. Lindsey Spiegelman. She is an Emergency Medicine Physician and Clinical Faculty at the University of California Irvine Medical Center.
She double majored in Neuroscience and Psychology at the University of Southern California and went to medical school at UC Irvine. She completed a Clinical Informatics Fellowship and MBA at UC Irvine as well. She is the lead medical informaticist for the UCI Emergency Department and a member of the Emergency Department Clinical Operations Team. She's particularly interested in projects related to ED throughput, hospital efficiency, and leveraging technology for an effective patient. Welcome, Dr. Spiegelman.
Thank you. I'm happy to be here.
Thank you for joining us. Our topic focuses more on the business side of Medicine, but before we get into all of that, Dr. Spiegelman, tell me a little bit about your background and where you grew up?
I grew up in Northern California in Palo Alto and came down to Southern California afterward to go to college at USC and went on to UC Irvine. I have been there for a bit now, finished medical school and emergency medicine residency, and did an Informatics Fellowship. I also tacked on an Administration Fellowship in addition to getting my MBA. Now I work on the Clinical Operations Team as the Associate Medical Director and the Lead Informaticist at UCI. I have been at UCI for a long time and love working there so far.
What made you decide to go into Medicine in the first place?
When I was an undergrad, I got involved in some biomedical research at a pharmaceutical company associated with my Neuroscience and Psychology background in Addiction Medicine. That was my taste in Medicine, science and research. I found that I liked that aspect of it, but I missed the component and the human interaction. I started volunteering at CHLA in various departments. I found that being able to link my interest in science and research with helping patients pushed me towards going into Medicine and pursuing my MD.
I had a similar path where when I was doing all of my PhD research, I also missed that human connection, and that was part of what led me to medical school. What made you choose emergency medicine in particular? That's a little different than Neuroscience and Psychology.
A lot of my exposure to Medicine going into medical school was pediatrics. I thought I might potentially do that, but I found that I wanted to take care of all patients, all ages, with such a diverse background. I loved that with Emergency Medicine. You never know what you are going to see that day and never know how your shift is going to go. You are always on your toes, having to think through cases every time. I think that the shift works for me well because it allows me time to pursue other interests work on projects, and ultimately it fits my personality well, and it's where I love to be. That's where I chose Emergency Medicine.
What's your favorite thing about Emergency Medicine? Is it one of those things or something different?
It's one of those things, but also the fact that I don't have to think about patients' insurance a lot of the time. You do when you ultimately admit the patient to the hospital sometimes. Ultimately, I can provide care to everyone and anyone regardless of insurance, where they come from, and why they are there. I think for me, that is very fulfilling.
There are times when we have to worry about the insurance and potentially transfer people if they need to be admitted, but for the most part, I am so with you. I appreciate that we can see everyone treat everyone regardless of that insurance status. What's your least favorite thing about Emergency Medicine?
My least favorite part of the Emergency Department is probably to know the counter to one of my favorite parts. I think the Emergency Department is the canary in the coal mine in a lot of ways. We see all the issues and the problems with the healthcare system. There are times when we can't provide access or get the patient what they need for that day. The fact that healthcare is so expensive at this point is also tough to see, but we do what we can. We provide whatever care we have access to, especially with UC Irvine being a county-type hospital at UCI. I feel like I am able to provide as much care as possible, even with all those constraints.
I think that's another great thing about Emergency Medicine is being able to provide that care no matter what your insurance and background are or where you are from. You don't have to worry about the geographic areas as much. Do you have a memorable case you can discuss anonymously that you think has an interesting teaching point?
Yes. At UC Irvine, we see a ton of patients. We have residents, so we have a ton of learners. I think in the Emergency Department, sometimes it's easy to take the word of the consultant. I thought an interesting case that I had was to remind us, as emergency physicians, that sometimes we need to stick to our guns a little bit even if a consultant maybe does not quite agree with you. This was a case of a 40 something-year-old gentleman who had a fall before. He went to an outside hospital, got an MRI of his shoulder, was found to have a ligament injury and shoulder, and was discharged with pain control and referral to see a surgeon with surgery planned in the next two weeks.
He presented to UCI with persistent pain, so much discomfort, using up his Norco faster than he was prescribed, and in a lot more pain than you would think someone might be with a ligament injury. I was going to my resident talk to the patient about multimodal pain control and how surgery coming up in two weeks is good. We sat down to do the physical exam, and his shoulder was so red, hot, tender, and he did not want to move it.
I was like, "It's a little bit odd for a septic joint, but it's possible and could happen." Even after consulting the orthopedist on call, they did not feel like a septic joint. We told them, "We are concerned enough that if you don't want to tap the joint, we are going to attempt it." Ultimately, they attempted to tap the joint but were only able to get a very small amount of fluid that couldn't give us a cell count. We were stuck with this case where we were concerned. Orthopedics was not concerned, and the patient was in a lot of pain. We had a nondiagnostic joint tap.
Ultimately, we ended up admitting the patient for pain control and further workup. He continued to have pain. They got a repeat MRI in a couple of days, and he ended up having a septic joint. People present in weird ways. They do not read the textbook. As someone had a fall and a ligament injury seen on an MRI, it does not mean that could be the only thing going on. Listen to your consultants, but if you feel that your concern is higher, stick to your guns.
COVID helped inspire people to move forward with new technologies.
I think that can be one of the toughest parts of our job is finding a way to balance relationships with consultants and advocating for patients when your Spidey sense, in a way, is telling you that there's something not right going on even if you don't have the perfect diagnostic test for that at time.
I remember looking at the patient when my resident was talking to him and looking at his shoulder, and I was like, "It's red. It should not be that hot, warm and angry." He ended up also having a fever too. There were too many things that did not quite fit with a ligament injury in the shoulder.
You also did a Fellowship in Informatics, and I'm genuinely asking what does that mean?
I get that question a lot. It's a new-ish field. The way that I describe it is computer plus person is better than either one by themselves. How do we do our jobs better leveraging technology to make us more efficient, have decreased errors, and ultimately provide better care to patients? When I try to explain informatics, that's what I say. Some specific examples would be how we design a pop-up or a BPA, Best Practice Alert, so that it shows up in the right place at the right time for the right person to be able to improve care.
Like a sepsis alert, for example, you have a patient who comes in with abnormal vital signs, and that pop-up tells you this patient might have sepsis, please evaluate them for sepsis.
It's easy sometimes to think that more alerts will change care, but it's about to do we need this alert, being vigilant about what we add to the EHR, who should see that alert, and what the options are after you implement it. That's one example. In addition, we make a lot of decisions very quickly about what we order for patients. How do we change the layout of the order sets or the quick list panel for you to pick the different orders that you would need and test what you would want to do?
That is important. I am very particular about how my orders look. That can be something that can be hugely timesaving. I'm glad that there are people like you putting a lot of thought into what makes it most efficient and useful.
I like it. I find that I can sometimes implement small, medium, big changes that our emergency doctors use and help. I get feedback that, "This helped my workflow, and I'm way more efficient now." For me, that's extremely rewarding because I can make some changes to improve our workflow.
I also appreciated your attention too when maybe too many pop-ups can interfere with efficiency because they can be great reminders when you need to think, "Did I calculate the heart score? Did I evaluate this patient appropriately for sepsis?” Any number of things, but when it's pop-up after pop-up, that starts to interfere with care at some point. It's cool that you are thinking about these things and thinking about how to improve efficiency and good care while also not putting so many roadblocks in the system that you can't get real work done.
Alert fatigue and physician burnout are interconnected. I think as the ED informaticist, that's one of the things that I try to do, is make sure that if we are making a change, we think it through it, and we are not making changes to make changes. It's going to be helpful and improve care.
Alert fatigue is interesting to me. I remember there was a place where I worked where there was so much caution tape everywhere. They would caution tape the floor stickers like outlining where the doors opened. It was to a point where when there was a real hazard, and it was almost you ignored that it was there because you are so used to seeing yellow caution tape everywhere.
I think the drug-drug interaction ones are a perfect example of this. We get so many drug-drug interaction BPAs that I don't know that at this point, they are helpful. Being vigilant about what we implement that we then impose on the rest of the physicians is super important.
You also got an MBA. I remember hearing in medical school over and over about people who are thinking about starting a private practice that physicians can be great clinicians and horrible business people. I think this is an interesting career choice for a physician to make. Can you tell me a little bit more about combining business and Medicine?
Ultimately, Medicine is a business, and the more that physicians try to pretend that it's not, I think the more that we do ourselves a disservice. We are not able to make changes within our field and advocate for ourselves. Specifically, with Informatics, there is so much overlap between what I learned in the MBA and Informatics, doing projects, working with everyone in the hospital, interpersonal relationships, understanding how to move things through the system with all the bureaucratic tape that might be around you. It's super helpful. Even if you don't get a full MBA, having a general understanding of billing, reimbursements, and all the intricacies of our healthcare system is helpful for all of us in the medical field.
I can say that my knowledge in those fields is lacking, and that's part of why I went into Emergency Medicine because I did not want to think about that, but I see your point in that. Physicians, in general, should know more about how all of that works so that we can better advocate for ourselves and our patients and improve those systems that we have been talking about.
I see myself in the future, hopefully continuing with ED operations, Informatics, and potentially, hospital administration and leadership. I wanted to spend these few years after residency making sure I had all the knowledge and skills, Informatics, Operations Fellowship, and MBA, so I had the solid background to be able to attack those projects, problems, and potential career aspirations in the future. It seemed like the right time to put in all the work right now.
Speaking of that, how do you think getting an MBA has helped you with improving hospital operations?
I mentioned this to you briefly before, but one of the projects that I have been working on is trying to get us another CT scanner in the Emergency Department. UC Irvine is a Level 1 Trauma Center. We are a stroke and STEMI Receiving Center. Our volumes have skyrocketed, and the length of stays for patients is long. Patients sit in our waiting room for a very long time. One of the limiting factors is getting another scanner.
I had a healthcare business class, and for that class, they had us write a proposal called A White Paper. I picked the CT scanner issue within our ED. I was able to use queuing logic and recommend that we need another CT scanner based on that. I looked at net present value and other business project tools to analyze whether this would be a good or a bad project based on reimbursements.
Ultimately, being able to compile my knowledge from the Emergency Department and the MBA and put together a paper to show that we do need this. Not only do we need this for patient safety, but if we can keep more patients from leaving without being seen or eloping part way through their treatment, we might gain more revenue.
Always listen to your health consultant. But if you feel that your concern is higher, stick to your guns and seek help.
If we can be up for EDSAT and get more of our ambulance runs, those patients tend to have better reimbursement. It might seem like we are spending more money for another scanner, but all the numbers that I was able to put together show that this might be beneficial for the hospital overall. I'm hopeful that it will go forward. We are still in the waiting period.
I hope it does go forward because I think that is a huge bottleneck sometimes in patient care when people are waiting for tests results to come back. If you can improve that throughput, that improves care, the wait time, and the ability for the emergency department to see more patients faster. It makes tons of sense.
It does. It's a matter of time before we get one. I know we need one. I hope it's sooner rather than later. We would be able to provide much better care if we had more access to CT.
Along the lines of operations as well, you have championed growing telemedicine. Tell me a little bit more about how you started working on the telemedicine effort and how it related to the pandemic as well?
This was such an interesting project. I was a first-year fellow when my mentor and the CMIO of UCI, Dr. Rudkin, came to me and said, "It's time to find you a big project. Let's find you something interesting." We are hoping to implement video visits or UCI Telemedicine for all of the ambulatory clinics that UCI. At that point, in 2020, before the pandemic had hit, and UCI was using Teladoc, an outsource company, to provide telemedicine, but we did not have access to it for our own doctors at that point.
The plan was to slowly roll out telemedicine to various clinics over a six-month, year-long process. COVID happened, and we completely revamped the project and went live with all the clinics within about a month and a half. It was quite the 180 to change the plan and get everybody access to this necessary tool.
In the beginning, we got a lot of people asking, "Is this necessary? I like seeing my patients in person. I don't know that I will ever use this. I don't think this is going to work for my workflows." A lot of people with questions and reservations about adoption and how it would fit in for their clinics. Fast forward two months later, when nobody could be seen in the clinic at all, the wording was very different. They were like, "When is my clinic going to have this technology? Why am I not already living with this?" It was interesting to see how a change in landscape and a change in the atmosphere and something like COVID moves us forward with this new technology, and people are now on board.
I hope that telemedicine can continue and will continue into the future because there are so many applications for telemedicine that I think can improve care. There are situations where you don't necessarily need to have an in-person visit, but you need to see a doctor or some clinician to help with whatever a particular issue is. Having telemedicine improve access to medical care, particularly in rural areas, is so great and important. I love seeing that this effort continues to grow.
This is another plug for the Informatics Team at UC Irvine. We have doctors from all specialties that help with projects, and everybody came together to implement this for all the clinics in such a short period of time. It would not have been possible without Judy Smith, our project manager, Dr. Rudkin, the CMIO, and all the other informatics faculty that helped move this forward. It was such a big lift and great to see everybody come together and 0 to 100 and make this happen.
You mentioned there are a lot of other specialties involved as well. Is the Informatics Fellowship open to other specialties, or is it just Emergency Medicine?
It is multidisciplinary, which is very cool. At the moment, we have an Internal Medicine fellow and an Emergency Medicine fellow, and soon we will have a Ped's fellow. We've had pathology in the past. The great thing about Informatics is that I get to work with people from all specialties, all across the hospital. It helps us understand each other our workflows and see the struggles and the things that the different specialties are dealing with on a day-to-day basis that you would not otherwise know. You only know the world that you trained in, but Informatics allows us to cross the disciplines and work together as a big team, which I think is great.
That's also such a great point. We train a certain way and know our own universes of the hospital, but when you are having a tough day, it does not matter whether you are seeing 20 or 30 patients in the Emergency Department or reviewing hundreds of slides in the Pathology Department. When you are overloaded, it does help to have some of that common knowledge and understand those struggles. Do you have any final words of advice before we wrap this up?
I have some words of advice. I think for me, one of the biggest learning points is that even though you may not think that a field will fit you perfectly, you should explore it. I say this because Clinical Informatics was something that I never intended to do or expected that I would do. I was introduced to it as a resident in Emergency Medicine by Dr. Rudkin, talking to me about his career and what he does on a day-to-day basis. The more I learned about it, the more I stopped being nervous about the fact that I was not super experienced in IT or had a lot of technical background.
I think the landscape is changing. The world has to adopt technology everywhere. You want to get ahead of it so that you are able to be involved in how everything is moving forward. Even if you might not feel that you are super techie or grew up coding or doing those kinds of experiences, there could still be a place for you in technology, Informatics, and deals like that. Keep your mind open, and it could open your eyes to a bunch of different things.
I think it's so cool how it was something that seemed almost a little bit scary at first when you are thinking about it and approaching it. Over time, you continue to learn and become more comfortable with the field. Now you are at the forefront of that field. Any causes you would like to champion or plug?
In line with what I mentioned is, women have done a great job of making their way into Medicine in general. I think we are starting to see even more women applying to Medicine and medical school these days, but I think even in IT and a lot of these more maybe technical subfields, we are still not seeing a ton of women. Even if it seems foreign or a little scary, explore and see if it might work for you.
There are pieces of informatics and IT that aren't quite as techie as you might think that they are. I want to make sure that people feel like it's approachable and should try to explore it themselves and see if it's potentially something that they would like. I have learned so much and am excited for my future career. If I had not taken that step, I would not have had those opportunities.
Thank you so much for all of the knowledge that you have shared and for bringing forward a lot of these different causes and interesting avenues that people in and out of Emergency Medicine can pursue.
Thank you so much. It was such a great experience being on this show.
Thanks for joining us.
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That's it for this episode. Our guest was Dr. Lindsey Spiegelman. This episode was supported by the National Geographic Society's Emergency Fund for Journalists. If you like what you hear, please give us a like, subscribe, or comment. Until next time.
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About Dr. Lindsey Spiegelman
Assistant Professor — Department of Emergency Medicine, UCI School of Medicine
Dr. Lindsey C. Spiegelman is a board-certified UCI Health emergency medicine physician. She earned her medical degree at UCI School of Medicine, where she also completed a residency in emergency medicine.
Dr. Speigelman sees patient at UCI Medical Center in Orange.