Medicine doesn’t stop for the game

Tonight, just prior to the kickoff of the Cowboys game (regionally required viewing) one of our hospitalists stopped by the ED, with the following pronouncement:

“The game’s about to start, so it might take a while for me to call back.”

To which I gave the only reply an ED doc can:

“Okay, call when you can and I’ll tell you how many I admitted to you.”

He called back very quickly, I must say.


For the record, I very much prefer working with hospitalists rather than the olden days of community physicians who admitted their own patients; I don’t have to advocate for a patients’ admission nearly as much with hospitalists versus the private physicians.  (And there are exceptions to every rule; right now I know of two private docs who are wonderful to call: encyclopedic knowledge of their patients and their problems, helpful, etc).  Kudos to my hospitalist colleagues.


  1. Hmm. Why do you say this? My experience has been the opposite. The community/private docs are more than happy to admit the patients that they know and are very familiar with. My experience with hospitalists at my esteemed training institution was the exact opposite…they wanted to send all the patients home after what they considered adequate treatment in the ED (for things like CHF, new onset atrial fibrillation, even questionable ACS).

  2. Perhaps my hospitalists work under different expectations than yours. I’m sorry yours aren’t as helpful.

  3. What? Giving props to Hospitalists??

  4. There shouldn’t necessarily be such a greased wheel for admitting patients. To some extent I think there should be a little tension between the ED doc and the admitting physician. Just because an ED doc thinks a patient should be admitted isn’t the last word.
    I overhear some of the hospitals coders at times scrambling to justify an admission so the hospital can get paid.

  5. Hmm, I worked up a patient who is in front of me, after a history and physical. If I think they need to be admitted, that’s a significant bias for admission.

    Now, I have had hospitalists not admit patients I wanted them to; twice in the last 4 1/2 years, to date. If the hospitalist doesn’t want to admit and I don’t feel terrifically strongly about it, fine; all I want is for the hospitalist to see and evaluate the patient, and put a note to the effect on the chart, after talking to me.

    Really, not that much tension.

  6. WHO DAT !!

  7. Goatwhacker says:

    Yeah, I have to agree with Greg P. There is a temptation for the ED doc to admit the borderline patients – it solves the problem of disposition, you don’t have to explain to a suspicious family why the patient is going home, there is less legal risk, etc. I know the newsletters I got from our insurance carrier while doing ED work sure encouraged admitting anything you had the slightest doubt about.

    Conversely there is temptation for the attending not to admit – doesn’t have to get out of bed, avoids extra work, etc. Of course often the attending will know the patient much better than the ED doc and that will influence the decision as well.

    I remember being in an ED dept meeting where one ED doc argued he shouldn’t have to know Medicare admission criteria and that it should be the responsibility of the attending to know the rules. The private doc is of course the one who has to deal with the Medicare or insurance flak later.

    Overall the counterbalance between the tendencies of the ED doc and the private doc is probably a good thing, and theoretically would cancel out the worst motivations of each.

  8. Soar Loosers says:

    Our hospital is smack downtown a few blocks away from the hospital. Come game day, there is always an unusual amount of patients who arrive to our ED by ambulance just right before kick off only to sign out AMA the minute after they get here. Our paramedics are fed up with being the Sunday morning taxi service. We tried getting the cops involved to arrest these folks for abusing the EMS system but it hasn’t gotten anywhere.

    On the tendencies of ED docs admitting every borderline patient, my feeling is that if they are “borderline” to begin with, why not err on the side of caution and admit them to make sure that they don’t fall to the wrong side of the border? I can name many cases that I’ve argued with consultants over the years and it’s the usual:

    *assymptomatic elderly patients who just had a TIA’s or syncope

    *Hypoglycemic patients on long acting oral agents

    *pneumonia (to the consultants apparently extremes in age and not being able to afford medications are not criterias for admission)

    *homeless patients who can’t afford medications or have no rides back to the hospital for infusion center therapy, etc.

    *and then of course there are all of the other social admits that they fight tooth and nail on.

  9. Well, ED docs don’t get paid for half the patients we see, so complaints about justifications for admission to satisfy insurance companies fall on deaf ears. Always do what’s BEST for the patient. In borderline cases, sometimes that’s going home if there is supportive family and PCP, and most of the time, it’s admisison.

  10. Goatwhacker says:

    Doc S. – You’re saying you don’t get paid for half the patients you say therefore you don’t care if patients meet admission criteria. That’s apples and oranges, one has nothing to do with the other unless you think the only problem that denials cause is my not getting paid.

    Soar – I certainly admit patients from the first three categories you mention fairly routinely and rarely run into the fourth. Certainly if one of my patients can’t afford his meds he can come by my office and we’ll set him up with some samples the best we can, or try to find an affordable substitute.

    On the social admissions, I have no good answer. Taking people who medically don’t need to be in a hospital and hospitalizing them anyway to solve a social problem pisses me off, but I understand sometimes there is no other good alternative.

  11. As a patient, I’ve never seen a hospitalist I’ve liked-they’ve all been impatient men who know nothing about me or my medical history. And they sure as hell want to be out of my room ASAP.

    And I’ve been sent home gasping for air, because the ED doc couldn’t convince the hospitalist I need anything more than a shot of ativan to ‘calm me down’.

    Would you like to give out those Doc’s names?