DB cannot help himself. He hates ER docs, and won’t stop talking about it

One way universal coverage can save costs | DB’s Medical Rants
An ER physician justifies an admission for expediency. This patient needed an outpatient evaluation, but our dysfunctional health care “system” make him consider inpatient evaluation the best option.

So this patient spent 3 days in the hospital, at an outrageous cost, to obtain the evaluation. Of course the ER physician justifies the admission.

This isn’t the first, or second, time he’s gone out of his way to cast aspersions on EM docs (see here and here), but this might be the dumbest.

I know nothing of this particular case, but I’ve been in the same situation: a patient who needs an eval by a good internist, or a specialist, but it’s the patient has no insurance/it’s a long holiday and the patient cannot wait/the patient is unlikely to follow up as an outpatient/ it takes little imagination to understand why this is occasionally done.  So, we get the patient admitted, usually to an overworked hospitalist who nonetheless understands the patients’ plight and admits them.

That’s right: it’s not the ER doc who admits patients.  It takes two to tango, and to admit.  The admission Dr. Centor is raving about here was done NOT by an EM physician, but an internist.  All any ER doc can do is plead their patients’ case, but it’s the internist who makes the decision.  Sounds like some displacement…

“Expediency”.  One persons’ expedience is anothers’ outstanding, expedited care.  Just because it’s inconvenient for Internal Medicne doesn’t make an admission wrong.  That the system is screwed up and costs several fortunes isn’t the fault of ER docs.

As there is a shortage of primary care docs in this country, his last paragraph (go read the rest) fails to impress.  We could go Single Payor/Universal care tomorrow and there would still be a primary care shortage for a decade, and that’s assuming primary care gets paid like they should.

DB is a very good blogger, and a terrible Emergency Medicine bigot.  Too bad, he’s missing out on the most interesting group of docs, personal and professional, ever.


Comments

  1. I think you misunderstood my point. I do understand why the patient was admitted and believe it does make some sense in our current system. If you read my title you will see that I believe this “necessity” argues for more primary care as part of universal coverage.

    I do not hate ER docs. I do have respect for many.

  2. Where’s the hatred of ER docs in DB’s post, Grunt? He’s clearly blaming the system, which he said made the ER doc admit the patient.

    His use of the term expediency could well have meant appropriateness to the situation.

    Really, what am I missing in his post?

  3. Just because a patient has Medicaid and didn’t take the responsibility to assign herself a primary care doc, it means we have to be paternalistic and assume they’re not going to follow up and, thus, admit them? Docs at my hospital work around this by placing a courtesy call to a clinic for the patient and ask to get them in quickly when they call for an appointment or will talk to the doc and then give the patient the phone and have them transferred to scheduling or something. Saves the state taxpayers a lot of money to place a phone call.

  4. The entire blame for the admission is laid at the feet of the Emergency Physician. It was ‘expedient’ for the EM doc to admit, and ‘the ER doc of course justifies the admission’.

    It’s all about the bad EM doc, and not a word about the IM team that admitted the patient (who apparently agreed with the ER doc enough to admit the patient). Where’s the castigation of the IM team? Oh, that would mean…the EM doc was right, so cannot have that.

    DB wants a villain, the ER’s always there. Sad.

  5. GruntDoc,

    I quote from the article:

    The medical resident assigned to take care of her in the hospital complained that the admission was “unnecessary,” reasoning that she could be cared for as an outpatient.

    Of course medical residents always do complain.

    The Emergency Medicine doc did admit the patient. I understand why. My rant was about our lack of a system. I am sorry I did not make that clear enough.

  6. Did you miss the part where he said the dysfunctional system made (he actually typed make, obviously meaning to say makes or made) the ER doc consider admission? So isn’t he blaming the system? How, then, can you say he was putting the entire blame on the ER doc?

    Regarding his comment that the ER doc justified the admission, well, of course the admission was justified because the system left no good alternative. Why is it necessary to read anything more than that into what he said?

  7. That just kills me. As an ED physician, I will be told on occasion, that a patient didn’t need admission, but then the patient will have a 3 day hospital stay. If the patient didn’t need admission, why wasn’t he discharged the next day??? Apparently, the admitting doctor needed 3 days to work him up and discharge the patient….who didn’t need an admission.

  8. I have been told by my consultants on occasion that “you know, this is a weak admission, you should really send this home” and then I follow along as they have a four day hospital stay with extensive testing. If it was so weak then they have Option A – Come see and discharge the patient if they are so confident OR Option B – Admit to OBs overnight and make alternative arrangements for the outpatient workup. When their neck is on the line after they get involved the unnecessary admission suddenly becomes the standard of care. One of the most professional hospitalists I know will never attempt a block on the phone. He will come down evaluate the patient and after laying hands on the patient and hearing the story will either admit as I desired or choose from the above two options and when he does I am confident that the right thing is being done for the patient. He’s not afraid of work.

  9. DB,
    I cannot find that quote in your article. Where is it?

  10. I think if we look at how fragmented decision-making can be on a practical level, and one delay leads to another, it can easily be argued that this patient was served well by her management.

    Someone with a primary MD, someone who is a VIP, someone who has a relative of an MD will have an advocate to get the evaluation done with an efficiency of time. One of the things this patient received was some reassurance that someone cared about her. The logic that a matter of days or weeks makes little difference in the prognosis in a case like this is of no significant psychological comfort to the patient who is told that they likely have cancer.

    Right now we have many forces which push people toward EDs — limited office hours, not enough primary care doctors, doctors who use EDs as evening and weekend coverage. Someone might create some kind of “intensive outpatient” admission for these patients, but until they do, the current system fills a gap.

  11. Jabulani says:

    IMHO, ER doctors (worldwide) are the same as our English GPs: Effluent Filters (you know, all those little nasties you have to sift your way through to get to the Important Stuff?!). Now there may be some who feel that effluent filters are not essential or that they are costly, but I’m pretty sure I’d rather not find out how my car functions without an air or fuel filter. So I’m damn sure I don’t want to find out how the medical world functions without the Effluent Filters!!

  12. Gruntdoc – the quote is not from my rant but from the linked article.

  13. Heh. I hadn’t read the article. Having read it, I agree with the WSJ physician. That patient needed admission.

  14. You sure it wasn’t “defensive medicine”?

  15. Goatwhacker says:

    This may not be the popular view, but to me it sounds like a BS admission. Yes the patient got her workup done quicker and everybody got warm fuzzies but if I read the article correctly she did not meet accepted admission criteria. This means if the admission is audited the hospital and admitting physician will have to defend the admission and there’s a good chance the state will refuse payment. Who probably WILL get paid is the ED doc (not much since she was Medicaid but something).

    The ED physician should not expect the hospital and admitting doc to work for free because the system sucks when the patients don’t meet admitting criteria. I like the line in the WSJ article “she told me she needed to be admitted to the hospital”. That’s great he has the patients decide on whether they need admitted or not, it probably saves him a lot of decision-making.

    I think Nurse K above has the right idea – I can’t remember ever saying no to any doc that has asked me to work somebody into my schedule.

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