Another way to look at the problem with our “specialty”

[zurned]

I would like to offer a couple of other POVs regarding the problems with our specialty that I don’t see discussed very often. That for 95% of our patients, there really is nothing a physician offers that a mid level can’t offer. The low to medium risk chest pain or the undifferentiated stable abd pains, or the majority of fast track/urgent care complaints that really does not require any special medical training to “manage”.

When 90% of our patients are these non-emergent things, why shouldn’t our job be given to the person who they don’t have to pay as much? You can actually make an arguement that mid levels should be paid closer to physician pay If they can actually treat most of the problems we see. This is especially true in the internet age, when most things can be looked up.


The other thing is our entire specialty only exists because of the way our American healthcare system is structured. For example, the fact that we can’t admit everyone with chest pains due to finances/hospital resources is what makes picking out the high risk chest pain vs the low risk chest pain a skill. That actual “skill” wouldn’t have any value if our admissions system isn’t the way it is. You’d have a 0% ACS miss rate if you could just admit everyone. The issue is that we can’t, thereby making that aspect of our jobs seem like somewhat special.

Basically, our entire speciality is basically holding the fort down cuz someone else who can also do the job isn’t there at that specific time (for I’d say 98% of patients, this is true). This is not really that valuable of a skill outside of the system. And also probably why most countries don’t have ED specialists. This is different from a surgeon. Removing an appendix or fixing a hip is a skill independent of the system.

TL;DR : Our entire speciality is kind of not that special. Which is why it is going through the problems it is now.

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[Torsion]

The other thing is our entire specialty only exists because of the way our American healthcare system is structured. For example, the fact that we can’t admit everyone with chest pains due to finances/hospital resources is what makes picking out the high risk chest pain vs the low risk chest pain a skill. That actual “skill” wouldn’t have any value if our admissions system isn’t the way it is. You’d have a 0% ACS miss rate if you could just admit everyone. The issue is that we can’t, thereby making that aspect of our jobs seem like somewhat special.

Good stewardship of resources is a skill no matter what system one works in. I'd doubt there is any healthcare system worldwide that would "just admit" every chief complaint that has a deadly item on the differential. It would be extremely resource inefficient to do so. There is a reason this specialty exists and I would guess now more than ever training has become so specialized that a physician with a broad knowledge base with good resuscitation skills is of real value.

Many of our IM residents can't even staple a scalp laceration or place an IV. Our ortho residents have to consult medicine to manage someone's mild diabetes. Our surgery residents, despite spending months throughout training on trauma, don't really know much about bones and muscles and would flounder if asked to reduce and splint a tib/fib fracture. We can do all of that on our own which should save hospital systems and patient's money because multiple specialist don't need consulting. As for mid-levels, you are correct that they can do much of this under the guidance of a ABEM physician. Our PAs and NPs that work for my residency's group can be highly efficient in the fast track, but it is the ability for the residency trained physician to deal with low acuity stuff and then also manage crashing patients, emergent airways, etc and recognize subtle findings that only comes with years of experience and consumption of academic literature that gives us our value.

 

[evert1de101]

People want to see doctors. Plain and simple. The idea of walking into a facility and seeing a board-certified physician without a 6 week wait is intoxicating to every american. The important thing is to advocate for clear role definitions between physicians and midlevels, combat the blurring of the lines with NP "residencies" and "doctor of nursing" degrees, and EMBRACE your supervision of the midlevels at your shop by demonstrating your knowledge, superiority and command over the patients that they are seeing via asking pointed questions and randomly dropping in on them...

 

[thegenius]

I would like to offer a couple of other POVs regarding the problems with our specialty that I don’t see discussed very often. That for 95% of our patients, there really is nothing a physician offers that a mid level can’t offer. The low to medium risk chest pain or the undifferentiated stable abd pains, or the majority of fast track/urgent care complaints that really does not require any special medical training to “manage”.

When 90% of our patients are these non-emergent things, why shouldn’t our job be given to the person who they don’t have to pay as much? You can actually make an arguement that mid levels should be paid closer to physician pay If they can actually treat most of the problems we see. This is especially true in the internet age, when most things can be looked up.


The other thing is our entire specialty only exists because of the way our American healthcare system is structured. For example, the fact that we can’t admit everyone with chest pains due to finances/hospital resources is what makes picking out the high risk chest pain vs the low risk chest pain a skill. That actual “skill” wouldn’t have any value if our admissions system isn’t the way it is. You’d have a 0% ACS miss rate if you could just admit everyone. The issue is that we can’t, thereby making that aspect of our jobs seem like somewhat special.

Basically, our entire speciality is basically holding the fort down cuz someone else who can also do the job isn’t there at that specific time (for I’d say 98% of patients, this is true). This is not really that valuable of a skill outside of the system. And also probably why most countries don’t have ED specialists. This is different from a surgeon. Removing an appendix or fixing a hip is a skill independent of the system.

TL;DR : Our entire speciality is kind of not that special. Which is why it is going through the problems it is now.

Yea buddy I understand your sentiment but your percentages are off. It's not 95% of stuff that comes into the ED can be managed by a nurse with two years of online medical training. This is prima facie FALSE, because nurse practitioners regularly send people to the ED who don't require emergency care. Because they don't know what they are doing.

It's probably more like 30-40%. It's still a lot, but not even close to 95%

Seriously, I just had a nurse practitioner send in a dialysis patient with a BNP of 4900. Because 4900 is too high.

 

[sylvanthus]

I had 2 abscesses (simple ones, not in any scary locations). sent in by an NP from urgent care. The charge RN called over and asked if the NP knew how to do an I and D. NP freaked out and started calling admininstration.

 

[VA Hopeful Dr]

I had 2 abscesses (simple ones, not in any scary locations). sent in by an NP from urgent care. The charge RN called over and asked if the NP knew how to do an I and D. NP freaked out and started calling admininstration.

Sorry, that's a jerk move. I had something similar (though not as straight forward a case) when I was working at an UC straight out of residency. The EP who was working that day called to berate me about sending over something "so simple". Its bad form and doesn't reflect well on the person in the ED who called.

 

[sylvanthus]

I stayed out of it, I knew no good could come from it.

 

[Brigade4Radiant]

Sorry, that's a jerk move. I had something similar (though not as straight forward a case) when I was working at an UC straight out of residency. The EP who was working that day called to berate me about sending over something "so simple". Its bad form and doesn't reflect well on the person in the ED who called.

Call admin and say they won’t be sending anyone to the ED watch what happens. Be complaining about an urgent care referral will get you in trouble because they are sending money to the hospital.

 

[Angry Birds]

I would like to offer a couple of other POVs regarding the problems with our specialty that I don’t see discussed very often. That for 95% of our patients, there really is nothing a physician offers that a mid level can’t offer. The low to medium risk chest pain or the undifferentiated stable abd pains, or the majority of fast track/urgent care complaints that really does not require any special medical training to “manage”.

When 90% of our patients are these non-emergent things, why shouldn’t our job be given to the person who they don’t have to pay as much? You can actually make an arguement that mid levels should be paid closer to physician pay If they can actually treat most of the problems we see. This is especially true in the internet age, when most things can be looked up.


The other thing is our entire specialty only exists because of the way our American healthcare system is structured. For example, the fact that we can’t admit everyone with chest pains due to finances/hospital resources is what makes picking out the high risk chest pain vs the low risk chest pain a skill. That actual “skill” wouldn’t have any value if our admissions system isn’t the way it is. You’d have a 0% ACS miss rate if you could just admit everyone. The issue is that we can’t, thereby making that aspect of our jobs seem like somewhat special.

Basically, our entire speciality is basically holding the fort down cuz someone else who can also do the job isn’t there at that specific time (for I’d say 98% of patients, this is true). This is not really that valuable of a skill outside of the system. And also probably why most countries don’t have ED specialists. This is different from a surgeon. Removing an appendix or fixing a hip is a skill independent of the system.

TL;DR : Our entire speciality is kind of not that special. Which is why it is going through the problems it is now.

Your percentage is way off and demeaning to our field.

 

[VA Hopeful Dr]

Call admin and say they won’t be sending anyone to the ED watch what happens. Be writing an urgent care referral will get you in trouble because they are sending money to the hospital.

I was maybe 3 weeks out of residency so was used to just taking that sort of thing.

 

[The Knife & Gun Club]

I would like to offer a couple of other POVs regarding the problems with our specialty that I don’t see discussed very often. That for 95% of our patients, there really is nothing a physician offers that a mid level can’t offer. The low to medium risk chest pain or the undifferentiated stable abd pains, or the majority of fast track/urgent care complaints that really does not require any special medical training to “manage”.

When 90% of our patients are these non-emergent things, why shouldn’t our job be given to the person who they don’t have to pay as much? You can actually make an arguement that mid levels should be paid closer to physician pay If they can actually treat most of the problems we see. This is especially true in the internet age, when most things can be looked up.


The other thing is our entire specialty only exists because of the way our American healthcare system is structured. For example, the fact that we can’t admit everyone with chest pains due to finances/hospital resources is what makes picking out the high risk chest pain vs the low risk chest pain a skill. That actual “skill” wouldn’t have any value if our admissions system isn’t the way it is. You’d have a 0% ACS miss rate if you could just admit everyone. The issue is that we can’t, thereby making that aspect of our jobs seem like somewhat special.

Basically, our entire speciality is basically holding the fort down cuz someone else who can also do the job isn’t there at that specific time (for I’d say 98% of patients, this is true). This is not really that valuable of a skill outside of the system. And also probably why most countries don’t have ED specialists. This is different from a surgeon. Removing an appendix or fixing a hip is a skill independent of the system.

TL;DR : Our entire speciality is kind of not that special. Which is why it is going through the problems it is now.

I’d like to point out that this is true of many fields in medicine.

Before EM, my career was transplant stuff. Our abd transplant surgeon- arguably one of the most specialized people in the hospital - had an NP who did all of his day to day management for him. And an organ procurement tech who operated as first assistant for his transplants. 95% of what they did was protocol - order the same handful of imaging studies and labs, recognize normal vs “somethings off” and escalate to attending surgeon if there’s an issue. Handful of simple procedures they could do and an attending for backup if things got hairy.

Thats a normal paradigm in medicine. You pay the doc not just for the 5% weirdness, but for all the time their expertise and skills are available.

You don’t pay an EP by the number of transvenous pacers they place or subtle stemis they catch in a year. You pay them for the number of hours they’re the only person available to perform such a task. Our speciality is recognizing badness and resuscitation and we do that exceptionally well. Many health systems using single payer models have EPs. Outcomes are better when we’re around.

 

[Clean7795]

I would like to offer a couple of other POVs regarding the problems with our specialty that I don’t see discussed very often. That for 95% of our patients, there really is nothing a physician offers that a mid level can’t offer. The low to medium risk chest pain or the undifferentiated stable abd pains, or the majority of fast track/urgent care complaints that really does not require any special medical training to “manage”.

When 90% of our patients are these non-emergent things, why shouldn’t our job be given to the person who they don’t have to pay as much? You can actually make an arguement that mid levels should be paid closer to physician pay If they can actually treat most of the problems we see. This is especially true in the internet age, when most things can be looked up.

The other thing is our entire specialty only exists because of the way our American healthcare system is structured. For example, the fact that we can’t admit everyone with chest pains due to finances/hospital resources is what makes picking out the high risk chest pain vs the low risk chest pain a skill. That actual “skill” wouldn’t have any value if our admissions system isn’t the way it is. You’d have a 0% ACS miss rate if you could just admit everyone. The issue is that we can’t, thereby making that aspect of our jobs seem like somewhat special.

Basically, our entire speciality is basically holding the fort down cuz someone else who can also do the job isn’t there at that specific time (for I’d say 98% of patients, this is true). This is not really that valuable of a skill outside of the system. And also probably why most countries don’t have ED specialists. This is different from a surgeon. Removing an appendix or fixing a hip is a skill independent of the system.

TL;DR : Our entire speciality is kind of not that special. Which is why it is going through the problems it is now.

You know in literally every other functioning nation they have ER rooms and ER physicians right (even if they aren't ER trained)? You realize you can never admit every patient, no matter what healthcare system you work in?

 

[RustedFox]

I would like to offer a couple of other POVs regarding the problems with our specialty that I don’t see discussed very often. That for 95% of our patients, there really is nothing a physician offers that a mid level can’t offer. The low to medium risk chest pain or the undifferentiated stable abd pains, or the majority of fast track/urgent care complaints that really does not require any special medical training to “manage”.

Sorry, amigo. False statement.

The legions of Jenny McJennysons out there mismanage those cases that you list all the time.
In 11 years, I have yet to find a PLP that even comes close to matching my knowledge of pathophysiology and related medical topics.
No mid-level can offer what I can offer.

 

[pkwraith]

It would certain solve some problems to admit every chest pain. We could reduce the homeless population to 0, reduce spending for outpatient psych as all the anxiety patient would just be in the hospital.
The side effect would just be a few trillions of dollars, a few hundred people injured from iatregenic harm or delays in emergent care, and the financial collapse of the hospital injury.

 

[thegenius]

Sorry, that's a jerk move. I had something similar (though not as straight forward a case) when I was working at an UC straight out of residency. The EP who was working that day called to berate me about sending over something "so simple". Its bad form and doesn't reflect well on the person in the ED who called.

I get pissed about those things too (pissed that something can be handled as an outpatient or UC and is sent to me), and I get angry because it exposes one of the things about my job I dont like. I don't have control over who I see. Outpatient and UC do. They can pick and choose who they see. I can't. It's the same thing when surgeons send in their POD #2 patients to the ED for a CT. For decades they would manage these patients themselves in the office and order the CT if needed. Now it's just "dump on the ED."

 

[thegenius]

It would certain solve some problems to admit every chest pain. We could reduce the homeless population to 0, reduce spending for outpatient psych as all the anxiety patient would just be in the hospital.
The side effect would just be a few trillions of dollars, a few hundred people injured from iatregenic harm or delays in emergent care, and the financial collapse of the hospital injury.

Probably tens of thousands!!

 

[VA Hopeful Dr]

I get pissed about those things too (pissed that something can be handled as an outpatient or UC and is sent to me), and I get angry because it exposes one of the things about my job I dont like. I don't have control over who I see. Outpatient and UC do. They can pick and choose who they see. I can't. It's the same thing when surgeons send in their POD #2 patients to the ED for a CT. For decades they would manage these patients themselves in the office and order the CT if needed. Now it's just "dump on the ED."

If you do not do exactly what the patient claims their previous doctor told them to do, does that doctor call you up and bless you out?

 

[thegenius]

If you do not do exactly what the patient claims their previous doctor told them to do, does that doctor call you up and bless you out?

That has happened. It somehow gets back to me either the doctor calls me or sends an email.

I think the better question is: Why can't I send the abscesses back to UC to have them drained? I can say "It's not a medical emergency."

 

[bravotwozero]

That has happened. It somehow gets back to me either the doctor calls me or sends an email.

I think the better question is: Why can't I send the abscesses back to UC to have them drained? I can say "It's not a medical emergency."

Is that really what’s best for the patient? I mean, the patient is already there, returning to the UC will be his third facility visit for the day…

 

[Ghee Buttersnaps]

The other thing is our entire specialty only exists because of the way our American healthcare system is structured. For example, the fact that we can’t admit everyone with chest pains due to finances/hospital resources is what makes picking out the high risk chest pain vs the low risk chest pain a skill. That actual “skill” wouldn’t have any value if our admissions system isn’t the way it is. You’d have a 0% ACS miss rate if you could just admit everyone. The issue is that we can’t, thereby making that aspect of our jobs seem like somewhat special.

Basically, our entire speciality is basically holding the fort down cuz someone else who can also do the job isn’t there at that specific time (for I’d say 98% of patients, this is true). This is not really that valuable of a skill outside of the system. And also probably why most countries don’t have ED specialists. This is different from a surgeon. Removing an appendix or fixing a hip is a skill independent of the system.

The top section implies admission is both appropriate and common for all chest pain in other countries. I doubt this is true and would be an incredible waste of resources and would be unlikely to improve outcomes. That's one of the points of risk stratification.

The second part suggests there either is or should be a system where every specialty is available at all times for every patient and no patients have issues that require more than one specialist or have subtle presentations where the appropriate specialist may not be immediately clear. Hence the need for an EP.

 

[VA Hopeful Dr]

Is that really what’s best for the patient? I mean, the patient is already there, returning to the UC will be his third facility visit for the day…

And the UC has already said "I can't handle this".

This is a great demonstration of why being paid on production is the way to go.

 

[thegenius]

Is that really what’s best for the patient? I mean, the patient is already there, returning to the UC will be his third facility visit for the day…

Of course it's not. This has been discussed ad nauseum on this forum.

My doors are open 24-7 for all people and for all complaints. I have chosen this career. Nobody has forced it upon me. Let me make that clear.

I also want to make it clear that this open door policy is taken advantage of by patients AND physicians. Without question this is true.

It means more business for me and I make more money, but there are innumerable number of unintended consequences as a result of this behavior. And the people who get hurt most by this are patients.

 

[GeneralVeers]

Of course it's not. This has been discussed ad nauseum on this forum.

My doors are open 24-7 for all people and for all complaints. I have chosen this career. Nobody has forced it upon me. Let me make that clear.

I also want to make it clear that this open door policy is taken advantage of by patients AND physicians. Without question this is true.

It means more business for me and I make more money, but there are innumerable number of unintended consequences as a result of this behavior. And the people who get hurt most by this are patients.

Also the increased healthcare costs help drive demand for a single payer system and lead to more insurance rationing.

 

[thegenius]

And the UC has already said "I can't handle this".

This is a great demonstration of why being paid on production is the way to go.

Well....OK. You and I both know UC can handle it. Unless UC doesn't carry lidocaine or a scalpel, but they do because they do simple lac repairs too.

Then UC can send the patient to surgery. They choose not to because it's more work for them. An abscess 99% of the time is not an emergency. So why send them to the ER?

Look....it's not an issue of can't handle the abscess. What it really comes down to is the work to drain is not worth the $$ or time cost for them. If draining abscesses paid 10 RVUs, you better bet UC's or even primary care offices would not be sending these to ERs. Moreover...it's more efficient and higher paying for UC to defer an abscess drainage in favor of seeing 2-3 patients as it makes more money.

Sorry in this case (without having seeing the abscess) one cannot claim superior clinical decision making as the reason behind these kinds of referrals. Occasionally yes but most of the time not.


Were people dying or suffering untoward consequences from abscess all time time prior to the advent of ERs? No! Of course not! ERs are overburdened for a variety of multifactorial reasons. There is not a single ER doctor on this board that will say the majority of referrals to the ER are appropriate use of resources.

I'm not convinced that FFS is the way to go as it leads to a tremendous amount of waste. Unfortunately doctors are humans too and are subject to all of the same human shortcomings of greed and laziness as in other professions. The problem with medicine however, is the consumer of products and services are not the payors.

 

[Brigade4Radiant]

That has happened. It somehow gets back to me either the doctor calls me or sends an email.

I think the better question is: Why can't I send the abscesses back to UC to have them drained? I can say "It's not a medical emergency."

Because the admin will freak. They will claim you don’t bring any business and that seeing non medical emergencies is part of your job.

Hosptial admin believes EM is everything medicine this is especially true at many hospitals like HCA

 

[GeneralVeers]

The worst for me are the non-emergent "My widget is malfunctioning". 90% of the time it's not an emergency, and I don't have IR in house to fix their dialysis catheter, nephrostomy tube, suprapubic catheter, pain pump, etc.

 

[VA Hopeful Dr]

Well....OK. You and I both know UC can handle it. Unless UC doesn't carry lidocaine or a scalpel, but they do because they do simple lac repairs too.

Then UC can send the patient to surgery. They choose not to because it's more work for them. An abscess 99% of the time is not an emergency. So why send them to the ER?

Look....it's not an issue of can't handle the abscess. What it really comes down to is the work to drain is not worth the $$ or time cost for them. If draining abscesses paid 10 RVUs, you better bet UC's or even primary care offices would not be sending these to ERs. Moreover...it's more efficient and higher paying for UC to defer an abscess drainage in favor of seeing 2-3 patients as it makes more money.

Sorry in this case (without having seeing the abscess) one cannot claim superior clinical decision making as the reason behind these kinds of referrals. Occasionally yes but most of the time not.


Were people dying or suffering untoward consequences from abscess all time time prior to the advent of ERs? No! Of course not! ERs are overburdened for a variety of multifactorial reasons. There is not a single ER doctor on this board that will say the majority of referrals to the ER are appropriate use of resources.

I'm not convinced that FFS is the way to go as it leads to a tremendous amount of waste. Unfortunately doctors are humans too and are subject to all of the same human shortcomings of greed and laziness as in other professions. The problem with medicine however, is the consumer of products and services are not the payors.

If the urgent care is run by a typical Jenny McJennerson, maybe they can't. Its not (usually) an equipment issue.

Your last sentence nails nails it.

 

[RustedFox]

The worst for me are the non-emergent "My widget is malfunctioning". 90% of the time it's not an emergency, and I don't have IR in house to fix their dialysis catheter, nephrostomy tube, suprapubic catheter, pain pump, etc.

I hate this, too. I even tried to post a thread on here several years ago asking for generalized tips on "my widget isn't working" situations, in an attempt to identify things that I could do to solve these problems that I hadn't yet thought of.

It wasn't an exciting thread.

 

[bravotwozero]

#1 go to option for non functioning widgets is to call the device company, especially if it's medtronic. (They make pain pumps too, not just icds/pacers). If that fails and no IR, then you're out of luck and looking at a transfer to the place where the device was installed vs admission.

 

[e30ftw]

Look....it's not an issue of can't handle the abscess. What it really comes down to is the work to drain is not worth the $$ or time cost for them. If draining abscesses paid 10 RVUs, you better bet UC's or even primary care offices would not be sending these to ERs. Moreover...it's more efficient and higher paying for UC to defer an abscess drainage in favor of seeing 2-3 patients as it makes more money.

Slight aside but I'm 100% RVU and a complicated (pack +/- deloculate) I/D actually pays pretty well. Total RVU for 10061 is 5.86 which in wRVU for gives me personally about $75, combined with the level 3 EM chart an i/d patient which takes like 10 minutes (walk into the room with your supplies, interview pt while performing I/D) bills quite a bit more than a high-risk chest pain/abd pain patient who sits in the ED for 3-4 hours..

I'm always amazed at the highly billable stuff urgent cares send us as lacs bill pretty well too.. we have many that "can't fix a laceration if it's on the hand or face. etc" I love picking up 3-4 of these patients at the end of a shift.. $$$.

 

[Questionsaboutmedicine]

Well....OK. You and I both know UC can handle it. Unless UC doesn't carry lidocaine or a scalpel, but they do because they do simple lac repairs too.

Then UC can send the patient to surgery. They choose not to because it's more work for them. An abscess 99% of the time is not an emergency. So why send them to the ER?

Look....it's not an issue of can't handle the abscess. What it really comes down to is the work to drain is not worth the $$ or time cost for them. If draining abscesses paid 10 RVUs, you better bet UC's or even primary care offices would not be sending these to ERs. Moreover...it's more efficient and higher paying for UC to defer an abscess drainage in favor of seeing 2-3 patients as it makes more money.

Sorry in this case (without having seeing the abscess) one cannot claim superior clinical decision making as the reason behind these kinds of referrals. Occasionally yes but most of the time not.


Were people dying or suffering untoward consequences from abscess all time time prior to the advent of ERs? No! Of course not! ERs are overburdened for a variety of multifactorial reasons. There is not a single ER doctor on this board that will say the majority of referrals to the ER are appropriate use of resources.

I'm not convinced that FFS is the way to go as it leads to a tremendous amount of waste. Unfortunately doctors are humans too and are subject to all of the same human shortcomings of greed and laziness as in other professions. The problem with medicine however, is the consumer of products and services are not the payors.

The flip side is, how do you know it for sure it is a simple abscess?

When I did PCP, if I did an InD in the office and missed a loculated abscess because I don't have any imaging and then patient goes into septic shock, then the pt suffers the most and potentially can die. Sending them to the ED and potentially getting imaging is the best for everyone imo. You have to remember that some PCP and UC offices can't even run a CBC that same day.

 

[RustedFox]

The flip side is, how do you know it for sure it is a simple abscess?

When I did PCP, if I did an InD in the office and missed a loculated abscess because I don't have any imaging and then patient goes into septic shock, then the pt suffers the most and potentially can die. Sending them to the ED and potentially getting imaging is the best for everyone imo. You have to remember that some PCP and UC offices can't even run a CBC that same day.

You not breaking up a loculation didn't cause the patient to go into septic shock, amigo.
Neither was you "not getting imaging".

 

[sylvanthus]

The flip side is, how do you know it for sure it is a simple abscess?

When I did PCP, if I did an InD in the office and missed a loculated abscess because I don't have any imaging and then patient goes into septic shock, then the pt suffers the most and potentially can die. Sending them to the ED and potentially getting imaging is the best for everyone imo. You have to remember that some PCP and UC offices can't even run a CBC that same day.

Wait what? Is this how pcps really think, especially with something this simple? Hell, just send everyone to the ED for everything so we can pan scan them so nothing gets missed. What could go wrong?

 

[Lexdiamondz]

The thing is, 1/20 of our patients (really closer to 1/10) requiring physician management is alot

my shop has 4 physicians on staff daytime and 3 overnight, each seeing 2 pph, each doing 12h shifts

say each of us sees one patient a shift that really needed a doctor. thats seven patients a day. multiplied by 365 days that's 2555 patients annually who become potential lawsuits should you decide to cheap out and hire an NP with an online "doctorate" from nabiscouniversity.com


You an MBA who wants to open yourself up to 2000 lawsuits annually? go ahead and hire a noctor.

 

[Questionsaboutmedicine]

You not breaking up a loculation didn't cause the patient to go into septic shock, amigo.
Neither was you "not getting imaging".

I worked in med mal office prior to med school. If someone did an InD and missed a loculation and they ended up in the ICU with septic shock, you know that pt's lawyer is going to rake the docs over the coals. We all know how lawyers are.

Wait what? Is this how pcps really think, especially with something this simple? Hell, just send everyone to the ED for everything so we can pan scan them so nothing gets missed. What could go wrong?

Let's treat everything in the office. What could go wrong?

I kid and don't mean to be snarky and really feel no negative feelings toward you. But a lot of offices aren't set up to do procedures. Most of the PCP offices (both community and academic) that I rotated through wouldn't even have a bin to catch all of the purulent d/c. Even if we had lidocaine and a scalpel, we just wouldn't have a bin or be able to pack it. We really would be doing a disservice to the pt treating them in the office.

 

[thegenius]

The flip side is, how do you know it for sure it is a simple abscess?

When I did PCP, if I did an InD in the office and missed a loculated abscess because I don't have any imaging and then patient goes into septic shock, then the pt suffers the most and potentially can die. Sending them to the ED and potentially getting imaging is the best for everyone imo. You have to remember that some PCP and UC offices can't even run a CBC that same day.

This doesn't happen

By definition an abscess is "Urgent Care". Like it should be done in the next 3 days. Abscesses are perfect for Urgent Care.

 

[thegenius]

Let's treat everything in the office. What could go wrong?

You would be surprised how much could be treated in the office. Doctors can order labs and imaging. And either wait for the results prior to treatment or treat empirically while waiting.

The day is going to come, and I fear quickly, that insurance carriers will not pay for "two visits" on the same day for something that can be done in one visit. Seeing the PCP for elevated BP and "I don't feel well" and then sending them to the ED for nonsense labs and a desire for a cardiology consultation which will never happen will result in the insurance getting two bills. Insurance will just pay one. Who is going to get the money? Should it be split evenly between the PCP and ER doc? First one to see the patient? Last one to see the patient?

 

[RustedFox]

I worked in med mal office prior to med school. If someone did an InD and missed a loculation and they ended up in the ICU with septic shock, you know that pt's lawyer is going to rake the docs over the coals. We all know how lawyers are.

Uhh. No.
I say again: missing a loculation isn't going to result in septic shock, and the imaging (or lack thereof) also didn't contribute. It doesn't work that way.

Where are you at in your medical education? No heat; just trying to gage where you're at, amigo.

 

[VA Hopeful Dr]

Wait what? Is this how pcps really think, especially with something this simple? Hell, just send everyone to the ED for everything so we can pan scan them so nothing gets missed. What could go wrong?

No, that is not how we think at all. Not even close.

 

[VA Hopeful Dr]

I worked in med mal office prior to med school. If someone did an InD and missed a loculation and they ended up in the ICU with septic shock, you know that pt's lawyer is going to rake the docs over the coals. We all know how lawyers are.


Let's treat everything in the office. What could go wrong?

I kid and don't mean to be snarky and really feel no negative feelings toward you. But a lot of offices aren't set up to do procedures. Most of the PCP offices (both community and academic) that I rotated through wouldn't even have a bin to catch all of the purulent d/c. Even if we had lidocaine and a scalpel, we just wouldn't have a bin or be able to pack it. We really would be doing a disservice to the pt treating them in the office.

You don't need a bin to catch pus, gauze works just fine. All you need to pack it is the packing material and a hemostat/forceps. So those, a scalpal, and lidocaine. That's literally it.

 

[cyanide12345678]

The flip side is, how do you know it for sure it is a simple abscess?

When I did PCP, if I did an InD in the office and missed a loculated abscess because I don't have any imaging and then patient goes into septic shock, then the pt suffers the most and potentially can die. Sending them to the ED and potentially getting imaging is the best for everyone imo. You have to remember that some PCP and UC offices can't even run a CBC that same day.

Lol i hardly ever image an abscess. Who needs to image an abscess unless perirectal or post surgical to see how deep they are. Most abscesses just need an 11 blade. That's it.

 

[Arcan57]

You don't need a bin to catch pus, gauze works just fine. All you need to pack it is the packing material and a hemostat/forceps. So those, a scalpal, and lidocaine. That's literally it.

You don't really need packing material. A couple of % difference in need for re I&D vs. 3x the amount of pain plus a guaranteed second visit.

 

[BoardingDoc]

You don't really need packing material. A couple of % difference in need for re I&D vs. 3x the amount of pain plus a guaranteed second visit.

Agreed.
Packing versus non-packing outcomes for abscesses after incision and drainage

TL;DR: In general, packing is not indicated. Possible exceptions include diabetic patient, immunocompromised patient, abscess >5cm.

 

[cyanide12345678]

I worked in med mal office prior to med school. If someone did an InD and missed a loculation and they ended up in the ICU with septic shock, you know that pt's lawyer is going to rake the docs over the coals. We all know how lawyers are.


Let's treat everything in the office. What could go wrong?

I kid and don't mean to be snarky and really feel no negative feelings toward you. But a lot of offices aren't set up to do procedures. Most of the PCP offices (both community and academic) that I rotated through wouldn't even have a bin to catch all of the purulent d/c. Even if we had lidocaine and a scalpel, we just wouldn't have a bin or be able to pack it. We really would be doing a disservice to the pt treating them in the office.

I'll tell you what can be treated in the office and shouldn't be sent to the ER:

For PCPs:

I&D, hypertension, rash unless SJS, cellulitis unless sick and old requiring potential admission.

For OB/Gyn:

Almost all vaginal bleeding. Threatened miscarriage in anyone with known IUP. I just don't understand why so many vaginal bleeders are sent in by ob/gyn.

The above two specialties are the biggest offenders in my opinion in not caring for their patients in the office for things they are more than capable of handling.

 

[The Knife & Gun Club]

I worked in med mal office prior to med school. If someone did an InD and missed a loculation and they ended up in the ICU with septic shock, you know that pt's lawyer is going to rake the docs over the coals. We all know how lawyers are.


Let's treat everything in the office. What could go wrong?

I kid and don't mean to be snarky and really feel no negative feelings toward you. But a lot of offices aren't set up to do procedures. Most of the PCP offices (both community and academic) that I rotated through wouldn't even have a bin to catch all of the purulent d/c. Even if we had lidocaine and a scalpel, we just wouldn't have a bin or be able to pack it. We really would be doing a disservice to the pt treating them in the office.

I’m confused here. Obviously I always break up all the loculations. And I always DOCUMENT that. If a person were to go into septic shock, how would anyone know that I missed a loculation? What imaging study proves that? What specialist can say it was my ID that caused them to be septic, not the giant abscess they had in their groin? And how would any lawyer ever have a case? I charted them all as broken up.

And what imaging is needed before hand? POC ultrasound can help verify it’s in fact an abscess not something else, but the vast majority can be done with palpating alone.

I can count on one hand the number of abscesses I’ve needed advanced imaging on in the last year.

Edit: to be clear, I totally get why PCPs don’t do this kind of thing…many don’t have the resources for it. But it certainly CAN be done.

 

[GeneralVeers]

Not sure how "not breaking up a loculation" leads to sepsis. More likely will prolong abscess healing. The very nature of an abscess is that it's walled off so it doesn't cause sepsis.

 

[Questionsaboutmedicine]

You don't need a bin to catch pus, gauze works just fine. All you need to pack it is the packing material and a hemostat/forceps. So those, a scalpal, and lidocaine. That's literally it.

Again, not all offices have the equipment to do it. Not all offices even have gauze. I would have to use paper towels to catch the d/c, which would be hard to do if there was >500 cc. Let's not even talking about hemostats and forceps, let alone POC US.

Uhh. No.
I say again: missing a loculation isn't going to result in septic shock, and the imaging (or lack thereof) also didn't contribute. It doesn't work that way.

Where are you at in your medical education? No heat; just trying to gage where you're at, amigo.

Fellow.

I have personally treated this in the ICU. They went and got an InD. Not all of it was drained. Then they don't f/u with anyone and just don't take care of themselves. They ignored all signs. Then they are brought in by family when they are in shock. I'll admit that this rare and unlikely, but it is possible. And to that pt, it isn't a rare occurance.

Heck, I had a pt go into shock after removing a small 2mm skin lesion. It got infected and they presented a few weeks later in shock. They were on my service and on pressors for weeks. True story. Now that I think about it, I should have published that case report because it was so unbelievable.

We just see different things as we function in different roles in the hospital. We can agree to disagree. You think you're right. I know I am right because I treated it in real life. There isn't much fruitful discussion that I can contribute on this topic as we are on an impasse. I won't be posting on this thread anymore. Thank you.

 

[VA Hopeful Dr]

Again, not all offices have the equipment to do it. Not all offices even have gauze. I would have to use paper towels to catch the d/c, which would be hard to do if there was >500 cc. Let's not even talking about hemostats and forceps, let alone POC US.

If an office doesn't have those minimum tools, it shouldn't be able to call itself a doctor's office.

 

[cyanide12345678]

Again, not all offices have the equipment to do it. Not all offices even have gauze. I would have to use paper towels to catch the d/c, which would be hard to do if there was >500 cc. Let's not even talking about hemostats and forceps, let alone POC US.


Fellow.

I have personally treated this in the ICU. They went and got an InD. Not all of it was drained. Then they don't f/u with anyone and just don't take care of themselves. They ignored all signs. Then they are brought in by family when they are in shock. I'll admit that this rare and unlikely, but it is possible. And to that pt, it isn't a rare occurance.

Heck, I had a pt go into shock after removing a small 2mm skin lesion. It got infected and they presented a few weeks later in shock. They were on my service and on pressors for weeks. True story. Now that I think about it, I should have published that case report because it was so unbelievable.

We just see different things as we function in different roles in the hospital. We can agree to disagree. You think you're right. I know I am right because I treated it in real life. There isn't much fruitful discussion that I can contribute on this topic as we are on an impasse. I won't be posting on this thread anymore. Thank you.

How many abssesses have 500cc of drainage? And what's wrong with paper towels?

A person can become septic from any infection. Even an abscess that is drained appropriately can reoccur, there's a failure rate to i and D that requires repeat drainage. It's weird to correlate becoming sick from an infection to drainage in the office. An ER drainage is just as likely to reoccur or worsen despite treatment. I don't know what fancy tools you think i have in the ER, i most likely did not use any of them when taking care of an abscess 😂

Your point of this being something that can't be handled in an office is ridiculous. Also you didn't answer fox's question, where are you at in your training because it doesn't sound like you are an attending yet.

 

[sylvanthus]

Looks like he/shes a fellow.