New Attending, How to Deal With Pushback?

[TheComebacKid]

I'm a relatively new attending in my first year out (did a fellowship last year with some moonlighting, but this is my first big boy job). I, like many new attendings tend to be on the more conservative side. At least once or twice on a shift, you get that patient that you know is going to be a soft admit, but you don't feel comfortable sending home. It sort of builds up over the next few hours as you prepare for the inevitable dreadful battle with the hospitalist, and sometimes I (regretfully) end up hoping I find something so I can keep them in the hospital. It's not that I have an issue discharging patients, but it's just that some people give you a high risk story, or have risk factors, or just look terrible despite what their numbers show. Sometimes, I just want them to be watched for awhile, but I know it's a soft admit and I'm going to get reamed by the hospitalist.

We really live by a doctrine of ensuring outpatient follow up for our patients. Well, if it takes 6 months to get in to see a cardiologist for a chest pain workup, I don't feel comfortable sending them home to just wait it out.

I really dread these "low risk" chest pain patients. At my hospital I have a hard time coordinating outpatient follow up for them. They say all the bad things. They have all the risk factors. But sometimes they lack objective data i.e. EKG changes or enzyme leak etc. Pitching these patients to the hospitalist is a nightmare, and I hate the phone call. "They have two negative troponins and a unchanged EKG, what are we going to do for them in the hospital?" or "They presented for the same thing 2 months ago and had a negative workup." These points and questions are valid on part of the hospitalist, and I do think avoiding unnecessary admissions is a good thing. HEART scores, while I love them, IMO seem very conservative and probably lead to many unnecessary admissions and stress tests. But I think my risk tolerance is exceedingly low, and when patients are old, or tell a good story, I just get nervous and err on the side of wanting to keep them. I'm not particularly proud of this, and don't think it makes me a great doctor, and sometimes I feel like a wuss.

2 nights ago I had a patient: 83 year old male, history of atrial fibrillation not on anticoagulation. Syncopized in the kitchen while cooking, broke his mandible on the kitchen counter. EKG just revealed atrial fibrillation (rate controlled). Troponin was negative. He just looked terrible. And he looked old. And I didn't have a reason for why he syncopized. His CHADS-2 score was 3. He was recommended by cardiology years ago to start anticoagulation, but for some reason, never did. He just looked awful, and I wanted to keep him despite any objective data, he seemed like a high risk person to me, and the hospitalist was having none of it.

My admits are probably overkill, and I fully concede that. But how do I become less conservative? Is it just time? How do I not get that patient that I am going to dread calling the hospitalist the entire time? I want to be a good steward of healthcare resources, the hospitalists time, etc but I also want to sleep at night. All of these things seem to be at odds with each other.

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[sylvanthus]

I'm a relatively new attending in my first year out (did a fellowship last year with some moonlighting, but this is my first big boy job). I, like many new attendings tend to be on the more conservative side. At least once or twice on a shift, you get that patient that you know is going to be a soft admit, but you don't feel comfortable sending home. It sort of builds up over the next few hours as you prepare for the inevitable dreadful battle with the hospitalist, and sometimes I (regretfully) end up hoping I find something so I can keep them in the hospital. It's not that I have an issue discharging patients, but it's just that some people give you a high risk story, or have risk factors, or just look terrible despite what their numbers show. Sometimes, I just want them to be watched for awhile, but I know it's a soft admit and I'm going to get reamed by the hospitalist.

We really live by a doctrine of ensuring outpatient follow up for our patients. Well, if it takes 6 months to get in to see a cardiologist for a chest pain workup, I don't feel comfortable sending them home to just wait it out.

I really dread these "low risk" chest pain patients. At my hospital I have a hard time coordinating outpatient follow up for them. They say all the bad things. They have all the risk factors. But sometimes they lack objective data i.e. EKG changes or enzyme leak etc. Pitching these patients to the hospitalist is a nightmare, and I hate the phone call. "They have two negative troponins and a unchanged EKG, what are we going to do for them in the hospital?" or "They presented for the same thing 2 months ago and had a negative workup." These points and questions are valid on part of the hospitalist, and I do think avoiding unnecessary admissions is a good thing. HEART scores, while I love them, IMO seem very conservative and probably lead to many unnecessary admissions and stress tests. But I think my risk tolerance is exceedingly low, and when patients are old, or tell a good story, I just get nervous and err on the side of wanting to keep them. I'm not particularly proud of this, and don't think it makes me a great doctor, and sometimes I feel like a wuss.

2 nights ago I had a patient: 83 year old male, history of atrial fibrillation not on anticoagulation. Syncopized in the kitchen while cooking, broke his mandible on the kitchen counter. EKG just revealed atrial fibrillation (rate controlled). Troponin was negative. He just looked terrible. And he looked old. And I didn't have a reason for why he syncopized. His CHADS-2 score was 3. He was recommended by cardiology years ago to start anticoagulation, but for some reason, never did. He just looked awful, and I wanted to keep him despite any objective data, he seemed like a high risk person to me, and the hospitalist was having none of it.

My admits are probably overkill, and I fully concede that. But how do I become less conservative? Is it just time? How do I not get that patient that I am going to dread calling the hospitalist the entire time? I want to be a good steward of healthcare resources, the hospitalists time, etc but I also want to sleep at night. All of these things seem to be at odds with each other.

Sometimes you have to be firm if you genuinely feel they need to be admitted. Tell them you are not comfortable discharging them from the ED. Done, end of story. Dont give a long winded explanation as the hospitalist will try and refute it point by point.

But remember if you do this alot, and the workup is completely benign each time, they will remember and you will be that guy.

 

[TheComebacKid]

But remember if you do this alot, and the workup is completely benign each time, they will remember and you will be that guy.

Definitely a reputation I’m trying to avoid.
Everyone in residency had “that attending” and I just don’t want to be that person.

 

[Torsion]

2 nights ago I had a patient: 83 year old male, history of atrial fibrillation not on anticoagulation. Syncopized in the kitchen while cooking, broke his mandible on the kitchen counter. EKG just revealed atrial fibrillation (rate controlled). Troponin was negative. He just looked terrible. And he looked old. And I didn't have a reason for why he syncopized. His CHADS-2 score was 3. He was recommended by cardiology years ago to start anticoagulation, but for some reason, never did. He just looked awful, and I wanted to keep him despite any objective data, he seemed like a high risk person to me, and the hospitalist was having none of it.

This would be an easy admit at my residency. He sounds like a high risk guy with unexplained syncope. I'm more curious to know what the hospitalist' justification was for not admitting.

I often feel like we admit every chest painer no matter how low risk at my hospital, but the story above seems like an entirely reasonable admission.

 

[Mount Asclepius]

First off. You are not alone. You should feel this way a little as a new attending or you are probably over confident.

high risk story, or have risk factors, or just look terrible despite what their numbers show

Tell them this. Usually works for me.

I really dread these "low risk" chest pain patients.

Low risk chest pain should usually be discharged. I don’t dread them as they bill well and have lower medicolegal risk. I often discharge HEART score moderate risk patients as well. Age and risk factors alone often make people moderate risk. If they have a terrible story and no history of exertional angina then I don’t usually feel an admission will benefit them. Not all admitted chest pain patients get stressed. Stress tests can lead to false positives, which lead to rare cath complications. We take on risk practicing emergency medicine and I feel comfortable discharging chest pain patients with negative workups. This took time and experience though to develop. I often also offer admission telling patients that it is the standard of care, but discuss why I think it is unnecessary. I then document something along the lines of admission offered and recommended per guidelines, but patient declines preferring outpatient management which I feel is reasonable.

2 nights ago I had a patient: 83 year old male, history of atrial fibrillation not on anticoagulation. Syncopized in the kitchen while cooking, broke his mandible on the kitchen counter. EKG just revealed atrial fibrillation (rate controlled). Troponin was negative. He just looked terrible. And he looked old. And I didn't have a reason for why he syncopized. His CHADS-2 score was 3. He was recommended by cardiology years ago to start anticoagulation, but for some reason, never did. He just looked awful, and I wanted to keep him despite any objective data, he seemed like a high risk person to me, and the hospitalist was having none of it.

Completely reasonable admit. A top ten list to explain why:

1) Mandible fracture. Can’t chew. Risk for inability to tolerate PO. Needs ENT consult for possible ORIF.
2) Unexplained syncope. Needs telemetry observation and further evaluation.
3) Needs clarification of anticoagulation.
4) Doesn’t follow up outpatient either due to access or noncompliance.
5) Looks awful. We teach medical students initially that this is the most important thing. Sick or not sick. Stick to your gestalt when you feel this.
6) 83.
7) Looks old. Apparently older than 83. 90+ year olds want admitted or discharged? Do what they want. It’s the last years of their lives. They want to spend time in a hospital, it’s their call. Also, sometimes they just know well when something is wrong.
8) Have the hospitalist evaluate the patient at bedside. Easy to reject an admission over the phone when you don’t have to see and actually think about a human being.
9) Troponin is typically worthless for syncope without chest pain (my two cents). It also gives the hospitalist ammo for not admitting. If it wasn’t checked then it makes them sometimes more squeamish if there isn’t more objective data to block an admission.
10) You are being conservative as a new attending, which you should be. This patient isn’t the one to worry about.

My admits are probably overkill, and I fully concede that. But how do I become less conservative? Is it just time? How do I not get that patient that I am going to dread calling the hospitalist the entire time? I want to be a good steward of healthcare resources, the hospitalists time, etc but I also want to sleep at night. All of these things seem to be at odds with each other.

Yes, it’s mostly time and experience. We don’t have the luxury to pick who walks in the door. We do have the skill and develop the experience to mostly dictate their disposition. Most of the time though it’s not your hill to die on. Objective abnormalities and a patient really wants to be in the hospital - so be it. Everything normal and the patient wants to go home - sweet deal, next patient. Eventually the yin and yang will work itself out about 3-5 years post graduation. Everything gradually gets smoother until that point, and dramatically so between 3-12 months. Hang in there!

 

[southerndoc]

Mandible fractures aren't a reason to admit. I drank protein shakes for weeks after my mandible fracture. And for that call to transfer these, 99% of them can go home and all are open by definition. I've never seen a mandible fracture (including my own) that didn't break the gumline.

 

[PianoMedic]

That guy is a high risk syncope. If you pass out suddenly without cause, they’re old and have a baseline arrhythmia that isn’t a low risk syncope to me. “I have a guy with a story concerning for cardiac syncope who needs further work up and admission”. Low risk chest pain is hard. I work at two different shops. One I can get a next day or sometimes same day stress without known coronary disease. If they have known cad, I talk with the cardiologist. At the other, we can’t get a stress for over a month and so our cardiologists would prefer the patients be admitted. It sounds like more of a culture or system problem. I’d talk with the other ED attendings at your shop to figure out what the local culture is on those kinds of things. We tend to discharge low risk syncope (nonconcerning story, no significant risk factors for cardiac syncope, neg h&p for other serious causes or neg work up, etc) at both shops but I don’t get pushback on high risk syncope. I do get pushback on soft admits, so I just lead with “hey this is a soft admit, I’m sorry about this…” then give my reasons why I don’t think they can go home. I try to involve the patient in the decision making if they’re reasonable, sometimes they’d rather go home and call their cardiologist. I just give very good return precautions on when to return. My shop has been dealing with the hospitalists for years so a lot of things have gotten hashed out as formal or informal protocols which help a lot. At the stress test shop, the hospitalists are “consulted for admission”. So we can fall back on the fact that we have seen the patient and they haven’t. If they want to discharge the patient after examining them, they’re welcome to do so if they don’t think patient meets criteria or whatever their reasoning. But this is part of an established written protocol and it is well known there, so we can draw the line in the sand if we have to. I don’t do it often (maybe three times in the past two or three years) but it is there if we have to. And one of those times the Hospitalist came down, gave another 80 mg lasix, got the guy off oxygen and discharged him. Don’t know if any of that rambling was helpful. Good luck and ask around.

 

[Mount Asclepius]

Mandible fractures aren't a reason to admit. I drank protein shakes for weeks after my mandible fracture. And for that call to transfer these, 99% of them can go home and all are open by definition. I've never seen a mandible fracture (including my own) that didn't break the gumline.

A mandible fracture by itself may not need admission. It very well may though if the patient was 83 and it was secondary to a fall or syncopal episode. You send these home and it’s 50/50 if they bounce back and get admitted because something else was concomitantly occurring or they failed to thrive at home.

 

[southerndoc]

A mandible fracture by itself may not need admission. It very well may though if the patient was 83 and it was secondary to a fall or syncopal episode. You send these home and it’s 50/50 if they bounce back and get admitted because something else was concomitantly occurring or they failed to thrive at home.

Syncope may be an indication for admission, but a mandible fracture is not.

 

[Jabbed]

You just need to use the buzz words that the hospitalists know will meet inpatient billing criteria.

Your first patient is clearly a high risk cardiac syncope by any criteria so I'm not sure why there was any pushback. I'll regularly use (and chart) decision-making tools so that there's no ambiguity. With a stone cold normal EKG and labs your 83 year old is a medium risk syncope by Canadian Syncope Risk Score and has an 8.1% 30-day mortality. This warrants inpatient eval. There's really no rational way to argue with this.

There are two sides to this of course: if you're routinely admitting your HEART < 3, you're doing it wrong. The new GRACE-1 guidelines, while based on expert consensus, also give you more justification for discharging recurrent low-risk chest pain.

Mandibular fracture is not inpatient criteria. A patient that is an unsafe discharge because they are elderly and live alone and can't take care of themselves is. Does your mandibular fracture have intractable pain that was unresponsive to two doses of IV opiates (even 2 mg morphine x 2)? Are they unable to ambulate?

 

[Jabbed]

The real tricky dispos though are the one's with known CAD, PCI q1-2years, non-compliant, but had a "negative stress test" last month. I still admit these and get flack sometimes. If it's daytime hours you can maybe call cards to come dispo. Most times they'll request an obs admit, but at least the hospitalist now has a specialist in their corner with a defined plan. On overnights I'll use up my goodwill with the hospitalists and admit these to obs.

 

[Jabbed]

Also the number of patients discharged from EDs that go home to have an MI has been roughly 2% for years despite all these changes in risk stratification and expedited follow-ups. You're going to miss one eventually (probably within your first year). You need to be okay with the idea of this or it'll eat you alive.

 

[Porfirio]

If the Heart score is low and you are concerned, first call Cardiology to get their recs.

If the Heart score is moderate and negative recent work up, first call Cardiology to get their recs.

If the hospitalist wants to go against Cardiology and EM recs, have them come write a discharge note from the ED. (Very bad hospitalist btw if this happens)

I find hospitalists want me to tell them what to do. Hospitalists are consult jockeys - many of them act more as a mid-level than practice true medicine. Just tell them what to do. That old guy with risk factors and concerning story for syncope = tell hospitalist that he needs tele and observation for cardiac arrhythmia or if the dude is on meds that alter mentation (heavy blood pressure meds and his pressures are semi soft) tell the hospitalist he needs observation for medication metabolism and maximizing outpatient blood pressure control in addition to the tele.

You are not being that attending from residency that admits everything. You are being the attending that cares about their patient.

All lawsuits start with a bad outcome (some cannot be avoided).

 

[Groove]

I'm a relatively new attending in my first year out (did a fellowship last year with some moonlighting, but this is my first big boy job). I, like many new attendings tend to be on the more conservative side. At least once or twice on a shift, you get that patient that you know is going to be a soft admit, but you don't feel comfortable sending home. It sort of builds up over the next few hours as you prepare for the inevitable dreadful battle with the hospitalist, and sometimes I (regretfully) end up hoping I find something so I can keep them in the hospital. It's not that I have an issue discharging patients, but it's just that some people give you a high risk story, or have risk factors, or just look terrible despite what their numbers show. Sometimes, I just want them to be watched for awhile, but I know it's a soft admit and I'm going to get reamed by the hospitalist.

We really live by a doctrine of ensuring outpatient follow up for our patients. Well, if it takes 6 months to get in to see a cardiologist for a chest pain workup, I don't feel comfortable sending them home to just wait it out.

I really dread these "low risk" chest pain patients. At my hospital I have a hard time coordinating outpatient follow up for them. They say all the bad things. They have all the risk factors. But sometimes they lack objective data i.e. EKG changes or enzyme leak etc. Pitching these patients to the hospitalist is a nightmare, and I hate the phone call. "They have two negative troponins and a unchanged EKG, what are we going to do for them in the hospital?" or "They presented for the same thing 2 months ago and had a negative workup." These points and questions are valid on part of the hospitalist, and I do think avoiding unnecessary admissions is a good thing. HEART scores, while I love them, IMO seem very conservative and probably lead to many unnecessary admissions and stress tests. But I think my risk tolerance is exceedingly low, and when patients are old, or tell a good story, I just get nervous and err on the side of wanting to keep them. I'm not particularly proud of this, and don't think it makes me a great doctor, and sometimes I feel like a wuss.

2 nights ago I had a patient: 83 year old male, history of atrial fibrillation not on anticoagulation. Syncopized in the kitchen while cooking, broke his mandible on the kitchen counter. EKG just revealed atrial fibrillation (rate controlled). Troponin was negative. He just looked terrible. And he looked old. And I didn't have a reason for why he syncopized. His CHADS-2 score was 3. He was recommended by cardiology years ago to start anticoagulation, but for some reason, never did. He just looked awful, and I wanted to keep him despite any objective data, he seemed like a high risk person to me, and the hospitalist was having none of it.

My admits are probably overkill, and I fully concede that. But how do I become less conservative? Is it just time? How do I not get that patient that I am going to dread calling the hospitalist the entire time? I want to be a good steward of healthcare resources, the hospitalists time, etc but I also want to sleep at night. All of these things seem to be at odds with each other.

You're just going to have to get used to discharging low risk chest pain. Especially in this day an age where bed shortages abound and we need to prioritize those few remaining beds for the sick patients. There is copious data to support an outpatient work up for the majority of relatively low risk chest pain patients with negative work up in the ER. I send them home for outpatient work up all day, every day. I only admit the high risk players. If you are nervous sending some of these home, consult cards for "buy in" regarding their disposition home for outpatient work up and you can add their name and the consult details to the note.

The syncope patient is a very reasonable admit for telemetry to rule out arrhythmogenic etiologies. Is he having brief runs of RVR? VT? Does he have labile BP with the afib? Is it properly rate controlled? Anti-coagulation? TIA? This case easily fails San Francisco Syncope and OESIL clinical decision rules.

If you want to "Buff" the admission as I call it. Then call and get "buy in" from a specialist prior to calling the hospitalist. Whether that's neuro, cards, etc.. Obtaining buy in is pretty easy as you are calling them to run a case by them, get recs and ultimately ascertain whether they are copacetic with seeing the pt in the hospital as a consult. Once you get buy in, you can call the hospitalist and sell it as an admission that the specialist thought was reasonable and they have X, Y, Z planned and/or wanted to see the pt in consultation. It's usually too difficult for the hospitalist to waste time seeing the pt, then calling the specialist and trying to override your consult. Ultimately, you can always tell them that you are uncomfortable sending them home and are formally consulting the hospitalist to evaluate the pt in the ED and add a note to the chart indicating why they are refusing admission. Most hospitalists don't want to go this route either because it's time consuming. It's also not a request that can be ignored as it's an EMTALA violation if they refuse and most hospital bylaws dictate that they are required to see the pt within X number of hours. If you want to get nasty, you can threaten to transfer the pt to another facility for admission because you are uncomfortable sending them home and inform the hospitalist/specialist that you intend on putting their name on the transfer form as refusing the consult leading to transfer which constitutes an EMTALA violation and will be letting hospital administration know about the violation prior to transfer.

The last example is very nasty and not recommended as although it will brute force your admission, you burn bridges with your consultants in this way and you better be damn sure the pt has a legit reason for admission if you go down this road. However, it just goes to show how the ED holds a lot more "aces in the deck" than it might appear at first glance. Now, all that being said....being comfortable with discharging patients takes time, lots of cases, familiarity with hospital work ups and what's appropriate for inpatient vs outpatient work up, etc.. You'll form a clinical gestalt with time that will start to give you the confidence needed to discharge reasonable patients. My hospitalists love me because I rarely admit BS. If I call them, it's almost always legit and I have a great working relationship with them because they know I am moving heaven and earth to discharge as many people as I reasonably can for outpatient work ups.

2 quick recommendations. Find the reporting functionality in your EMR and generate 2 reports each month. One report shows all your hospital admissions and the other report shows 3d or 5d bounce backs resulting in either discharge or admission. I have followed my inpatient admits throughout my entire career and am intimately familiar with the routine indications for inpatient work up and it's given me a great deal of familiarity with what sorts of tests need to be completed prior to discharge and this helps as when you call the hospitalist for admission, you already know what needs to happen next and can sometimes list out X, Y, Z as reasonable next steps when the hospitalist goes "Well, what am I going to do with them in the hospital??". Next, the 72h or 5d bounce back will give you confidence over time that many of these patients that you sent home did just fine and didn't show back up for admission in the next few days. I've generated these types of reports over my entire career thus far with different EMRs and run them at least once a month. I follow almost all of my admits out of curiosity to see what they found, etc.. All of that might give you extra confidence in the long run for both admits and discharges. Good luck. You'll do fine.

 

[Angry Birds]

Don't be that guy. But the fact you don't want to be that guy means you're probably not.
My CT scan use in first year as attending was sky high. Not any more. You learn.

 

[TheComebacKid]

Low risk chest pain should usually be discharged. I don’t dread them as they bill well and have lower medicolegal risk. I often discharge HEART score moderate risk patients as well. Age and risk factors alone often make people moderate risk. If they have a terrible story and no history of exertional angina then I don’t usually feel an admission will benefit them. Not all admitted chest pain patients get stressed. Stress tests can lead to false positives, which lead to rare cath complications. We take on risk practicing emergency medicine and I feel comfortable discharging chest pain patients with negative workups. This took time and experience though to develop. I often also offer admission telling patients that it is the standard of care, but discuss why I think it is unnecessary. I then document something along the lines of admission offered and recommended per guidelines, but patient declines preferring outpatient management which I feel is reasonable.

I find that chest pain folks come in a couple of flavors.

The low riskers: younger, no significant risk factors, negative troponin x2, no concerning EKG changes. Low HEART scores. I can discharge these all day everyday.

The moderate riskers: middle aged/elderly, a handful of risk factors. EKG/troponins are not concerning. Maybe their HEART score is low to moderate risk. They show up to the ED several times a year for chest pain. They sometimes will get stressed, or they often times get dismissed as having "atypical chest pain" or MSK related complaints. Don't have established follow up. Sometimes they have a history of CAD, but they were just in the ED two weeks ago with the same complaint, and were sent home and now they are back. They will have a UDS that is positive for cocaine a month ago that the hospitalist will latch onto. Maybe they are homeless. These are the patients that I hate arguing with the hospitalist for.

The high riskers: Prior stents, multiple cardiovascular risk factors, concerning story etc. Its easy if they have elevated enzymes or EKG changes to admit.


I think you hit the nail on the head... there are some patients, no matter what happens, EVERY SINGLE TIME they set foot in an ED, they are moderate to high risk based on age/risk factors alone. They may have had a Cath 6 months ago, or a recent stress test. But they are still having chest pain symptoms. I sometimes struggle with "is today the day that it all goes to hell for them?"

I don't live in an area where cardiologists are answering my calls and saying "sounds reasonable, I'll see them in the clinic in the next 48 hours and work them up". If they've had the same chest pain for weeks, I also don't understand why the PCPs and cardiologists are sending them to the ED, and then getting upset when we try to tee them up for an admit.


In residency, the moderate risk patients were very easy to admit for me. Now not so much. I usually could pretty easily admit any patient with a history of CAD who presented with chest pain, irrespective of what their EKG/enzymes were. Maybe it's COVID pinching beds, but there's definitely a lot more pushback at my new job to admit these folks.

 

[TheComebacKid]

This would be an easy admit at my residency. He sounds like a high risk guy with unexplained syncope. I'm more curious to know what the hospitalist' justification was for not admitting.

I often feel like we admit every chest painer no matter how low risk at my hospital, but the story above seems like an entirely reasonable admission.

My hospital has "high risk" syncope admission guidelines. This is the standard stuff that we all know of. New EKG changes, exertion syncope, CHF with depressed EF, valvular disease, family history of sudden cardiac death etc. There's nothing in the guidelines about "really old, with an underlying arrhythmia that hasn't really been treated, with a broken jaw and just looks s***y. Doesn't have expedited PCP follow up" I could admit this in residency very easily too.

 

[TheComebacKid]

If the Heart score is low and you are concerned, first call Cardiology to get their recs.

If the Heart score is moderate and negative recent work up, first call Cardiology to get their recs.

If the hospitalist wants to go against Cardiology and EM recs, have them come write a discharge note from the ED. (Very bad hospitalist btw if this happens)

I find hospitalists want me to tell them what to do. Hospitalists are consult jockeys - many of them act more as a mid-level than practice true medicine. Just tell them what to do. That old guy with risk factors and concerning story for syncope = tell hospitalist that he needs tele and observation for cardiac arrhythmia or if the dude is on meds that alter mentation (heavy blood pressure meds and his pressures are semi soft) tell the hospitalist he needs observation for medication metabolism and maximizing outpatient blood pressure control in addition to the tele.

You are not being that attending from residency that admits everything. You are being the attending that cares about their patient.

All lawsuits start with a bad outcome (some cannot be avoided).

Thanks for your comments.

I find calling cardiology for recommendations to be very different than consulting cardiology and them seeing the patient and writing a note. Outside of a STEMI or maybe a high risk NSTEMI that needs an urgent Cath, cardiologists aren't coming down to the ED to see patients, especially not after hours.

I would argue that low risk HEART score patients won't even get a call from cards from me. PCPs can deal with many of these patients, if the patient has a PCP to begin with.

As I stated in my prior post, the moderate risk patients are very challenging. Cards won't often times be interested in these patients.

I recognize that chest pain patients utilize tons of resources, often times have extremely benign workups, or false positive stress tests that lead to unnecessary testing. But they also lead to big malpractice payouts and unfortunately lead to bad outcomes for the patients if there's a missed opportunity.

In my opinion, if cardiologists and hospitalists don't like admitting these chest pain patients, then more needs to be done to optimize their care on their end as opposed to sending them to the ED. I really don't feel comfortable writing off a guy with a prior CABG, CAD, multiple PCIs as having "MSK related chest pain" just because he presents to the ED for this frequently.

 

[Birdstrike]

I'm a relatively new attending in my first year out (did a fellowship last year with some moonlighting, but this is my first big boy job). I, like many new attendings tend to be on the more conservative side. At least once or twice on a shift, you get that patient that you know is going to be a soft admit, but you don't feel comfortable sending home. It sort of builds up over the next few hours as you prepare for the inevitable dreadful battle with the hospitalist, and sometimes I (regretfully) end up hoping I find something so I can keep them in the hospital. It's not that I have an issue discharging patients, but it's just that some people give you a high risk story, or have risk factors, or just look terrible despite what their numbers show. Sometimes, I just want them to be watched for awhile, but I know it's a soft admit and I'm going to get reamed by the hospitalist.

We really live by a doctrine of ensuring outpatient follow up for our patients. Well, if it takes 6 months to get in to see a cardiologist for a chest pain workup, I don't feel comfortable sending them home to just wait it out.

I really dread these "low risk" chest pain patients. At my hospital I have a hard time coordinating outpatient follow up for them. They say all the bad things. They have all the risk factors. But sometimes they lack objective data i.e. EKG changes or enzyme leak etc. Pitching these patients to the hospitalist is a nightmare, and I hate the phone call. "They have two negative troponins and a unchanged EKG, what are we going to do for them in the hospital?" or "They presented for the same thing 2 months ago and had a negative workup." These points and questions are valid on part of the hospitalist, and I do think avoiding unnecessary admissions is a good thing. HEART scores, while I love them, IMO seem very conservative and probably lead to many unnecessary admissions and stress tests. But I think my risk tolerance is exceedingly low, and when patients are old, or tell a good story, I just get nervous and err on the side of wanting to keep them. I'm not particularly proud of this, and don't think it makes me a great doctor, and sometimes I feel like a wuss.

2 nights ago I had a patient: 83 year old male, history of atrial fibrillation not on anticoagulation. Syncopized in the kitchen while cooking, broke his mandible on the kitchen counter. EKG just revealed atrial fibrillation (rate controlled). Troponin was negative. He just looked terrible. And he looked old. And I didn't have a reason for why he syncopized. His CHADS-2 score was 3. He was recommended by cardiology years ago to start anticoagulation, but for some reason, never did. He just looked awful, and I wanted to keep him despite any objective data, he seemed like a high risk person to me, and the hospitalist was having none of it.

My admits are probably overkill, and I fully concede that. But how do I become less conservative? Is it just time? How do I not get that patient that I am going to dread calling the hospitalist the entire time? I want to be a good steward of healthcare resources, the hospitalists time, etc but I also want to sleep at night. All of these things seem to be at odds with each other.

Do what you think is right. Period. Don't worry about "being that guy." It's normal to be extra cautious when you're new. You should be. And it's normal for hospitalists to complain about admissions. That will never change. If you're "that guy" for a while. So be it. Someone's got to be. The grizzled, burnout out hospitalists can suck it up. They knew every ER has one. Tough cookies.

 

[Porfirio]

Thanks for your comments.

I find calling cardiology for recommendations to be very different than consulting cardiology and them seeing the patient and writing a note. Outside of a STEMI or maybe a high risk NSTEMI that needs an urgent Cath, cardiologists aren't coming down to the ED to see patients, especially not after hours.

I would argue that low risk HEART score patients won't even get a call from cards from me. PCPs can deal with many of these patients, if the patient has a PCP to begin with.

As I stated in my prior post, the moderate risk patients are very challenging. Cards won't often times be interested in these patients.

I recognize that chest pain patients utilize tons of resources, often times have extremely benign workups, or false positive stress tests that lead to unnecessary testing. But they also lead to big malpractice payouts and unfortunately lead to bad outcomes for the patients if there's a missed opportunity.

In my opinion, if cardiologists and hospitalists don't like admitting these chest pain patients, then more needs to be done to optimize their care on their end as opposed to sending them to the ED. I really don't feel comfortable writing off a guy with a prior CABG, CAD, multiple PCIs as having "MSK related chest pain" just because he presents to the ED for this frequently.

Some patients are going to have chest pain their entire life until they have the big one that takes them out. It is a game of Russian roulette that we all play as doctors. You want as many fingerprints on the revolver as possible.

 

[turkeyjerky]

My hospital has "high risk" syncope admission guidelines. This is the standard stuff that we all know of. New EKG changes, exertion syncope, CHF with depressed EF, valvular disease, family history of sudden cardiac death etc. There's nothing in the guidelines about "really old, with an underlying arrhythmia that hasn't really been treated, with a broken jaw and just looks s***y. Doesn't have expedited PCP follow up" I could admit this in residency very easily too.

Dude--that syncope patient is not a soft admit. It's a stone cold, 100% guaranteed, do-no-pass-go admission. (Just know why you're admitting. It's not for ORIF, w/u of afib, to clarify question of anticoagulation, high CHADS2 or ABCD2 criteria or other nonsense. It's cause he had a presentation concerning for cardiac syncope (?sick-sinus syndrome and transient CHB. If he's got afib, by definition he has some element of conducting system disease. Moreover, if it's non-cardiac syncope, he's likely unable to maintain his hydration and will come back in worse shape).

With the rest, I'd recommend trying to figure out what the sticking points for admission are. As mentioned above, different hospitals and hospitalists have different cultures w/ regard to soft admits and it takes a while to tease out. At one place I used to work it was pulling teeth to get someone admitted for nursing home placement but they'd bring in chest pain rule-outs w/o any issue. Opposite at another one. So sometimes it becomes about manipulating the reasons--"this patient needs to come in b/c they're too weak to walk and need overnight hydration and to clarify their social situation". Find a decision rule that justifies whatever you wanted to do anyway.

Also, sometimes hospitalists get weird and task-focused and just need to be called out for it. I had one patient come in w/ a hgb in the 3's. I call up the hospitalist, say I've ordered a few units and they need to come in and get met w/ a response of, "well I'm not sure what else I would do fro them. Can't you just send them home after the transfusion is done?" A few weeks ago I got pushback on a patient who came in w/ fairly typical CP who'd been discharged earlier that week. They'd had an abnml stress test but cards had decided against cath based on age/comorbidities. His trop was even bumped a little higher than before. Hospitalist pushed back saying that cards isn't going to cath him so why admit. I had to kindly remind him that there are reasons beyond PCI to admit patients w/ ACS, as well as the fact that the patient was, by definition, now failing noninvasive management. Not to mention how bad it would look for all the hospital if the patient went home and died of an arrhythmia.

 

[Mount Asclepius]

Sometimes I think the HEART score does us a disservice when we put people into separate low, medium and high risk boxes. Some people will always be medium risk by definition, but may be low or high risk depending upon the day, story and presentation. Everyone has some risk. EPs are going to have differing risk tolerances. I probably have a higher risk tolerance for patients with negative ED chest pain work ups than some. I’m not sure stress tests offer a ton of benefit. Everyone has seen someone with a recent negative stress go on to have a MI. My personal favorite was the one that started having chest pain during his ED ‘negative’ stress and then went on to have a full blown NSTEMI while still in the ED after the negative stress test report was finalized. Caths outside of STEMI or OMI also offer questionable benefit. People are ticking time bombs. Load the boat, or don’t. Eventually your ship will sink and it may or may not even result in litigation. Your older homeless cocaine addict with no family who comes to the ED every other day for chest pain, probably isn’t going to sue you if your thousandth negative work up precedes you being the last one holding the hot potato. Becoming comfortable with the unknown and risk is an important part of this job, otherwise it will eat you alive and you will become that attending you didn’t want to be.

Another point I forgot to add is that falls and syncope are often harbingers of something else. I include both as it can be tough to differentiate between the two. People often fall when they become ill. Falls frequently are in the top five chief complaints of people with sepsis. People often syncopize due to hypovolemia, which may or may not be secondary to another cause. Arrhythmogenic syncope as many others have alluded to is a concern for your example. Just because a lot of people have benign causes and normal workups of falls or syncope, doesn’t mean everyone will.

 

[Mount Asclepius]

The mandibular fracture may seem like an outpatient thing, but if it requires fixation, good luck finding a surgeon who will fix it in a timely manner for a 83 year with non-managed atrial fibrillation who just syncopized without cardiac clearance first. Admission is the soonest means to an end and most beneficial for the patient.

 

[e30ftw]

As stated the elderly syncope should be an easy admission. Now at the same time I would certainly discharge that patient if they wanted to go home and had good follow up and were aware of risks, etc, but if the overall arc of the encounter is admission you should have no problem admitting that patient.

It may say something about either your hospitalist culture or the tone of your presentation if you're getting pushback on those cases.

I get pushback maybe once a year on patients. Usually it's something like intractable n/v w chronic abd pain and 5 ED visits in past 48 hours. I try very hard not to admit these but ultimately we all get stuck sometimes and it just is what it is.. The last was an obese diabetic with severe symptomatic dyspnea due to acute bilateral pulmonary emboli. Technically lower risk PE as CT did not show RH strain and her trop was neg but was so SOB couldn't walk to bathroom unassisted w sat 92% and generally unhealthy, etc. It was a new hospitalist who gave me a speech about how during his residency the ICU attending would rant about how PEs can be managed outpatient and why can't I just discharge her on eliquis, etc..

We all know obviously know this but as EM physicians how many technically "low risk" PEs have you seen code and die after being admitted? > 5 for me and this lady clearly would just come right back or call EMS and clearly stated "I don't feel safe going home." So you just tell hospitalist in a clear monotone voice "This is an unhealthy, ill-appearing patient with poor social support, who is unable to ambulate unassisted due to acute bilateral pulmonary emboli, I am concerned about her safety if discharged and would like you to evaluate the patient."

Per most hospital policies, they're required to see the patient. Again this is like a once a year situation. Most of our hospitalist are great.

The key is knowing CMS admission criteria and framing your presentation in a way that the hospitalist understands the only possible option is this patient being admitted to the hospital. A lot depends on your tone and confidence with presentations, which should increase with time.

When you call a consultant or call for admission, you're not asking for help or advice, you're telling the physician that he/she has a new patient. Not asking, telling. You can be very cordial and pleasant and nice about it but ultimately waking ENT up at 0200 for a patient with stridor due to a laryngeal mass and a 2mm subglottic airway, you don't ask, "What would you like the next step in management to be?" because they'll just tell you to discharge the patient, you say "I am admitting a patient high-risk for airway obstruction to the ICU and the admitting physician will be consulting you.." etc.

Again, we all try to play nice and I'll try to bundle gen surg c/s at night to only wake them up once etc, but ultimately my responsibility is to the patient and as the expert in emergency medicine, if I do not think the patient is safe to go home, for whatever reason, I am admitting them and hospitalist can eval and dispo.

 

[cardsperson]

As stated the elderly syncope should be an easy admission. Now at the same time I would certainly discharge that patient if they wanted to go home and had good follow up and were aware of risks, etc, but if the overall arc of the encounter is admission you should have no problem admitting that patient.

It may say something about either your hospitalist culture or the tone of your presentation if you're getting pushback on those cases.

I get pushback maybe once a year on patients. Usually it's something like intractable n/v w chronic abd pain and 5 ED visits in past 48 hours. I try very hard not to admit these but ultimately we all get stuck sometimes and it just is what it is.. The last was an obese diabetic with severe symptomatic dyspnea due to acute bilateral pulmonary emboli. Technically lower risk PE as CT did not show RH strain and her trop was neg but was so SOB couldn't walk to bathroom unassisted w sat 92% and generally unhealthy, etc. It was a new hospitalist who gave me a speech about how during his residency the ICU attending would rant about how PEs can be managed outpatient and why can't I just discharge her on eliquis, etc..

We all know obviously know this but as EM physicians how many technically "low risk" PEs have you seen code and die after being admitted? > 5 for me and this lady clearly would just come right back or call EMS and clearly stated "I don't feel safe going home." So you just tell hospitalist in a clear monotone voice "This is an unhealthy, ill-appearing patient with poor social support, who is unable to ambulate unassisted due to acute bilateral pulmonary emboli, I am concerned about her safety if discharged and would like you to evaluate the patient."

Per most hospital policies, they're required to see the patient. Again this is like a once a year situation. Most of our hospitalist are great.

The key is knowing CMS admission criteria and framing your presentation in a way that the hospitalist understands the only possible option is this patient being admitted to the hospital. A lot depends on your tone and confidence with presentations, which should increase with time.

When you call a consultant or call for admission, you're not asking for help or advice, you're telling the physician that he/she has a new patient. Not asking, telling. You can be very cordial and pleasant and nice about it but ultimately waking ENT up at 0200 for a patient with stridor due to a laryngeal mass and a 2mm subglottic airway, you don't ask, "What would you like the next step in management to be?" because they'll just tell you to discharge the patient, you say "I am admitting a patient high-risk for airway obstruction to the ICU and the admitting physician will be consulting you.." etc.

Again, we all try to play nice and I'll try to bundle gen surg c/s at night to only wake them up once etc, but ultimately my responsibility is to the patient and as the expert in emergency medicine, if I do not think the patient is safe to go home, for whatever reason, I am admitting them and hospitalist can eval and dispo.

And this attitude, folks, is why ~20% of EM physicians will be out of work in about ten years and replaced by midlevels. When you're admitting every PE with no e/o hemodynamic issues who is satting fine on room air and is anxious about their diagnosis, you're essentially just reading off a script that says "if PE -> then admit".

 

[TheComebacKid]

so much of it has to deal with what I am comfortable with, and my comfort level is based on my experience in training.

In residency, if they had a PE, we admitted them, not just for initiation of anticoagulation but also hypercoaguable work up, dopplers, monitoring etc. I recognize there are patients who appear well with a new PE and can be discharged on a DOAC. I’ve just never really done it before… I suppose I have to start somewhere.

Same thing with transfusions. In residency if anyone got a unit of blood they got admitted. At my new spot, there’s an expectation of transfuse and discharge. I mean, what is the etiology of this persons anemia? Are they some sort if cancer patient that gets weekly transfusions, if so that’s one thing. But the conservative part of my training tells me these patients need to stay and get a work up

 

[southerndoc]

The mandibular fracture may seem like an outpatient thing, but if it requires fixation, good luck finding a surgeon who will fix it in a timely manner for a 83 year with non-managed atrial fibrillation who just syncopized without cardiac clearance first. Admission is the soonest means to an end and most beneficial for the patient.

I disagree. Trauma surgery has admitted these patients for other reasons and they were discharged to outpatient follow-up for fixing their mandible.

Maybe my OMF surgeons are just doing what they're supposed to do as an outpatient. Having said that, the majority of mandibular fractures do not need surgery.

 

[southerndoc]

And this attitude, folks, is why ~20% of EM physicians will be out of work in about ten years and replaced by midlevels. When you're admitting every PE with no e/o hemodynamic issues who is satting fine on room air and is anxious about their diagnosis, you're essentially just reading off a script that says "if PE -> then admit".

I partially agree with what you're saying. We as emergency physicians are often too uncomfortable discharging someone that doesn't need admission: low risk PE's, BIG1 minor head bleeds, moderate risk chest pain (hsTrops for the win), diverticulitis just because they have pain, etc.

Just as STEMI's once were in the hospital for a week, cardiology has changed to discharge them 24 hours after their cath. DKA has transitioned to an observation admission even if going to the ICU. The low risk stuff that I mentioned previously should go home. The hospital loses money because of DRG's or worse, the patient gets stuck with a bill for an unnecessary admission. Before anybody asks, no, you don't need a neurosurgery consultation to discharge a BIG1 patient.

 

[RustedFox]

I partially agree with what you're saying. We as emergency physicians are often too uncomfortable discharging someone that doesn't need admission: low risk PE's, BIG1 minor head bleeds, moderate risk chest pain (hsTrops for the win), diverticulitis just because they have pain, etc.

Just as STEMI's once were in the hospital for a week, cardiology has changed to discharge them 24 hours after their cath. DKA has transitioned to an observation admission even if going to the ICU. The low risk stuff that I mentioned previously should go home. The hospital loses money because of DRG's or worse, the patient gets stuck with a bill for an unnecessary admission. Before anybody asks, no, you don't need a neurosurgery consultation to discharge a BIG1 patient.

Hey; you got a link for a good read on the BIG1/2/3 guidelines? My google-fu isn't quite cutting it. I get abstracts, but nothing good.

 

[cardsperson]

so much of it has to deal with what I am comfortable with, and my comfort level is based on my experience in training.

In residency, if they had a PE, we admitted them, not just for initiation of anticoagulation but also hypercoaguable work up, dopplers, monitoring etc. I recognize there are patients who appear well with a new PE and can be discharged on a DOAC. I’ve just never really done it before… I suppose I have to start somewhere.

Same thing with transfusions. In residency if anyone got a unit of blood they got admitted. At my new spot, there’s an expectation of transfuse and discharge. I mean, what is the etiology of this persons anemia? Are they some sort if cancer patient that gets weekly transfusions, if so that’s one thing. But the conservative part of my training tells me these patients need to stay and get a work up

For low risk PEs, there is no role for routine dopplers. None.

Similarly, for all PEs, we almost never do hypercoag workup as inpatient, as some of the tests will be falsely negative in the acute setting while others are affected by whatever anticoagulation the patient gets. Occasionally we'll send off the genetic tests as inpatient (FVL, prothrombin), but even this practice is probably a waste of resources given that it never changes acute management and costs the patient a lot more money than if it was done as outpatient. Usually what happens is that we put the patient on a DOAC and have them follow up with hematology (if we suspect a hypercoag disorder) in 3-6 months, at which point heme will ask them to stop the anticoag for a few days and obtain all of the desired hypercoag eval testing and use that to decide if the patient should be on anticoag lifelong (although, realistically, if the PE isn't provoked and there's no strong reason to stop AC, most experts recommend indefinite anticoagulation).

In other words, the reason why the hospitalists roll their eyes when you try to admit a low risk PE is you're basically asking them to stop the heparin drip you ordered, order 10 mg apixaban, and discharge the patient home on a starter pack a couple hours later. It's not a good use of hospital resources.

For transfusions, it depends on the story. For cancer patients, it's very common for them to have transfusions in clinic and go home, so the few times they come to the ED for a transfusion it's appropriate to transfuse and discharge. Similarly, if a patient is known to have severe IDA, it's appropriate to transfuse and discharge. If you have no obvious reason for the anemia severe enough to need a transfusion, then yes they should be admitted for monitoring (although realistically, what happens is that most of these are from slow GI bleeds and they may or may not be scoped as inpatient depending on their course).

 

[aafisahar]

I dunno why hospitalists push back, esp admitters. You can pound out a chest pain admit in like 15 minutes, including note, orders, and talking to the patient. RVUs don't care if the admit is soft or not. That PE lady? 20 mintues max.

I'm not here to play steward of the hospital. The time you spent arguing is time you could have spent putting in orders.

 

[cardsperson]

I dunno why hospitalists push back, esp admitters. You can pound out a chest pain admit in like 15 minutes, including note, orders, and talking to the patient. RVUs don't care if the admit is soft or not. That PE lady? 20 mintues max.

I'm not here to play steward of the hospital. The time you spent arguing is time you could have spent putting in orders.

"Just do the work because it's easier than arguing" is a terrible argument to make (whether in work life or personal life), especially when you're talking about setting up a culture for the hospital. The times when other physicians have argued with me are when I've learned the most and also impacted how I practice going forward the most.

 

[TheComebacKid]

"Just do the work because it's easier than arguing" is a terrible argument to make (whether in work life or personal life), especially when you're talking about setting up a culture for the hospital. The times when other physicians have argued with me are when I've learned the most and also impacted how I practice going forward the most.

I actually agree with you. It's also not in the best interest of the patient to get a hospital bill for something that can be managed as an outpatient just because it's an easy admit. It's also not worth your time either, which is valuable.

I know it's my job as an ED doc to be trained appropriately, be comfortable discharging patients and taking on a degree of risk.

Some of us are new at this. Some of us trained at places where things were managed differently. I think as a new attending, if I gave you one of these soft admits say, new low risk PE with class I PESI, etc. it would be helpful for you to come see the patient, write a note, and help me discharge them. I guarantee you after a few of these consults, the ED docs would stop calling you and be comfortable taking on the risk on their own. You may say, "that isn't my job" which is fair too. But if you are looking for system-wide improvement, I think measures like this help.

These are also nuanced decisions, that quite frankly I haven't had much training in. As an EM resident when I rotated on medicine, half my IM attendings anti coagulated sub segmental PEs. The other half didn't. I haven't developed enough of a practice pattern to know when to initiate this therapy, and guidance from people like yourself would go a long way. With time I think I could develop my own practice pattern and not need your help.

Changing practice takes some time, and collaboration with the hospitalist group makes a huge difference. As you are probably aware, ED docs are often fairly risk averse. We all dread the patient who goes home and comes back in cardiac arrest. I know that often times this fear creates unfair and unacceptable work for you. But as a new attending, I've also taken care of the saddle PE that rolls into the ED peri-arrest, which informs my decisions and leads to often times a more conservative approach.

 

[cardsperson]

I actually agree with you. It's also not in the best interest of the patient to get a hospital bill for something that can be managed as an outpatient just because it's an easy admit. It's also not worth your time either, which is valuable.

I know it's my job as an ED doc to be trained appropriately, be comfortable discharging patients and taking on a degree of risk.

Some of us are new at this. Some of us trained at places where things were managed differently. I think as a new attending, if I gave you one of these soft admits say, new low risk PE with class I PESI, etc. it would be helpful for you to come see the patient, write a note, and help me discharge them. I guarantee you after a few of these consults, the ED docs would stop calling you and be comfortable taking on the risk on their own. You may say, "that isn't my job" which is fair too. But if you are looking for system-wide improvement, I think measures like this help.

These are also nuanced decisions, that quite frankly I haven't had much training in. As an EM resident when I rotated on medicine, half my IM attendings anti coagulated sub segmental PEs. The other half didn't. I haven't developed enough of a practice pattern to know when to initiate this therapy, and guidance from people like yourself would go a long way. With time I think I could develop my own practice pattern and not need your help.

Changing practice takes some time, and collaboration with the hospitalist group makes a huge difference. As you are probably aware, ED docs are often fairly risk averse. We all dread the patient who goes home and comes back in cardiac arrest. I know that often times this fear creates unfair and unacceptable work for you. But as a new attending, I've also taken care of the saddle PE that rolls into the ED peri-arrest, which informs my decisions and leads to often times a more conservative approach.

I agree 100%. We're all shaped by our prior experiences and we all carry biases. I absolutely hate it when hospitalists/specialists/etc roll their eyes at ED physicians as a matter of course. The retrospectoscope is also very real and an unfair practice a lot of inpatient teams apply to ED thinking. And I will say that probably ~80% of the time when an admission looks inappropriate from my end on initial chart review (initially hospitalist, now cards fellow), I change my mind when I see the patient. And believe it or not, we all know who the really good ED docs are, the ones who when they call, I know I only need about 20 words of info because they wouldn't be calling me otherwise.

Regarding subsegmental PEs, lol, these continue to plague us all as to what the right course of action is. I lean towards treating because why else would someone have obtained a CTA, but we do sometimes see them on contrasted CTs done for other indications. In those scenarios, I do obtain LE duplexes, because if there's clot there the shoe fits a bit better plus you now have a solid indication to anticoagulate.

 

[aafisahar]

I actually agree with you. It's also not in the best interest of the patient to get a hospital bill for something that can be managed as an outpatient just because it's an easy admit. It's also not worth your time either, which is valuable.

If we learned anything, if it isn't the fluff that comes into the hospital, then we are ****ed as a profession. Our salaries basically depend on admitting and dispoing softballs. Look what happened in EM when all those soft walk-ins stopped coming. I'm a cardiology fellow (who moonlights as a hospitalist/nocturnist) and during the height of the lockdown, we were doing a handful of consults (like 2-3 vs 15 during normal operations), our inpatient services were like 2-3 patients, zero heart transplants/LVADs, <10 echos/day, 0 TEEs for months, basically zero EP procedures, <1 cath/day. You can't justify 400k salaries on that volume. We were doing basically what was necessary and nothing more. If you cut out all the unnecessary/borderline consults, procedures, we actually don't have all that much to do.

 

[e30ftw]

And this attitude, folks, is why ~20% of EM physicians will be out of work in about ten years and replaced by midlevels. When you're admitting every PE with no e/o hemodynamic issues who is satting fine on room air and is anxious about their diagnosis, you're essentially just reading off a script that says "if PE -> then admit".

My standard of practice since graduating 7 years ago has been to discharge low risk PE on DOAC. I actually implied this ("We all know this..") in the post you quoted. This particular patient needed to be admitted. As a presumed cardiologist, who neither sees patients in the ED nor routinely admits them, the intent of your post is questionable at best.

Great example to residents and new attendings of how important it is for you as the EM physician to be your patient's advocate. The vast majority of consultants are great and we have a very professional working relationship, however sometimes due to inherent bias or miscommunication, a consultant won't listen to anything you say and/or have preconceived and incorrect ideas on management. At this point you have to do what's right for the patient, both as an ethical obligation and because the hospital will likely hold you ultimately responsible.

You are the expert in Emergency Medicine. Don't ask, tell.

 

[e30ftw]

I partially agree with what you're saying. We as emergency physicians are often too uncomfortable discharging someone that doesn't need admission: low risk PE's, BIG1 minor head bleeds, moderate risk chest pain (hsTrops for the win), diverticulitis just because they have pain, etc.

I manage all those patients as outpatient and have for many years. I still call NSGY about most ICH prior to discharge since it is local standard of practice.

However, if you agree that obs'ing/admitting a severely dyspneic morbidly obese diabetic with no social support who can't walk to the bathroom with a borderline sat and acute bilateral PEs will be the "cause of 20% of EM physicians being replaced by midlevels in ten years" then I disagree on that point.

 

[RustedFox]

I manage all those patients as outpatient and have for many years. I still call NSGY about most ICH prior to discharge since it is local standard of practice.

However, if you agree that obs'ing/admitting a severely dyspneic morbidly obese diabetic with no social support who can't walk to the bathroom with a borderline sat and acute bilateral PEs will be the "cause of 20% of EM physicians being replaced by midlevels in ten years" then I disagree on that point.

Sadly (on top of what you're saying) - this is an increasingly large percentage of society.... the "severely dyspneic morbidly obese diabetic with no social support who... " yeah... they live like this.

Somehow, they survive in spite of themselves.
I'm not being argumentative. I'm not crossing swords with you.
I'm just dumbstruck.

Before anyone chimes in (and they should) and say - "Dude, this is all you talk about anymore; how much you hate society, knock it off and stuff" - yeah, you're right.

 

[e30ftw]

Oh they're definitely out there and I discharge about a hundred a month. When your RR is > 30 and you can't walk because your physiologic reserve is so low that your PEs have rendered you partially potato, I'm not going to fight you if you want to be admitted. Also iirc this pt had one main artery embolus (R?) and then several segmental emboli on the other side so not sub-segmental.

 

[Mount Asclepius]

I disagree. Trauma surgery has admitted these patients for other reasons and they were discharged to outpatient follow-up for fixing their mandible.

Maybe my OMF surgeons are just doing what they're supposed to do as an outpatient. Having said that, the majority of mandibular fractures do not need surgery.

So they were still admitted apparently. I think you’re getting a little hung up on the mandible. You break a mandible, sternum, scapula or femur, then there is possibly something else going on. The most common missed fracture is…the second one. Older adults often syncopize or have a mechanical fall secondary to another cause. My point wasn’t arguing that the 20 year old who was punched in the jaw with a crack through the mandible should be admitted or fixed. It’s the entire picture that matters. We often admit patients because they don’t follow the textbook example of clear outpatient or inpatient dispositions. Local practice patterns are also very different for chest pain, syncope, TIA, BIG criteria, etc. When I was in residency we’d scoff at the small traumatic SAH or subacute/chronic SDH that was transferred for neurosurgical consultation. They still were consulted and added their name to the chart. In the community one of our neurosurgeons wants all of these admitted to the ICU. That may be outdated and unnecessary, but it’s the local standard of care. Doing the right thing for a patient and fighting the system to implement change are separate issues. I don’t think we really actually disagree and are just talking around each other on a relatively minor point.

 

[Mount Asclepius]

Sadly (on top of what you're saying) - this is an increasingly large percentage of society.... the "severely dyspneic morbidly obese diabetic with no social support who... " yeah... they live like this.

Somehow, they survive in spite of themselves.
I'm not being argumentative. I'm not crossing swords with you.
I'm just dumbstruck.

Before anyone chimes in (and they should) and say - "Dude, this is all you talk about anymore; how much you hate society, knock it off and stuff" - yeah, you're right.

I used to genuinely like people, ya know, even the average, uneducated person. Granted I’ve often always felt Americans seem a little rude and entitled compared to the rest of the world. I went into medicine partially though because I preferred a career with people over the thought of a possible alternative consisting of writing grants and pipetting in a lab. Now I can’t stand a large percentage of people. I put on my smile and a perform a charade to maintain my compensation, and also perhaps for that rare person with whom I connect. I see myself traveling further and further down the road of jadedness over time. I don’t know if practicing EM is an unhealthy high level of exposure to people, seeing the worst of society, people are becoming worst, or if I was just naive from the start. Other than my spouse, friends and family don’t understand why I don’t like most people anymore. I’ve wondered if maybe I need to cut and run before I become a hermit hating all of society with an inability to return back to my pre-medicine, non-corrupted self. All of that to say that I can relate to your sentiment. I’m not sure I know how to fix it other than to walk away from the ED, or just share common experiences with anonymous EPs online while savoring that rare great patient or exciting case.

 

[Mount Asclepius]

If we learned anything, if it isn't the fluff that comes into the hospital, then we are ****ed as a profession. Our salaries basically depend on admitting and dispoing softballs. Look what happened in EM when all those soft walk-ins stopped coming. I'm a cardiology fellow (who moonlights as a hospitalist/nocturnist) and during the height of the lockdown, we were doing a handful of consults (like 2-3 vs 15 during normal operations), our inpatient services were like 2-3 patients, zero heart transplants/LVADs, <10 echos/day, 0 TEEs for months, basically zero EP procedures, <1 cath/day. You can't justify 400k salaries on that volume. We were doing basically what was necessary and nothing more. If you cut out all the unnecessary/borderline consults, procedures, we actually don't have all that much to do.

You hire another Cardiologist, you’ll have more caths. You hire another surgeon - more surgeries. You build another hospital - more patients. In some areas there is truly a need for more healthcare. Not all places though. In this country we’ve primarily decided (unconsciously) as society that we’d rather fix our problems with pills and interventions. The outcomes may not be any better, but it’s serviceable. Expensive, but it gets us by. Our jobs depend on the unnecessary fluff. It’s big business.

 

[RustedFox]

I used to genuinely like people, ya know, even the average, uneducated person. Granted I’ve often always felt Americans seem a little rude and entitled compared to the rest of the world. I went into medicine partially though because I preferred a career with people over the thought of a possible alternative consisting of writing grants and pipetting in a lab. Now I can’t stand a large percentage of people. I put on my smile and a perform a charade to maintain my compensation, and also perhaps for that rare person with whom I connect. I see myself traveling further and further down the road of jadedness over time. I don’t know if practicing EM is an unhealthy high level of exposure to people, seeing the worst of society, people are becoming worst, or if I was just naive from the start. Other than my spouse, friends and family don’t understand why I don’t like most people anymore. I’ve wondered if maybe I need to cut and run before I become a hermit hating all of society with an inability to return back to my pre-medicine, non-corrupted self. All of that to say that I can relate to your sentiment. I’m not sure I know how to fix it other than to walk away from the ED, or just share common experiences with anonymous EPs online while savoring that rare great patient or exciting case.

It gets worse when you add on to that the fact that these "people" completely discount anything that you say despite your terminal degree and years of experience and just want what they want because "their niece is thinking about becoming a nurse practitioner and she said that...".

One day, I came home from a shift and called up a buddy of mine who understands me very well.
I said to him: "My job would be better if they just created a hologram of me that smiled and told patients the things that they wanted to hear; it would free me up to do the actual brain-bending work of the medicine itself."

 

[Dr Mantis Toboggan]

I used to genuinely like people, ya know, even the average, uneducated person. Granted I’ve often always felt Americans seem a little rude and entitled compared to the rest of the world. I went into medicine partially though because I preferred a career with people over the thought of a possible alternative consisting of writing grants and pipetting in a lab. Now I can’t stand a large percentage of people. I put on my smile and a perform a charade to maintain my compensation, and also perhaps for that rare person with whom I connect. I see myself traveling further and further down the road of jadedness over time. I don’t know if practicing EM is an unhealthy high level of exposure to people, seeing the worst of society, people are becoming worst, or if I was just naive from the start. Other than my spouse, friends and family don’t understand why I don’t like most people anymore. I’ve wondered if maybe I need to cut and run before I become a hermit hating all of society with an inability to return back to my pre-medicine, non-corrupted self. All of that to say that I can relate to your sentiment. I’m not sure I know how to fix it other than to walk away from the ED, or just share common experiences with anonymous EPs online while savoring that rare great patient or exciting case.

Wow it’s weird when someone you’ve never met completely nails how you yourself are feeling, but this is me 100%.

 

[RustedFox]

Wow it’s weird when someone you’ve never met completely nails how you yourself are feeling, but this is me 100%.

All of us, amigo.
All of us.

 

[Birdstrike]

...no, you don't need a neurosurgery consultation to discharge a BIG1 patient.

They want you to see exploding numbers of patients in triage/waiting room all in less than 15 minutes all while pushing you to send head bleeds home, now?

W H A T T H E . . . ?

 

[Birdstrike]

I used to genuinely like people, ya know, even the average, uneducated person. Granted I’ve often always felt Americans seem a little rude and entitled compared to the rest of the world. I went into medicine partially though because I preferred a career with people over the thought of a possible alternative consisting of writing grants and pipetting in a lab. Now I can’t stand a large percentage of people. I put on my smile and a perform a charade to maintain my compensation, and also perhaps for that rare person with whom I connect. I see myself traveling further and further down the road of jadedness over time. I don’t know if practicing EM is an unhealthy high level of exposure to people, seeing the worst of society, people are becoming worst, or if I was just naive from the start. Other than my spouse, friends and family don’t understand why I don’t like most people anymore. I’ve wondered if maybe I need to cut and run before I become a hermit hating all of society with an inability to return back to my pre-medicine, non-corrupted self. All of that to say that I can relate to your sentiment. I’m not sure I know how to fix it other than to walk away from the ED, or just share common experiences with anonymous EPs online while savoring that rare great patient or exciting case.

I've been there, @Mount Asclepius . I see where you're coming from, 100%. There's a word for this ^^^^ , you know?

 

[RustedFox]

I've been there, @Mount Asclepius . I see where you're coming from, 100%. There's a word for this ^^^^ , you know?

What... what's that word? B-b...

 

[larpleston]

They want you to see exploding numbers of patients in triage/waiting room all in less than 15 minutes all while pushing you to send head bleeds home, now?

W H A T T H E . . . ?

I find it hilarious that neurosurgeons want us to discharge head bleeds based on a retrospective study. Sorry mister important consultant, but you have to see the boring BS too, just like the rest of us.

 

[Mount Asclepius]

We think about patient dispo more than patients themselves. It’s the name of the game in emergency medicine. I’m surprised when I see a slam-dunk-admission who wants to go home and is shocked by the idea of coming into the hospital. Remind me why you came to the ED again? I’m also perturbed by the people who want to be admitted who have no reason to stay. We feel pressure from patients one way or another regarding hospital admission. We then have hospitalists or other admitting services occasionally give us their opinion or judgement in response to admitting patients. We are caught in the middle with limited autonomy. On top of that, if we make the wrong decision and send someone home, then it is scrutinized by peer review. If we bring someone in softly we are heavily judged as being a wuss or conservative. This is another element that contributes to burnout that is not usually mentioned. We don’t have much control over the process. It’s hard to bat 100% regarding decision to admit, but that’s what is expected by patients and hospitalists alike. Sometimes they have competing interests and it’s a game of pickle between two bases with us in the middle.