The Convenience Department

[deleted128562]

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[gman33]

They don't bother me too much, they just eat up time.
This will likely bother me much more when I get a job where my compensation is tied to patient satisfaction.

Now, I'll have a conversation about how I can't get "X" done, but I'll try to offer contact info for someone who can.
This often doesn't go well, but I just stand firm and tell them they are being d/c.

I get more annoyed at the "my doctor sent me here for.." requests.
This is just lazy and terrible medicine.
If it's someone on staff, I'll just call and ask if they want the patient admitted to their service.

Being a resident, it's hard to tell an attending from another specialty that they are out of line.
So in some cases I'll just order the MRI or whatever other BS they sent them over for.
That's not a battle I'm going to try to win.
There is no win in that game.

If it's just a random community doc that sent the patient over, they just get d/c as well.

 

[Pudortu]

I once had a pmd send in a patient for a disimpaction. This was when I was an intern and didn't know better. Luckily my program director happened to be my attending that day and he placed a call to this PMD and ended up yelling at him.

In the end, I still did the rectal.

 

[Birdstrike]

Some days I think that we should change our titles from "emergency physicians" to "convenience physicians". There are many reasons why an increasing percentage of the population, and even of our colleagues, view the emergency department as the Convenience Department where all problems can and should be solved in just a few short hours. Among them administration focus on rapid door-to-doctor times, advertisements promising short waits and stays, lack of consequences for using the ED inappropriately, and the reality that we do have numerous diagnostic and therapeutic modalities at our fingertips not readily available in the outpatient care setting.

I find that many/ most of my patients and colleagues are not malicious in their intent; they simply have been truly led to believe that we are the one stop convenience shop, where anything and everything can be done as easily as if ordering from a menu at the local steakhouse.

In just the past few days I have had: 1) A patient who was genuinely shocked and disappointed that we could not fit him for orthotics. He had significant problems with his feet and had a podiatry appointment for fitting the next week, but figured we could just take care of it sooner. That was the entire reason he came in. It seriously took me several attempts to convince him that we did not stock orthotics in the ED, and that I'd have no idea what to do with them even if we did. 2) A primary care doctor who couldn't get his patient in for a non-emergent MRI until next month, who sent the patient to the ED to "get the MRI done". I called him and explained that the patient had no emergent indications for the MRI and that I couldn't just somehow get him in for one, and his response was, "he's in pain, you need to get this done for him now, that's why you're there". 3) A patient who has had headaches for years and seen multiple specialists, who came in because she wanted us to figure out what was going on. She genuinely thought that I would be able to sort out the cause of her headaches in just a single visit to the ED, even after numerous headache specialists had supposedly failed to do so.

I'm finding this to be, far and away, the most frustrating aspect of being an emergency medicine resident. A lot of people complain about the patients who come in with colds, want a work note, etc, but honestly I don't find those patients all that troubling. It takes me all of 5 minutes to see them, they're easy to chart on, they make my numbers look good. What really wears me out is the constant flow of people who have these grandiose expectations of what I can do for them.... They end up feeling totally disappointed and frustrated, I end up feeling helpless and guilty, and it's just an all-around unsatisfying interaction for everyone.

Unfortunately I fear it is only going to get worse. Anyone else been feeling this way?

Did you read my mind? Because I was in process of writing this, and was going to expand on it, but I'll post it now since I can't think of a better way to completely agree in response (accept for suggesting slightly different terminology):
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The Specialty of Demand Medicine (and Emergentology) (formerly known as Emergency Medicine)


"We hold these truths to be self-evident, that all chief complaints are created equal" ​

I'd propose that in many places Emergency Medicine, in the truest sense of the word, no longer exists, defined as a practice where:


Trained specialists in Emergency Care standing by, primarily to treat ill and injured patients with life or limb threatening conditions as well as patients with potentially life or limb threatening conditions, in an orderly manner by triage according to likely severity, while as a courtesy treating or referring low priority patients during periods of downtime, with a lower sense of urgency and priority.


That concept is dead or dying. Instead, the businessmen have created a system where every patient has the priority of an emergency. Every patient needs to be seen in 0-15 minutes. Once a commitment is made to see every patient, regardless of acuity, on demand and within 0-15 minutes, the entire concept of an "emergency" and acuity-based triage itself starts to lose any meaning. Whether you personally have the mental, physical or emotional "surge capacity" to see 5, 10, or 20 patients in the next 15 minute "surge" is irrelevant. This is where the "crisis" in ED over capacity is. Seeing every "customer" (and that's what they've morphed your "patients" into) in < 15 minutes to maximize profits, as opposed to seeing all emergencies and urgencies within 15 minutes to provide emergency care. So why even pretend to constantly be "surging" beyond the 2pph or whatever number that is expected?

To me it's just crazy, because it's a false crisis. It's fabricated with smoke and mirrors to squeeze the most productivity out of staff for hospital profits. There's no other reason. The doctors I've seen who've seemed to do the best over the long haul with job satisfaction in a Emergency Medicine (and I would not include myself in that category) were those that plugged along around the group average or slightly below, and seemed unaware or uncaring of the recurrent roller coaster of imagined crises of surges in "customers". Those that I've seen, that tried to take the world and those supposed "surges" on their shoulders, always seemed to bear the heaviest emotional burden.

As long as they can get everyone to buy in into the myth, that the average community Emergency department is constantly in crisis, overwhelmed with "emergencies" then they have everyone working near redline for max profits. If, " >poof< " one day the mirage disappears, and everyone realizes, "Wait? 2/3 of these aren't and never will be emergent/urgent yet we're being expected to frantically rush to them as such....." and, "Wait a minute? Is there really a billboard sign out there on the highway, that has an arrow pointing to this building, and a headline saying, 'Go here, wait time only 15 min', then one realizes,

1- There's no ED "crisis" at all.

2- These unexpected and unplanned "surges" are in fact, expected, planned and welcome.

3- If one truly wanted to handle the "surges" they'd staff manpower for the surge volume, not average volume and expect staff to oscillate continuously between average pace/volume, and understaffed "surge" pace and volume.

4- The system is working exactly the way those in control want it to.

In my opinion, Emergency Medicine in the truest sense of the word, will soon no longer exist, if it still does at all. The alternative is just too profitable. Emergencies, urgencies and non-emergencies will all be seen as the same. Medical services on demand: No wait time, no matter, "See me now." To put the word "Emergency" in the title is outdated, inaccurate and a misleading misnomer. Prior to the advent of Penicillin, The Archives of Dermatology used to be called The Archives of Dermatology and Syphilology (thank you, Diane Birnbaumer MD) yet was changed when the invention of Penicillin rendered rashes from syphilis a minority ofthe specialty's focus. For the outdated, old fashioned and nostalgic title "Emergency" Medicine, perhaps one containing the term, "Demand Medicine " is a much more honest, accurate, and progressive title, appropriate for current and future times. I do propose that since the concept of taking care of "emergencies" does play a minority role in the specialty, that the term be allowed to remain a part of the specialty title, if for no other than nostalgic reasons. Hence the specialty of:



Demand Medicine (and Emergentology)

 

[Birdstrike]

I guess great minds think alike

True dat.

 

[Groove]

My "Weltanschauung", and no that's not VeltanShlong..., in the context of our specialty, is really more "glass half full". So, although I have my frustrated moments and periodic temper tantrums at work where I might go postal on the occasional internist, I really don't see too much to complain about. Sure, we see only see 10% true "emergencies". However, It won't change your training and if your training does change in any shape, way or form, it will only give you versatility. Hell, I'd love to have extra manpower or the experience to know how to handle (and BILL) for orthotics. Slow day and want me to charge you for an ED visit and an MRI? No problem (though I do refuse most of these...how many of us have "slow days"?). You already checked into the ED and are getting a bill, so do you want a joint injection? Trigger point injection? Do you want me to rub your tummy? NO PROBLEM!

Don't forget that as much as we have to complain about the sniffly noses, work excuses and prenatal ED well checks... we are IN DEMAND. The easy cases are just that....EASY. In and out. As long as my salary is tied to my productivity, I can smile at these people all day long and make sure they have an excellent ED experience. Each one of these pt's makes my metrics look better. Of all the specialties, we probably have the greatest job security and salary protection at the moment. Our salaries are high because we are a valuable commodity right now. Want to turn EDs into true "Emergency Shops"?? Then get ready to see 0.5 pts/hr and have your salary chopped in half. If seeing the low acuity pt's bugs you that much, hire a bunch of MLPs. We utilize a ton of them who are very well trained and I get to focus on all the high acuity cases with a smattering of lower acuity ones which makes my job satisfaction that much better. That being said, tomorrow morning I'll be doing a morning shift and for a few hours will have no MLP, so I'll be seeing all the work excuses and everything else. You know what? I'm looking forward to it. I hope to ring in between 2.5-3pt/hr tomorrow by the end of my shift.

 

[Groove]

EDs will always bill at a premium compared to an outpatient setting. Primary Care is in a crisis and will be for the next 10-20 years. We can do absolutely nothing to avoid the funneling of pt's to the emergency departments and although it's misappropriation of resources and improper use of the ultimate design of an "emergency department", it's an avalanche that can't be stopped and we just need to hang on and wait to see how the landscape changes once the snow is settled. Either way, EDs are busting at the seams and as frustrating as it can be on busy days when I've got tons of true emergencies, it's nice to be part of a specialty that is truly in demand. I hate being harangued and pestered as much as the next guy by these headhunters but how many other specialists have people buzzing their phone almost daily trying to get them to work at another hospital for premium compensation? We really don't have it THAT bad. A lot of these level 4s and 5s and even 3s, I can get rid of really fast so that the waiting room is not backing up.

Personally, I think the happy medium is hiring MLPs to handle the majority of the lower acuity pt's at the moment. EDs are growing faster than EPs can be trained and I don't see any other option. It makes perfect economic sense in our current environment.

 

[Perrin]

I hate being harangued and pestered as much as the next guy by these headhunters but how many other specialists have people buzzing their phone almost daily trying to get them to work at another hospital for premium compensation? We really don't have it THAT bad.

I agree. I can't think of many professions where you get called weekly with job offers. I'll start worrying when the phone calls stop.

 

[Birdstrike]

You guys are missing the point. Does the specialty of "Emergency Medicine" as it was conceived exist anymore? I agree: Glass half full. But don't call an apple an orange because you really want to think of it as an orange.

Call a spade a spade.

Ophthalmologists are not called "Lens physicians" for a reason. Because lens work is a part of, but a minority of what they do.

Ear, Nose, Throat doctors (Otorhinolaryngeologists) are not called Rhinologists for a reason. Because nasal work is a part of, but a minority of what they do.

Family Physicians are not called Gynecologists for a reason. Because Gynecology is a part of, but a minority of what they do.

Emergency physicians spend a minority of their time taking care of emergencies. Cardiologists spend minority portion of their time taking care of STEMI emergencies. General Surgeons spend a minority of their time treating surgical emergencies. Neurologists spend a minority of their time taking care of patients with stroke or meningitis emergencies. All four spend a very small minority of their time taking care of patients with emergencies. It's not that ER doctors aren't the best expert at treating the widest array of emergencies, because they are. I just don't think anyone that anyone who was there when the specialty was conceived could have seen what was coming.

There is no specialty of Emergency Medicine as it was conceived, due to the changes foisted upon it. The name does not identify primarily what the specialty is.

Mr. Hat was spot on with his post. He is ahead of his time. When he finishes his residency, he will have a high paying, important job in high demand, but it may not be the specialty he thought he signed up for.

 

[gman33]

I could not disagree more with Birdstrike on the above post.
My specialty is "Emergency Medicine".
That is what I am trained to do and what I think about on every patient.

I agree that only a small percentage have an emergency.
In that regard, maybe it should no longer be called an Emergency Department.

Once I've determined there is no emergent condition, I just think about dispo. Admit vs. d/c.
Just get them out of the ED as fast as possible.
Many patients come in who would be much better served by someone who actually cares about their non emergent condition.

I just do the best I can for them and try to direct them to the appropriate care.

Greg Henry has spoken on this topic in the past.
We need to staff the ED much differently.
More techs, more MLPs. Get rid of most of the nursing documentation and things not related to care.

At some point (maybe we are already there), you need to open 24 hour primary care clinics in or next to the ED.
I don't mean fast track stuff, clinics staffed by PMDs who will actually follow up with the patients.

Either that or relax EMTALA and med/mal and just tell a bunch of people to beat it when they show up asking for BS.

 

[dotcb]

This sounds like weak leadership and trying to cater to satisfaction rather than doing what we're trained to do. I'll do an H & P on just about anyone, but if they don't have an emergency and I'm pretty sure of it, I'm going to do very little for them other than give them phone numbers, clinic info, and point them in the right direction. I tell them I'm sorry to waste their time, but they came to the wrong place, and I'm not trained to do what they're asking.

 

[DrBowtie]

2) A primary care doctor who couldn't get his patient in for a non-emergent MRI until next month, who sent the patient to the ED to "get the MRI done". I called him and explained that the patient had no emergent indications for the MRI and that I couldn't just somehow get him in for one, and his response was, "he's in pain, you need to get this done for him now, that's why you're there". 3) A patient who has had headaches for years and seen multiple specialists, who came in because she wanted us to figure out what was going on. She genuinely thought that I would be able to sort out the cause of her headaches in just a single visit to the ED, even after numerous headache specialists had supposedly failed to do so.

From a rads perspective, not only does that MRI slow us down considerably from the real ER stuff, but the patient is less likely to receive subspecialty interpretations than an outpatient planned and protocoled exam. I don't think the PCP realizes this.

 

[Groove]

Bird, you're like EM's version of Anna Chapman. I honestly can't tell which side you are on most of the time.

We're trained to quickly recognize, diagnose, manage and disposition acute emergencies spanning all of the subspecialties. We're emergent airway experts and resuscitation experts. There's not a single specialist with a better body of relevant knowledge base to manage and treat the acute and emergent patient subset. Sure, it might be a minority of the pt's we see on a daily basis, but we're the absolutely best trained physicians to do the job. We work in an emergency department. We're trained to deal with emergencies, regardless of who we see. What would you call us, then? Emergency AND Internal Medicine Specialists with a minor in Obstetrics? Emergentology trained Generalists? It's all semantics.

Do you think a general surgeon primarily performs surgeries? Do you think an ENT surgeon feels like one on most clinic days when he sees middle aged women with headaches, kids with gastroenteritis, elderly dizzy patients with TIAs or people with actinic keratosis lesions on their nose? My dad sure as heck didn't and griped as loud as we do about irrelevant and non specialty related cases. Some days he felt like a generalist. Some days he felt like an oncologist or even a dermatologist and other days he felt like an actual ENT surgeon. I think you really have to super specialize to keep from seeing a certain amount of "fluff" and by that time, you're wishing you had "more variety" in your practice. That's ubiquitous among all the subspecialties to some degree.

EDs will never see "mainly emergencies" because "emergencies" are largely defined by what the pt perceives to be a true emergency while very much being a victim of failed healthcare policy. That being said, I certainly still see my fair share of them on a daily basis so I don't know about you but I feel very much the part of an "emergency physician".

"Emergentologist" does have a certain ring to it though....

 

[filhodeinferno]

Bird, you're like EM's version of Anna Chapman. I honestly can't tell which side you are on most of the time.

We're trained to quickly recognize, diagnose, manage and disposition acute emergencies spanning all of the subspecialties. We're emergent airway experts and resuscitation experts. There's not a single specialist with a better body of relevant knowledge base to manage and treat the acute and emergent patient subset. Sure, it might be a minority of the pt's we see on a daily basis, but we're the absolutely best trained physicians to do the job. We work in an emergency department. We're trained to deal with emergencies, regardless of who we see. What would you call us, then? Emergency AND Internal Medicine Specialists with a minor in Obstetrics? Emergentology trained Generalists? It's all semantics.

Do you think a general surgeon primarily performs surgeries? Do you think an ENT surgeon feels like one on most clinic days when he sees middle aged women with headaches, kids with gastroenteritis, elderly dizzy patients with TIAs or people with actinic keratosis lesions on their nose? My dad sure as heck didn't and griped as loud as we do about irrelevant and non specialty related cases. Some days he felt like a generalist. Some days he felt like an oncologist or even a dermatologist and other days he felt like an actual ENT surgeon. I think you really have to super specialize to keep from seeing a certain amount of "fluff" and by that time, you're wishing you had "more variety" in your practice. That's ubiquitous among all the subspecialties to some degree.

EDs will never see "mainly emergencies" because "emergencies" are largely defined by what the pt perceives to be a true emergency while very much being a victim of failed healthcare policy. That being said, I certainly still see my fair share of them on a daily basis so I don't know about you but I feel very much the part of an "emergency physician".

"Emergentologist" does have a certain ring to it though....

I agree, especially with paragraph 3. Every specialty deals with a great deal of crap on a day to day basis that technically doesn't fit their exact job description.

 

[EctopicFetus]

I wonder if you got paid to order an MRI and dc the patient and that put $200 in your pocket if you would feel differently. I am not saying it will. Personally, the easier the case the more annoying. I then remind myself thats ok.. I make my living caring for people and what they view as an emergency.

I/we can spend time outside of work thinking through how to change it and make it better but it never annoys me at work.

Even when the UC sends in someone with a mild HA for CT/LP/MRI/Hip Arthrocentesis/Lyme titer/ Rheumatoid Factor/ bleeding time/ etc. If the test isnt harmful to the patient I discuss and order.

I have refused to do drug screens on kids just cause the parents want it and a slew of other things. However with patient sat becoming a factor as well as length of stay etc. I have a quick discussion and usually do it.

Again, if that 3 minute visit was worth $1-200 to you would it change your mind?

 

[Birdstrike]

Bird, you're like EM's version of Anna Chapman. I honestly can't tell which side you are on most of the time.

Like the sexy Russian double-agent spy? (I must admit she was extremely hot, though.) Who do you think I'm a "double agent" or a spy for, and what side do you think I'm on?

Administrators?

The politicians?

Malpractice plaintiff lawyers?

The Russians, for $!&$@€# 's sake?

I'm forever and always on the side of the people who trained to be Emergency physicians and sometimes feel that they're in a system where a 24-hour On Demand Convenience Physician seems to be more valued by the important people. I'm on the side of all doctors, nurses and patients. My beef is not with the doctors and nurses who struggle to do the right thing within a nonsensical system. It is with the people who made the system the way it is, and continue to stoke the flames, almost always with the underlying motivation of either money or a political agenda. My last post was provocative (probably overly so), not entirely finished and not my best thought out, so I edited out some of the garbage. To the extent that it came across as rude or insulting, I apologize. It was not meant to be that way. The OP posted what he posted, and I agreed. A simple "+1" or "like" may have been more effective.

We're trained to quickly recognize, diagnose, manage and disposition acute emergencies spanning all of the subspecialties. We're emergent airway experts and resuscitation experts. There's not a single specialist with a better body of relevant knowledge base to manage and treat the acute and emergent patient subset. Sure, it might be a minority of the pt's we see on a daily basis, but we're the absolutely best trained physicians to do the job....

This is all true, and all the more reason these skills should be valued most, not convenience store skills.

Do you think an ENT surgeon feels like one on most clinic days when he sees middle aged women with headaches, kids with gastroenteritis, elderly dizzy patients with TIAs or people with actinic keratosis lesions on their nose? My dad sure as heck didn't and griped as loud as we do about irrelevant and non specialty related cases. Some days he felt like a generalist. Some days he felt like an oncologist or even a dermatologist and other days he felt like an actual ENT surgeon. I think you really have to super specialize to keep from seeing a certain amount of "fluff" and by that time, you're wishing you had "more variety" in your practice. That's ubiquitous among all the subspecialties to some degree.

Did your father have a guy in a suit telling him, "Sure, you're a 'ENT' but you must see 80% non-ENT cases?" Did that same guy in a suit obsessively track his minute to minute metrics on those non-ENT cases, and threaten his contract if the ENT cases got in the way of their profit margin on the non-ENT cases? Did the guy in the suit tell him and his partners they had to extend their night, weekend and holiday call coverage, to maximize metrics on exactly the cases that had nothing to do with ENT?

My guess is that he'd say, "No." But to the extent ENTs and doctors in general, continue to go to work more as hospital employees, these things could potentially all be on the table for them in the future.

EDs will never see "mainly emergencies" ....

That's true. That's why I suggested a name change, that more accurately reflects what EDs mainly do. You can decide if it was entirely serious, or to some extent tongue in cheek.

"emergencies" are largely defined by what the pt perceives to be a true emergency

To a certain extent, yes. But you know as well as I do, a huge portion of patients go to EDs knowing full well they don't have an emergency.

while very much being a victim of failed healthcare policy.

Yes, that's the point. The failed healthcare policy has changed the specialty from what it was intended to focus on, to where the primary focus, is no longer in focus. If it was, all metrics on non-urgents and non-emergents would be ignored as "not part of our primary focus." But they ARE the focus. The emergencies are the foot note, in the eyes of some very influential people.

I feel very much the part of an "emergency physician".

I feel like someone who always wanted to become an Emergency Physician, and became one. I knew that I'd be seeing lots of easy, non-emergency stuff, and I thought it would be exactly that: easy stuff. But I had no clue that the focus would be so hyper-obsessed to maximize that aspect of my job, and that the true emergency care, and the stuff I had dedicated my career to focus on, would start to feel like no one really care about it but me. I never had someone come and say, "Hey, couldn't you have gotten that intubation in quicker?" or "Hey, man, you're resuscitation skills are slack. Pick it up." It never happened, nor did it need to happen.

But I can say, that probably one hundred or more times, I was talked to about metrics, times, PG scores, or a completely invalid and outrageous complaint that would have been ignored by any convenience store owner with common sense. Almost every single time, nearly without exception, those issues and discussions were related to non-emergencies. Repeatedly the message was, "Get this right or we'll lose our contract." It was always a given that the "emergencies" would be dealt with properly, but the focus entirely on everything else. This is coming from someone who's always ranked very well on things like patient satisfaction, patient, complaints, efficiency and metrics, and I still do.

Eventually I realized that although I trained to become an Emergency Physician, considered myself an Emergency Physician, and greatly prided myself on that fact, I was being used primarily as something completely different. When the focus switched from, "Major in Emergency Medicine with Minor in Convenience Medicine on Demand," to "Major in Convenience Medicine with Minor in Emergency Medicine" it really changed my view on things. Being a medical student and a resident, I really had no clue how obsessed the people who write the pay checks would be with the Convenience Medicine on Demand aspect. I really, truly had no idea that jobs would be threatened over it. I naively thought it would not be the primary focus. It is that obsession that drives the burnout in the specialty, in my opinion, because of the emotional toll it takes and the staffing manpower to see the 85% non-emergencies in a 0-15 minute wait time, 24 hr per day, 365 days per year. There's no reason the wait time on non-emergencies couldn't be allowed to hit 30 minutes or longer, which would decrease the night/weekend/holiday burden of the staff, other that to maximize profits for the businessmen. This would reduce burnout and improve the quality of life of ER doctors, nurses and other staff.

For you it balances out, it doesn't drain you, or affect you, or maybe you've had a different experience. That's good, because it's not likely to change. It could change if people refused to put up with it, but I'm not holding my breath. Things definitely won't change by ignoring what's changed. Things definitely can improve on the individual level, but only if people take more control over their practice lives (fellowships, urgent-care ownership or free-standings, knowing how to spot good /bad jobs, knowing how to stay least attached/most mobile).

So I stated the completely obvious, that the specialty was invented to focus on one thing, and was titled after it, yet has become something with a majority focus on something completely different, to the extent the name no longer accurately describes it. I even suggested I was renaming it myself. Provocative? Yes, very much like that hottie Anna Chapman.

My take home point to anyone in any specialty that's read this far or cares what I think: Look for ways to improve your own control over your practice life, in any way you can. As this profession of Medicine becomes more and more politicized and corporatized, and more doctors take the employee role, autonomy will be at a premium.

 

[Birdstrike]

I think you guys are still missing the point a little - Birdstrike especially wasn't arguing we need to make it "better" or that we need to find a way to see true emergencies only. He is simply arguing, as am I, that the name "emergency medicine" does not describe what we really do most of the time. Listen, if you offered me $300,000 a year to be a "clay sculptor" but then had me drawing pictures with crayon instead, I'd still gladly do the job. I'd just argue that it wouldn't really be very accurate to call me a clay sculptor. Same reasoning applies here. Sure, I'm going to have a good, secure, in-demand job, but to call it practing "emergency medicine" is a bit of a misnomer when most of what I do is actually practice medicine on demand (with occasional emergency treatment).

In fact, I think calling things what they are is actually HELPFUL. If I can actually acknowledge that what I really am is a "doctor on demand", with some additional training so I can handle the occasional true emergency, then I'm a lot less likely to be disappointed and frustrated when I go in to work every day. Want to pay me $300,000 a year for ordering MRI's for a PCP? Heck, sign me up. But just tell me that's what I'm actually signing up for.

Yes. We're not expecting anything to change, but only asking for honesty and transparency.

 

[alpinism]

• Patients come to the ED for one of five reasons:
  • Imaging
  • Antibiotics
  • A note for work
  • Pain killers
  • Pregnancy test

 

[e30ftw]

dunno around here some days it seems like the only patients I see are people who wrecked cars and stopped breathing, woke up w/ a headache and couldn't move half their body, high risk w/ crushing chest pain, undifferentiated unresponsive and you have no idea whats going on etc etc.. not to mention the endless train of nonspecific complaints with unclear history that could be one of many life threatening diagnoses..

5 consultants calling you back at the same time, multiple crashing patients, hospitalist requesting you to LP some patient with fever and a UTI but also HA x 3 days w/ no other sign of meningitis, some cardiologist is pissed because your pt w/ an NSTEMI normally goes to another hospital etc etc

those are the days when I love getting people with viral pharygitis jacked up on steroids..

 

[EvoDevo]

Like the sexy Russian double agent? I'll let that one go. She was extremely hot, though. What the heck side do you think I'm on?

Administrators?

The politicians?

Malpractice plaintiff lawyers?

The Russians?

I'm forever and always on the side of the people who trained to be Emergency physicians and sometimes feel that they're in a system where a 24-hour On Demand Convenience Physician seems to be more valued by the important people. I'm on the side of all doctors, nurses and patients. My beef is not with the doctors and nurses who struggle to do the right thing within a nonsensical system. It is with the people who made the system the way it is, and continue to stoke the flames, almost always with the underlying motivation of either money or a political agenda. My last post was provocative (probably overly so), not entirely finished and not my best thought out, so I edited out some of the garbage. To the extent that it came across as rude or insulting, I apologize. It was not meant to be that way. The OP posted what he posted, and I agreed. A simple "+1" or "like" may have been more effective.



This is all true, and all the more reason these skills should be valued most, not convenience store skills.

Did your father have a guy in a suit telling him, "Sure, you're a 'ENT' but you must see 80% non-ENT cases?" Did that same guy in a suit obsessively track his minute to minute metrics on those non-ENT cases, and threaten his contract if the ENT cases got in the way of their profit margin on the non-ENT cases? Did the guy in the suit tell him and his partners they had to extend their night, weekend and holiday call coverage, to maximize metrics on exactly the cases that had nothing to do with ENT?

My guess is that he'd say, "No." But to the extent ENTs and doctors in general, continue to go to work more as hospital employees, these things could potentially all be on the table for them in the future.



That's true. That's why I suggested a name change, that more accurately reflects what EDs mainly do. You can decide if it was entirely serious, or to some extent tongue in cheek.

To a certain extent, yes. But you know as well as I do, a huge portion of patients go to EDs knowing full well they don't have an emergency.

Yes, that's the point. The failed healthcare policy has changed the specialty from what it was intended to focus on, to where the primary focus, is no longer in focus. If it was, all metrics on non-urgents and non-emergents would be ignored as "not part of our primary focus." But they ARE the focus. The emergencies are the foot note, in the eyes of some very influential people.



I feel like someone who always wanted to become an Emergency Physician, and became one. I knew that I'd be seeing lots of easy, non-emergency stuff, and I thought it would be exactly that: easy stuff. But I had no clue that the focus would be so hyper-obsessed to maximize that aspect of my job, and that the true emergency care, and the stuff I had dedicated my career to focus on, would start to feel like no one really care about it but me. I never had someone come and say, "Hey, couldn't you have gotten that intubation in quicker?" or "Hey, man, you're resuscitation skills are slack. Pick it up." It never happened, nor did it need to happen.

But I can say, that probably one hundred or more times, I was talked to about metrics, times, PG scores, or a completely invalid and outrageous complaint that would have been ignored by any convenience store owner with common sense. Almost every single time, nearly without exception, those issues and discussions were related to non-emergencies. Repeatedly the message was, "Get this right or we'll lose our contract." It was always a given that the "emergencies" would be dealt with properly, but the focus entirely on everything else. This is coming from someone who's always ranked very well on things like patient satisfaction, patient, complaints, efficiency and metrics, and I still do.

Eventually I realized that although I trained to become an Emergency Physician, considered myself an Emergency Physician, and greatly prided myself on that fact, I was being used primarily as something completely different. When the focus switched from, "Major in Emergency Medicine with Minor in Convenience Medicine on Demand," to "Major in Convenience Medicine with Minor in Emergency Medicine" it really changed my view on things. Being a medical student and a resident, I really had no clue how obsessed the people who write the pay checks would be with the Convenience Medicine on Demand aspect. I really, truly had no idea that jobs would be threatened over it. I naively thought it would not be the primary focus. It is that obsession that drives the burnout in the specialty, in my opinion, because of the emotional toll it takes and the staffing manpower to see the 85% non-emergencies in a 0-15 minute wait time, 24 hr per day, 365 days per year. There's no reason the wait time on non-emergencies couldn't be allowed to hit 30 minutes or longer, which would decrease the night/weekend/holiday burden of the staff, other that to maximize profits for the businessmen. This would reduce burnout and improve the quality of life of ER doctors, nurses and other staff.

For you it balances out, it doesn't drain you, or affect you, or maybe you've had a different experience. That's good, because it's not likely to change. It could change if people refused to put up with it, but I'm not holding my breath. Things definitely won't change by ignoring what's changed. Things definitely can improve on the individual level, but only if people take more control over their practice lives (fellowships, urgent-care ownership or free-standings, knowing how to spot good /bad jobs, knowing how to stay least attached/most mobile).

So I stated the completely obvious, that the specialty was invented to focus on one thing, and was titled after it, yet has become something with a majority focus on something completely different, to the extent the name no longer accurately describes it. I even suggested I was renaming it myself. Provocative? Yes, very much like that hottie Anna Chapman.

My take home point to anyone in any specialty that's read this far or cares what I think: Look for ways to improve your own control over your practice life, in any way you can. As this profession of Medicine becomes more and more politicized and corporatized, and more doctors take the employee role, autonomy will be at a premium.

This is completely true. I have worked in three EDs since graduation and it's always the same. Colleagues at other sites and other systems... All the same. If a patient complains that they waited too long, even if there were critically ill patients in the department.. It becomes an Administrator Alert!

F******* ridiculous

 

[link2swim06]

I had a patient with worsening vision come to the ER for a seeing eye dog once.

I explained that indeed we do NOT have cocker spaniels in the pyxis.

 

[OCDEMS]

...A patient who was genuinely shocked and disappointed that we could not fit him for orthotics. He had significant problems with his feet and had a podiatry appointment for fitting the next week, but figured we could just take care of it sooner. That was the entire reason he came in. It seriously took me several attempts to convince him that we did not stock orthotics in the ED, and that I'd have no idea what to do with them even if we did.

Whoa, whoa...whoa. So you're telling me that I can't get custom arch support at 3 AM in the emergency room? What third world country is this? What if I really, really need to run a 5k tomorrow?

'Merica.

 

[Birdstrike]

I had a patient with worsening vision come to the ER for a seeing eye dog once.

I explained that indeed we do NOT have cocker spaniels in the pyxis.

Lol. That's awesome.

Give me 30 of these in a 10 hour shift every day and I'm a happy man. Or give me 10 critically ill/injured only in 10 hours and I'm also a happy man. But give me both, and tell me all the "chief complaint: need a seeing eye-dog stat" patients have to be seen if <15 minutes or I "lose the contract," and I'm out.

PS Link2swim06: delete your post immediately or some administrator will find a technology that allows seeing eye dogs to be dispensed from all pyxis's in under 15 minutes. Lol. Delete. Now!

 

[Siggy]

PS Link2swim06: delete your post immediately or some administrator will find a technology that allows seeing eye dogs to be dispensed from all pyxis's in under 15 minutes. Lol. Delete. Now!

That would be ruff.

 

[deleted547339]

That would be ruff.

Just the way your mother likes it, Trebek.

 

[HooliganSnail]

You guys are missing the point. Does the specialty of "Emergency Medicine" as it was conceived exist anymore? I agree: Glass half full. But don't call an apple an orange because you really want to think of it as an orange.

Call a spade a spade.

Ophthalmologists are not called "Lens physicians" for a reason. Because lens work is a part of, but a minority of what they do.

Ear, Nose, Throat doctors (Otorhinolaryngeologists) are not called Rhinologists for a reason. Because nasal work is a part of, but a minority of what they do.

Family Physicians are not called Gynecologists for a reason. Because Gynecology is a part of, but a minority of what they do.

Emergency physicians spend a minority of their time taking care of emergencies. Cardiologists spend minority portion of their time taking care of STEMI emergencies. General Surgeons spend a minority of their time treating surgical emergencies. Neurologists spend a minority of their time taking care of patients with stroke or meningitis emergencies. All four spend a very small minority of their time taking care of patients with emergencies. It's not that ER doctors aren't the best expert at treating the widest array of emergencies, because they are. I just don't think anyone that anyone who was there when the specialty was conceived could have seen what was coming.

There is no specialty of Emergency Medicine as it was conceived, due to the changes foisted upon it. The name does not identify primarily what the specialty is.

Mr. Hat was spot on with his post. He is ahead of his time. When he finishes his residency, he will have a high paying, important job in high demand, but it may not be the specialty he thought he signed up for.

The specialty may have been created with certain intentions in mind, but to say that no one at the time could imagine EM becoming what it has seems unlikely.

At its most basic and rudimentary level, Emergency Physicians are hired to solve a major problem of every hospital; people keep showing up at the door. The ED is the gateway to the hospital, and if you work in one then you are the gatekeeper. It is the reality of your job. We are all a little bit like Frank Underwood, we "clear the pipes and keep the sludge moving through". Most sludge goes home, some stays to see a doctor upstairs, some sludge dies. It is the simple truth of our profession.

Some choose to accept this and find happiness in their work. Some fight upstream against the flood of reality, and are frustrated.

 

[Birdstrike]

The specialty may have been created with certain intentions in mind, but to say that no one at the time could imagine EM becoming what it has seems unlikely.

At its most basic and rudimentary level, Emergency Physicians are hired to solve a major problem of every hospital; people keep showing up at the door. The ED is the gateway to the hospital, and if you work in one then you are the gatekeeper. It is the reality of your job. We are all a little bit like Frank Underwood, we "clear the pipes and keep the sludge moving through". Most sludge goes home, some stays to see a doctor upstairs, some sludge dies. It is the simple truth of our profession.

Some choose to accept this and find happiness in their work. Some fight upstream against the flood of reality, and are frustrated.

Are you suggesting the specialty name be changed to,

"Sludge Medicine"?

 

[GeneralVeers]

I don't have a prolem with seeing the non-emergent people. My frustration comes in that I can't tell people the ER is an inappropriate venue for their specific complaint. The hospital does not want me turning away "customers".

 

[Arcan57]

The specialty may have been created with certain intentions in mind, but to say that no one at the time could imagine EM becoming what it has seems unlikely.

At its most basic and rudimentary level, Emergency Physicians are hired to solve a major problem of every hospital; people keep showing up at the door. The ED is the gateway to the hospital, and if you work in one then you are the gatekeeper. It is the reality of your job. We are all a little bit like Frank Underwood, we "clear the pipes and keep the sludge moving through". Most sludge goes home, some stays to see a doctor upstairs, some sludge dies. It is the simple truth of our profession.

Some choose to accept this and find happiness in their work. Some fight upstream against the flood of reality, and are frustrated.

We exist as a specialty because we took something that no one did well and proved we were better at it then the people who weren't us. That bought us a foot in the door and also established the mentality that we provide care for those who have no other way of obtaining it (either do to being to critical to wait or having no access). What our founders may have suspected but probably never grasped fully would be that the existence of competent acute care would become wide-spread just as our ability to do things to patients exploded. This was followed in short order by an exponential surge in our patients demanding things be done to them. The medical community responded rationally by pumping out proceduralists who could do the things patients wanted done, while at the same time allowing the part of the system that figures out what needs to be done to whom to atrophy. As the wait times to have anything done on an outpatient basis grew ridiculously long, we were the only way to get care. And once we proved that we could secure care and reasonable outpatient follow-up, we became the defacto place for acute care.

 

[Birdstrike]

We exist as a specialty because we took something that no one did well and proved we were better at it then the people who weren't us. That bought us a foot in the door and also established the mentality that we provide care for those who have no other way of obtaining it (either do to being to critical to wait or having no access). What our founders may have suspected but probably never grasped fully would be that the existence of competent acute care would become wide-spread just as our ability to do things to patients exploded. This was followed in short order by an exponential surge in our patients demanding things be done to them. The medical community responded rationally by pumping out proceduralists who could do the things patients wanted done, while at the same time allowing the part of the system that figures out what needs to be done to whom to atrophy. As the wait times to have anything done on an outpatient basis grew ridiculously long, we were the only way to get care. And once we proved that we could secure care and reasonable outpatient follow-up, we became the defacto place for acute care.

There's various dates you could pick to try to date the birth of the specialty (I picked 1968 above due to ACEP being founded) but regardless, all of them came before EMTALA being passed (1986) and all came before the explosion in the hyper-corporatization of Medicine with the growth of CMGs, patient satisfaction, metrics and the opiate boom. How they would have predicted all that, I have no clue.

 

[Groove]

Like the sexy Russian double-agent spy? (I must admit she was extremely hot, though.) Who do you think I'm a "double agent" or a spy for, and what side do you think I'm on?

Administrators?

The politicians?

Malpractice plaintiff lawyers?

The Russians, for $!&$@€# 's sake?

I'm forever and always on the side of the people who trained to be Emergency physicians and sometimes feel that they're in a system where a 24-hour On Demand Convenience Physician seems to be more valued by the important people. I'm on the side of all doctors, nurses and patients. My beef is not with the doctors and nurses who struggle to do the right thing within a nonsensical system. It is with the people who made the system the way it is, and continue to stoke the flames, almost always with the underlying motivation of either money or a political agenda. My last post was provocative (probably overly so), not entirely finished and not my best thought out, so I edited out some of the garbage. To the extent that it came across as rude or insulting, I apologize. It was not meant to be that way. The OP posted what he posted, and I agreed. A simple "+1" or "like" may have been more effective.



This is all true, and all the more reason these skills should be valued most, not convenience store skills.

Did your father have a guy in a suit telling him, "Sure, you're a 'ENT' but you must see 80% non-ENT cases?" Did that same guy in a suit obsessively track his minute to minute metrics on those non-ENT cases, and threaten his contract if the ENT cases got in the way of their profit margin on the non-ENT cases? Did the guy in the suit tell him and his partners they had to extend their night, weekend and holiday call coverage, to maximize metrics on exactly the cases that had nothing to do with ENT?

My guess is that he'd say, "No." But to the extent ENTs and doctors in general, continue to go to work more as hospital employees, these things could potentially all be on the table for them in the future.



That's true. That's why I suggested a name change, that more accurately reflects what EDs mainly do. You can decide if it was entirely serious, or to some extent tongue in cheek.

To a certain extent, yes. But you know as well as I do, a huge portion of patients go to EDs knowing full well they don't have an emergency.

Yes, that's the point. The failed healthcare policy has changed the specialty from what it was intended to focus on, to where the primary focus, is no longer in focus. If it was, all metrics on non-urgents and non-emergents would be ignored as "not part of our primary focus." But they ARE the focus. The emergencies are the foot note, in the eyes of some very influential people.



I feel like someone who always wanted to become an Emergency Physician, and became one. I knew that I'd be seeing lots of easy, non-emergency stuff, and I thought it would be exactly that: easy stuff. But I had no clue that the focus would be so hyper-obsessed to maximize that aspect of my job, and that the true emergency care, and the stuff I had dedicated my career to focus on, would start to feel like no one really care about it but me. I never had someone come and say, "Hey, couldn't you have gotten that intubation in quicker?" or "Hey, man, you're resuscitation skills are slack. Pick it up." It never happened, nor did it need to happen.

But I can say, that probably one hundred or more times, I was talked to about metrics, times, PG scores, or a completely invalid and outrageous complaint that would have been ignored by any convenience store owner with common sense. Almost every single time, nearly without exception, those issues and discussions were related to non-emergencies. Repeatedly the message was, "Get this right or we'll lose our contract." It was always a given that the "emergencies" would be dealt with properly, but the focus entirely on everything else. This is coming from someone who's always ranked very well on things like patient satisfaction, patient, complaints, efficiency and metrics, and I still do.

Eventually I realized that although I trained to become an Emergency Physician, considered myself an Emergency Physician, and greatly prided myself on that fact, I was being used primarily as something completely different. When the focus switched from, "Major in Emergency Medicine with Minor in Convenience Medicine on Demand," to "Major in Convenience Medicine with Minor in Emergency Medicine" it really changed my view on things. Being a medical student and a resident, I really had no clue how obsessed the people who write the pay checks would be with the Convenience Medicine on Demand aspect. I really, truly had no idea that jobs would be threatened over it. I naively thought it would not be the primary focus. It is that obsession that drives the burnout in the specialty, in my opinion, because of the emotional toll it takes and the staffing manpower to see the 85% non-emergencies in a 0-15 minute wait time, 24 hr per day, 365 days per year. There's no reason the wait time on non-emergencies couldn't be allowed to hit 30 minutes or longer, which would decrease the night/weekend/holiday burden of the staff, other that to maximize profits for the businessmen. This would reduce burnout and improve the quality of life of ER doctors, nurses and other staff.

For you it balances out, it doesn't drain you, or affect you, or maybe you've had a different experience. That's good, because it's not likely to change. It could change if people refused to put up with it, but I'm not holding my breath. Things definitely won't change by ignoring what's changed. Things definitely can improve on the individual level, but only if people take more control over their practice lives (fellowships, urgent-care ownership or free-standings, knowing how to spot good /bad jobs, knowing how to stay least attached/most mobile).

So I stated the completely obvious, that the specialty was invented to focus on one thing, and was titled after it, yet has become something with a majority focus on something completely different, to the extent the name no longer accurately describes it. I even suggested I was renaming it myself. Provocative? Yes, very much like that hottie Anna Chapman.

My take home point to anyone in any specialty that's read this far or cares what I think: Look for ways to improve your own control over your practice life, in any way you can. As this profession of Medicine becomes more and more politicized and corporatized, and more doctors take the employee role, autonomy will be at a premium.

Yes, Anna Chapman was hot and apparently wants to marry Ed Snowden of all people. Well said, and I probably agree with you more than I disagree. Perhaps I misinterpreted the intent of your original post but it did leave some room for that sort of thing. All in all, I think I'm just tired of the modern day Cassandra posts that are replete with doom and gloom in regards to the specialty. I just don't particularly find them productive even if they are correct. Anyway, I'm not sure why Anna Chapman came to mind but you have to admit... you DID have fun googling her pics.

 

[Birdstrike]

Yes, Anna Chapman was hot and apparently wants to marry Ed Snowden of all people. Well said, and I probably agree with you more than I disagree. Perhaps I misinterpreted the intent of your original post but it did leave some room for that sort of thing. All in all, I think I'm just tired of the modern day Cassandra posts that are replete with doom and gloom in regards to the specialty. I just don't particularly find them productive even if they are correct. Anyway, I'm not sure why Anna Chapman came to mind but you have to admit... you DID have fun googling her pics.

Oh. You bet, buddy. You have n o o o idea.











Lol.




Just kidding.



PS (The sky IS falling.)



Just kidding. It's actually not.

 

[HooliganSnail]

Are you suggesting the specialty name be changed to,

"Sludge Medicine"?

It's really not that far off in reality.......

 

[sum dude]

Glory days, my friend. That whole definition of EM youre taught first day of residency is either dead, or (more likely) never really existed. No place has an 80% admit rate and nothing but sick and interesting patients. In residency you're shielded from a lot of the BS, either by PA's, Attendings, off-service residents or even interns. You're supposed to be good at that stuff, so most programs funnel those patients your way, especially as a 3rd year. In residency I went from sick patient to sick patient, dropping tubes, lines, reductions, etc. Now I spend a lot of time working up viruses, chronic problems, and BS chest pain. It is what it is...still get interesting patients every once and a while, but the whole notion that our only job is "sick..not sick go home" is long gone. And if you are saying to yourself "not at my hospital", then just wait--your place will soon be bought out by a hospital that realizes maximizing efficiency and customer service make more money, which let them buyout dinosaur hospitals which let patients rot in the ED halls.
The sooner we acknowledge EM is not exactly like our ideal picture we had as 3rd and 4th years of medical school, the happier you will be with your job. As for government and admin policies, well either get involved and try to do something about it, or go back to sittinng in Triage clicking boxes so that your hospital can put 5 min. for average door to provider times on the Freeway

 

[Birdstrike]

Glory days, my friend. That whole definition of EM youre taught first day of residency is either dead, or (more likely) never really existed. No place has an 80% admit rate and nothing but sick and interesting patients. In residency you're shielded from a lot of the BS, either by PA's, Attendings, off-service residents or even interns. You're supposed to be good at that stuff, so most programs funnel those patients your way, especially as a 3rd year. In residency I went from sick patient to sick patient, dropping tubes, lines, reductions, etc. Now I spend a lot of time working up viruses, chronic problems, and BS chest pain. It is what it is...still get interesting patients every once and a while, but the whole notion that our only job is "sick..not sick go home" is long gone. And if you are saying to yourself "not at my hospital", then just wait--your place will soon be bought out by a hospital that realizes maximizing efficiency and customer service make more money, which let them buyout dinosaur hospitals which let patients rot in the ED halls.
The sooner we acknowledge EM is not exactly like our ideal picture we had as 3rd and 4th years of medical school, the happier you will be with your job. As for government and admin policies, well either get involved and try to do something about it, or go back to sittinng in Triage clicking boxes so that your hospital can put 5 min. for average door to provider times on the Freeway

I agree.

 

[Jamers]

Some days I think that we should change our titles from "emergency physicians" to "convenience physicians". There are many reasons why an increasing percentage of the population, and even of our colleagues, view the emergency department as the Convenience Department where all problems can and should be solved in just a few short hours. Among them administration focus on rapid door-to-doctor times, advertisements promising short waits and stays, lack of consequences for using the ED inappropriately, and the reality that we do have numerous diagnostic and therapeutic modalities at our fingertips not readily available in the outpatient care setting.

I find that many/ most of my patients and colleagues are not malicious in their intent; they simply have been truly led to believe that we are the one stop convenience shop, where anything and everything can be done as easily as if ordering from a menu at the local steakhouse.

In just the past few days I have had: 1) A patient who was genuinely shocked and disappointed that we could not fit him for orthotics. He had significant problems with his feet and had a podiatry appointment for fitting the next week, but figured we could just take care of it sooner. That was the entire reason he came in. It seriously took me several attempts to convince him that we did not stock orthotics in the ED, and that I'd have no idea what to do with them even if we did. 2) A primary care doctor who couldn't get his patient in for a non-emergent MRI until next month, who sent the patient to the ED to "get the MRI done". I called him and explained that the patient had no emergent indications for the MRI and that I couldn't just somehow get him in for one, and his response was, "he's in pain, you need to get this done for him now, that's why you're there". 3) A patient who has had headaches for years and seen multiple specialists, who came in because she wanted us to figure out what was going on. She genuinely thought that I would be able to sort out the cause of her headaches in just a single visit to the ED, even after numerous headache specialists had supposedly failed to do so.

I'm finding this to be, far and away, the most frustrating aspect of being an emergency medicine resident. A lot of people complain about the patients who come in with colds, want a work note, etc, but honestly I don't find those patients all that troubling. It takes me all of 5 minutes to see them, they're easy to chart on, they make my numbers look good. What really wears me out is the constant flow of people who have these grandiose expectations of what I can do for them.... They end up feeling totally disappointed and frustrated, I end up feeling helpless and guilty, and it's just an all-around unsatisfying interaction for everyone.

Unfortunately I fear it is only going to get worse. Anyone else been feeling this way?

Eh, these patients and providers are generally the ones that don't bother me (they just need a little teaching). The ones that get me are the "nothing you do is good or fast enough for me." You know the chronic painer who not only comes with a list of demands but a timeline for which those demands need to be met. No matter the amount of teaching here...you just can't fix stupid.

But, you are right. We have turned into a 7-11 of sorts: why wait for that non emergent US of your pelvis (I mean you just found out you were pregnant 2 hours ago) go to the ED, fein some pelvic pain or bleeding, lie about your dates...its just easier! After all, this is the society that has never been told to wait. Where instant gratification is the norm...hmm...now I am depressed.