The opposite of "emergency"

[WilcoWorld]

I'd just like to point out that Diaphon has now referenced merde del toro and Don Quixote in the same thread. !Muy impresionante!

Also, I am 7 years out, and I still follow up on patients after pretty much every shift (EMRs make this very easy). I've learned much more from this than I learned from any floor months in residency.

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[deleted480308]

There are ED fellowships in family medicine they are 1 year long. Jackson TN has them. You can work in the ED as a FM doc about half of the docs in the ED are not ER trained or certified.

Those fellowships don't get you EM boarded...just a clarification

 

[fahimaz7]

This is the exact kind of arrogance I'm talking about.

http://www.westsuburbanmc.com/resid...cy-program/curriculum/curriculum-summary.aspx
Many family medicine programs do 3-4 months of ICU, with a rotation in every year of residency. .

Our FM residents do zero ICU months, where we do 1 CICU, 3 MICU, 1 SICU, and 1 PICU month + 3 years of critical patients in the ED.

 

[fahimaz7]

My point still stands that if you only admit and never see the criticism from the other side (and proud of the fact that you do 0 weeks of inpatient medicine or surgery), then you are like the surgeon who never sees any of his own postops. At the end of the day, he can only hope that he did some good, but he can't really ever know or refine his method. And if he were to hear some criticism, he would think he is personally attacked because he has never seen his postop complications and failures himself.

I can follow up on any patient that I admit by clicking on their MRN and reading their admission course, discharge summary, and labs/imaging that occured during their stay. Occasionally we are suprised with what we read, but >98% of the time we already know what they are going to have done and what their disposition will be like.

You assert yourself on here as a prodigy in medicine. In the ED, we get 5-10 minute histories on often very complex medical patients and we have to decide, without much hesitation, what an appropriate workup is, intervention, and disposition. Sometimes this is straight forward and easy. Sometimes patients are just "too sick" to go home. Sometimes they can't go home, and that is the reason for why they are being admitted.

If you are so unhappy in the academic setting then try the private practice shoe on for size. If you had to guess, what % of FM graduates are actively managing patients in the hospital? I would guess (yes it's a guess) that less than 5% of board certified FM doctors manage patients in the hospital. I would also venture to guess that <0.01% manage critically ill patients (perhaps rural ICU's where their #1 mission is to get the patient out of the ICU and to a different hospital).

I'd like to see a FM doc manage a serious MVC, facial trauma, with intubation, bilateral chest tubes, requiring massive transfusion and pressor support - all while arranging life flight and transfer to definitive care.

 

[NurWollen]

Our FM residents do zero ICU months, where we do 1 CICU, 3 MICU, 1 SICU, and 1 PICU month + 3 years of critical patients in the ED.

Sounds like the FM residency where you are sucks.

 

[VentJockey]

As an IM PGY2, I think I could confidently handle 80% of what walks in the door of an ER. The other 20%....not so much. But doesn't it make sense that if I wanted to cross train in EM, that I would have a program that focused on training me in the things I don't know how to deal with, rather than making me repeat all the stuff I already know? An EM doc wouldn't require a three year IM residency to be able to competently hold down a hospitalist service....

I'm mindful of the benefits of specialization, but I think we're taking it too far these days. A doctor is a doctor, and we all (should) be able to do a good H&P, think logically, and recognize when we need help.

This also applies to the hypothetical situation of an ER doc wanting to learn internal medicine. They would not need a three year residency to learn that...

 

[goodoldalky]

As an IM PGY2, I think I could confidently handle 80% of what walks in the door of an ER. The other 20%....

I am paid for that other 20%, at a rate of new patients per hour that no other physician in the hospital comes close to. I am confident that no one with (insert some other specialty training here) can do my job, and vice versa.

 

[Doctor Bob]

The trouble sometimes can be differentiating the 80% one knows from the 20% one doesn't.

 

[VentJockey]

I never suggested that I could do your job. I suggested that I would need less training to do your job

I am paid for that other 20%, at a rate of new patients per hour that no other physician in the hospital comes close to. I am confident that no one with (insert some other specialty training here) can do my job, and vice versa.

I never suggested that I can or should do your job with my current training. What I suggested is that I could learn to do your job in less time than could someone fresh out of medical school with no residency training under their belt. I don't think that is a controversial statement.

The trouble sometimes can be differentiating the 80% one knows from the 20% one doesn't.

It is a core competency for every physician to know what they are capable of doing and what they are not capable of doing. I do not need an ER boarded doc to pre screen my patients for me to make sure they're appropriate for my skill set. I can do that myself, I assure you.

 

[womp]

Right now the reimbursement scheme favors emergent care, so we naturally get more emergent care that are actually not emergencies. It's a simple solution: reimburse emergency providers and EDs the same amount of money as a clinic visit for the same problem. If you literally did nothing for the patient except some ginger ale and 5 minute counseling on keeping hydrated, then that's exactly how much money you and your ED should be paid. None of this upcoding to Level 4/5 BS for the majority of all your patients. When we do that, watch all these non-emergent patients get kicked out of the ED after a quick medical screening exam. You may need to complement this with some sort of malpractice protection after a negative MSE.

The trouble sometimes can be differentiating the 80% one knows from the 20% one doesn't.

From the sheer number of ******ed consults I got from the ED in just the last 24 hours (like the isolated one-level TP fracture), I'm not sure y'all know either.

 

[Doctor Bob]

I do not need an ER boarded doc to pre screen my patients for me to make sure they're appropriate for my skill set. I can do that myself, I assure you.

... ... ... ok







Job security.

 

[Doctor Bob]

From the sheer number of ******ed consults I got from the ED in just the last 24 hours (like the isolated one-level TP fracture), I'm not sure y'all know either.

Blame the lawyers (or even more irritatingly, hospital protocols) for the vast majority of those...

 

[goodoldalky]

Right now the reimbursement scheme favors emergent care, so we naturally get more emergent care that are actually not emergencies. It's a simple solution: reimburse emergency providers and EDs the same amount of money as a clinic visit for the same problem.

When someone comes to the emergency department for any complaint, they are paying a premium for the resources available that may be necessary. I.E: BC EM physician, advanced airway equipment, ACLS equipment, access to extremely rapid nursing care, radiography, and lab work. That cannot be provided at a clinic fee schedule, period, because of the upfront resources required to run and staff a department (even if the abdominal pain, etc., turns out to be non emergent).

From the sheer number of ******ed consults I got from the ED in just the last 24 hours (like the isolated one-level TP fracture), I'm not sure y'all know either.

Frankly this seems like a lot of big talk from someone who was worried about how much information from their first year of medical school they were having trouble remembering in 2011, and whether the paint would chip on their black stethoscope if they bought one. Your posts suggest that you're inexperienced and have little if any idea what the practice of these other specialties are like. I find that most attending physicians (you will be one soon) have a mutual respect for clinicians outside of their field and have an awareness of their limitations in understanding someone else's job. This comes from experience, making mistakes occasionally, saving the behind of a another physician, and having your own behind saved from time to time because of the inherent difficulty in the practice of medicine. Although relatively new myself I have understood this more and more with the passage of time.

 

[womp]

Frankly this seems like a lot of big talk from someone who was worried about how much information from their first year of medical school they were having trouble remembering in 2011, and whether the paint would chip on their black stethoscope if they bought one. Although relatively new myself I have understood this more and more with the passage of time.

LOL. What a douchebaggery post coming from a junior ED attending. I think this highlights a few other posters' comments about the inability for EPs to take criticism because you've never been the guy who has been awake for 24 hours, 10 minutes before morning signout with 3 new ED consults, and 2 of them are isolated TP fractures and another is rule out nec fasc for 3-day old cellulitis in an alert patient with minimal pain or signs. It sounds far-fetched, but it happens regularly at most academic hospitals in this country. You rarely see how absurd many of your consults are and how everyone else in the hospital rolls their eyes. You are a service that is used to giving more work to other people who already have a full day of existing duties, often work that is CYA, redundant and a waste of taxpayer money, while you are on the shift and get to go home regardless of what happens to your patient. There's no give and take for you like there is for the rest of us (we consult and we get consulted).

For all the talk about mutual respect among clinicians, I've found that your specialty is extremely disrespectful of primary care docs. There are multiple articles published in leading emergency medicine journals bashing primary care as being useless and criticizing specialists for taking jobs that do not take call.

Dr. Glausser, Emergency Physician at Cleveland Clinic: "How could we as physicians ever allow a doctor to call himself primary care when he can't manage simple chronic illness, cannot definitively treat acute illness or injury, often has no skills to save lives and no access to equipment if he had the skills, and does not even see patients at their own (the customers') convenience? Did I mention seeing people who simply need care, regardless of ability to pay? .... I would find the clinical skills of many primary care providers to differentiate splenomegaly from lymphoma or a direct from an indirect hernia suspect."
http://journals.lww.com/em-news/pag...=2008&issue=12000&article=00003&type=fulltext

http://blogs.aafp.org/fpm/noteworthy/entry/anti_primary_care_editorial_borders
http://journals.lww.com/em-news/Ful...rspective_of_an__Overpaid_Specialist_.24.aspx

And to give readers an update, my all-black Littmann Cardiology III stethoscope has not chipped in all these years. Great buy. And repetition is the best way to retain medical knowledge, which you would think on your 30th isolated TP fracture that you sent home after consulting ortho, you would remember.

 

[WilcoWorld]

But the Littmann Cardiology III makes such a lousy reflex hammer...

 

[Xerxes1729]

It's a simple solution: reimburse emergency providers and EDs the same amount of money as a clinic visit for the same problem.

Sounds good. Will you be keeping your clinic open all day, every day, forever, and seeing any patient that shows up for any reason without asking for insurance? Because if I could just tell everyone with back pain to go see the 24-hour, no-money-up-front spine surgeon up on the third floor, I'd definitely do that.

 

[BJJVP]

As an IM PGY2, I think I could confidently handle 80% of what walks in the door of an ER. The other 20%....not so much. But doesn't it make sense that if I wanted to cross train in EM, that I would have a program that focused on training me in the things I don't know how to deal with, rather than making me repeat all the stuff I already know? An EM doc wouldn't require a three year IM residency to be able to competently hold down a hospitalist service....

I'm mindful of the benefits of specialization, but I think we're taking it too far these days. A doctor is a doctor, and we all (should) be able to do a good H&P, think logically, and recognize when we need help.

This also applies to the hypothetical situation of an ER doc wanting to learn internal medicine. They would not need a three year residency to learn that...

I agree with this sentiment. There is some overlap and I don't think those from EM should find this statement to be offensive.

From the sheer number of ******ed consults I got from the ED in just the last 24 hours (like the isolated one-level TP fracture), I'm not sure y'all know either.

You must be at an academic center as this shouldn't happen in a community setting (assuming that was really the ONLY injury). What I have seen during my time at an academic institution was that these consults are often generated due to policies and discussions between depts that residents are not privy to. For example, where I trained, there was this asinine policy that all ED pts from this one specific subspecialty gets an automatic consult. The rotating consultant resident/intern was probably not aware of this. The call to the resident almost always led to an essentially automatic request for labs and CT before the consulting resident would even see the pt. Now both the radiology and consulting resident would think we were "******ed." Another example: pts with traumatic pneumos would get a trauma "consult." You couldn't just put in the chest tube and admit to thoracic surgery. I once had to consult plastics for a relatively simple lac. Why? We were a referral center and the pt was sent from some urgent care to see a plastic surgeon.

Believe it or not, I didn't enjoy asking for these consultations. Although, I ran into my fair share of resistance from consultants, I usually understood their point of view. However, your disrespectful attitude is somewhat shocking to me. It's a reminder to me that leaving the academic setting was one of my best decisions after residency.

 

[Brigade4Radiant]

Most of us are polite and just take the consult (unless it's truly egregious), and avoid making a scene in the ED, or we have departments that just accept every consult by policy (our department is like that, and I don't know how the ED residents learn when to consult in a setup like that). I've found ED residents to be very aggressive and belligerent in pushing for inane consults, backed up by your attending next to you. And unfortunately in the academic setting you have the upper hand in the power dynamic because your attending is right beside you, while our attending is often at home sleeping and cannot easily back us up at 2 in the morning, and the ED loves to pull the "I can call your attending if you would like" card. I also understand that you have a ton of people in the waiting room and you need to dispo your patients even if it's a weak admit; in the end you just need to clear your beds.




PCPs do it because there often isn't the imaging and lab resources in clinic that EDs have, not because they don't know how to do an ACS workup. Clinics don't have instant troponin labs. EDs have all that resources at their disposal and yet we still get a huge proportion of inane consults from the ED. Chest pain that's not GERD or obvious palpable tenderness is almost universally worked up in the ED because the ED has the STAT labs and cardiologists on call. That isn't an inane consult.

My point still stands that if you only admit and never see the criticism from the other side (and proud of the fact that you do 0 weeks of inpatient medicine or surgery), then you are like the surgeon who never sees any of his own postops. At the end of the day, he can only hope that he did some good, but he can't really ever know or refine his method. And if he were to hear some criticism, he would think he is personally attacked because he has never seen his postop complications and failures himself.

Everyone always says that ED makes bad consults but guess what every service does. Ortho for some reason needs medicine to place anticouagulation on their post op patients or deal with them after the surgery. Cards wanted GI consulted about a parapharengeal mass that was cleared for the TEE by ENT. The GI thought that it was an idiotic consult. Medicine consulted OB to give a stat birth control council or because of history of abnormal pap. Every service makes dumb consults.

ED also supplies the patients and workload for other services. That is what we give to them. We also give a place were they send all their clinic patients who call them with any problem. I had an ortho patient come in to the ED because of itchyness after cast removal.

ED physicians work really hard when they are on every ER consult that the one may see we also saw it and 2 other patients but it even's out in that we are off more days than we work. Some even consider it a lifestyle specialty and I would agree with them if we compare it to most medical specialties.

 

[Birdstrike]

To non-EM residents:

This whining about "weak consults" is "I'm a resident and I haven't grown up yet" stuff. In private practice, you'll be paid on productivity, with near 100% certainty, either through your collections in private practice or wRVUs if hospital employed. Then, "weak consult" becomes, "Aw geez, thanks. That was the easiest consult I've had in a while, and I got paid the same as the hard ones!" When you're an attending, you'll have to hire a PA to screen your consults if you don't want to do "weak ones." Otherwise, no one gives a flying **** if you don't like getting paid to do the work you do.

While still a resident, keep b¡tchin' if it makes ya'll feel better, but the whambulance ain't comin' 'cause it's already full. Just suck it up and do your time. Residency might suck but it isn't forever.

 

[pinipig523]

This actually sounds like a horrible way to train ED docs. You only get to see the pre-admission but have no perspective of whether such consult or admission was even warranted. Basically you call to admit only based on what your ED attending or protocol tells you, and not at all from the perspective of people taking care of the patient on the other side. It's like a surgeon who never sees his post-ops; he can't really learn or improve, to him every surgery hopefully helped.

Agreed. It helps to know what you are admitting the patient to or consulting about.

 

[deleted109597]

Agreed. It helps to know what you are admitting the patient to or consulting about.

Yeah, but most of us in residency went to medical school, and had to do some specified number of weeks of surgery, medicine, psych, etc. Or do you guys not do that anymore. Or just not pay attention during it?

 

[deuist]

I just looked into this thread and I figure I'll reply to everyone at once.

This actually sounds like a horrible way to train ED docs. You only get to see the pre-admission but have no perspective of whether such consult or admission was even warranted. Basically you call to admit only based on what your ED attending or protocol tells you, and not at all from the perspective of people taking care of the patient on the other side. It's like a surgeon who never sees his post-ops; he can't really learn or improve, to him every surgery hopefully helped.

I follow up on all of my admissions via the EMR. I think that all EP's should do the same. Every now and then I learn something.

It's pretty clear to me that EM residents need more real IM and surgery rotations than just floor scut, because you guys clearly don't get it.

Nope, they sure don't. I did a surgical internship before my EM residency and other than learning how to put in a chest tube, that year was largely a waste. Following daily labs to write nutrition orders, getting social work consults, dressing changes... none of that stuff helps me now. You can argue that we need high-yield education away from scut, but you're just not going to be able to get away from all of the scut.

You don't work any harder than the rest of us, the only difference is you never get consulted

I get consulted all the time---it's just that few docs me beforehand. Some examples:
* Asymptomatic hypertension --- "Go to the ER to get checked out"
* Asymptomatic anemia --- "Go to the ER to get checked out"
* Post-operative pain --- "Go to the ER to get checked out"
* A neuro clinic sent us someone for a lumbar puncture before the neurologist was too busy to do it in his office
* A 2-day-old wouldn't breast feed. Mother told to come to the ED by labor & delivery.
* "Go to the ER to get admitted to the hospital" at 4pm on a Friday. No reason given to the patient. No call ahead, no paperwork, office closed and not returning phone calls.
* I regularly get called upstairs for procedures such as arterial lines and intubations
* I go to all of the hospital's codes. There's usually an ACLS-certified internist standing by when I arrive.
* Every outpatient answering service says "Go to the emergency room" for any complaint that does not have an opening available on the schedule.

ED also supplies the patients and workload for other services.

When I was in residency, we were told to consult ob/gyn for every gyn-related issue because the gyn department asked us to. Their program's leadership wanted the residents to see as many pelvic complaints as possible, much to the wailing and gnashing of teeth.

As for community hospitals, we do supply the majority of consults for most specialists---and the hospital's CEO loves us for it. At a moonlighting job, the CEO told me that 91% of cardiology's patients come through the ED. The service would go bankrupt if not for us. You're complaining now, but you'll be thankful for the consults later since that's how you get paid.

 

[Birdstrike]

Funny thing I've noticed about these "bullcrap" consults and admits - They're always bullcrap when the liability for discharging the patient still falls squarely on me and my attending....

But the minute one of us says, "OK, could you just write a consult note and put it on the chart before I d/c the patient?" - It turns out that the patient does need the admission or the procedure after all!

Of course.

 

[Old Grunt]

I deal with it by typing up a 1 minute note with lots of negative exam findings and ROS and then hitting the "discharge" button.

 

[Old Grunt]

Most of us are polite and just take the consult (unless it's truly egregious), and avoid making a scene in the ED, or we have departments that just accept every consult by policy (our department is like that, and I don't know how the ED residents learn when to consult in a setup like that). I've found ED residents to be very aggressive and belligerent in pushing for inane consults, backed up by your attending next to you. And unfortunately in the academic setting you have the upper hand in the power dynamic because your attending is right beside you, while our attending is often at home sleeping and cannot easily back us up at 2 in the morning, and the ED loves to pull the "I can call your attending if you would like" card. I also understand that you have a ton of people in the waiting room and you need to dispo your patients even if it's a weak admit; in the end you just need to clear your beds.




PCPs do it because there often isn't the imaging and lab resources in clinic that EDs have, not because they don't know how to do an ACS workup. Clinics don't have instant troponin labs. EDs have all that resources at their disposal and yet we still get a huge proportion of inane consults from the ED. Chest pain that's not GERD or obvious palpable tenderness is almost universally worked up in the ED because the ED has the STAT labs and cardiologists on call. That isn't an inane consult.

My point still stands that if you only admit and never see the criticism from the other side (and proud of the fact that you do 0 weeks of inpatient medicine or surgery), then you are like the surgeon who never sees any of his own postops. At the end of the day, he can only hope that he did some good, but he can't really ever know or refine his method. And if he were to hear some criticism, he would think he is personally attacked because he has never seen his postop complications and failures himself.

Once you get out of residency, you can be as big of a jerk as you want to (I am not saying you are currently a jerk) about what you deem to be bad consults and admits, but you aren't going to improve your life ultimately when the people that generate revenue for you via consults and admissions and patient's start handing business to the next guy.

I get the residency pipe dream of "once I am an attending" probably gets a lot of us through the night, but pragmatically, things change very little. I think it's more realistic to realize that in medicine you are always going to be over worked and you are likely going to have to deal with a lot of things you feel aren't worthy of your time.

If you think your institution has a systemic problem with the ED dumping bad patient's or consults and you are eager to play the "Attending Game", then you guys should push your attendings to take in house call and fight back. Good luck with that.

 

[womp]

Sounds good. Will you be keeping your clinic open all day, every day, forever, and seeing any patient that shows up for any reason without asking for insurance? Because if I could just tell everyone with back pain to go see the 24-hour, no-money-up-front spine surgeon up on the third floor, I'd definitely do that.

It's not like you're the one up and working for 24 hours. But many consultants actually are when on call, and still have to go to work the next day. I would love to triple the demand for my own specialty so that we could cover our field 24 hours a day and work 3 shifts a week too.

And the see everyone including those with no money is not exactly from the kindness of your heart, it's actually federal law, and looking at the latest Medscape salary survey, you guys do pretty well, probably on average the most well compensated medical specialty per hour of work, with the exception of maybe spine surgery. Will you still do EM if you were paid like primary care with a 60% Medicaid pool?

I do agree that much of my rant is institutional and systems-wide, not really the fault of individual EPs, and it's primarily motivated by medicolegal concerns or hospital administration collection schemes. Doesn't make it any less frustrating.

 

[KnuxNole]

Just a student, but I want to know how some of you who have been in the game a long time deal with those people who come in for utter non-sense. 2 quick examples:

30 y/o female shows up at 12am with complaint of "I can't sleep." No other complaints at all, and doesn't even want any drugs. Just "I can't sleep."

20 something y/o male shows up one day after work because he is "dehydrated." He walks in with a bottle of water in his hand and clutching his chest in panic, saying he is dehydrated. "Are you having chest pain or SOB or have you fainted or anything?" "No, I'm dehydrated." Really? U come to the hospital because ur thirsty?

Have only seen 1 relatively older attending (65) take some of these people to task by saying things, "So you feel good about yourself wasting a community resource for a problem that could handled with common sense?" Younger attendings + residents just get annoyed but don't complain. Me... I just laugh, because really what else can you do in such a stupid broken system that allows these dingbats to get away with this.

While these peeps are annoying, for some, it's the only way to get seen by a doctor after 5PM or on the weekends....which does make some sense in the ED setting. For weekends on 9-5, there are urgent care for these peeps. But, there will be still be plenty of non-emergent cases in the emergency room. And, it does make sense that people get told to go to the ED if they can't wait for clinic opening....in a perfect world people shouldn't have to do that, but in 2015, there's no current solution for that. Clinics usually have their final appointments around 4-4:30pm.

Hell, a lot of people still use the ED as their PCP :O

 

[Birdstrike]

It's not like you're the one up and working for 24 hours. But many consultants actually are when on call, and still have to go to work the next day.

What you describe is a poor life choice. Don't do it unless you love it. If you don't, don't make your misery, that of others. You're not that important that anyone, anywhere, any place, needs you to work 24 hours and then the next day, really. It's a load of bulls**t. We're all replaceable, myself included. You'll learn this one way or the other. Even a President of the United States has someone waiting in the wings, to replace him in a minute. Don't play this, "I have to work 24 hrs straight, and then the next day," crap. No you don't. No one does. Some people do buy that used car, because they're told they must, and they fall in the sales trap. But it's a choice. In my opinion, it's a very poor life choice. I did it in residency, and it was horrible, life ruining. But it my choice and mine alone. Yet I had, and have, the character so as not to make my misery that of another. We make choices in life, even sometimes without knowing it.

There are no part-time a**holes in this life. You either are or you aren't. Make that choice while you still can otherwise it will be made for you.




"Graveyards are full of indispensable men" - Charles De Gaulle

 

[Hercules]

Great post Bird. I've always loved that quote and have pulled it out many a time myself.

 

[Jonassen]

NYT today has an article from Ezekiel Emanuel about reducing ED visits. Looks like he is taking a page of the NHS patient education plan. Though the $200 copay for ED visits probably is the main driver.

http://www.nytimes.com/2015/05/06/opinion/how-to-solve-the-er-problem.html

This administration loves to use the NYT as a teaser of its policy changes. Just prior to Obamacare was a series of articles about medical bankruptcy and poor life expectancy in the US.


First, it offers a $100 cash incentive if workers complete four steps. The steps evolve each year but have included signing up for MyGroupHealth, an online platform where workers can email doctors, order prescriptions, and access health information and self-help resources; completing a “health risk assessment,” a tool commonly used in corporate wellness programs; and completing preventive primary care and dental appointments.

Second, it increased the co-pay for an emergency room visit to $200, while the out-of-pocket charge for an urgent care visit remained at just $15.

Third, it introduced a “Care Begins With You” social media campaign to educate workers about the proper use of the emergency room. The campaign includes a short video that workers view as part of their re-certification process. It reinforces the co-pay information and explains the differences between urgent care and emergency room care. Urgent care is the place to go for coughs, headaches and back pain, while the emergency room should be reserved for life-threatening conditions, like crushing chest pain.

 

[Birdstrike]

NYT today has an article from Ezekiel Emanuel about reducing ED visits. Looks like he is taking a page of the NHS patient education plan. Though the $200 copay for ED visits probably is the main driver.

http://www.nytimes.com/2015/05/06/opinion/how-to-solve-the-er-problem.html

This administration loves to use the NYT as a teaser of its policy changes. Just prior to Obamacare was a series of articles about medical bankruptcy and poor life expectancy in the US.


First, it offers a $100 cash incentive if workers complete four steps. The steps evolve each year but have included signing up for MyGroupHealth, an online platform where workers can email doctors, order prescriptions, and access health information and self-help resources; completing a “health risk assessment,” a tool commonly used in corporate wellness programs; and completing preventive primary care and dental appointments.

Second, it increased the co-pay for an emergency room visit to $200, while the out-of-pocket charge for an urgent care visit remained at just $15.

Third, it introduced a “Care Begins With You” social media campaign to educate workers about the proper use of the emergency room. The campaign includes a short video that workers view as part of their re-certification process. It reinforces the co-pay information and explains the differences between urgent care and emergency room care. Urgent care is the place to go for coughs, headaches and back pain, while the emergency room should be reserved for life-threatening conditions, like crushing chest pain.

Are you really pointing us to Ezekiel Emmanuel for guidance on this? You must be joking. Ezekiel Emmanuel, who worked with Gruber both of whom knowingly and admittedly lied to the public about their proposed healthcare reforms, aka, the ACA? You're going to trust them to "fix" anything?

They're the ones who lied to the country, and now admit to doing so, by selling the ACA as a way to "reduce ED visits" in the first place, and solve other systemic problems, which have only gotten worse with their own so called "solution." Now that they've given us their "solution," the massive overhaul that is the ACA, we're to believe they've secretly hidden the "real solution" and are now are finally revealing it to us?

No.

I'm not taking the word of Ezekiel Emmanuel on this. No thanks. I'm good.

 

[TheBlueBlazer]

I do agree, though, that a copay of even $10 for some of the folks that don't pay anything at all would probably reduce a bunch of the garbage that I see people showing up for. Of course it might also keep that person teetering on the edge of decompensation from coming in too. Not sure which side of that I'd rather be on. I don't really have all that much of a problem taking care of the not-even-urgent care patients.

 

[Birdstrike]

I do agree, though, that a copay of even $10 for some of the folks that don't pay anything at all would probably reduce a bunch of the garbage that I see people showing up for. Of course it might also keep that person teetering on the edge of decompensation from coming in too. Not sure which side of that I'd rather be on. I don't really have all that much of a problem taking care of the not-even-urgent care patients.

Do you really think it's that easy? How long have you worked in an ED?

I don't know where you live, but virtually no rational thought process dissuades the average ED patient from coming to an ED, whenever, wherever or for whatever they want as far as I've been able to tell. When you have a law in place (EMTALA) that requires you to see them even if they say, "Sorry, don't got no cash" then such policies are futile. In principle, I completely agree with having copays and collecting them up front as aggressively as possible, but doing so will not reduce non-urgent visits, since so many are adept at gaming the system and a generation has been raised to feel entitled to do so. Charge a co-pay of $100, $200, or $2,000, but if people know that the law allows them to say "No," and you still must see them, the great majority of the ED population will say, "No." This is in a country where the poor in this country have government provided food (stamps), healthcare, subsidized housing, health insurance, cash-for-clunkers, disability payments, welfare payments, and cell phone subsidies.

Combine EMTALA with the fact that once an EP shakes hands and establishes a doctor patient relationship with a patient, making him fully liable for that patient medically, you have a perfect storm for a never ending ED over crowding crisis that shows no signs of going away, without a radical change in leadership.

 

[Arcan57]

Charging a co-pay has some deterrent value for some portions of the population. That level of deterrent is going to depend on income, size of co-pay, and perceived urgency of problem. The people referred to in this article seem to have jobs and aren't on Medicaid so there presumably is some hit to not paying their bills. I'd imagine most of the effect is going to be offering an incentive that has some value to the patient that is higher than their incentive to seek ED care. Giving people money for meeting health goals is going to move the needle in a way that more PCP appointments or urgent care after-hours availability will not. Consider the costs involved in making sure a 58 yo with DM, uncontrolled HTN, and CKD presenting with epigastric pain radiating to the chest doesn't have a life threatening emergency. You could PAY that same person $25 every time they saw a PCP and make their urgent care visits free and still save money.

 

[Jonassen]

Are you really pointing us to Ezekiel Emmanuel for guidance on this? You must be joking. Ezekiel Emmanuel, who worked with Gruber both of whom knowingly and admittedly lied to the public about their proposed healthcare reforms, aka, the ACA? You're going to trust them to "fix" anything?

They're the ones who lied to the country, and now admit to doing so, by selling the ACA as a way to "reduce ED visits" in the first place, and solve other systemic problems, which have only gotten worse with their own so called "solution." Now that they've given us their "solution," the massive overhaul that is the ACA, we're to believe they've secretly hidden the "real solution" and are now are finally revealing it to us?

No.

I'm not taking the word of Ezekiel Emmanuel on this. No thanks. I'm good.

Not pointing anyone on you for guidance. This was just today's article. And you can bet if it's published in the NYT, it's an idea that is floating around somewhere in this administration and this "ER problem" is certainly something that is concerning them. It doesn't matter if you take the word of Ezekiel Emmanuel or not. Consider it more like white smoke or gray smoke. Jeesh.

 

[Birdstrike]

Not pointing anyone on you for guidance. This was just today's article. And you can bet if it's published in the NYT, it's an idea that is floating around somewhere in this administration and this "ER problem" is certainly something that is concerning them. It doesn't matter if you take the word of Ezekiel Emmanuel or not. Consider it more like white smoke or gray smoke. Jeesh.

I have no issue with you, just your source. Read Dr. Emanuel declaring to the world that he wants to die in 17 yrs at age 75 and how his closest friends and relatives think he's crazy (his words, not mine). I wonder how many of his patients over 75, he secretly looks at and thinks, "You'd be better off dead." I wonder if he feels the same way about his friend Hilary Clinton, who if elected President in 2016, would be over 75 yrs old in the last 2 years of a second term.

http://www.theatlantic.com/features/archive/2014/09/why-i-hope-to-die-at-75/379329/

 

[Estrace]

I'm really surprised at what I'm reading here. I went to the ER on Monday because I had swelling on my both fingers, toes, ankles. My left hand was on fire like there was something burning inside my skin and I felt a lot of pressure on the left side of my chest. I couldn't sleep the whole night because I was too scared to close my eyes. Being that I have a medical condition that is proving very hard to diagnosis for 6 months now, I was really scared. The doctor at the ED wanted to discharge without even listening to what I had to say. Then when I got upset at how rude he was, he just told me he will order some tests. I was left in this room for 12 hours with NPO order. They completely ignored me. Being in healthcare field myself, I tried to be understanding. To read here that the NPO order was on purpose is ridiculous. I don't think anyone will love to spend 12 hours in the ED, calling off work and stuff just for the fun of it.

So you only have to be rushed in by ambulance to get medical attention in the ED?

 

[TooMuchResearch]

I'm really surprised at what I'm reading here. I went to the ER on Monday because I had swelling on my both fingers, toes, ankles. My left hand was on fire like there was something burning inside my skin and I felt a lot of pressure on the left side of my chest. I couldn't sleep the whole night because I was too scared to close my eyes. Being that I have a medical condition that is proving very hard to diagnosis for 6 months now, I was really scared. The doctor at the ED wanted to discharge without even listening to what I had to say. Then when I got upset at how rude he was, he just told me he will order some tests. I was left in this room for 12 hours with NPO order. They completely ignored me. Being in healthcare field myself, I tried to be understanding. To read here that the NPO order was on purpose is ridiculous. I don't think anyone will love to spend 12 hours in the ED, calling off work and stuff just for the fun of it.

So you only have to be rushed in by ambulance to get medical attention in the ED?

No. That was sarcasm.

 

[GeneralVeers]

I'm really surprised at what I'm reading here. I went to the ER on Monday because I had swelling on my both fingers, toes, ankles. My left hand was on fire like there was something burning inside my skin and I felt a lot of pressure on the left side of my chest. I couldn't sleep the whole night because I was too scared to close my eyes. Being that I have a medical condition that is proving very hard to diagnosis for 6 months now, I was really scared. The doctor at the ED wanted to discharge without even listening to what I had to say. Then when I got upset at how rude he was, he just told me he will order some tests. I was left in this room for 12 hours with NPO order. They completely ignored me. Being in healthcare field myself, I tried to be understanding. To read here that the NPO order was on purpose is ridiculous. I don't think anyone will love to spend 12 hours in the ED, calling off work and stuff just for the fun of it.

So you only have to be rushed in by ambulance to get medical attention in the ED?

Are you for real? Or is this a cynical post subtly commenting on the thought processes of many of our patients?

If it's real, then you don't understand what the ED is for. You said yourself you had this condition for "6 months" and it was "hard to diagnose". We are trained to see emergencies. You were evaluated by an ED physician, he assessed you and determined that there was no emergency, and then tried to discharge you. I'm not sure what your complaint is at this point. I probably would have discharged you too without one single test, as most on here would have as well.

 

[Psai]

I'm really surprised at what I'm reading here. I went to the ER on Monday because I had swelling on my both fingers, toes, ankles. My left hand was on fire like there was something burning inside my skin and I felt a lot of pressure on the left side of my chest. I couldn't sleep the whole night because I was too scared to close my eyes. Being that I have a medical condition that is proving very hard to diagnosis for 6 months now, I was really scared. The doctor at the ED wanted to discharge without even listening to what I had to say. Then when I got upset at how rude he was, he just told me he will order some tests. I was left in this room for 12 hours with NPO order. They completely ignored me. Being in healthcare field myself, I tried to be understanding. To read here that the NPO order was on purpose is ridiculous. I don't think anyone will love to spend 12 hours in the ED, calling off work and stuff just for the fun of it.

So you only have to be rushed in by ambulance to get medical attention in the ED?

Man this post fits so well into the theme of the thread

 

[BoardingDoc]

I'm really surprised at what I'm reading here. I went to the ER on Monday because I had swelling on my both fingers, toes, ankles. My left hand was on fire like there was something burning inside my skin and I felt a lot of pressure on the left side of my chest. I couldn't sleep the whole night because I was too scared to close my eyes. Being that I have a medical condition that is proving very hard to diagnosis for 6 months now, I was really scared. The doctor at the ED wanted to discharge without even listening to what I had to say. Then when I got upset at how rude he was, he just told me he will order some tests. I was left in this room for 12 hours with NPO order. They completely ignored me. Being in healthcare field myself, I tried to be understanding. To read here that the NPO order was on purpose is ridiculous. I don't think anyone will love to spend 12 hours in the ED, calling off work and stuff just for the fun of it.

So you only have to be rushed in by ambulance to get medical attention in the ED?

If you came in by ambulance with the same chief complaint, you would still have received the same treatment. You admittedly came in for what you're selling as an exacerbation of a chronic condition. The emergency department does not have the responsibility or the resources to treat these complaints. Our job is more or less to make sure that you are not about to drop dead. I'm guessing you were kept for a couple sets of troponins because of your chest pain, but that, an EKG and a quick physical exam is the most you could have needed from that visit based on what you wrote. If you expected more than that, you have a misunderstanding of what the ED is supposed to accomplish.

 

[Estrace]

If you came in by ambulance with the same chief complaint, you would still have received the same treatment. You admittedly came in for what you're selling as an exacerbation of a chronic condition. The emergency department does not have the responsibility or the resources to treat these complaints. Our job is more or less to make sure that you are not about to drop dead. I'm guessing you were kept for a couple sets of troponins because of your chest pain, but that, an EKG and a quick physical exam is the most you could have needed from that visit based on what you wrote. If you expected more than that, you have a misunderstanding of what the ED is supposed to accomplish.

I understand that and I was not expecting anything more than that. I have gone to a different ER closer to my work 2 months ago because of the same complaints and was treated better. I was there for 4 hours and the doctor even though was confused by my condition tried her best to make sure I was going to be okay until I could see my doctor the next day.
Dismissing my compliant as non emergency was wrong. It is my body and as a pharmacist, I know enough to know when to be alarmed. I didn't go there for him to diagnose me. What if I had walked out in the parking lot and dropped dead? He didn't have to be rude or was it necessary for him to stuck me in a roo for 12 hours with a NPO order. What did he accomplished by doing that?

 

[turkeyjerky]

I understand that and I was not expecting anything more than that. I have gone to a different ER closer to my work 2 months ago because of the same complaints and was treated better. I was there for 4 hours and the doctor even though was confused by my condition tried her best to make sure I was going to be okay until I could see my doctor the next day.
Dismissing my compliant as non emergency was wrong. It is my body and as a pharmacist, I know enough to know when to be alarmed. I didn't go there for him to diagnose me. What if I had walked out in the parking lot and dropped dead? He didn't have to be rude or was it necessary for him to stuck me in a roo for 12 hours with a NPO order. What did he accomplished by doing that?

I can only assume that he observed you and kept you NPO for the next 12 hrs due a concern that you were about to drop dead, so that the team would be able to readily resuscitate you, and that your airway would be easier if NPO. Seems to me that you should be thanking him for directly addressing and mollifying your chief concern (that you were about to drop dead).

 

[racerwad]

Dismissing my compliant as non emergency was wrong. It is my body and as a pharmacist, I know enough to know when to be alarmed. I didn't go there for him to diagnose me.

What in all creation were you hoping for if not a diagnosis? I'm sure you'll reply that you wanted to be treated, but you can't have effective treatment without a proper diagnosis.

Also, what is wrong about being told that your complaint is not an emergency? Without knowing that the treating EP told you, perhaps you are conflating being told that you are experiencing a non-emergent condition with having a non-problem. Just because it isn't life-threatening doesn't mean you are experiencing real symptoms that are disrupting your life. It is just that the emergency department is not (hopefully!) where you are going to find the answer to your problem. People who have problems that are adequately addressed by the ED are not people you should want to trade places with.

 

[WilcoWorld]

Dismissing my compliant as non emergency was wrong.

Can you help me understand what emergency you had?

 

[Birdstrike]

Can you help me understand what emergency you had?

 

[Droperidol]

This is all speculation and conjecture but with your complaints of chest pain in addition to other problems maybe the physicians felt it was necessary to perform serial cardiac enzymes and kept you npo for a possible stress test. Physicians do not routinely starve patients simply for their own amusement or to punish someone for coming in to see them (despite the off handed comment in this thread).


Sent from my iPhone using Tapatalk

 

[EM4life]

I understand that and I was not expecting anything more than that. I have gone to a different ER closer to my work 2 months ago because of the same complaints and was treated better. I was there for 4 hours and the doctor even though was confused by my condition tried her best to make sure I was going to be okay until I could see my doctor the next day.
Dismissing my compliant as non emergency was wrong. It is my body and as a pharmacist, I know enough to know when to be alarmed. I didn't go there for him to diagnose me. What if I had walked out in the parking lot and dropped dead? He didn't have to be rude or was it necessary for him to stuck me in a roo for 12 hours with a NPO order. What did he accomplished by doing that?

It sounds like you have two complaints, one is that the EP who saw you dismissed you as having a non emergency and second is that you were kept NPO in a room for 12 hours. But seems like second complaint would be a nonissue if you felt like the EP actually seemed "concerned" about your symptoms. This is an issue of bedside manner and not of the actual care that was provided. NPO isn't a punishment for having a nonemergency, it is important to protect you if you were to crash and need an emergent airway. No one wants to put a tube down your throat along with your dinner too, I KNOW you wouldn't want that. It is also in this case perfectly acceptable to be honest with your provider and say "hey i've had these symptoms for 6 months but it really freaked me out tonight" - I would have a lot more empathy for this patient than one who showed up hoping that I'd provide an answer for them after 6 months of seeing pcps/specialists etc.

"I know enough" Dangerous words to utter for many who know just enough to be concerned but not enough to know why they shouldn't be. The more I do medicine, the more I realize how much we don't know, the more patients I see that fall out of the standard deviation of classic presentation for many a diagnosis. You are right to seek care for your complaints, but it seems like the emergency department (especially going back a second time for the same complaints) is not going to provide you any answers and just increase your frustration.

 

[Doctor Bob]

Dismissing my compliant as non emergency was wrong.

Actually, as you are still here to write these posts, it would seem the ED doc was correct.

It is my body and as a pharmacist, I know enough to know when to be alarmed.

Argument contrary to fact. You were wrong in your assessment that you were having an emergency.

What if I had walked out in the parking lot and dropped dead?

But you didn't.

You will get little to no sympathy from a forum full of EM docs when you complain about how another EM doc didn't give you good customer care for your non-emergency.

 

[Estrace]

It sounds like you have two complaints, one is that the EP who saw you dismissed you as having a non emergency and second is that you were kept NPO in a room for 12 hours. But seems like second complaint would be a nonissue if you felt like the EP actually seemed "concerned" about your symptoms. This is an issue of bedside manner and not of the actual care that was provided. NPO isn't a punishment for having a nonemergency, it is important to protect you if you were to crash and need an emergent airway. No one wants to put a tube down your throat along with your dinner too, I KNOW you wouldn't want that. It is also in this case perfectly acceptable to be honest with your provider and say "hey i've had these symptoms for 6 months but it really freaked me out tonight" - I would have a lot more empathy for this patient than one who showed up hoping that I'd provide an answer for them after 6 months of seeing pcps/specialists etc.

"I know enough" Dangerous words to utter for many who know just enough to be concerned but not enough to know why they shouldn't be. The more I do medicine, the more I realize how much we don't know, the more patients I see that fall out of the standard deviation of classic presentation for many a diagnosis. You are right to seek care for your complaints, but it seems like the emergency department (especially going back a second time for the same complaints) is not going to provide you any answers and just increase your frustration.

You seem to be the only one that understands my issue with this doctor. Yes, the NPO order wouldn't have been an issue if he actually show any concerned or even took more than 2 minutes to listen. I actually didn't feel like I was being punished until the evening shift nurse came in (almost 10hrs into the whole ordeal). The first thing the doctor asked me when he came in was what brought me in that day? I felt like I needed to give him some back history so that my compliants that day will make a little sense to him but he wouldn't let me. He cuts me off and proceeded to ask me to tell him why I came in that day? So I told him the issues I was having that day.
The first time I went to the ER for this issue, the doctor that saw me was very patient. I showed her some pics on my phone , gave her history of my battle with this illness, told her what I thought it was and why no doctor will give me a diagnosis. She listened, helped me the best she could, and gave me name of a rheumatologist to see. Even went as far as calling them the next day for me to make sure I get seen immediately.
I have seen eight specialists (4 rheumatologists )in the past six months and only my hematologist agreed with me that I have some type of connective tissue disease. I have all the symptoms (some are just presented differently) but all my lab results comes back clean except for a positive ANA test. I get flare up every couple of weeks and they differ in severity. Sometimes, it can be excessive dryness (dry eyes, dry mouth, dry skin) and I deal with those. Other times, it's massive inflammation (I can feel my organs swollen), my voice will change and I will turn pale. I have only gone to the emergency department for this because it scares me.
I understand that this disorder is very hard to diagnose because it's several things presented together but I can't help it when I get those scary systemic inflammation. I wish more doctors know how to handle cases that don't fall within the standard guideline . I will never go to an ER to look for an answer for this type of illness because I know they are not equipped to provide me with an answer. This is also all new to me as well and sometimes, I get symptoms that will scare me enough to head straight to the ER.