2 sets and home, known CAD?

[two guys]

Thought I'd throw this up for discussion.

I work at a community job where all chest pain without hx of CAD (and not STEMI, NSTEMI, unstable angina, or really bad story) gets ED CP obs, stressed and discharged. Patients with known CAD and CP and negative first set get cardiology consults and admitted to cards. The hospitalists don't admit any chest pain.

One of the cardiologists has recently been pushing for discharge after 2 sets of trops 3 hrs apart. This is over the phone, without generating any note or official consult. These are not patients known to him. He will come and see the patient if I really push but it takes enduring a fair bit of condescending speech and complaints. He generally admits these folks if he comes to see them.

I'm aware of the studies with 2 sets for low risk patients, most of these include some provision for eventual stress test. I'm also aware of the AHA guidelines for low risk patients which basically says they all need stress tests although doesn't specify a timing.

I'm not aware of any studies for this type of practice in patients with known CAD, CABGs, etc. It seems crazy to me to do less for someone with known lesions who is 70 than for a 45 yo with no history.

I do send some folks home with 2 sets who have known CAD/CABG if their story isn't very concerning and they want to go home. This is of course after offering admission and doing some shared decision making. But when they want to come in after shared decision making, I consult cards.

Most of my peers just do what cards says and record it in the chart because they don't want to fight. I know there is some protection for me by charting that I discussed it with him but it doesn't seem like much. I think I see about 500 patients like this a year. It sure seems that one of them will have an event after discharge over the life of my career.

What do you guys think?

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[xaelia]

Totally reasonable strategy. If they're maximally medically managed and their coronary disease is known, there's basically no benefit to hospitalization after you've ruled them out for nSTEMI. A lot of folks are shifting over to the concept that "Unstable Angina" as traditionally described – active plaque rupture with coronary thrombosis/recanalization – is going to have measurable troponin leak on modern assays, and the 3-sets 6-hours apart adds no value.

If it's been awhile since they'd been stressed/angiography, you could make a case that "something might have changed", and the patient might benefit from observation with additional cardiac imaging. But, that's an individualized treatment decision.

Pretty much also ought to be expected one of these CAD patients will eventually drop dead within 30 days of discharge. Hopefully these folks, because they have well-described/managed CAD, they have someone they can make contact with quickly after discharge. Just have to be up-front with the family re: what you can actually address at that visit in the ED, and that their heart could go south at any time and staying the hospital won't change that. If you get a bad vibe from the patient/family, do whatever you need to protect yourself.

 

[two guys]

Thanks xaelia. This is different from how I've practiced for the last several years where chest pain with history gets admission no questions asked. What that always meant for me was that I'd admit them if they had a worrisome story, had poor follow up, or want to be admitted. Otherwise they'd go home without a consult.

With this consultant my strategy has been to insist on face to face consult or a note in the chart if they have a worrisome story, poor follow up, or want to be admitted. After a dozen or so conversations with this guy and my partners it seems that I'm the only one with this strategy. His recommendation is all patients with chest pain and cad can go home after 2 sets. I've started to wonder which one of us is in the wrong. I'm the only one of my peers who doesn't just accept what he says, put it in the chart and discharge. He's the only one of his peers who recommends discharge after a phone consult. He does admit them once I insist on a face to face consult or note in the chart, either because it's now his liability or it's just easier to admit after I've set that expectation.

I do agree that there's not much to be gained if there's no cath or stress in the morning. I've got no problem explaining this to patients with good follow up and getting them home. For the others who have bad follow up or are truly convinced they're having an MI, I don't see how I'd have a leg to stand on with a bad outcome and no cardiologist on the chart. All the plaintiff would have to do is whip out the AHA guidelines and remind the jury that these were written by cardiologists for patients less risky than mine. Why wouldn't I get a formal cardiology consult?

Maybe I'm looking at this wrong, I certainly would appreciate any feedback.

 

[RustedFox]

Chest pain either

1.) Gets admitted
2.) Gets sent home with an appointment with THEIR cardiologist in 1-2 days (documented and agreed)
or 3.) Leaves AMA.

This cardiologist sounds shifty.

 

[WilcoWorld]

He generally admits these folks if he comes to see them.

Simplified it for you.

That being said. As I recently mentioned here, I send a lot of those patients home.

 

[gman33]

I have a hard time sending a patient home based on a rec of someone who has not seen the patient.
If something goes wrong, I will be the one thrown under the bus.
There needs to be a standard established by your group.
If you are not comfortable sending a patient home, at a minimum the consultant should come see the patient and write a formal consult.
I have similar disputes with hospitalists from time to time.
generally I just state that i think they need to be admitted, but they can come to the ED and d/c the patient.

 

[deleted109597]

Chest pain either

1.) Gets admitted
2.) Gets sent home with an appointment with THEIR cardiologist in 1-2 days (documented and agreed)
or 3.) Leaves AMA.

This cardiologist sounds shifty.

I don't think he sounds shifty at all. He's likely just overwhelmed by the sheer number of useless tests that are being done. If they've got two negative sets, and an unchanged EKG, how many have you admitted that had the "OMG they had a huge lesion you saved their life by admitting them for their stress!" I haven't had any. It's nice to practice where I can tell patients what I think is going on, and what they need to do about it (usually medically manage better). But I would run out of beds in the hospital by 9am if I admitted every single chest pain.

Do you have an age cutoff?

I think the AHA has done too good of a job telling people to see their doctor about chest pain actually. We still get a large number of pts who ignore their pain when they're actually having ACS, but it isn't helped by the people who bring in their 8 year old because he has chest pain. Or the 15 year old girl for the 30th time this month. Or the 80 yr old who has angina, 4 caths in the last year that show microvascular disease that's not fixable, but every time his chest hurts they call 911. I don't have an answer to fix that, but admitting them all isn't it either.

 

[Birdstrike]

Thought I'd throw this up for discussion.

I work at a community job where all chest pain without hx of CAD (and not STEMI, NSTEMI, unstable angina, or really bad story) gets ED CP obs, stressed and discharged. Patients with known CAD and CP and negative first set get cardiology consults and admitted to cards. The hospitalists don't admit any chest pain.

One of the cardiologists has recently been pushing for discharge after 2 sets of trops 3 hrs apart. This is over the phone, without generating any note or official consult. These are not patients known to him. He will come and see the patient if I really push but it takes enduring a fair bit of condescending speech and complaints. He generally admits these folks if he comes to see them.

I'm aware of the studies with 2 sets for low risk patients, most of these include some provision for eventual stress test. I'm also aware of the AHA guidelines for low risk patients which basically says they all need stress tests although doesn't specify a timing.

I'm not aware of any studies for this type of practice in patients with known CAD, CABGs, etc. It seems crazy to me to do less for someone with known lesions who is 70 than for a 45 yo with no history.

I do send some folks home with 2 sets who have known CAD/CABG if their story isn't very concerning and they want to go home. This is of course after offering admission and doing some shared decision making. But when they want to come in after shared decision making, I consult cards.

Most of my peers just do what cards says and record it in the chart because they don't want to fight. I know there is some protection for me by charting that I discussed it with him but it doesn't seem like much. I think I see about 500 patients like this a year. It sure seems that one of them will have an event after discharge over the life of my career.

What do you guys think?

Just go back and read your own post one more time.

You're talking about patients you're uncomfortable letting go home, to the extent you work them up, get at least two sets of troponins on, and feel the need to call cardiology regarding

*You're not comfortable sending them home*

Then, cardiology bucks the consult, makes you and your partners "put up a fight" to have them either admit the patient or come see the patient. When you actually do listen to your gut and go to the mat asking them to come see the patient, Cardiology "generally admits these folks." In other words:

*Cardiology is not comfortable sending them home*

So what do we have here?

We have two doctors, neither of whom are comfortable sending home a patient, due to their combined years of experience. But because one of the doctors doesn't want the extra work or liability of coming to see the patient (Cardiology) therefore now you are sending the patient home, and even though you know damn well your gut tells you not to, and even though you know damn well the cardiologist HIMSELF would not if he was forced to be the last one holding the hot potato?

You're not going to cure the ills of over-testing, out of control medical costs, or the scourges of defensive medicine by sending home a patient your gut tells you to admit.

Decision rules are fine.

Medical Society guidelines are fine.

But listen to your gut, man. Listen to your gut. It's the one single thing, distilled from all those years of long nights in residency, ICU rotations, reading, board studying and cranking out 3,000-5,000 patients per year in the ED.

Last I checked, missed MI is number one on the list of plaintiff's award dollars levied against Emergency Physicians.

Your Cardiologist is smart. He's not willing to send these patients home, and he knows damn well if one arrests post discharge, his defense will be, "I never saw the patient. The ER doctor said he was fine, and that I didn't need to come see him. If I knew the patient was having an MI, OF COURSE I would have come seen him, but since I didn't I can't really say anything about it, other than I never would have told Dr TwoGuys to send this patient home, because this patient was OBVIOUSLY having a heart attack."

He's got a memory bank full stories like this, "Holy, crap. Remember that young guy with the crappy story, that V fibbed on the floor and rule in?" just like you and I do.

Word to the wise, don't ignore your gut.

 

[Birdstrike]

Totally reasonable strategy. If they're maximally medically managed and their coronary disease is known, there's basically no benefit to hospitalization after you've ruled them out for nSTEMI. ....their heart could go south at any time and staying the hospital won't change that. If you get a bad vibe from the patient/family, do whatever you need to protect yourself.

I agree your last bolded line, but not the first. Heart disease patients don't die of "elevated troponins" or "elevated ST segments." They die suddenly from arrhythmias. If Mr "Known Coronary Disease" V fibs or brady's down while at home, asleep in bed next to Gladys, I'm not as confident in the chances of turning that around, whereas monitored in the hospital, you've at least got a chance at turning around an arrhythmia. Such patients don't even need to be having ischemia to have a fatal or life threatening arrhythmia. That's the whole concept behind an AICD, that such events can come without warning, be easily cardioverted, but otherwise be fatal if not treated within seconds to minutes. So to argue that "there's basically no benefit" to hospitalizing a patient with known coronary disease, who's actively having chest pain, unless they've specifically ruled in, is a stretch in my opinion.

These are people who know they have a bad heart, and are worried enough they might be having an MI to come to the ER, however iffy their story may be. If they have "only a 1% chance" of going into V FIb from their "untreatable" CAD, do you send that home?

 

[Khaos]

Patients with great follow up, chest pain free now and have had recent stress or testing, I'm less likely to argue if I have two sets that are negative and EKG not showing STEMI. If they have not had testing in quite a while or poor follow up you could insist on one of two things. He could come and see the patient now or recommend you send him to obs, have the rest of the testing and possible stress in the morning, and he or a partner could see the patient in the morning. The ED then gets to bill for obs and you still have the patient seen no matter what.This way there is a compromise if allowed by the group and the guy can pass the buck and his partners will eventually catch on and get pissed at him.

 

[RustedFox]

I don't think he sounds shifty at all. He's likely just overwhelmed by the sheer number of useless tests that are being done. If they've got two negative sets, and an unchanged EKG, how many have you admitted that had the "OMG they had a huge lesion you saved their life by admitting them for their stress!" I haven't had any. It's nice to practice where I can tell patients what I think is going on, and what they need to do about it (usually medically manage better). But I would run out of beds in the hospital by 9am if I admitted every single chest pain.

Do you have an age cutoff?

I think the AHA has done too good of a job telling people to see their doctor about chest pain actually. We still get a large number of pts who ignore their pain when they're actually having ACS, but it isn't helped by the people who bring in their 8 year old because he has chest pain. Or the 15 year old girl for the 30th time this month. Or the 80 yr old who has angina, 4 caths in the last year that show microvascular disease that's not fixable, but every time his chest hurts they call 911. I don't have an answer to fix that, but admitting them all isn't it either.

He's overwhelmed by the number of useless tests that are being done.

We're overwhelmed by the number of pointless lawsuits that are being filed.

I have an age cutoff, yes - but its flexible depending on comorbidities... young people these days aren't healthy, they're fat and lazy. I sent a 36 year old guy to the cath lab recently... big circumflex lesion. Stented. Guaranteed that would have been an excess limits judgment.

Its just not worth it, dude.

 

[The Buff]

If it makes you feel any better, my cardiologist admit next to no one. Known CAD, concerning story, mildly positive troponin (they are not highly specific after all), advanced age...depending on the cardiologist a combination of these things might get an admission. But a combination of these things might also get blocked..and no, they are not coming in overnight. Now this has been going on for years, and there are no bad outcomes that I know of, which is why my older partners put up with this. And to be fair the cardiologist are good about quick outpt followup, but overall it makes me extremely nervous. One of the reasons I am obtaining new employment.

 

[deleted109597]

He's overwhelmed by the number of useless tests that are being done.

We're overwhelmed by the number of pointless lawsuits that are being filed.

So fix your state, or go practice in a state with tort reform. Putting your head in the sand (which admitting all patients regardless of need is) won't fix the problem, but will break healthcare sooner.

 

[RustedFox]

We're trying to fix it. Elections are coming up. I recently posted a story about tort reform efforts here.

Dude, I love your contributions to this forum, but "just move to Texas" just isn't a feasible option for everyone.

 

[deleted109597]

We're trying to fix it. Elections are coming up. I recently posted a story about tort reform efforts here.

Dude, I love your contributions to this forum, but "just move to Texas" just isn't a feasible option for everyone.

Texas isn't the only state with meaningful tort reform.

 

[RustedFox]

Texas isn't the only state with meaningful tort reform.

Gimme a short list.

 

[deleted109597]

Gimme a short list.

No.
But here's a long pdf. Pages 125 and 126 are what you want.

 

[RustedFox]

Here's a quick assessment of the top 10 states on the list for "Medical Liability Environment"

1. CO - Good luck finding a job.
2. TX - Was once its own country. Still thinks it is. Some parts actually have a climate. Texans.
3. ID - Cold. Potatoes.
4. KS - Rectangular and boring.
5. NE - Often confused with Kansas. Easy to see why.
6. OH - Welcome to Ohio. Ha Ha, now you're stuck in OHIO.
7. SC - The less literate Carolina.
8. ND - Might actually be a part of Canada. Not sure if anyone actually lives there.
9. AK - Yeah, right.
10. MT - Nobody lives there, either. More sheep than people. Sheeple.

"Just move" isn't a realistic solution. I'd rather break the system faster so it gets "fixed", rather than fall on my sword and suffer the phyrric victory.

 

[exsanguination]

Do you basically have to train at Denver health to get a job in CO?

 

[two guys]

I appreciate the response guys. Sounds like there's a broad spectrum. Birdstrike, my initial thought has always been the same as yours - the guy just doesn't want to come in. But, since I appear to be in the minority in my group I've started to wonder if its just me. Doesn't sound like it is.

McNinja, are we talking about the same patients? Let's say patient is in his 70's, incarcerated, hx of cabg with cath 2 years ago showing >70% lesions in the graft and total occlusion in the native. He's been off plavix and ASA for 1 year. He's got mild left sided chest pain that occurs in 5 miute episodes with some radiation and mild nausea. Comfortable in the ER. EKG with old q's and t wave inversions with no old ekg to compare to. Is calling cards on this guy sticking my head in the sand? I agree he doesn't have STEMI, NSTEMI or a spooky story. Still, seems a little tough to send home without a caridologists name on the chart, right? (or maybe not...)

 

[deleted109597]

Here's a quick assessment of the top 10 states on the list for "Medical Liability Environment"

1. CO - Good luck finding a job.
2. TX - Was once its own country. Still thinks it is. Some parts actually have a climate. Texans.
3. ID - Cold. Potatoes.
4. KS - Rectangular and boring.
5. NE - Often confused with Kansas. Easy to see why.
6. OH - Welcome to Ohio. Ha Ha, now you're stuck in OHIO.
7. SC - The less literate Carolina.
8. ND - Might actually be a part of Canada. Not sure if anyone actually lives there.
9. AK - Yeah, right.
10. MT - Nobody lives there, either. More sheep than people. Sheeple.

"Just move" isn't a realistic solution. I'd rather break the system faster so it gets "fixed", rather than fall on my sword and suffer the phyrric victory.

Then continue to "Occupy Florida".

 

[Old_Mil]

One of the cardiologists has recently been pushing for discharge after 2 sets of trops 3 hrs apart. This is over the phone, without generating any note or official consult. These are not patients known to him. He will come and see the patient if I really push but it takes enduring a fair bit of condescending speech and complaints. He generally admits these folks if he comes to see them.

This is on page 98 of the book "How to Be Lazy On Call", evidenced by the fact that he admits people he was telling you to discharge the minute his name is on the chart.

Most of my peers just do what cards says and record it in the chart because they don't want to fight. I know there is some protection for me by charting that I discussed it with him but it doesn't seem like much. I think I see about 500 patients like this a year. It sure seems that one of them will have an event after discharge over the life of my career.

What do you guys think?

More than one of them is going to have an event in the "am I going to get sued window." Recording what a specialist tells you to do to a patient he has not seen his sort of like typing Dr. Seuss quotes into the chart.

 

[em1234]

one fish, two fish, red fish, sued fish.
Straight up work avoidance being supplanted by risk intolerance. As long as you and your group members are will to absorb the risk of their outpatient bad outcomes, the cardiologist gets to stay in bed. Once out of bed, he realizes his own risk tolerance isn't high enough to send these patients home, so why should you?
Is the data on our side for sending these patients home, yes. Will that help you if you live in Florida, Illinois, Philadelphia, etc and you have an n=1 vfib arrest in their bed awaiting their next day cards appointment, I wouldn't bet on it. Just ask Robert McNamara about the value of having literature on your side when the people judging you don't have a hope or prayer of understanding it.
I'm fine admitting these people all day, everyday, without question and almost without exception...unless a cardiologist (preferably their cardiologist) comes down, evals, formally consults and wants them discharged home.

 

[Birdstrike]

one fish, two fish, red fish, sued fish.
Straight up work avoidance being supplanted by risk intolerance. As long as you and your group members are will to absorb the risk of their outpatient bad outcomes, the cardiologist gets to stay in bed. Once out of bed, he realizes his own risk tolerance isn't high enough to send these patients home, so why should you?
Is the data on our side for sending these patients home, yes. Will that help you if you live in Florida, Illinois, Philadelphia, etc and you have an n=1 vfib arrest in their bed awaiting their next day cards appointment, I wouldn't bet on it. Just ask Robert McNamara about the value of having literature on your side when the people judging you don't have a hope or prayer of understanding it.
I'm fine admitting these people all day, everyday, without question and almost without exception...unless a cardiologist (preferably their cardiologist) comes down, evals, formally consults and wants them discharged home.

I agree completely. This mentality of, "I'm going to fix the problem of over testing, defensive medicine and out of control health care spending myself" on my shift, on my watch, on my chart, with my name on it is either stupid or naive, I'm not sure which.

It's fine for the academic types that are protected in their cozy "You're god no matter what happens" environment, work one shift a month and therefore have minimal liability as it is, but for the grunt doc out in private practice it's *****ic.

It's also fine for the neo-political and media docs, who really can't hack grinding it out in the pit anymore, who want to spit policy pablum to gain favor with the society heads, media and political types so they can get a cush desk job, cut down on their load of nights, grunt shifts or the stressful work of actually being a real doctor. So they're fine with throwing you under the bus and preaching, "Reduce testing, reduce defensive medicine, reduce costs!" as long as it advances their post-patient-care cushy, low stress career as a "consultant" making 5 times what you're making per hour. They're lying to you, and when you get served by a man in a badge at work with the subpoena, you look down and it's

THEIR FRICKIN' NAME!!!!!

signing off as the expert witness on the lawsuit against you, from a different state, never having met you. You've seen the names on your textbooks do this already. They won't be there to testify in your favor. They'll be there to charge $1,000 per hour to say they would've done it different, you're a hack and it should've immediately jumped to your mind that the 1 in a million presentation was laying there before you, on your shift, with zero signs or symptoms out of the ordinary, even though you did what every other excellent physician would have done.

Don't listen to any fool that tries to sell you down the river, or feed you some nonsense that won't prepare for the real world. Listen to your attendings that pull you aside and say, "This isn't the answer on the boards, but I'm telling you, in the real world, this is how it's done."

I'm paradoxically bullish on being a doctor right now, but it can be a sleazy set of circumstances if you're not hardened to what the real world is about, as a doctor. This is where residencies and academics are frickin' horrible. They should be putting people through mock depositions, and set up mock "process server" events where on a shift you're served a subpoena, mock trials, mock job loss situations where a theoretical contract loss occurs, or your boss threatens to fire you for doing something politely, right and medically correct that generated a "customer complaint." Don't be one of these naive docs writing blogs about how terrible it is to be a doctor in 2014.

I'm telling you:

Medical Training Right Now Is Horrible, Horrible, Horrible

and isn't preparing you for the REAL WORLD.

It's not. It's not. It's not.

It's molding thousands, and thousand, and thousand of THIS kind of doctor:

http://www.thedailybeast.com/articl...tor-became-the-most-miserable-profession.html

And it's LYING to young doctors in training. There is an incredibly sleazy underworld to being a doctor right now, from business types threatening you for not violating your oath, to lawyers wanting to feed off of you for doing your job correctly, to insurance companies that arbitrarily will just not pay the bill for the services provided by you, hoping your billing people will just blow it off and not appeal it. These things are bleeding the American Physician anemic and very few are equipped to deal with it.

Being a doctor right now, is like being an honest man, trying to run a grocery store on a street controlled by the mob. Know the system, people. Be prepared, don't be naive and you can actually have a great career. Don't be one if these people, depressed and wanting to kill yourself in a midlife crisis, disillusioned because being a doctor has got you down.

http://www.kevinmd.com/blog/2014/05/physician-suicide-etiquette-doctor-dies-suddenly.html

Be naive, and it can eat you alive. Be real, be ready, and it can be a great career.

 

[deleted109597]

I agree completely. This mentality of, "I'm going to fix the problem of over testing, defensive medicine and out of control health care spending myself" on my shift, on my watch, on my chart, with my name on it is either stupid or naive, I'm not sure which.

It's fine for the academic types that are protected in their cozy "You're god no matter what happens" environment, work one shift a month and therefore have minimal liability as it is, but for the grunt doc out in private practice it's *****ic.

Certainly you need to protect yourself, but to say it's the fault of the academics is wrong. McNamara was academic. Most academic physicians I know are just as conservative as the average doc, if not more so. My personal practice is incredibly different from what I did in residency. I also make sure and tell my residents that should they decide to leave TX for a state with a different liability climate, they shouldn't do anything "cavalier" like they can do here.
Also, not every academic guy works just one shift a month. I personally think every academic doc should have to work at least one shift a month at a community "move the meat" type shop without residents, so they remember how to make the department flow.

It's also fine for the neo-political and media docs, who really can't hack grinding it out in the pit anymore, who want to spit policy pablum to gain favor with the society heads, media and political types so they can get a cush desk job, cut down on their load of nights, grunt shifts or the stressful work of actually being a real doctor. So they're fine with throwing you under the bus and preaching, "Reduce testing, reduce defensive medicine, reduce costs!" as long as it advances their post-patient-care cushy, low stress career as a "consultant" making 5 times what you're making per hour. They're lying to you, and when you get served by a man in a badge at work with the subpoena, you look down and it's

THEIR FRICKIN' NAME!!!!!

signing off as the expert witness on the lawsuit against you, from a different state, never having met you. You've seen the names on your textbooks do this already. They won't be there to testify in your favor. They'll be there to charge $1,000 per hour to say they would've done it different, you're a hack and it should've immediately jumped to your mind that the 1 in a million presentation was laying there before you, on your shift, with zero signs or symptoms out of the ordinary, even though you did what every other excellent physician would have done.

I disagree that they're lying to you. I agree that in many places, Amal Mattu's "admit everyone with chest pain" is the right answer, because your liability is huge. But the neopolitical guys aren't telling you to practice risky medicine, they're telling you to fix the system. If you don't fix the system now, you're really going to be screwed when the ACA loses so much money that they start mandating you not admit people without risk factors, and you still have the liability. Then they're going to force you to do what you don't want to.

Don't listen to any fool that tries to sell you down the river, or feed you some nonsense that won't prepare for the real world. Listen to your attendings that pull you aside and say, "This isn't the answer on the boards, but I'm telling you, in the real world, this is how it's done."

Agree completely. Only difference is there is a fair amount of variability, so make sure and ask that guy at the place you practice how it's done, not necessarily the guy who taught you in residency on the other side of the country.

I'm paradoxically bullish on being a doctor right now, but it can be a sleazy set of circumstances if you're not hardened to what the real world is about, as a doctor. This is where residencies and academics are frickin' horrible. They should be putting people through mock depositions, and set up mock "process server" events where on a shift you're served a subpoena, mock trials, mock job loss situations where a theoretical contract loss occurs, or your boss threatens to fire you for doing something politely, right and medically correct that generated a "customer complaint." Don't be one of these naive docs writing blogs about how terrible it is to be a doctor in 2014.

I agree that M&M should be this format occasionally, but too many people want to make sure and hold everyone's hand and not make anyone feel bad for doing things. It doesn't need to be malignant (think OB/GYN M&Ms), but it can be confrontational as long as there are ground rules. The courtroom will certainly be confrontational.

Being a doctor right now, is like being an honest man, trying to run a grocery store on a street controlled by the mob. Know the system, people. Be prepared, don't be naive and you can actually have a great career. Don't be one if these people, depressed and wanting to kill yourself in a midlife crisis, disillusioned because being a doctor has got you down.

http://www.kevinmd.com/blog/2014/05/physician-suicide-etiquette-doctor-dies-suddenly.html

Be naive, and it can eat you alive. Be real, be ready, and it can be a great career.

Yep, and it's sad. Be a cog in the machine and keep your head down, and you won't be frustrated at work. Just say yes to everything at face value, and keep doing what you're doing. If you try to change things at your own shop you're going to be disappointed.
But you can be an agent for change at your medical society, or state or national organized medicine. Sometime it's just rearranging the deck chairs, but other times you can effect real change, like getting ACEP to take down their misguided tPA policy.

 

[Groove]

I work at a community job where all chest pain without hx of CAD (and not STEMI, NSTEMI, unstable angina, or really bad story) gets ED CP obs, stressed and discharged. Patients with known CAD and CP and negative first set get cardiology consults and admitted to cards. The hospitalists don't admit any chest pain.

So, in essence... The ones that are low risk get the full monty and the ones at high risk get the minimal work up? I would never send home a high risk pt with #2 3h trops unless they left AMA or cards wrote a note. Period. There is no AHA guideline that supports this and it's a cardiologist who is using his weight to keep from putting his name on a chart so that he's held medical liable if the pt has an MI. I don't care how many of your colleagues are writing his name after a phone consult. If the pt has an MI and sues, he never saw them in the ED and was never formally consulted and never wrote a note and will throw you under the bus in a heartbeat. Hell, if one of your high risk pt's has an MI in the obs unit, one of the cardiologist would ask why they weren't consulted sooner for such a high risk pt.

You know what I think? I think your hospitalists and cardiologists have manipulated the system and hospital environment and yes.... (ED) to minimize almost any medical liability to a subset of pt's with potential pathology that allows zero error and is HIGHLY litigious. It sounds like a great r/o MI hospital where the ED docs take the brunt of the liability. I'd tell this cardiologist to go screw himself or come down and write a note and that in the future, if I have any high risk pt's with chest pain, I will refuse to discharge them without a note.

I hate to sound like an ass, and God knows I've sent home my fair share of low risk 2 trop with neg delta pt's but high risk? Noway man. That's an absolute set up to get burned. Cards knows it. That's why he doesn't want to touch the pt. I think chest pain obs are awesome and a Godsend to helping dispo so much of the atypical chest pain, but personally I don't think high risk pt's should be held there in the first place. I've seen chest pain obs units with guidelines to that effect which I think is totally appropriate. It's for low risk rule outs, not the guy with CABG and stents.

I'd recommend bringing this up with your ED director, administrator or find a more favorable environment to practice emergency medicine.

 

[Bostonredsox]

Hospitalists don't admit any CP??? I need to come to your shop. No CP admissions would cut down my total admissions at least 25%

 

[two guys]

Appreciate the responses.

Bostonredsox, do you mean it would cut down your admissions or your INCOME by 25%?

The guy is one of about 15 cardiologists, thankfully my overnights (when he usually pushes back) and his call nights don't line up that often. I'm going to continue to do what I've been doing which is insist on a note if I call (=admit). I did talk with my director and group about it, they don't seem nearly as concerned as me which is why I brought it up here. Their lack of concern really made me question if I was being overly risk averse.

As far as the arrangement of how CP is dealt with at my shop, it's not ideal. I don't like EM run CP obs for just that reason. Basically the hospitalists won't take low risk because we can stress them ourselves, the cardiologists try hard to not take anyone without positive enzymes or STEMI. It leaves this huge gap in the middle of people with real disease who no one wants to sit on because no one is in the habit of obs'ing anyone (since we do all the low risk obs and stess).

This arrangement isn't likely to change. Overall, its a good job so I'm not likely to "vote with me feet." This is just part of the deal here. The patient population is really, really good and people have PCPs and follow up. Waits aren't crazy long and patients are satisfied with the care, thankful and nice. I can always get something done if I insist, just sucks having to insist when it seems like the obvious right thing for the patient.

Bostonredsox, I'd be interested in your opinion on hospitalist groups who only admit a small portion of the overall admissions. At my shop they take about 50%. All ortho goes to ortho (even 90 yo hips with mult comorbidities), all urology goes to urology (spetic stones, etc), pulm takes all pulm and icu (simple pna on the floor, etc), cards takes all heart failure, a fib, etc. None of the specialists like this arrangement and its definitely a pain to get people admitted and takes forever. Other places I've been the hospitalists want everybody, here they're in house 24/7 but only admit about 15 of the 30 admissions each day. The other 15 end up getting split up among a bunch of docs (cards, surg, uro, ortho, pulm) who have to drive in to see the patient and do a fair bit of foot dragging.

 

[Bostonredsox]

We admit 90%+ of all admissions. All ortho comes to us. Pretty much all gen surg that's not emergent or comes to us. All medicine admits come to us, only one pcp in the area still admits his own pts. Icu is closed and comes through us. Chest pain obs is our most common admission. Stemi get admitted by cardio, go to icu and get icu consult, which is a hospitalist. All nstemi, UA, and chest pain rule out obs come to us. we admit them, they get three sets of enzymes and a couple of ekgs and if they rule out and were truly atypical pain, they get discharged home with referral for outpt stress. If they rule out but I truly think they have real disease, cardio sees them in house... And then discharges them for outpt stress as they get reimbursed better for the stress In their office. If they rule out but are high risk AND are uninsured, they stress them in house the next morning and then I dc them. It's a terrible system but it's what we have so it results in a lot of workload for me. And as I'm not paid any differently for 18 encounters with 4 admits or 12 encounters with 1 admit they are a bit aggravating. Especially the 60 year old with minimal to no risk factors with clear gi related pain who still gets admitted for a rule out. They're fast and easy admits. Senior resident can admit them in 20 min...but still adds more annoying work when I'm trying to get to the real sick pts er is sending.