5 reasons EM is Harder than it looks.

[Redpancreas]

I'm not EM but recently came off an ED rotation and wanted to pay tribute to the specialty despite all the flack it's getting. It's not a field we need corporatized and filled with NP/PAs. If I was a hospital CEO, I'd pay EM physicians handsomely. That said, do yourselves a favor and look elsewhere before you consider EM due to the job market.

Limited Time to Think:
1.) If you try to go into hospitalist mode and search up the comorbids in a systematic way, you'll get shredded and you'll have missed an opportunity to intubate a patient and help with a code. You need to find the few important co-morbids, get a history, make a plan with contingencies, and hunt down the attending who's busy doing something else. You also don't have time to dig into all the psychosocial dynamics at play by reading all the psych notes from last admission. Hopefully whatever's important was in the last DC Summary.

Two Stories:
2.) Patients truly come in undifferentiated and their stories fluctuate from morning to evening. Their chief complaints are often non-specific. There will be a patient who insists that all that happened was he fell down the stairs and his hit back. No chest pain, SOB, abdominal pain, fevers/chills, etc. Some abdominal scan you do picks up the tip of a PE and patient meets 1/4 SIRS criteria for other reasons and you admit him despite the hospitalist insisting otherwise. Overnight, he spikes a fever and his AM CBC reveals leukocytosis. The admitting HPI written by the hospital will inevitably list the chief complaint as "pleuritic chest pain" and "chills". Then some subspecialist comes and looks at the ED notes/orders through the lens of this retrospectively derived chief complaint and wonder what the ED was thinking and why blood cultures and antibiotics weren't ordered STAT...Then when you see this enough as an ED provider, you start over-pursuing which gets you ridiculed for the opposite reasons. Basically, the EM physician is the equivalent of being the first of several in line for an individual impromptu challenge where the non-participants get to watch closely when the first person struggles and fails.

Dumping Ground:
3.) Yes, IM gets dumped on by EM but every specialty dumps on ED. Surgeons or PCPs get a call about a non-specific complaint at midnight? They're just going to tell the patient to go to the ED. When they come into the ED, it's very hard to make a decision on what to do with patients. You don't have the option of holding them in the hospital for another day to see which direction they turn. You either admit, DC, or place in obs (which has specific criteria which need to be met) with utilization management breathing down your neck once someone has been in the ED for more than 2 hrs. When it comes to specialist recommendations, not all specialists are the same.

It's Dirty:
4.) Giving medications in the ED is hard. A large majority of patients come in at their most acute presentation (i.e.) they're vomiting with AKIs hence why their potassium's not repleted orally and why they're not pan-scanned before they come upstairs. Also, not that it affects your ability to handle patient care but the HF patient you see on the floor with his legs wrapped? In the ED, his legs were rotting with maggots in them with an odor will waft and get caught in the mask you're wearing during the rest of the shift.

They're not ordering tests blindly:
5.) It may not be the ED ordering all the unnecessary CT scans on patients. Prior to admission, ED sells the admission to IM but IM usually takes the chance to request ED to do a few things prior to admission since there's a CT scanner there already. ED usually caves to the hospitalists requests (as they are sometimes contingencies to accepting the admission) and they order the contrasted images despite the kidney function because they assume IM knows what will and won't hurt the kidneys and assume IM will monitor since the patient will monitored under IM. The order will inevitably show up under the EM physician's name though and many ED physicians won't bother to document that they ordered XYZ per admitting hospitalist's recommendation. Two days later, there's a raging AKI and everyone blames ED for ordering contrast while the accepting hospitalist already has his name off the chart.


All I'm saying is that EM is a lot tougher than a lot of specialties dumping on it give it credit for. Next time a resident from another field gives the ED flack, consider the above and take it with a grain of salt.

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[CyrilFiggis]

One of my favorite lines is that an ED doc is the second best doctor in every service. We are trained to identify and treat strokes, STEMIs, reduce fractures/dislocations, sedate, intubate, insert chest tubes, deliver babies, manage heart failure and afib w/ RVR, manage DKA, SBOs, sickle cell crises, newborns, kids, adults and geriatrics. But since we’re not cardiologists, endocrinologist, OBs, Orthopedics, etc we get a lot of criticism for our work ups and initial plans by those who ultimately manage them in house.

 

[Wordead]

I dunno, my criticism is usually never "oh they didnt do the standard of care for my specialty". It's more "they called a consult and after I talked to them realized they never even saw the patient and called it from a handoff from a PA" or "hey thanks for calling me at 3 am for an abscess Im obviously not going to come in to drain at this hour dingus, admit it to obs or medicine and we will consult"

 

[Redpancreas]

I dunno, my criticism is usually never "oh they didnt do the standard of care for my specialty". It's more "they called a consult and after I talked to them realized they never even saw the patient and called it from a handoff from a PA" or "hey thanks for calling me at 3 am for an abscess Im obviously not going to come in to drain at this hour dingus, admit it to obs or medicine and we will consult"

Yeah no one’s perfect. There are some bad actors in EM too. I know a particular resident notorious for getting bad histories. One time vascular surgery was consulted de novo (their fistula wasn’t even done by anyone here) regarding a dialysis issue but low and behold when you interviewed the patient, they just received dialysis through it yesterday. That happens. Most EM residents I’ve encountered will be very explicit and truthful to a tee and tell you exactly what they know and don’t know. They’ll be like, I last saw the patient 4 hrs ago, this is what was the case then, this is what he or she told me, etc.

Regarding consultation without seeing the patient, in terms of post-surgical issues, if the patient is coming to the ED for a post-surgical evaluation especially if the surgery was recent, a majority of attending surgeons (because our workflow was to call them first) I’ve interacted with would much rather have the opportunity to see or be consulted on the patient (regardless of which trainees have to be woken up) rather than have ED do an assessment and dismiss the patient because their exam is benign and labs are OK. It got to the point where certain attendings would just answer, say we will see them, and hang up and go back to bed. Any consult orderer knows the golden rule is to see the patient consulting but when surgery is going to have to be called anyway, sometimes the call gets put out to throughput and the EM resident goes to see the patient but then gets diverted to something else and when the surgery resident calls back, the EM resident isn’t prepared.

 

[NITRAS]

I don’t know. EM doctors have to be very good At recognizing things that are emergent, urgent, and can wait. They have to know which test to order to appropriately triage and dispo patient. Know when to call the specialist and when to let the admitting team do it. THey need to be good with resuscitation and realize what treatment needs to be initiated urgently.

I work with a lot of EM residents, but even the staff are not nearly as good as they think they are. You find a few that are really good, and they are amazing to work with. I feel like the system I work for encourages EM residents to think less.

I really try hard not to ask for stuff that won’t change disposition or isn’t emergent/ urgent, and I know i am not good at it always.

 

[Lawpy]

I dunno, my criticism is usually never "oh they didnt do the standard of care for my specialty". It's more "they called a consult and after I talked to them realized they never even saw the patient and called it from a handoff from a PA" or "hey thanks for calling me at 3 am for an abscess Im obviously not going to come in to drain at this hour dingus, admit it to obs or medicine and we will consult"

I don’t know. EM doctors have to be very good At recognizing things that are emergent, urgent, and can wait. They have to know which test to order to appropriately triage and dispo patient. Know when to call the specialist and when to let the admitting team do it. THey need to be good with resuscitation and realize what treatment needs to be initiated urgently.

I work with a lot of EM residents, but even the staff are not nearly as good as they think they are. You find a few that are really good, and they are amazing to work with. I feel like the system I work for encourages EM residents to think less.

I really try hard not to ask for stuff that won’t change disposition or isn’t emergent/ urgent, and I know i am not good at it always.

I feel like this problem is hospital dependent though. Some sites have really good EM service/training who don’t bother with crappy consults and are good in what they do

I like the ideas listed in the OP but honestly, i’m increasingly realizing how hospital dependent a lot of problems are

 

[DOVinciRobot]

Regarding consultation without seeing the patient, in terms of post-surgical issues, if the patient is coming to the ED for a post-surgical evaluation especially if the surgery was recent, a majority of attending surgeons (because our workflow was to call them first) I’ve interacted with would much rather have the opportunity to see or be consulted on the patient (regardless of which trainees have to be woken up) rather than have ED do an assessment and dismiss the patient because their exam is benign and labs are OK. It got to the point where certain attendings would just answer, say we will see them, and hang up and go back to bed. Any consult orderer knows the golden rule is to see the patient consulting but when surgery is going to have to be called anyway, sometimes the call gets put out to throughput and the EM resident goes to see the patient but then gets diverted to something else and when the surgery resident calls back, the EM resident isn’t prepared.

If it’s an obvious surgical site infection then sure, but it is inappropriate to call the surgery team without doing any sort of a work up or without seeing the patient. Just because someone had their gallbladder out 3 weeks ago doesn’t mean their current brand new abdominal pain is related to the surgery. We frequently get called on post op patients we operated on 2+ weeks prior under the assumption their current complaint is somehow related to the surgery. It is almost never related to their surgery.

 

[CyrilFiggis]

Criticism of ER docs not thinking is valid. We have attendings at our shop that all residents dread working with. But at the end of the day, we are glorified bouncers for the hospital. We determine who comes in or goes home. Throughput is a major metric in every department - door to dispo, patients per hour are in a vast majority of contracts. Plus we do not have high RVU billing. I need to see 10 chest pain patients to equal the same RVU as an orthopedic hip replacement. That’s 30 hours of time if you get 2 trops. Epistaxis management pays $93. I can’t bill critical care time on a cardiac arrest if it doesn’t go on for more than 30 minutes. That doesn’t forgive lazy docs or incompetence, but you start to see why the incentive is to not necessarily do the best job, but just finish the job.

 

[guytakingboards]

That's a nice review of ER practice in a tertiary academic setting. In the community, the negatives of ER get exacerbated horribly.

From a radiology perspective, there's a gross over-utilization of imaging in the name of cookbook medicine. The pre-test probability on the stuff that gets seen at the local doc-in-the-box ER/urgent care or smaller ERs (usually by midlevels) is low and the actual positive rate is crazy low. It's all done in the name of 'moving the meat' but there's absolutely limitations on how many studies can be read by a radiology service.

There's absolutely a "lemme order a bunch of stuff and let radiology/the labs tell me whats wrong with this patient" vibe.

 

[Wordead]

Criticism of ER docs not thinking is valid. We have attendings at our shop that all residents dread working with. But at the end of the day, we are glorified bouncers for the hospital. We determine who comes in or goes home. Throughput is a major metric in every department - door to dispo, patients per hour are in a vast majority of contracts. Plus we do not have high RVU billing. I need to see 10 chest pain patients to equal the same RVU as an orthopedic hip replacement. That’s 30 hours of time if you get 2 trops. Epistaxis management pays $93. I can’t bill critical care time on a cardiac arrest if it doesn’t go on for more than 30 minutes. That doesn’t forgive lazy docs or incompetence, but you start to see why the incentive is to not necessarily do the best job, but just finish the job.

Im not sure you're going to get much sympathy for "ER gives poor care because admin tells us to be more productive" or "I dont get paid enough if I do a thorough job".

 

[VA Hopeful Dr]

Im not sure you're going to get much sympathy for "ER gives poor care because admin tells us to be more productive" or "I dont get paid enough if I do a thorough job".

I do have sympathy for the former since many of us sometimes do things we don't always agree with because we're told to do so.

 

[Wordead]

I do have sympathy for the former since many of us sometimes do things we don't always agree with because we're told to do so.

I know as a surgical subspecialist I'm talking from a place of privilege but I think if you're being forced to provide poor patient care you should find another job.

 

[Lawpy]

I know as a surgical subspecialist I'm talking from a place of privilege but I think if you're being forced to provide poor patient care you should find another job.

That’s basically impossible in EM because the job market is a disaster

 

[VA Hopeful Dr]

I know as a surgical subspecialist I'm talking from a place of privilege but I think if you're being forced to provide poor patient care you should find another job.

I've never been forced to do anything, but I've done things that I don't necessarily agree with (but are not dangerous to patients) because of the increasing emphasis on patient satisfaction. Giving antibiotics to patients with viral URIs is preferable to weekly e-mails about patients pissed off because they didn't get their z-pack or getting x-rays on joints that absolutely don't need them because a) patients like x-rays and b) you need those x-rays before insurance companies will cover any other imaging/PT/referrals. I definitely order labs that patients want when there's no good reason to do so (lookin at you blood type and COVID antibodies).

If I was ever forced, or even strongly encouraged, to do anything that was actively harmful or negligent I would absolutely quit.

 

[Candidate2017]

You also don't have time to dig into all the psychosocial dynamics at play by reading all the psych notes from last admission. Hopefully whatever's important was in the last DC Summary.

In reality, they place a consult to the social worker and psych, or request an admit to psych, and then never check back in on them for a couple shifts. I can't tell you how many times the ED doc couldn't answer any medical questions I needed answered prior to me accepting the patient to the psych ward because "The off-going doctor handed off this patient to me, so I haven't seen the patient yet."

There's also the time I got a "suicide" consult for a 90 year old who wanted to die because of his cancer pain. No one looked at his EKG that was ordered 8 hours ago. New onset A-fib.

This is not just an ED thing, but indicative of many physicians who dismiss medical issues once the deem a patient "psych".

 

[Redpancreas]

If it’s an obvious surgical site infection then sure, but it is inappropriate to call the surgery team without doing any sort of a work up or without seeing the patient. Just because someone had their gallbladder out 3 weeks ago doesn’t mean their current brand new abdominal pain is related to the surgery. We frequently get called on post op patients we operated on 2+ weeks prior under the assumption their current complaint is somehow related to the surgery. It is almost never related to their surgery.

Agreed on calling before seeing the patient. My aforementioned post is just an honest explanation of what I've seen, not a defense.

Now my question, if I'm rotating in the ED and I had a 3 week post-op lap cholecystectomy, I'll do the basic lab work-up (+lipase, +liver panel, r/o ACS, and PRN imaging to r/o other pathologies based on symptomatology/demographics), but if that's negative I'd definitely touch base with the surgical team unless this patient is the x10-admissions-for-questionable-pancreatitis phenotype or has some other medical history more likely to explain this. If they had surgery 3 weeks ago and before that, they never had issues to bring them into the ER, I think surgery should be notified if there's a negative work-up because I don't know what I don't know and I'm not sure what else it could be. In my limited experience, surgery attendings seem to always appreciate it. I guess the point of contention is when they're notified in the work-flow. Sometimes my attendings request I call them first in interest of workflow/getting things done. As an added complication, before selling the aforementioned characterized admission to the hospitalist, I was always asked "if surgery has evaluated the patient" even if there's nothing to suggest a surgical complication and am told to call back after surgery has cleared the patient. To be fair to them, I suppose it affects their triage.

Out of academic curiosity, what are the post-op patient's abdominal pains (excluding frequent fliers) most often related to? I followed a few charts of abdominal pain I admitted. One was a pretty severe gastritis which to be fair to ED, would not have been caught on the evaluation they're limited to. Clinical acumen can narrow suspicion, but stuff mimics other stuff all the time.

 

[Redpancreas]

In reality, they place a consult to the social worker and psych, or request an admit to psych, and then never check back in on them for a couple shifts. I can't tell you how many times the ED doc couldn't answer any medical questions I needed answered prior to me accepting the patient to the psych ward because "The off-going doctor handed off this patient to me, so I haven't seen the patient yet."

There's also the time I got a "suicide" consult for a 90 year old who wanted to die because of his cancer pain. No one looked at his EKG that was ordered 8 hours ago. New onset A-fib.

This is not just an ED thing, but indicative of many physicians who dismiss medical issues once the deem a patient "psych".

I mean, I've seen a few thoughtful ED residents look stuff up and convey to me a pretty accurate impression in person, but then it's not documented in the notes. I have had the same experience you describe with certain ED residents, but then there are others which are quite good in that they reviewed the pertinent information and know what they don't know. In terms of psychiatry, you obviously must have lots of experience and are probably familiar with the 3-5 essential things to know prior to IP admission as you've done it dozens/hundreds of times. Maybe residents aren't. I suppose I'd rather have them say, "I don't know", etc. than straight up guess/lie. Oftentimes, if an ED resident doesn't know >2 questions I need answered, I'd either run down and ask myself or ask the ED resident to call back nicely (and give them my cell so they don't have to triage). If they give me pushback to that, that's when I'll have an issue (but unfortunately I have no say in what gets admitted or not).

 

[DOVinciRobot]

Now my question, if I'm rotating in the ED and I had a 3 week post-op lap cholecystectomy, I'll do the basic lab work-up (+lipase, +liver panel, r/o ACS, and PRN imaging to r/o other pathologies based on symptomatology/demographics), but if that's negative I'd definitely touch base with the surgical team unless this patient is the x10-admissions-for-questionable-pancreatitis phenotype or has some other medical history more likely to explain this. If they had surgery 3 weeks ago and before that, they never had issues to bring them into the ER, I think surgery should be notified if there's a negative work-up because I don't know what I don't know and I'm not sure what else it could be.

This is what I’m driving at. A phone call after you’ve done a work up like this is completely acceptable and appreciated. Unfortunately it’s common place where I’m at to get the call before any work up at all has been done and what it really ends up being is the ED hoping we’ll just take over and do the work up for them.

Honestly when the EM residents call after having done a thorough work up like you describe it’s awesome and even our attendings notice.

notified in the work-flow. Sometimes my attendings request I call them first in interest of workflow/getting things done.

Yeah which is the behavior that drives both the residents and attendings nuts.

Out of academic curiosity, what are the post-op patient's abdominal pains (excluding frequent fliers) most often related to?

At my shop our patient population has quite a few of the frequent flyer type. Typically gastritis or pancreatitis is what it ends up being (not just talking about lap chole patients. If a lap chole patient comes back with pancreatitis I’m very suspicious)

Sometimes it’s just a case of dilaulopenia.

 

[CliveStaples]

This is what I’m driving at. A phone call after you’ve done a work up like this is completely acceptable and appreciated. Unfortunately it’s common place where I’m at to get the call before any work up at all has been done and what it really ends up being is the ED hoping we’ll just take over and do the work up for them.

Honestly when the EM residents call after having done a thorough work up like you describe it’s awesome and even our attendings notice.


Yeah which is the behavior that drives both the residents and attendings nuts.

At my shop our patient population has quite a few of the frequent flyer type. Typically gastritis or pancreatitis is what it ends up being (not just talking about lap chole patients. If a lap chole patient comes back with pancreatitis I’m very suspicious)

Sometimes it’s just a case of dilaulopenia.

I wonder if it's possible you're misunderstanding the purpose of the early consult. I will give you two scenarios.

Scenario 1: Post-op patient 1 week from lap-chole who presents with RUQ abdominal pain. ER resident order labs, CT scan, pain medication, fluids, etc. Results come back after 3 hours showing whatever you want (post op abscess, biloma, constipation, nothing, etc). Regardless of results, the patient is a post-op patient belonging to the general surgery group who have asked that they be notified when their post-op patients come to the ER for all the obvious reasons (safety, patient satisfaction, taking pride in owning their patients, etc). General surgery is consulted and the resident sees the patient, then the attending, and two hours later a disposition is made on the patient (admit, discharge, etc). Total length of stay in the ER? 5 hours.

Scenario 2: Exact same patient. Exact same workup is ordered after seeing the patient. Only, instead of waiting for any results, the ER resident consults general surgery right away. The general surgery resident isn't happy because there's nothing resulted in the computer but evaluates the patient anyways, has to tell their attending about the patient who comes and sees the patient, and by the time the results are all in, they're ready to make a disposition within 30 minutes of the results. Total length of stay in the ER? 3.5 hours.

Scenario 2 is the way ER physicians are trained to work. In parallel, not sequentially. Much like how you should not order tests whose results will change your decision making, you should not wait to call consults when they'll be called regardless of what the workup shows.

To most people in the hospital, the job of the ER physician is to work their patients up and present them with a nice little bow. The purpose of the ER doctor is to resuscitate and determine disposition.

 

[Redpancreas]

I wonder if it's possible you're misunderstanding the purpose of the early consult. I will give you two scenarios.

Scenario 1: Post-op patient 1 week from lap-chole who presents with RUQ abdominal pain. ER resident order labs, CT scan, pain medication, fluids, etc. Results come back after 3 hours showing whatever you want (post op abscess, biloma, constipation, nothing, etc). Regardless of results, the patient is a post-op patient belonging to the general surgery group who have asked that they be notified when their post-op patients come to the ER for all the obvious reasons (safety, patient satisfaction, taking pride in owning their patients, etc). General surgery is consulted and the resident sees the patient, then the attending, and two hours later a disposition is made on the patient (admit, discharge, etc). Total length of stay in the ER? 5 hours.

Scenario 2: Exact same patient. Exact same workup is ordered after seeing the patient. Only, instead of waiting for any results, the ER resident consults general surgery right away. The general surgery resident isn't happy because there's nothing resulted in the computer but evaluates the patient anyways, has to tell their attending about the patient who comes and sees the patient, and by the time the results are all in, they're ready to make a disposition within 30 minutes of the results. Total length of stay in the ER? 3.5 hours.

Scenario 2 is the way ER physicians are trained to work. In parallel, not sequentially. Much like how you should not order tests whose results will change your decision making, you should not wait to call consults when they'll be called regardless of what the workup shows.

To most people in the hospital, the job of the ER physician is to work their patients up and present them with a nice little bow. The purpose of the ER doctor is to resuscitate and determine disposition.

I think this is a really good point. There is that lag (the "1.5 hrs.") between surgery familiarizing themselves with the patient, writing the note, and presenting it to the attending. In most cases, EM time (for patient, not EM resident) is saved while only in a few select cases (it ends up being definitely something else MSK/hernia, abdominal scan PE dx., etc.) is surgery's time wasted. In my limited experience the breakdown is usually a few surgical, most unclear, and some non-surgical. For the unclear ones, surgery still needs to see the patient. Speaking of experience, if we are getting technical, the ones with the best vantage point is EM physicians because they see all the patients: the ones surgery is consulted on vs. not consulted on. Surgery OTOH does not see the ones ED doesn't consult them on hence their reference frame is skewed. Same with other specialties.

I think if EM-GS coordinate, there can be a more efficient solution (i.e. come up with two distinct notifications). One could be for someone with an acute abdomen vs. another could be for grey areas of minimal acuity like this so it doesn't involve troubling someone who's in the OR or sleeping.

 

[DOVinciRobot]

I wonder if it's possible you're misunderstanding the purpose of the early consult. I will give you two scenarios.

Scenario 1: Post-op patient 1 week from lap-chole who presents with RUQ abdominal pain. ER resident order labs, CT scan, pain medication, fluids, etc. Results come back after 3 hours showing whatever you want (post op abscess, biloma, constipation, nothing, etc). Regardless of results, the patient is a post-op patient belonging to the general surgery group who have asked that they be notified when their post-op patients come to the ER for all the obvious reasons (safety, patient satisfaction, taking pride in owning their patients, etc). General surgery is consulted and the resident sees the patient, then the attending, and two hours later a disposition is made on the patient (admit, discharge, etc). Total length of stay in the ER? 5 hours.

Scenario 2: Exact same patient. Exact same workup is ordered after seeing the patient. Only, instead of waiting for any results, the ER resident consults general surgery right away. The general surgery resident isn't happy because there's nothing resulted in the computer but evaluates the patient anyways, has to tell their attending about the patient who comes and sees the patient, and by the time the results are all in, they're ready to make a disposition within 30 minutes of the results. Total length of stay in the ER? 3.5 hours.

Scenario 2 is the way ER physicians are trained to work. In parallel, not sequentially. Much like how you should not order tests whose results will change your decision making, you should not wait to call consults when they'll be called regardless of what the workup shows.

To most people in the hospital, the job of the ER physician is to work their patients up and present them with a nice little bow. The purpose of the ER doctor is to resuscitate and determine disposition.

I’m not misinterpreting the early consult. I just fundamentally disagree with the idea that surgery should be called the moment a post op patient shows up in the ED before the resident/attending/midlevel even lays eyes on them. I’ve personally seen it lead to delayed care for non-surgical issues.

 

[CliveStaples]

I’m not misinterpreting the early consult. I just fundamentally disagree with the idea that surgery should be called the moment a post op patient shows up in the ED before the resident/attending/midlevel even lays eyes on them. I’ve personally seen it lead to delayed care for non-surgical issues.

It sounds like a straw man to say that my position is that surgery should be consulted on a patient before the patient is seen by an ER physician (with rare exceptions, such as arriving patients from other hospitals with known pathologies that are time sensitive, like Type A Aortic Dissections, AAA leaks, etc.) since in both examples the patient was evaluated by the ER prior to consultation. We must be talking about two different kinds of scenarios. I would also be frustrated if I discovered one of my residents was consulting another service prior to a physical examination except in those rare circumstances I listed.

 

[Redpancreas]

I’m not misinterpreting the early consult. I just fundamentally disagree with the idea that surgery should be called the moment a post op patient shows up in the ED before the resident/attending/midlevel even lays eyes on them. I’ve personally seen it lead to delayed care for non-surgical issues.

I think if the EM team figuratively dusts off their hands and props their feet up in lieu of doing parallel work-up because they've consulted surgery who will come and fix everything, that's the fault of the individual EM providers you witnessed in place, not with the procedure (early consultation) in place...unless surgical evaluation somehow competes with an EM provider's ability to provide parallel evaluation which I can't really see. I suppose, if a diagnosis was missed because they were admitted to a surgery service and an alternative etiology was found the next day, it's still an issue with the EM team anchoring and the diagnosis still may have been missed and the patient likely would have been sent to medicine instead where the correct diagnosis may or may not have been earlier. I do agree that it is good practice to do an evaluation to inform the consultant of the acuity.

 

[Wordead]

I've never been forced to do anything, but I've done things that I don't necessarily agree with (but are not dangerous to patients) because of the increasing emphasis on patient satisfaction. Giving antibiotics to patients with viral URIs is preferable to weekly e-mails about patients pissed off because they didn't get their z-pack or getting x-rays on joints that absolutely don't need them because a) patients like x-rays and b) you need those x-rays before insurance companies will cover any other imaging/PT/referrals. I definitely order labs that patients want when there's no good reason to do so (lookin at you blood type and COVID antibodies).

If I was ever forced, or even strongly encouraged, to do anything that was actively harmful or negligent I would absolutely quit.

I don't count those things as poor patient care. You know the indications, risks/benefits, and make a decision to give a treatment that isnt likely to help but isnt likely to harm to keep the patient happy. I doubt any doctor can say they don't do that.

That is very different than not properly working up a patient because you feel too busy or you are afraid that the admin is going to criticize you for not moving the meat fast enough. Your duty is to the patient and to provide the standard of care. I mean the guy saying he only gets 93 dollars for a nosebleed and doesnt get paid as much as an ortho surgeon is laughable.

 

[DOVinciRobot]

It sounds like a straw man to say that my position is that surgery should be consulted on a patient before the patient is seen by an ER physician (with rare exceptions, such as arriving patients from other hospitals with known pathologies that are time sensitive, like Type A Aortic Dissections, AAA leaks, etc.) since in both examples the patient was evaluated by the ER prior to consultation. We must be talking about two different kinds of scenarios. I would also be frustrated if I discovered one of my residents was consulting another service prior to a physical examination except in those rare circumstances I listed.

I’ve been pretty clear that’s what I am talking about.

My issue is with, “Hey pt X is here, just got in room 8. Abdominal pain and had a hernia fixed a month ago, what labs and imaging do you want?” (This happens at least once a week)

Telling me a post op is in the ED with X complaint and you’ve got X, Y, and Z already cooking in the work up but would like us to take a look at them and see if we have anything to add is an appropriate phone call and not what I’m addressing.

 

[Taddy Mason]

In reality, they place a consult to the social worker and psych, or request an admit to psych, and then never check back in on them for a couple shifts. I can't tell you how many times the ED doc couldn't answer any medical questions I needed answered prior to me accepting the patient to the psych ward because "The off-going doctor handed off this patient to me, so I haven't seen the patient yet."

There's also the time I got a "suicide" consult for a 90 year old who wanted to die because of his cancer pain. No one looked at his EKG that was ordered 8 hours ago. New onset A-fib.

This is not just an ED thing, but indicative of many physicians who dismiss medical issues once the deem a patient "psych".

Some of my favorites to add to this:

a) Patient comes with a psych complaint or behavioral issues. ED consults psych without seeing the patient and asks if we can dig through the patient’s records and get collateral to see if they “actually” need to consult us. On the plus side this gives us some leverage in avoiding inappropriate consults and often doesn’t take much more than 5min, and rarely/almost never beyond 10min. Though on the other hand the ED doesn’t seem to have an issue spending much more time digging through charts and outside records when working with non-psych patients so not really sure what makes doing the same for psych issues any different.

b) ED consults psych on a patient who clearly can’t engage in interview due to intoxication and/or having just received chemical restraints. These consults are often at 3am or they’re repeatedly paging us every 30min asking if/why we haven’t seen the patient (EtOH was 400s an hour ago, you’ve given the patient some combo of Haldol/droperidol/olanzapine/lorazepam/midazolam once or twice since they got here, and you know damn well you aren’t going to follow any recs I offer re: agitation - wtf do YOU think I haven’t bothered to see the patient yet). Wait until the patient is “clinically sober,” reassess, and if there’s an indication for a psych consult then (which based on anecdotal experience >50% of the time there isn’t) let us know. I’d probably be less salty about these consults if the ED would actually follow any of our med recs wether prns, for agitation, or sadly even just scheduled meds.

c) Consulting psych for obvious social issues with no clear acute psych issue and refusing to consider consulting SW until AFTER the patient is “cleared” by psych.

d) Not doing an appropriate (or any) medical work-up for patients (almost always >40-50yo) with no psych Hx and new onset AMS or acute behavioral changes and then pushing back HARD if I request basic labs, toxicology, and imaging (if indicated) before seeing or being formally consulted on the patient. A variation on this being consulted in a similar situation and a neuro etiology is suspected either based on reported Hx or we agree to see the patient and then want a formal neuro eval/work-up before pursuing inpatient psych. ED’s response is “yeah, neuro said it’s not neuro and that they don’t need to see the patient.” Okay….so why is the ball in our court and we can’t say “it’s not psych until you do an appropriate medical and neuro work-up.” In my experience, this scenario tends be more so an issue with residents and PAs, though EM attendings often take their side when we push back. However, whenever the resident/PA middleman is removed rarely (though it does happen from time to time) is this an issue when ED attendings are the ones seeing the patient and placing consults.

e) Reasonable consult but ED attending/resident only spends 15-20min seeing the patient. After spending over an hour talking to patient and getting collateral from family, outside records, and talking to outpatient psychiatrist and therapist get a MUCH different story of the circumstances that led to the patient coming in, strongly feel they don’t need IPLOC, and arrange close outpatient follow-up. ED doesn’t care and demands inpatient hospitalization. Okay, go for it if that’s your prerogative but good luck getting any hospital or inpatient psych unit to accept the patient with psych documentation clearly detailing why IPLOC is neither warranted nor appropriate. Don’t bully us because your gut instinct on a 15min cursory assessment was different than our recommendations after a 90-120min more detailed eval; I’m not going to lie in my documentation just because you want me to and can’t admit your initial assessment wasn’t accurate.

f) And my absolute favorite consult that I never get tired of, no matter what time what time of day it comes in - “I don’t think the patient needs to be admitted but they asked to talk to you” or “patient seems a little sad/anxious/depressed can you just come talk with him/her for a bit?” You wouldn’t consult cards just because a patient came in with a complaint of chest pain demanding to see cardiology and no other history, or GI because a patient has a tummy ache - why is psych somehow different?

I totally appreciate that EM has to know a lot, be able to manage acute situations, and know when to call for help but I don’t get how they get a complete pass on anything psych related, get to incessantly dump ****ty consults on psych that they wouldn’t consider doing to almost any other specialty, and then have the balls to argue with our assessment/recs after we spend >30-90min seeing the patient, getting collateral, etc. when at best they talked to the the patient for 5min and more often than not did not even bother to check old records, easy sources of collateral, pharmacy database, etc. I’ve seen ED attendings/residents spend several hour working-up medical patients before consulting another service or requesting admission, why do psych complaints get 5-10min then punt?

 

[Cognovi]

That's a nice review of ER practice in a tertiary academic setting. In the community, the negatives of ER get exacerbated horribly.

From a radiology perspective, there's a gross over-utilization of imaging in the name of cookbook medicine. The pre-test probability on the stuff that gets seen at the local doc-in-the-box ER/urgent care or smaller ERs (usually by midlevels) is low and the actual positive rate is crazy low. It's all done in the name of 'moving the meat' but there's absolutely limitations on how many studies can be read by a radiology service.

There's absolutely a "lemme order a bunch of stuff and let radiology/the labs tell me whats wrong with this patient" vibe.

You know what would move the meat faster? Not imaging.

 

[Tenk]

This thread is a showcase of the number one negative of EM: Monday Morning Quarterbacking.

 

[mrbreakfast]

I think it all depends on the specialty service. At my institution we (neurology) prefer early consultation. We're going to get consulted anyway. There's no point in the ED trying to work something up first if they're going to just guess at what they should order and if we're going to get consulted regardless of the findings. On a busier day we may get 20 ED consults. I'm already in the ED seeing someone else as is, just call me and ask me to see the patient.

 

[Dr G Oogle]

Agreed on calling before seeing the patient. My aforementioned post is just an honest explanation of what I've seen, not a defense.

Now my question, if I'm rotating in the ED and I had a 3 week post-op lap cholecystectomy, I'll do the basic lab work-up (+lipase, +liver panel, r/o ACS, and PRN imaging to r/o other pathologies based on symptomatology/demographics), but if that's negative I'd definitely touch base with the surgical team unless this patient is the x10-admissions-for-questionable-pancreatitis phenotype or has some other medical history more likely to explain this. If they had surgery 3 weeks ago and before that, they never had issues to bring them into the ER, I think surgery should be notified if there's a negative work-up because I don't know what I don't know and I'm not sure what else it could be. In my limited experience, surgery attendings seem to always appreciate it. I guess the point of contention is when they're notified in the work-flow. Sometimes my attendings request I call them first in interest of workflow/getting things done. As an added complication, before selling the aforementioned characterized admission to the hospitalist, I was always asked "if surgery has evaluated the patient" even if there's nothing to suggest a surgical complication and am told to call back after surgery has cleared the patient. To be fair to them, I suppose it affects their triage.

Out of academic curiosity, what are the post-op patient's abdominal pains (excluding frequent fliers) most often related to? I followed a few charts of abdominal pain I admitted. One was a pretty severe gastritis which to be fair to ED, would not have been caught on the evaluation they're limited to. Clinical acumen can narrow suspicion, but stuff mimics other stuff all the time.

By and large I think a problem within the general vicinity of a surgical site is going to be related to the surgery. I have had patients come in for appendicitis after prolapse surgery and even pelvic floor botox. The most common call I get is about constipation, which while not technically a surgical “complication” is related to surgery.

 

[Mad Jack]

I'm not EM but recently came off an ED rotation and wanted to pay tribute to the specialty despite all the flack it's getting. It's not a field we need corporatized and filled with NP/PAs. If I was a hospital CEO, I'd pay EM physicians handsomely. That said, do yourselves a favor and look elsewhere before you consider EM due to the job market.

Limited Time to Think:
1.) If you try to go into hospitalist mode and search up the comorbids in a systematic way, you'll get shredded and you'll have missed an opportunity to intubate a patient and help with a code. You need to find the few important co-morbids, get a history, make a plan with contingencies, and hunt down the attending who's busy doing something else. You also don't have time to dig into all the psychosocial dynamics at play by reading all the psych notes from last admission. Hopefully whatever's important was in the last DC Summary.

Two Stories:
2.) Patients truly come in undifferentiated and their stories fluctuate from morning to evening. Their chief complaints are often non-specific. There will be a patient who insists that all that happened was he fell down the stairs and his hit back. No chest pain, SOB, abdominal pain, fevers/chills, etc. Some abdominal scan you do picks up the tip of a PE and patient meets 1/4 SIRS criteria for other reasons and you admit him despite the hospitalist insisting otherwise. Overnight, he spikes a fever and his AM CBC reveals leukocytosis. The admitting HPI written by the hospital will inevitably list the chief complaint as "pleuritic chest pain" and "chills". Then some subspecialist comes and looks at the ED notes/orders through the lens of this retrospectively derived chief complaint and wonder what the ED was thinking and why blood cultures and antibiotics weren't ordered STAT...Then when you see this enough as an ED provider, you start over-pursuing which gets you ridiculed for the opposite reasons. Basically, the EM physician is the equivalent of being the first of several in line for an individual impromptu challenge where the non-participants get to watch closely when the first person struggles and fails.

Dumping Ground:
3.) Yes, IM gets dumped on by EM but every specialty dumps on ED. Surgeons or PCPs get a call about a non-specific complaint at midnight? They're just going to tell the patient to go to the ED. When they come into the ED, it's very hard to make a decision on what to do with patients. You don't have the option of holding them in the hospital for another day to see which direction they turn. You either admit, DC, or place in obs (which has specific criteria which need to be met) with utilization management breathing down your neck once someone has been in the ED for more than 2 hrs. When it comes to specialist recommendations, not all specialists are the same.

It's Dirty:
4.) Giving medications in the ED is hard. A large majority of patients come in at their most acute presentation (i.e.) they're vomiting with AKIs hence why their potassium's not repleted orally and why they're not pan-scanned before they come upstairs. Also, not that it affects your ability to handle patient care but the HF patient you see on the floor with his legs wrapped? In the ED, his legs were rotting with maggots in them with an odor will waft and get caught in the mask you're wearing during the rest of the shift.

They're not ordering tests blindly:
5.) It may not be the ED ordering all the unnecessary CT scans on patients. Prior to admission, ED sells the admission to IM but IM usually takes the chance to request ED to do a few things prior to admission since there's a CT scanner there already. ED usually caves to the hospitalists requests (as they are sometimes contingencies to accepting the admission) and they order the contrasted images despite the kidney function because they assume IM knows what will and won't hurt the kidneys and assume IM will monitor since the patient will monitored under IM. The order will inevitably show up under the EM physician's name though and many ED physicians won't bother to document that they ordered XYZ per admitting hospitalist's recommendation. Two days later, there's a raging AKI and everyone blames ED for ordering contrast while the accepting hospitalist already has his name off the chart.


All I'm saying is that EM is a lot tougher than a lot of specialties dumping on it give it credit for. Next time a resident from another field gives the ED flack, consider the above and take it with a grain of salt.

Another big issue is the churn. The worst part of any hospital job is admissions and discharges, and in the ER you're functionally doing mini-admit assessments with every patient you see, then prepping them for discharge often within the same shift, only to repeat the process with whomever takes their place. Progress notes on inpatient services provide breathing room to rest and think, but this is, as you noted, largely nonexistent in the ER. It is shameful that such a difficult job is being tossed to midlevels like it's nothing, all for the sake of profit

 

[Candidate2017]

I mean, I've seen a few thoughtful ED residents look stuff up and convey to me a pretty accurate impression in person, but then it's not documented in the notes. I have had the same experience you describe with certain ED residents, but then there are others which are quite good in that they reviewed the pertinent information and know what they don't know. In terms of psychiatry, you obviously must have lots of experience and are probably familiar with the 3-5 essential things to know prior to IP admission as you've done it dozens/hundreds of times. Maybe residents aren't.

I was referring to EM attendings not being able to answer basic medical clearance questions, prior to me accepting them to the psych unit, because the attending never laid eyes on the patient or even the chart. Things like where are the trops for this patient who is charted as having CP and has a prolonged QT on EKG, what's going on with this cavitary looking thing on CXR, where's the CT head for this AMS patient with no psych history, no one ordered COVID a test etc etc?

Residents though, are generally pretty good, especially off service residents. They still fear screwing up and aren't busy checking their stocks or flirting with scribes.

 

[CliveStaples]

I was referring to EM attendings not being able to answer basic medical clearance questions, prior to me accepting them to the psych unit, because the attending never laid eyes on the patient or even the chart. Things like where are the trops for this patient who is charted as having CP and has a prolonged QT on EKG, what's going on with this cavitary looking thing on CXR, where's the CT head for this AMS patient with no psych history, no one ordered COVID a test etc etc?

Residents though, are generally pretty good, especially off service residents. They still fear screwing up and aren't busy checking their stocks or flirting with scribes.

Do you think, maybe, it’s a bad look to come to a thread that was created to say “hey maybe don’t discredit this entire field of medicine” in order to say “but hey, EM attendings are in appropriate flirts with their coworkers and are too busy with personal investments causing harm to people by turfing to psych too soon?”

If an ER doc came to a thread about appreciating the work of psychiatrists and said “but psychiatrists aren’t real doctors, they just punt inpatients from their psychiatric hospital to their local ER for asymptomatic hypertension and for disimpactions when they’re constipated” that we would find that kind of interspecialty browbeating distasteful?

“Punching down” to EM is easy. You can be better than that, I’m sure.

 

[Lawpy]

I wonder if Dr. G saw this thread

 

[Redpancreas]

Do you think, maybe, it’s a bad look to come to a thread that was created to say “hey maybe don’t discredit this entire field of medicine” in order to say “but hey, EM attendings are in appropriate flirts with their coworkers and are too busy with personal investments causing harm to people by turfing to psych too soon?”

If an ER doc came to a thread about appreciating the work of psychiatrists and said “but psychiatrists aren’t real doctors, they just punt inpatients from their psychiatric hospital to their local ER for asymptomatic hypertension and for disimpactions when they’re constipated” that we would find that kind of interspecialty browbeating distasteful?

“Punching down” to EM is easy. You can be better than that, I’m sure.

Another issue is that every field gets to critique EM's work. The reverse is not true and most other fields get the benefit of the black box. If a surgical procedure is done and the patient comes in with a complication, it would take some investigating and colleague-curbsiding off the records to figure out of it was poor technique in the OR or just a common, inevitable thing. Sometimes I have a question about why a specialty is or is not doing XYZ and I ask them, but I'm in the minority there as most primary teams defer issues they're not familiar with to consults. Sometimes the specialties have a good answer, but many times it's just that "these are the things we always do, etc" hence EM is not the only field that can have aspects “taken over by PAs/NPs”.

Needless to say, EM is a legitimate and challenging field and if such a skillset disappeared, we'd have a real problem. I just find it unprofessional how many new interns who were just M4s months ago suddenly feel they now have the license to crap on some seasoned, and pretty sharp EM physicians because they've learned it from their superiors who are likely far removed from their EM rotation in PGY-1 or maybe didn't even have one. The more experience I have in medicine, the more I realize how tough EM can be and there's no acknowledgement of that...It's like EM screwing up is on everyone's differential diagnosis for what went wrong for the patient or why they're readmitted. Also, we hardly see EM success stories in residency because our training is primarily inpatient and most inpatients likely had a few ED visits prior to admission.

 

[Taddy Mason]

Another issue is that every field gets to critique EM's work. The reverse is not true….

STRONGLY disagree with this which in the context of my previous post is where some of my issues with EM come from. That said, agree completely with your second paragraph. I can think of plenty of EM physicians that don’t fit the negative stereotypes, but there certainly is a particular trend. Though this is true for all specialties and likely a combo of inherently bad/sloppy/lazy/whatever habits and reasonable factors we may not be immediately privy to from a given perspective.

 

[solitarius]

EM is a terrible field even if there was not labor supply problem. So glad the blinders came off for me during med school.

 

[throwaway123342]

This is disrespectful but simply true. EM doctors are extremely willing to just order things. Abdominal pain? Get a CT abdomen. etc.

The problem with this thinking is that anyone can follow that logic, including NPs and PAs.

When EM docs are confronted with this, they will just make excuses that they have been burned before or refer to ligitation risk.

My conclusion is that EDs are fine to be staffed by an EM doc overseeing midlevels. There really isn't much difference in the care delivered by NPs and EM docs in the ED in many situations. Largely because both types will over-order or consult anyway.

 

[Redpancreas]

STRONGLY disagree with this which in the context of my previous post is where some of my issues with EM come from. That said, agree completely with your second paragraph. I can think of plenty of EM physicians that don’t fit the negative stereotypes, but there certainly is a particular trend. Though this is true for all specialties and likely a combo of inherently bad/sloppy/lazy/whatever habits and reasonable factors we may not be immediately privy to from a given perspective.

You’re probably right that EM isn’t exclusively in this camp and I presume you’re referring to your own field. In my limited experience of consultation with inpatient psychiatry, I have not any consult change management and or have the psychiatrist see the patient the same day (n=1). That said, I’m sure there’s a completely different side to it I have not even considered due to my lack of clinical training/experience in that area.

I’m sure there is a reason from a psychiatric standpoint for why things are done that many primary fields like medicine or EM have little appreciation for leading others to second guess psychiatry. I imagine there’s also a great of litigation in psychiatry and second guessing from many fields.

That said, I still think every inpatient field’s patients start in the ER and hence every single admitting team is in a position to critique EM and in some fields we wouldn’t be doing our job if we didn’t (ie -IM). The issue occurs when we can’t put ourselves in their shoes and realize they’re also doctors who went to medical school and have a specific skill set and work within parameters that are different from the ones we work in on a daily basis. It leads to anchoring on "ED screwed up, they missed XYZ" whereas the actual case is no they didn't...it's something really atypical that only got caught after 3 admissions.

 

[Redpancreas]

This is disrespectful but simply true. EM doctors are extremely willing to just order things. Abdominal pain? Get a CT abdomen. etc.

The problem with this thinking is that anyone can follow that logic, including NPs and PAs.

When EM docs are confronted with this, they will just make excuses that they have been burned before or refer to ligitation risk.

My conclusion is that EDs are fine to be staffed by an EM doc overseeing midlevels. There really isn't much difference in the care delivered by NPs and EM docs in the ED in many situations. Largely because both types will over-order or consult anyway.

You make broad statements that I don’t know but suspect are a product of a lack of inquiry. Take a case tomorrow, go down the rabbit hole, and figure out why exactly the CT etc. was ordered. Listen to the patient’s story, the EM nurse’s, the resident’s, etc. I am pretty the answer is not just “the ED wanted it”.

In regards to following a string of orders (ie CMP, CBC, UA, Troponin, Lipase, and imaging admit if abnormal), that applies to subset of patients that get admitted. Medical reasoning has nuances that require some experience to get right. You can easily mistake sepsis for cancer in a medically complex patient and what to do with that patient becomes a disposition challenge. Also, what about the patient’s that don’t get admitted or the patients that have to be managed by ED (plenty of Ortho, ENT trauma, etc. ED does on its own). The breadth is quite astonishing and spans across several patient populations from nosebleeds to pregnancies to children with fevers.

 

[CliveStaples]

This is disrespectful but simply true. EM doctors are extremely willing to just order things. Abdominal pain? Get a CT abdomen. etc.

The problem with this thinking is that anyone can follow that logic, including NPs and PAs.

When EM docs are confronted with this, they will just make excuses that they have been burned before or refer to ligitation risk.

My conclusion is that EDs are fine to be staffed by an EM doc overseeing midlevels. There really isn't much difference in the care delivered by NPs and EM docs in the ED in many situations. Largely because both types will over-order or consult anyway.

And general surgeons just take out the gallbladder without thinking if it's really the cause of their pain. Cardiologists catheterize patients without thinking about the indications or repercussions. Gastroenterologists will scope anything from the top and bottom without thinking of the indications. I guess an NP or PA can do all of these fields too.

Any test should be ordered in the context of the risk and their pre and post test probabilities. Why does every person over 65 with acute abdominal pain get a CT? Because the pre-test probability of that abdominal pain having a surgical origin that can only be accurately identified and treated after a CT scan is so high, it's the standard of care to do so. It would be like a chest pain patient with a D-Dimer of 5000 not getting a CTA of the chest. But I guess if an NP or PA can follow that logic, then it's not real medicine?

What about belly pain in a 30 year old? An ER doctor isn't going to CT that every time. They might some of the time. How do you teach that logic to a PA or NP? How about when it's not just chest and belly pain, but respiratory failure? Septic shock? Diplopia in a pregnant woman? Undifferentiated altered mental status? Angioedema of the oropharynx? Neonatal cardiac arrest?

Trust me, when you're a patient in the ER you'll care that you're either seen by a physician or that a physician is at least intimately involved with the care you receive. And when you become a practicing physician, you may learn that your perspective isn't disrespectful, it's simply ignorant.

 

[throwaway123342]

You make broad statements that I don’t know but suspect are a product of a lack of inquiry. Take a case tomorrow, go down the rabbit hole, and figure out why exactly the CT etc. was ordered. Listen to the patient’s story, the EM nurse’s, the resident’s, etc. I am pretty the answer is not just “the ED wanted it”.

I’m regards to following a string of orders (ie CMP, CBC, UA, Troponin, Lipase, and imaging admit if abnormal), that applies to subset of patients that get admitted. Medical reasoning has nuances that require some experience to get right. You can easily mistake sepsis for cancer in a medically complex patient and what to do with that patient becomes a disposition challenge. Also, what about the patient’s that don’t get admitted or the patients that have to be managed by ED (plenty of Ortho, ENT trauma, etc. ED does on its own). The breadth is quite astonishing and spans across several patient populations from nosebleeds to pregnancies to children with fevers.

Explain the answer to this simple question to me. American doctors order twice the number of CT scans per patient compared to overseas. Why?

 

[throwaway123342]

And general surgeons just take out the gallbladder without thinking if it's really the cause of their pain. Cardiologists catheterize patients without thinking about the indications or repercussions. Gastroenterologists will scope anything from the top and bottom without thinking of the indications. I guess an NP or PA can do all of these fields too.


What about belly pain in a 30 year old? An ER doctor isn't going to CT that every time. They might some of the time. How do you teach that logic to a PA or NP? How about when it's not just chest and belly pain, but respiratory failure? Septic shock? Diplopia in a pregnant woman? Undifferentiated altered mental status? Angioedema of the oropharynx? Neonatal cardiac arrest?

Trust me, when you're a patient in the ER you'll care that you're either seen by a physician or that a physician is at least intimately involved with the care you receive. And when you become a practicing physician, you may learn that your perspective isn't disrespectful, it's simply ignorant.

All of those examples you gave before are great examples of why NPs could replace GI doctors in that context...if they had the skillset to do so. On the other hand, it doesn't take any skillset to click "order CT abdomen/pelvis" in EPIC.

Regarding the 30 year old, ER doctors already overorder in that population. We know from a public health perspective that American doctors order imaging at a wildly higher rate than international doctors. You cannot honestly tell me that our EM docs are exercising the highest levels of judgement.

 

[CliveStaples]

All of those examples you gave before are great examples of why NPs could replace GI doctors in that context...if they had the skillset to do so. On the other hand, it doesn't take any skillset to click "order CT abdomen/pelvis" in EPIC.

Regarding the 30 year old, ER doctors already overorder in that population. We know from a public health perspective that American doctors order imaging at a wildly higher rate than international doctors. You cannot honestly tell me that our EM docs are exercising the highest levels of judgement.

You seem very fixated on the ordering of advanced imaging as if that were the only skillset that's practiced in the ED. But on that topic, if the rate that ER doctors order CT scans offends you, then the fact that NPs order them at higher rates than ER doctors should certainly result in you advocating for more ER trained physicians to staff departments, and not to have them replaced with NPs/PAs!

Whatever specialty you go into, I do hope that you'll end up valuing your ER colleagues better than you do right now. I think you'll find your own career will be more rewarding when you do.

 

[Redpancreas]

Explain the answer to this simple question to me. American doctors order twice the number of CT scans per patient compared to overseas. Why?

I googled "American doctors order twice the number of CT scans per patient compared to overseas" and from a cursory glance didn't see anything that popped out. Obviously, I'm not saying that what you're saying is not true, but it would be nice to have a concrete statistic/source we can both interpret and discuss.

Anyways, assuming what you say is absolute truth, I will admit that I suspect most of those CTs are ordered in the emergency department, but then I would further question WHY the emergency department is ordering all those scans. If you told me all nations have an EMTALA equivalent, all nations have a medicolegal system where patients can sue like they do here...and furthermore, if you tell me it's only CT scans that are ordered in the US at double the rate (and not antibiotic prescriptions, heart catheterizations, endoscopies, arthroscopies, etc.) then I think that would be a stronger argument. Also, please take note that in my original post I state that sometimes someone getting the CT scan is the accepting team's condition prior to admission to their service. Again, not to be a broken record but inpatient specialties only see who the ED admits, not who they discharge. Who they admit is a function of who gets referred to the ED from the outpatient setting and the strength of American public health.

Overall, I repeat what I said here earlier which is that I just see a lack of inquiry on your part drawing you to preliminary conclusions. Whether laziness, specialty tribalism, an underlying bias, or something else is driving that, I'm not sure.

Anyways, I just wanted to give my thoughts on the field. Maybe a few people read the discussions and thought about it for a bit because I think doing that makes everyone a better physician. I personally don't think most EM physicians really care about what medical students think about their field...in fact maybe they welcome/encourage anti-EM posts in droves to drive down their supply.

 

[Splenda88]

Most of our ED docs leave it to us (hospitalists) to call consultants. I dont mind TBH because I know their job is not easy. My job would be a lot easier if our ED docs would call consultants.

 

[Redpancreas]

Most of our ED docs leave it to us (hospitalists) to call consultants. I dont mind TBH because I know their job is not easy. My job would be a lot easier if our ED docs would call consultants.

Seems to vary institutionally. At my current shop, I feel bad...EM residents have to look up which group the patient follows with because we have multiple groups for various specialties, then go on a wild goose chase trying to track down the right consultant...granted there's throughput. The hospitalists here dictate sometimes that surgical consults see patients before the patient is admitted to medicine mainly for appropriate disposition, but they sometimes also ask medicine consults to evaluate stable patients in the EM which I feel is inappropriate and hardly changes management. tl;dr seems to be affected by institutional expectations.

 

[Splenda88]

Seems to vary institutionally. At my current shop, I feel bad...EM residents have to look up which group the patient follows with because we have multiple groups for various specialties, then go on a wild goose chase trying to track down the right consultant...granted there's throughput. The hospitalists here dictate sometimes that surgical consults see patients before the patient is admitted to medicine mainly for appropriate disposition, but they sometimes also ask medicine consults to evaluate stable patients in the EM which I feel is inappropriate and hardly changes management. tl;dr seems to be affected by institutional expectations.

I wish we had a system like that. We sometimes write and H&P and discharge summary at the same time. Again, we have good rapport with the EM docs; they know most of us will not give any pushback.

 

[mrbreakfast]

The hospitalists here dictate sometimes that surgical consults see patients before the patient is admitted to medicine mainly for appropriate disposition, but they sometimes also ask medicine consults to evaluate stable patients in the EM which I feel is inappropriate and hardly changes management. tl;dr seems to be affected by institutional expectations.

We are often consulted for "neuro clearance" prior to admittance to another service, which the EM docs are always very apologetic about. Never changes management. In some academic institutions there is plenty of quibbling about disposition between services.

 

[Candidate2017]

In my limited experience of consultation with inpatient psychiatry, I have not any consult change management and or have the psychiatrist see the patient the same day (n=1).

Psychiatrists usually have a 24 hour clause set by contract or hospital bylaw. If the hospital wants us to see ED consults ASAP, the CEO can dip into their pocket to pay us thousands per shift to standby, like they do for ortho etc. But they don't. Unlike ortho, cards, etc, psychiatrists aren't called in to fix things like set a fracture or put in a balloon. No, we are consulted to soak up liability, read tea leaves as to whether it's ok to release from the ED a stranger who made threats to shoot themselves and others, and add our names next to the EM physician on the defendant list.

Also, there aren't many psych emergencies. Emergencies are related to lethal harm or med reactions (DRESS, SJS, NMS, SS). But the patient is already in the ED/hospital, so there should be no lethality issues and med reactions are within the domain of EM, IM, CC etc.

I imagine there’s also a great of litigation in psychiatry

There isn't. Likely because our purely cognitive work requires us to spend more time and thought on patients, as reflected in our hefty notes (which no one wants to read, except lawyers), relative to other specialties. We are also the only specialty that routinely testifies in court during residency.

The issue occurs when we can’t put ourselves in their shoes and realize they’re also doctors who went to medical school and have a specific skill set and work within parameters that are different from the ones we work in on a daily basis.

Psychiatrists have a bit of insight about the BS in the ED. We spend a chunk of residency in the ED for emergency psych and psych consults. Some programs have psych residents rotate in the ED as... EM residents. Despite a significant portion of ED (and FM) visits being related to psychiatric complaints, how many EM programs require EM residents to rotate on the psych ward?

During training, many EM physicians would tell me about the "tricks" to get patients accepted to the psych ward. Seriously, do you not see "Psychiatry" emblazoned on my white coat? Who do you think you will be asking to admit your ED patients tonight?

So when we stroll into the ED after lunch, it's because we know. Or better yet, when we decline to ever work in the ED.