Community Docs Can't Handle the Simplest Issues

[docB]

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I have been known to rant about primary docs and specialists who dump on the ER and/or refuse consults and/or admissions.


This isn’t one of those.

I have had several cases in the past several months that have illustrated just how dependent our system has become on the ERs of this country. Primary docs and specialists in the office really can’t deal with even minor issues. They have given up this role because addressing these issues is inconvenient, poorly compensated and entails liability.

For example:

Primary care docs in my area can’t even treat a sprained ankle in their offices. Getting the required authorizations for an x-ray is too time consuming. They have no crutches or splinting materials available. They refer all acute injuries into the ED. Oh and before you suggest that x-rays aren’t necessary in all extremity injuries remember that if the patient went to the doctor they expected an x-ray and that while we hear about dissatisfied “customers” via Press Ganey they hear about it when paying patients bail on them. They also know that missed fracture is a hot button liability issue for them as it is for us. So they send these patients in to us after telling them “You need an x-ray. Go to the ER.” And lets be honest, how many of us then deny them that x-ray and deliver a dissertation on the Ottowa ankle rules?

OBs in my area have given up doing in office ultrasounds. Most of them got rid of their machines. They still have those 3D jobs around that patients pay cash for but to hear them tell it there is no money in doing a regular US in the office so they no longer have the equipment for it. So I routinely get first trimester patients referred into the ED BY THEIR OB/GYNs for “cramping, US to r/o miscarriage.” In other words the patient is nervous and wants to see the baby. That takes an ED bed, a pregnant patient sent by her OB to be evaluated by me.

In my area all admissions go through the ED otherwise they require a byzantine preauthorization process. So a patient who reports chest pain a week ago to their primary doctor will be sent to the ER rather than directly admitted to avoid that headache. Perish the thought of an outpatient work up. Should the patient have an event between the PMD and the cardiologist the PMD would be liable so that’s not an option. We do frequently get patients sent tot he ED for a chest pain evaluation and are told they will go home after (i.e. have the ER doc touch you then go home and have your family sue him if you die). But that’s a different issue.

So I stand on my assertion that community physicians have abdicated their responsibilities and capabilities to deal with even some of the simplest issues and have become dependent on the ED to an astounding degree.

 

[Birdstrike]

Community docs can't handle the simplest issues

DocB, come on. You know better than that. Of course they can handle that stuff. Are you kidding me? Why should he finish the job when there's nothing more to be milked out of the cpt code, when he can dump on the ED and crank out the next one? These guys aren't dumb.

 

[GeneralVeers]

DocB, come on. You know better than that. Of course they can handle that stuff. Are you kidding me? Why should he finish the job when there's nothing more to be milked out of the cpt code, when he can dump on the ED and crank out the next one? These guys aren't dumb.

DocB deals with the same primery care, and urgent care *****s that I do. I honestly don't know if any of them are actually doctors and can do anything more than hand out Z-packs for viral URIs.

The one I can't figure out are lacerations and abscess I&Ds. Urgent cares always send these to the ER for reasons I can't fathom. Usually these are insured patients, these procedures are relatively quick, and the reimbursement is relatively high.

 

[TrumpetDoc]

Word!

Let's not forget the time honored "abnormal labs" Pt. Granted, sometimes this is legit, but a mildly elevated K with normal kidneys, c'mon.

 

[diphenyl]

Don't get me started. Most of the guys in my area are far to lazy to admit their own. The weekends are understandable but at 11 am on a Monday? Are you kidding me? Stop being lazy and do your job PMD's!
I swear the next guy who sends their patient to the ER for K of 3.4, I will be knocking on ur door at 3 am.

 

[AmoryBlaine]

We are victims of our own success on this one. We've staffed EDs with competent docs who are there 24/7 and who don't push back against this kind of thing.

It's not horrible at my shop, nothing like what you are saying. But most non-EM docs don't understand the concept that if they are going to use the ED like this they can't be surprised when the wait is really long.

I had an OB screaming at me on the phone because she had sent over a hyperemesis patient for IVF from her office. She called and demanded that this non-sick patient be brought immediately to a room, I said I would do the best I could. When the patient was made to sit in the waiting room she called back and was enraged.

Meanwhile, the OBs at my shop have NS and IV catheters in their offices....

Using the ED as an admission desk is really a far worse sin. We are regularly clogged up with subspecialty patients just waiting for beds.

 

[deuist]

It's really bad when a community doc sends a patient in for admission but does not include a note or phone call as to why. If they aren't answering their pagers, I'm then left wondering why the hell an ambulatory patient with no complaints and normal vitals needs an admission. Our all time low was a patient was scheduled to have surgery the next morning and was sent in for prep, as opposed to just coming in the next day like normal.

 

[Greenbbs]

Word!

Let's not forget the time honored "abnormal labs" Pt. Granted, sometimes this is legit, but a mildly elevated K with normal kidneys, c'mon.

The worst is the "abnormal lab" stating an INR of 5+with no active bleeding sent in for management. Many PMD's I talk to about this don't grasp the hold coumadin and recheck in 2 days concept. What's worse, many people with INR's of 5+ get sent in with an expectation for oral Vit. K. I'll usually call the PMD back, kindly explain our thought process, and jokingly send the guy to the grocery to buy a bag of spinach salad.

 

[Arcan57]

We are victims of our own success on this one. We've staffed EDs with competent docs who are there 24/7 and who don't push back against this kind of thing.

It's not horrible at my shop, nothing like what you are saying. But most non-EM docs don't understand the concept that if they are going to use the ED like this they can't be surprised when the wait is really long.

I had an OB screaming at me on the phone because she had sent over a hyperemesis patient for IVF from her office. She called and demanded that this non-sick patient be brought immediately to a room, I said I would do the best I could. When the patient was made to sit in the waiting room she called back and was enraged.

Meanwhile, the OBs at my shop have NS and IV catheters in their offices....

Using the ED as an admission desk is really a far worse sin. We are regularly clogged up with subspecialty patients just waiting for beds.

The number of "unstable angina" patients that get transferred ED to ED after a complete work-up so that we can save the cardiologists from having to write admit orders is staggering. And of course we are chronically short of monitored beds.

 

[Stitch]

I was getting frustrated by this sort of thing the other day and wanted to do a study on it. What's the referral rate to the ED of a private peds practice and how does it go up with proximity to a large tertiary peds center. My friends out in the country tell me they have to take care of a LOT more by themselves, because the closest peds center is a while away, and the local EM doc will just call them in to help out. Adds a little incentive when you're held responsible.

 

[docB]

It's really bad when a community doc sends a patient in for admission but does not include a note or phone call as to why. If they aren't answering their pagers, I'm then left wondering why the hell an ambulatory patient with no complaints and normal vitals needs an admission. Our all time low was a patient was scheduled to have surgery the next morning and was sent in for prep, as opposed to just coming in the next day like normal.

There's an ortho surgeon in my area who sends several patients in for "preop labs, cxr, ekg admit to hospitalist" every Thursday afternoon because his OR day is Friday. He does this not so much because he's lazy or malicious but because most of his patients are HMO and it's very difficult to get preauth for their surgeries. If they're admitted he can go ahead and do the procedures.

 

[Stitch]

There's an ortho surgeon in my area who sends several patients in for "preop labs, cxr, ekg admit to hospitalist" every Thursday afternoon because his OR day is Friday. He does this not so much because he's lazy or malicious but because most of his patients are HMO and it's very difficult to get preauth for their surgeries. If they're admitted he can go ahead and do the procedures.

Is this an arrangement he has with the hospital higher ups? It sounds like something he does because he's allowed to or even encouraged. Either way a waste of time.

 

[GeneralVeers]

Is this an arrangement he has with the hospital higher ups? It sounds like something he does because he's allowed to or even encouraged. Either way a waste of time.

The hospitals in our area (like most) depend upon highly-reimbursing surgeries to make a profit for the facility. As a result most of the surgical specialisists have broad latitude and few restrictions from administration. When administration tries to correct their behavior, they throw a tantrum and threaten to leave for another facility and take their surgical patients with them.

 

[skontroller]

Okay. Let's say these communtiy docs do inappropriately send patients to the ED. If said patients are insured shouldn't the ED docs be greatful for the referral? These patients represent easy sources of revenue. The real issue would arise if the community docs were selecting the self pay for the ED.

SK

 

[GeneralVeers]

Okay. Let's say these communtiy docs do inappropriately send patients to the ED. If said patients are insured shouldn't the ED docs be greatful for the referral? These patients represent easy sources of revenue. The real issue would arise if the community docs were selecting the self pay for the ED.

SK

That would be true if I wasn't at the limit of patients. I average 3.2/hour at our one site and 2.8/hour at the other. I would be more than happy to turn away a few patients if I could see fewer.

 

[Apollyon]

That would be true if I wasn't at the limit of patients. I average 3.2/hour at our one site and 2.8/hour at the other. I would be more than happy to turn away a few patients if I could see fewer.

If it's been like that since you finished residency and started practice, "you're dumber than I thought." (Reference to Heartbreak Ridge, there.) I don't know what they're paying you, but it should be enough that you can work 8 shifts of 8 hours a month at that rate. If you are doing 12 or 14 shifts, or doing 12s, of 3 pph, that's CRAZY busy and just plain CRAZY. If they can't add on other doctors, that's one thing, but, if they WON'T, that would be my time to plan an escape strategy.

 

[Birdstrike]

DocB deals with the same primery care, and urgent care *****s that I do. I honestly don't know if any of them are actually doctors and can do anything more than hand out Z-packs for viral URIs.

The one I can't figure out are lacerations and abscess I&Ds. Urgent cares always send these to the ER for reasons I can't fathom. Usually these are insured patients, these procedures are relatively quick, and the reimbursement is relatively high.

They can knock out enough easy follow up visits in the time it takes to do an I&D that they overall capture greater compensation doing this. 9 out of 10 times, they're playing dumb.

The worst is the "abnormal lab" stating an INR of 5+with no active bleeding sent in for management. Many PMD's I talk to about this don't grasp the hold coumadin and recheck in 2 days concept. What's worse, many people with INR's of 5+ get sent in with an expectation for oral Vit. K. I'll usually call the PMD back, kindly explain our thought process, and jokingly send the guy to the grocery to buy a bag of spinach salad.

Once, again, they're playing dumb. They know darn well that there's nothing to do here other than to have their butt covered if the patient goes home, falls, hits his head and gets a subdural, "well I sent him to the ED, Your Honor". "I knew he needed to be admitted, that's why I sent him". But if it's their turn to take call, of course, they'll tell you he doesn't need to be admitted.

The number of "unstable angina" patients that get transferred ED to ED after a complete work-up so that we can save the cardiologists from having to write admit orders is staggering. And of course we are chronically short of monitored beds.

Again, a classic dump. Sends the patient with a heart issue to the ED, when you call him and tell him his patient is here, he says, "Why haven't you worked him up? Don't you know what you're doing?" when in fact he has effectively consulted you to see this heart patient. Then you work him up and call him back and he calls medicine to admit the patient so he can consult.

There's an ortho surgeon in my area who sends several patients in for "preop labs, cxr, ekg admit to hospitalist" every Thursday afternoon because his OR day is Friday. He does this not so much because he's lazy or malicious but because most of his patients are HMO and it's very difficult to get preauth for their surgeries. If they're admitted he can go ahead and do the procedures.

Another example, of not incompetence or stupidity, but in fact just the opposite: a supreme knowledge of how to manipulate the system, of which the ED is an integral part.

Another classic one seen at a community hospital: pediatrician sends in some child that doesn't seem that sick but for whatever reason needs a huge workup. When you call him to admit the child, all of a sudden, the kid isn't sick and can be sent home. Then when you explain that, yes he looks okay, the work up doesn't look too bad, but there's definitely enough here to have the child observed, now all of a sudden he needs to be transferred to the nearest tertiary referral center. Too sick to be in the peds office, but not sick enough to be admitted to the community hospital, but so sick he needs to be transferred to the nearest University with PICU, NICU.

That would be true if I wasn't at the limit of patients. I average 3.2/hour at our one site and 2.8/hour at the other. I would be more than happy to turn away a few patients if I could see fewer.

You either have a super efficient system you work in or you just see too darn many patients. The place I recently left used to average about 2.5/hr when I started several years ago, but due to system changes, some ObamaCare/government/JointCommission- induced, some corporate, they average about 1.8/hr now. 3 per hour is doable in a low acuity setting with a super hard working doc in a super efficient system with low acuity. Otherwise, its just way too painful, or you're having to stay 2 hr late to clean up (which wouldn't actually be 3 per hour), or you have heavy PA/house staff support. I agree with Apollyon, I hope they're paying you at least $200/hr, plus all benefits and malpractice or $250/hr IC equivalent.

 

[EM2BE]

While on the patients per hour discussion, during residency I remember someone posting numbers we should be seeing. Can anyone remember or give a general idea of what you think is appropriate? During my intern year, I usually saw 20 patients in the 11 hours I picked them up. I know at my program we are expected to do this and expected to increase as time passes. During the day shift, it was much more difficult to reach this number as all the patients were level 3 acuity or higher (fast track is open). Is this similar to other programs?

 

[Arcan57]

2 pts/hr unless it's mostly fast-track is going to be overwhelming for most interns/2nd years. It always seemed like you got absolutely killed, but I found when I started keeping track of patients that it was relatively rare to pick up more the 16-20 in an 8/12 hr shift. The long turn around time at most teaching hospitals is usually going to limit you to being able to turn over your assigned beds twice a shift. I think we averaged 1.4-1.6/hr, although they never quite were accurate as to who saw which patient.

 

[EM2BE]

2 pts/hr unless it's mostly fast-track is going to be overwhelming for most interns/2nd years. It always seemed like you got absolutely killed, but I found when I started keeping track of patients that it was relatively rare to pick up more the 16-20 in an 8/12 hr shift. The long turn around time at most teaching hospitals is usually going to limit you to being able to turn over your assigned beds twice a shift. I think we averaged 1.4-1.6/hr, although they never quite were accurate as to who saw which patient.

I always seemed to have a point in the shift in which I felt completely overwhelmed. Usually because I would be pretty much maxed out when a really sick person was brought back for me to see. We don't really do any signing out of patients unless they are psych and are expected to be there for a while (including alcoholics). We are not staffed well in the ED, which puts a lot more responsibility on the residents in there. I keep telling myself things will get easier, but I found the more knowledge I get the harder it is to rush through things. That and being out of the department for 6-7 months is going to make me quite rusty when I get back. Kind of nervous.

 

[Ceez]

I guess my biggest complaint about these patients that get referred from clinic to the ED is that the patient's primary doesn't communicate with the hospitalist. So the patient comes in with the expectation of getting admitted for something semi-urgent, and of course the HMO hospitalist is gonna block it, but guess who the patient gets upset with??

 

[GeneralVeers]

We are not well compensated and we are short on docs, which is why we see so many. I'm not as "stupid" as you think. I would leave, except a combination of personal reasons, great location, and easy vacation time makes the job tolerable.

 

[Apollyon]

I'm not as "stupid" as you think.

Never saw Heartbreak Ridge, eh? If you didn't, then you missed the point (which is why I referenced the film - directly). If I thought you were actually stupid, I wouldn't have said it (because, if you don't have something nice to say, don't say it).

I'm in a great location, I get easy vacation time (less than 1 month notice, and up to 2 weeks off), we are short of docs, and we are poorly compensated, but I don't get my ass run off every shift.

 

[AmoryBlaine]

Another classic one seen at a community hospital: pediatrician sends in some child that doesn't seem that sick but for whatever reason needs a huge workup. When you call him to admit the child, all of a sudden, the kid isn't sick and can be sent home. Then when you explain that, yes he looks okay, the work up doesn't look too bad, but there's definitely enough here to have the child observed, now all of a sudden he needs to be transferred to the nearest tertiary referral center. Too sick to be in the peds office, but not sick enough to be admitted to the community hospital, but so sick he needs to be transferred to the nearest University with PICU, NICU.

That would pretty much drive me straight to the bottle.

I have a new favorite. PMDs have sent a few people in who clearly don't need admit but they call ahead saying "this person needs to be admitted." One recent one was a 60 something year old lady who had a BP of like 170 in the office and was a little bit dizzy. She felt great by the time she got to the ED, BP 140. Called PMD, "I'd really like her admitted."

"For what?"

"For acute HTN."

"....."

 

[bulgethetwine]

Okay. Let's say these communtiy docs do inappropriately send patients to the ED. If said patients are insured shouldn't the ED docs be greatful for the referral? These patients represent easy sources of revenue. The real issue would arise if the community docs were selecting the self pay for the ED.

SK

That's missing the point entirely. Source of revenue pffffttttt.

 

[docB]

Okay. Let's say these communtiy docs do inappropriately send patients to the ED. If said patients are insured shouldn't the ED docs be greatful for the referral? These patients represent easy sources of revenue. The real issue would arise if the community docs were selecting the self pay for the ED.

SK

That's missing the point entirely. Source of revenue pffffttttt.

skontroller makes a good point and that is the reason why no one fights inappropriate ER referrals at the administrative level. Volume = $$$.

I would argue though that this trend is bad for primary care, EM and for society. It's bad for primary care to be forced by economics to give up their ability (and by atrophy eventually their skills) to deal with simple, urgent problems. These are needs of their patients that they can and should be allowed to treat.

It's bad for EM for us to be forced by economics to redirect ourselves away from emergent problems to urgent and even non-urgent issues. This financial paradigm forces (lures?) us into continually expanding EDs, expanding staffing rates and expanding the use of midlevels for these urgent and non-urgent patients. As a specialty we push for the gold standard of ERs staffed with only board certified EPs yet we depend economically on having as big a percentage of our patient load as possible be patients who really can be treated by non-boarded practitioners. We need to cut out the fat and cone down to what we are really supposed to be.

It's bad for society because we are very expensive, poor quality, wasteful primary care doctors. Urgent and non-urgent patients should be triaged to appropriate levels of care. By failing to do so and worse, incentivizing us to depend on these patients, we are squandering a lot of our scarce healthcare resources.

 

[fiznat]

Called PMD, "I'd really like her admitted."

"For what?"

"For acute HTN."

"....."

Excuse my ignorance here, but can't you just refuse him?

 

[GeneralVeers]

Excuse my ignorance here, but can't you just refuse him?

You can, but then that doctor complains to medical staff, and you get in trouble. For admin it's all about keeping a referral base of INSURED patients coming into the hospital. In order to do that they want to keep the surgeons, specialists, and primary doctors happy.

Emergency physicians are the crack-****** of the hospital.

 

[fiznat]

You can, but then that doctor complains to medical staff, and you get in trouble. For admin it's all about keeping a referral base of INSURED patients coming into the hospital. In order to do that they want to keep the surgeons, specialists, and primary doctors happy.

Ugh. That kinda makes me sick to my stomach.

 

[TrumpetDoc]

You can, but then that doctor complains to medical staff, and you get in trouble. For admin it's all about keeping a referral base of INSURED patients coming into the hospital. In order to do that they want to keep the surgeons, specialists, and primary doctors happy.

Emergency physicians are the crack-****** of the hospital.

Too true...and really something you just can't get a feel for in training. Maybe some can, but I didn't.

 

[NSAIDAllergy]

emergency physicians are the crack-****** of the hospital.

🙂

 

[Mighty Mouse]

reading these posts reminded me of a case i had last week moonlighting in a single coverage free standing ED attached to some outpatient offices. the difference in this case is i basically had to beg the cardiologist to send me the patient...

he calls me and says, "so i have this 82 yo lady in my office for a follow up visit after a NSTEMI. the nurse took her BP and her systolic was in the 70s. nurse left the room, and when i walked in, the patient was slumped over and unresponsive. she didn't have a pulse. we did CPR for about 10 seconds and she woke up. she feels better now, i think i'm going to send her home, unless you'd be interested in taking a look at her first."

after realizing that he wanted to send home a post arrest patient, i said, "you know what, why don't you wheel her up here and i'll check her out and we can admit her downtown to our cardiology floor."

i honestly couldn't believe i was having this conversation

 

[WilcoWorld]

reading these posts reminded me of a case i had last week moonlighting in a single coverage free standing ED attached to some outpatient offices. the difference in this case is i basically had to beg the cardiologist to send me the patient...

he calls me and says, "so i have this 82 yo lady in my office for a follow up visit after a NSTEMI. the nurse took her BP and her systolic was in the 70s. nurse left the room, and when i walked in, the patient was slumped over and unresponsive. she didn't have a pulse. we did CPR for about 10 seconds and she woke up. she feels better now, i think i'm going to send her home, unless you'd be interested in taking a look at her first."

after realizing that he wanted to send home a post arrest patient, i said, "you know what, why don't you wheel her up here and i'll check her out and we can admit her downtown to our cardiology floor."

i honestly couldn't believe i was having this conversation

The only sense I can make of this is that the Cardiologist wanted another MD's name on the chart so that he could have someone to help him "carry the coffin".

 

[AmoryBlaine]

Excuse my ignorance here, but can't you just refuse him?

Maybe if I was an attending...

 

[Daiphon]

The only sense I can make of this is that the Cardiologist wanted another MD's name on the chart so that he could have someone to help him "carry the coffin".

If by "carry the coffin" you mean "share in both the malpractice and wrongful death lawsuits," then I agree.

d=)

-t

 

[docB]

The only sense I can make of this is that the Cardiologist wanted another MD's name on the chart so that he could have someone to help him "carry the coffin".

This brings up another facet of this. Remember that this thread isn't about ranting (which I never do 🙄). It's about the real world reasons that have caused community docs to abandon their ability to care for a lot of common, simple, non-emergent problems and dump them into the ED.

The specter of liability is one of the main reasons PMDs dump. Good examples include low TIMI score cardiac work ups that could be done out patient in a cardio office and asymptomatic hypertension.

The best example though is the patient sent in for "r/o DVT." The patient with a swollen leg really needs an out patient US and then treatment for peripheral edema if negative, a script for Lovenox and coumadin and follow up if positive. But the answers I always get when I ask why they're dumping them is "Well, what if they throw a PE before all that gets done?" You put that fear of liability together with the difficulties of getting the ultrasound authorized and it's off to the ER.

 

[GeneralVeers]

Had one 70 year old guy sent in this week by PMD. He had some cough, no fever, no chills, no respiratory problems. The PMD was treating him for "pneumonia" with Penicillin. He had done outpatient X-ray, outpatient CT (with results pending), but he really sent him in for the CBC that had a WBC of 18,000. I'm still not sure why he sent the guy in. I did a chest X-ray (which showed probable lung cancer mass), changed his antibiotics to Avelox and sent the guy home.

 

[docB]

Had one 70 year old guy sent in this week by PMD. He had some cough, no fever, no chills, no respiratory problems. The PMD was treating him for "pneumonia" with Penicillin. He had done outpatient X-ray, outpatient CT (with results pending), but he really sent him in for the CBC that had a WBC of 18,000. I'm still not sure why he sent the guy in. I did a chest X-ray (which showed probable lung cancer mass), changed his antibiotics to Avelox and sent the guy home.

I had the same thing happen yesterday. A large, HMO run clinic (Veers knows what I mean 😉) sent in a guy because they had done an outpatient CT of the chest and it showed a mass. An NP at the clinic called the guy and told him to come right to the ER "So the surgeon could meet him here." I think it might have been because it was Friday afternoon. Anyway I apologized to the guy because I couldn't do anything for him. The HMO doctor came and talked to him and he apologized to him and set him up with the appropriate out patient follow up.

 

[The White Coat Investor]

skontroller makes a good point and that is the reason why no one fights inappropriate ER referrals at the administrative level. Volume = $$$.

I would argue though that this trend is bad for primary care, EM and for society. It's bad for primary care to be forced by economics to give up their ability (and by atrophy eventually their skills) to deal with simple, urgent problems. These are needs of their patients that they can and should be allowed to treat.

It's bad for EM for us to be forced by economics to redirect ourselves away from emergent problems to urgent and even non-urgent issues. This financial paradigm forces (lures?) us into continually expanding EDs, expanding staffing rates and expanding the use of midlevels for these urgent and non-urgent patients. As a specialty we push for the gold standard of ERs staffed with only board certified EPs yet we depend economically on having as big a percentage of our patient load as possible be patients who really can be treated by non-boarded practitioners. We need to cut out the fat and cone down to what we are really supposed to be.

It's bad for society because we are very expensive, poor quality, wasteful primary care doctors. Urgent and non-urgent patients should be triaged to appropriate levels of care. By failing to do so and worse, incentivizing us to depend on these patients, we are squandering a lot of our scarce healthcare resources.

That's a pretty profound statement. I'm not sure it is possible for us to only see emergencies, economically or pragmatically.

I don't quite agree with your statement that we depend on non-emergent problems. We do, however, depend on insured, or at least paying, patients. The fact remains that I would prefer to take care of a 3 cm laceration on an insured 4 year old than a 15 prozac tablet suicide attempt by an uninsured 35 year old female. The patient and family are more grateful for the care, I make more of a difference, I spend a lot less time, and I make more money. But you know as well as I do which one qualifies as an "emergency" and which one the primary doctor would take care of if given the option. The last thing we need is for other doctors to take the patients who actually pay us away from us. No margin, no mission.

We don't want to create more urgent care type situations. Urgent Cares rape emergency medicine. They only see paying patients. They only see patients that don't consume much time. And they choose which emergencies they want to take care of (i.e., the high margin ones like lacs, abscesses, fractures, URIs, UTIs etc. that provide high reimbursement for time expended) If it isn't high margin it gets referred to the PCP or to the ED depending on severity.

I would argue that keeping urgent care type stuff in the ED is the way to go. EDs are, for the most part, run on a fixed expense basis. Whether I see 5 patients or 20 on my shift the hospital has the same costs to keep the doors open-nurses, techs, clerk, lab, radiology, electricity, climate control, equipment etc. I haven't had a shift in a long time where I didn't have the time to see 2 or 3 more patients during the shift. Just like a restaurant is more profitable (and usually provides a better dining experience) when all the tables are full and turning over quickly, so is an ED. Now there is a careful line to walk with regards to overcrowding, at a certain point additional patients make care worse (and even less profitable), not better, but edging up to that peak on the graph is the ideal.

In short, seeing those 4 year olds with their 5 minute lacerations allows me to stay in business so I'm there to take care of uroseptic grandma, suicidal housewife, and the Friday night bar fight participants. If we want our specialty to survive, we cannot afford to let the emergent and urgent issues that pay the bills get taken elsewhere. If a few non-urgent issues come in too, fine. This is really quite a low percentage of my practice though to be honest.

 

[GeneralVeers]

In short, seeing those 4 year olds with their 5 minute lacerations allows me to stay in business so I'm there to take care of uroseptic grandma, suicidal housewife, and the Friday night bar fight participants. If we want our specialty to survive, we cannot afford to let the emergent and urgent issues that pay the bills get taken elsewhere. If a few non-urgent issues come in too, fine. This is really quite a low percentage of my practice though to be honest.

I'd be happy to see fewer patients. My life would be better, I'd be calmer, and I might look forward to going to work. If our urgent cares or PMDs could just handle a few coughs/colds or simple pneumonias we would be much better off at my facility.

 

[The White Coat Investor]

The best example though is the patient sent in for "r/o DVT." The patient with a swollen leg really needs an out patient US and then treatment for peripheral edema if negative, a script for Lovenox and coumadin and follow up if positive. But the answers I always get when I ask why they're dumping them is "Well, what if they throw a PE before all that gets done?"

Answer the question. What IF they throw a PE? It isn't like it doesn't happen. What is the safe interval to get that work-up done in and can most doctors or patients arrange for it to happen in that time period? I would argue that this is one of those things that EDs do very well. The patient comes in, gets a quick exam, I check a couple labs and an US and they walk out 2 hours later having had a dose of lovenox and coumadin, scripts for both, and follow-up with their primary doctor next week arranged. All done in 2 hours. It would be a pain for the PCP to do this. It would require the patient to go to an imaging center and an outpatient laboratory, then return to the clinic in a couple days when the results come in. It would require the PCP to keep lovenox in the clinic too to be able to train the patient on it at the follow-up visit. Add in holidays, weekends, and a full clinic schedule and it might be a week before the patient actually gets a dose of lovenox. Could you put them on it empirically? Sure, with additional expense and risk. I can tell you what I'd prefer to do as a patient. It's faster, safer, more efficient, and more convenient to take care of this problem in the ED. It isn't a dump, it's appropriate.

I'm always surprised when I have a patient transferred to the ED for admission for appendicitis with the PCP having done outpatient labs and CT over the last day or two. I could have taken care of that problem in a couple hours with little hassle. It's appropriate to send some patients to the ED. You're doing them a disservice by having the PCP do the work-up as an outpatient. I'm better than a PCP at diagnosing appendicitis. I have the tests to do so at my ready disposal. I am set up to easily give fluids, pain meds, nausea meds, and antibiotics. Why kick against the pricks to try to recreate an ED in your clinic? Sometimes the radiology department intervenes on the patient's behalf. They hold the patient after their outpatient CT for acute abdominal pain until the radiologist reads it, then when it shows appendicitis they walk the patient down to the ED to check in.

 

[GeneralVeers]

I'm always surprised when I have a patient transferred to the ED for admission for appendicitis with the PCP having done outpatient labs and CT over the last day or two. I could have taken care of that problem in a couple hours with little hassle. It's appropriate to send some patients to the ED. You're doing them a disservice by having the PCP do the work-up as an outpatient. I'm better than a PCP at diagnosing appendicitis. I have the tests to do so at my ready disposal. I am set up to easily give fluids, pain meds, nausea meds, and antibiotics. Why kick against the pricks to try to recreate an ED in your clinic? Sometimes the radiology department intervenes on the patient's behalf. They hold the patient after their outpatient CT for acute abdominal pain until the radiologist reads it, then when it shows appendicitis they walk the patient down to the ED to check in.

Yes, we can do things (a bit) faster, but at 10 times the cost and use of resources. For something like appendicitis it's worth it, but for something like DVT? Just because you start them on Lovenox or Coumadin doesn't magically eliminate the risk of PE.

 

[The White Coat Investor]

I'd be happy to see fewer patients. My life would be better, I'd be calmer, and I might look forward to going to work. If our urgent cares or PMDs could just handle a few coughs/colds or simple pneumonias we would be much better off at my facility.

How long do you spend on a URI or simple pneumonia patient? Including charting I bet I spend less than 15 minutes on most. You think taking 3 of those out of your day would make you enjoy your job more? Studies have shown time and time again that it isn't the non-urgent patients clogging up our EDs. It's getting the sick patients upstairs.

Want to see fewer patients per shift? Cut your income by putting more docs on at a time. Not that tough, just a balancing act. What kind of a business actually hopes for fewer customers? You sound like you're in a situation where you're not in control of physician staffing decisions and where your pay doesn't increase with doing more work.

 

[The White Coat Investor]

Yes, we can do things (a bit) faster, but at 10 times the cost and use of resources. For something like appendicitis it's worth it, but for something like DVT? Just because you start them on Lovenox or Coumadin doesn't magically eliminate the risk of PE.

What's the increased use of resources? They still get lovenox, an US, and some labs. Same resources. Sitting in an ED bed for 2 hours certainly doesn't multiply the "resources used" by 10. The charges might be higher (not 10 times), but the resources are pretty similar.

Of course lovenox doesn't magically eliminate the risk of PE. But it does decrease it, and the sooner you get it on board the sooner it decreases it.

 

[The White Coat Investor]

Ugh. That kinda makes me sick to my stomach.

Some of you seem to think that medicine doesn't need to be a viable business. Go cruise the Sermo forums for a week and see how many doctors out there are only making $60K a year because they can't run a business. Can you pay your loans on $60K a year? Is that what you spent 10-15 years training to look forward to?

Some here seem to think that you can just sit up in your ivory tower stamping out disease without ever having to develop any business sense, negotiate contracts, or build relationships with doctors, hospitals etc. You're in for a rude awakening. No margin, no mission. If you can't get along with admin or the medical staff, you and your group won't be in the ED for long. That doesn't mean you need to practice bad medicine, but it does mean you need to consider the business aspects as you care for your patients. No margin, no mission.

 

[The White Coat Investor]

Word!

Let's not forget the time honored "abnormal labs" Pt. Granted, sometimes this is legit, but a mildly elevated K with normal kidneys, c'mon.

I just see these transfers as rescuing the patient from an incompetent doctor. If he thinks he needs to send me the patient for a K of 5.9, I think the patient deserves to have a real doctor evaluate whatever concern they went to see that provider for.

It isn't like you have the right to turn down the transfer anyway. You might as well pleasantly accept them and know that the next time that doctor needs to send a real emergency to the ER it'll be to yours instead of the one down the street.

 

[Boatswain2PA]

It's bad for EM for us to be forced by economics to redirect ourselves away from emergent problems to urgent and even non-urgent issues. This financial paradigm forces (lures?) us into continually expanding EDs, expanding staffing rates and expanding the use of midlevels for these urgent and non-urgent patients. As a specialty we push for the gold standard of ERs staffed with only board certified EPs yet we depend economically on having as big a percentage of our patient load as possible be patients who really can be treated by non-boarded practitioners. We need to cut out the fat and cone down to what we are really supposed to be.

Doc - I'm curious why (it seems) you think midlevels are a bad thing here. Even in the perfectly constructed ED you would have a certain percentage of less-acute patients. Lets say you remove the PMD "referred" patients from your ED, you would still have a mix of high, medium, and low acuity patients. What do you see wrong with using mid-levels, especially those who work under the supervision of a "real" doctor (ie - you), in these situations. It seems to me that a mid-level could remove some of the chaff so you could catch up on paperwork, and help out with the higher-acuity patients when you are swamped. What am I missing??

 

[emergiQ]

Doc - I'm curious why (it seems) you think midlevels are a bad thing here. Even in the perfectly constructed ED you would have a certain percentage of less-acute patients. Lets say you remove the PMD "referred" patients from your ED, you would still have a mix of high, medium, and low acuity patients. What do you see wrong with using mid-levels, especially those who work under the supervision of a "real" doctor (ie - you), in these situations. It seems to me that a mid-level could remove some of the chaff so you could catch up on paperwork, and help out with the higher-acuity patients when you are swamped. What am I missing??

The problem is that Emergency Medicine, more so than any other specialty, isn't just about treating pathology x; It's also about being able to recognize (and consider) more sinister pathology y and z.

Most of the mistakes I see mid-levels make aren't related to the treatment of 'x' (hell, with Up-to-date and various other real-time resources, googling the treatment and carrying it out once the diagnosis is secure is not that difficult) but rather related to pre-mature closure with regard to wide differentials. The Fournier's gangrene that was mistaken for jock itch. The indigestion that was treated in the patient having the MI. The arthritis that resulted from the missed scaphoid fracture. In other words, what seems like the 'chaff' to the triage nurse or the mid-level might be more sinister pathology that a board-certified EP is more likely to get (but we miss these too, of course!).

The trouble is, health systems and hospital administrators, used to running companies along economic theory of optimization of resources, place almost no value on the subspecialty training a EM residency affords. They are only interested in trimming budgets, optimizing their provider to patient ratios, etc. They see it as mid-levels being able to render good care to >90% of patients and thus see it as a viable cost savings to replace EPs with midlevels. I see it as hazardous care to ~10% of the patients, a far more devastating cost that the public doesn't appreciate.

Let's not forget that the whole concept of mid-levels was conceived to provide primary care in an era of dwindling primary care MDs. But somewhere, not surprisingly since the mid-levels are no doubt just as bored with primary care as the MDs were, the mid-levels have crept into subspecialty medicine (including emergency and ICU settings) as various forces have sought to contain costs (the ultimate cost remains to be determined). To think that the mass replacement of MDs by cheaper mid-levels won't have consequences beyond dollars and cents is surely folly.

Plus, the notion that "real docs" supervise mid-levels is just not true. In the groups I've worked in, there's been little (if any) time to go over the patients the mid-levels see. When I did, half the time I ended up doing my own exams and workups that certainly negated any efficiency. Hell, I usually felt like they added more work. Some places -- including big academic centers I've worked at -- don't even try to hide the fact that the mid-levels operate without any real supervision. Often the attending in the main ED ends up co-signing mid-level charts without seeing the patient. It's like an unspoken, acceptable fraud perpetrated on the public.

The public, if they could be educated enough about it, should be revolting about mid-level creep into medical care in this country.

I also think it's just a matter of time before a malpractice claim targets the administrator who replaced all the MDs with mid-levels. And I can't say I'm not cheering just a little for that lawsuit....

 

[Old_Mil]

So I stand on my assertion that community physicians have abdicated their responsibilities and capabilities to deal with even some of the simplest issues and have become dependent on the ED to an astounding degree.

In defense of the community physician, many have little control over their lives. As a medical student I rotated through a medium sized family medicine clinic. It was run by a nurse administrator who cracked the whip. On paper, the physicians had 15 minutes to see repeat visits and 30 minutes to see new patients. New patients were regularly scheduled for 15 minute visits. If a clinician requested a longer appointment for a given patient with scheduling, that request ignored. Plans were in the works to change repeat office visits to 12 minutes (6 patients an hour). At that pace, you really can't deal with anything out of the ordinary (application of a splint, EKG, etc).

This is merely another symptom of physicians having lost control of the practice of medicine.

 

[docB]

That's a pretty profound statement. I'm not sure it is possible for us to only see emergencies, economically or pragmatically.

I don't quite agree with your statement that we depend on non-emergent problems. We do, however, depend on insured, or at least paying, patients. The fact remains that I would prefer to take care of a 3 cm laceration on an insured 4 year old than a 15 prozac tablet suicide attempt by an uninsured 35 year old female. The patient and family are more grateful for the care, I make more of a difference, I spend a lot less time, and I make more money. But you know as well as I do which one qualifies as an "emergency" and which one the primary doctor would take care of if given the option. The last thing we need is for other doctors to take the patients who actually pay us away from us. No margin, no mission.

We don't want to create more urgent care type situations. Urgent Cares rape emergency medicine. They only see paying patients. They only see patients that don't consume much time. And they choose which emergencies they want to take care of (i.e., the high margin ones like lacs, abscesses, fractures, URIs, UTIs etc. that provide high reimbursement for time expended) If it isn't high margin it gets referred to the PCP or to the ED depending on severity.

I would argue that keeping urgent care type stuff in the ED is the way to go. EDs are, for the most part, run on a fixed expense basis. Whether I see 5 patients or 20 on my shift the hospital has the same costs to keep the doors open-nurses, techs, clerk, lab, radiology, electricity, climate control, equipment etc. I haven't had a shift in a long time where I didn't have the time to see 2 or 3 more patients during the shift. Just like a restaurant is more profitable (and usually provides a better dining experience) when all the tables are full and turning over quickly, so is an ED. Now there is a careful line to walk with regards to overcrowding, at a certain point additional patients make care worse (and even less profitable), not better, but edging up to that peak on the graph is the ideal.

In short, seeing those 4 year olds with their 5 minute lacerations allows me to stay in business so I'm there to take care of uroseptic grandma, suicidal housewife, and the Friday night bar fight participants. If we want our specialty to survive, we cannot afford to let the emergent and urgent issues that pay the bills get taken elsewhere. If a few non-urgent issues come in too, fine. This is really quite a low percentage of my practice though to be honest.

You are quite right in that you are talking about the realties of EM now. I'm talking about how I think things should be. The problem we have now is that the insured worried well pay our bills so that we can continue to exist as a social safety net. We would all be better served if this changed. We continue to be too expensive for the worried well and if those resources could be redirected we would all benefit.

Answer the question. What IF they throw a PE? It isn't like it doesn't happen. What is the safe interval to get that work-up done in and can most doctors or patients arrange for it to happen in that time period? I would argue that this is one of those things that EDs do very well. The patient comes in, gets a quick exam, I check a couple labs and an US and they walk out 2 hours later having had a dose of lovenox and coumadin, scripts for both, and follow-up with their primary doctor next week arranged. All done in 2 hours. It would be a pain for the PCP to do this. It would require the patient to go to an imaging center and an outpatient laboratory, then return to the clinic in a couple days when the results come in. It would require the PCP to keep lovenox in the clinic too to be able to train the patient on it at the follow-up visit. Add in holidays, weekends, and a full clinic schedule and it might be a week before the patient actually gets a dose of lovenox. Could you put them on it empirically? Sure, with additional expense and risk. I can tell you what I'd prefer to do as a patient. It's faster, safer, more efficient, and more convenient to take care of this problem in the ED. It isn't a dump, it's appropriate.

I'm always surprised when I have a patient transferred to the ED for admission for appendicitis with the PCP having done outpatient labs and CT over the last day or two. I could have taken care of that problem in a couple hours with little hassle. It's appropriate to send some patients to the ED. You're doing them a disservice by having the PCP do the work-up as an outpatient. I'm better than a PCP at diagnosing appendicitis. I have the tests to do so at my ready disposal. I am set up to easily give fluids, pain meds, nausea meds, and antibiotics. Why kick against the pricks to try to recreate an ED in your clinic? Sometimes the radiology department intervenes on the patient's behalf. They hold the patient after their outpatient CT for acute abdominal pain until the radiologist reads it, then when it shows appendicitis they walk the patient down to the ED to check in.

The "rule out DVT" issue should be an outpatient issue. Patients should be able to get some labs and an ultrasound within 12 to 24 hours after seeing their doctor. If positive scripts can be called in. Again I'm talking about how it should be. I acknowledge that reality if very different. We contribute nothing to the picture although we do bill and get paid for this. The ED accomplishes the same results at much higher expense. At the societal level this is a loss without a gain.

I would argue that if we had a system where lower cost, out patient DVT rule outs were done the savings would justify the very rare instances where someone actually had a DVT and then had a PE from it in the intervening time.

Some of you seem to think that medicine doesn't need to be a viable business. Go cruise the Sermo forums for a week and see how many doctors out there are only making $60K a year because they can't run a business. Can you pay your loans on $60K a year? Is that what you spent 10-15 years training to look forward to?

Some here seem to think that you can just sit up in your ivory tower stamping out disease without ever having to develop any business sense, negotiate contracts, or build relationships with doctors, hospitals etc. You're in for a rude awakening. No margin, no mission. If you can't get along with admin or the medical staff, you and your group won't be in the ED for long. That doesn't mean you need to practice bad medicine, but it does mean you need to consider the business aspects as you care for your patients. No margin, no mission.

I'm not saying medicine in general and EM specifically don't have to be viable businesses. I'm saying that we would be better off, i.e. we would get more out of our healthcare dollar if we used EDs for emergencies. When we are simply the keepers of the cat scans or the DVT ultrasound or the quick and easy second opinion to keep the lawyers at bay we all lose.