controversial, but i gotta ask

[anxiousnadd]

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Ok, let me say that this comment will be controversial. It's NOT my comment, but rather a comment from various residents and attendings in other specialties. I'm personally very interested in EM, and is my top choice as a specialty right now, but was just bothered by this comment and wanted to get your take on this and how one could deal with it.

The statement: "ER docs are nothing more than glorified triage nurses." Followed by, "In a few years, I can see how it would fiscally make sense if hospitals decided to man their ERs with mid-levels, since ER docs don't do much anyways, other than be kings of referrals."

😡

I'm sure this statement has been made MANY times, especially since I've heard it from folks from the west coast to the east.

 

[matt_mt19]

I can "do" alot of things... see below.

 

[Spaceman Spiff]

I did a bunch of surgical electives and I would hear that from the surgery residents while I was trying to decide between surgery and EM. It used to bother me, but then that comment just implies that they have little understanding of what EPs do. Triage nurses, nor surgeons for that matter, do not stabilize critical trauma AND medical patients, do airways/pacing/lines/delivers/you name it. EPs understand what is needed and why, which is often something that is beyond the training of mid-level providers. Knowing what is needed and why allows EPs to decide what's needed and to improvise as required.

I guess it's a matter of getting your reasons for wanting to do EM straight in your head. Then the jealous or ignorant comments of other services won't effect you anymore. Just think after you get all the sick people's **** squared away, you are going home to go mountain biking and have a beer, while the surgeon will still be there, bone tired, cursing how much they hate the hospital and their patients (from my experience). Just my two bits... Good luck.

 

[matt_mt19]

Since, as an EM physician, I don't "do" anything -- (ED/off service)

In one year (6/07-6/08) I've "done" the following (from my procedure log, each confirmed by the attending):
Abscess I&D - >50 (stopped logging after the stated #)
Arterial Lines - >30
Arthrocentesis - 21
Cardiac lac repair - 1
Cardiac pacing - 7
Casting/Splinting - > 30
Central Venous Access - >20
Chest tubes - 18
Conscious sedations - 16
Cricothyrotomy - 3
Cross Clamp Aorta - 4
Cutdown (venous) - 7
Defibrillation/Cardioversion - >20
Dislocation/Reduction - 14
Intraaortic balloon pump - 3
Intraosseus Access - 5
Intubation - 34 in ED (>20 14d anesth)
Laceration repair, complex - 13
Laceration repair, simple - >20
Laryngeal mask airway - 3
Nerve block - 9
Paracentesis - >10
Retrograde urethragram - 1
Spinal tap/LP - 13
Swan-Ganz insertion - >10
Thoracentesis - >10
Thoracotomy, left - 2
Thoracotomy, open (bil) - 2
Thrombolysis (fibrinolysis) - 5
Ultrasound - >150 (ED)

 

[dr. maybe]

Truly, sick or not sick, though seemingly easy takes medical training. Then, determining the type of care (after the ED), takes a medical professional. I would love to see my ED full of mid-level providers and triage nurses. Welcome to the jungle.

 

[docB]

Ok, let me say that this comment will be controversial. It's NOT my comment, but rather a comment from various residents and attendings in other specialties. I'm personally very interested in EM, and is my top choice as a specialty right now, but was just bothered by this comment and wanted to get your take on this and how one could deal with it.

The statement: "ER docs are nothing more than glorified triage nurses." Followed by, "In a few years, I can see how it would fiscally make sense if hospitals decided to man their ERs with mid-levels, since ER docs don't do much anyways, other than be kings of referrals."

😡

I'm sure this statement has been made MANY times, especially since I've heard it from folks from the west coast to the east.

This attitude is more prevalent in academic centers where #1 the residents on admitting and specialty services absolutley love to bitch and moan about every consult, have no financial incentive to see patients and have attendings who want to spend days ferreting out differentials that the ED "missed" and #2 all specialty services are in house all the time so it is possible for EPs to consult rather than just do it themselves. For example, where I trained, a few of the ortho residents complained so bitterly about being consulted about every fracture that we quit calling them and just splinted the patients and sent them to follow up clinic. After about 2 weeks of that the chair of ortho appeared in the ED ranting and raving about why none of these patients had the requisite ortho eval in their charts when they got to clinic. He was also angry that splints were being done with ACE wraps rather than bias (whatever🙄). The resultant memo from the ortho dept. mandating that an ortho resident see every patient that was referred to ortho clinic (yes, including sprains and chronic arthritic pain) was quite unpopular with everyone but stuck.

I don't anticipate midlevels taking over EM. Their role is growing but that's because the ED's role as the only outlet for primary and ambulatory care is growing. We tend to use midlevels for fast track and urgent care type patients and primary the critical ones ourselves.

I could argue (but diplomatically I won't😀) that it's not the EPs that don't do anything, it's the docs in the offices. The referrals into the ED from primary and specialty offices are staggaring. Anyone who parrots off that tired old "triage nurse" crap is welcome to never dump any of their patients into the ED. Based on our numbers and the fact that our biggest problem is overcrowding I just don't see it.

 

[tkim]

Easy peasy. 😉

 

[roja]

I look very cute in my triage nurse hat. Its white and spiffy, and has this really cute red cross on it.

 

[deleted109597]

I look very cute in my triage nurse hat. Its white and spiffy, and has this really cute red cross on it.

Pictures or it didn't happen.


You don't want to see me in white pants.

 

[southerndoc]

In all actuality, nurse practitioners and PA's can do 90% of physician work in ALL specialties except surgical. (That number is completely made up, but you get the point.) The vast majority of medicine is routine stuff that can be handled by ancillary providers.

Regarding consults, I probably consult specialists in about 5% of patients I see (again, random number, but the number is very low). I have to talk to an admitting physician about 20% of the time.

Residents and fellows are notorious for moaning about admissions and consults and often will say stuff like ED physicians always consult them, never think for themselves, yada yada yada. (I actually think it's funny how they moan about it.) The funny thing is that community attendings rarely moan about this stuff. I was shocked when a community urology attending told me he was going to admit a patient known to him with a 4 mm renal stone without complications simply because he couldn't get adequate pain relief after 3 doses of morphine. No hesitation to admit whatsoever. I remember my resident days where the urology residents tried to not admit, and when an admission was indicated, they would try to turf it to medicine.

 

[Hawkeye Kid]

The funny thing is that community attendings rarely moan about this stuff.

We have a recent grad that splits time between a local community ED and our academic center. He says that the same people that give the residents a hard time about admitting at the academic joint happily admit the same types of patients at the community shop. On one hand, it probably has to do with likelihood of insurance, etc...on the other it's probably just about who you can push around and who you can't.

 

[EctopicFetus]

Agreed. In our community setting you get no gruff. In an academic center they all think they know so much and how we are so dumb and clueless. I think you have to be happy in your skin and enjoy what you do. If you are worried what those other specialties think then EM might not be the best for you. The best part of EM is when those same guys are bitching and moaning about me and my colleagues we usually arent around to hear it.

Also if $ is your thing you can look for the right job and outearn those clowns too.

EF

 

[southerndoc]

The funny thing about people moaning about ED physicians consulting for every case is that every specialty seems to be consult happy.

Cases in point:

Surgery admits a patient with diabetes. I've seen numerous residents and attendings say "consult medicine for diabetes management" when someone just needs some sliding scale insulin or to restart their oral medicines.

PMD's consult cardiology, neurology, yada yada yada. The list goes on and on. Need a stat procedure, imaging (MRI), etc. without waiting for pre-approval? Send them to the ED. Have a patient you aren't sure of? Send them to the ED and have the "ER physician evaluate."

Everyone consults, and instead of other physicians recognizing the importance of having specialists with their specialty-specific knowledge that most physicians do not have, we seem instead to just trash other specialties for asking for help. It's ok to ask for help when we're over our heads or unsure of something. We owe it to our patients to ensure their safety by doing so. Instead of bickering among ourselves, we should instead concentrate on fighting off the nurse practitioners that want doctorate degrees so they can open their own clinics. No physician knows everything, and for any physician to say that he or she doesn't need to consult others is either full of himself and a danger to his patients or he's God and is truly a gift to humanity.

 

[roja]

Pictures or it didn't happen.


You don't want to see me in white pants.

😎😀Its part of the mystery. 😎

 

[SolisR]

"You gots to get yo' head right, Luke." (name that movie??)

Easy, Cool Hand Luke; the sweatiest movie of all time...


I Don't care if it rains or freezes...

-R

 

[theCamel]

The funny thing about people moaning about ED physicians consulting for every case is that every specialty seems to be consult happy.

Cases in point:

Surgery admits a patient with diabetes. I've seen numerous residents and attendings say "consult medicine for diabetes management" when someone just needs some sliding scale insulin or to restart their oral medicines.

PMD's consult cardiology, neurology, yada yada yada. The list goes on and on. Need a stat procedure, imaging (MRI), etc. without waiting for pre-approval? Send them to the ED. Have a patient you aren't sure of? Send them to the ED and have the "ER physician evaluate."

Everyone consults, and instead of other physicians recognizing the importance of having specialists with their specialty-specific knowledge that most physicians do not have, we seem instead to just trash other specialties for asking for help. It's ok to ask for help when we're over our heads or unsure of something. We owe it to our patients to ensure their safety by doing so. Instead of bickering among ourselves, we should instead concentrate on fighting off the nurse practitioners that want doctorate degrees so they can open their own clinics. No physician knows everything, and for any physician to say that he or she doesn't need to consult others is either full of himself and a danger to his patients or he's God and is truly a gift to humanity.

amen southerndoc --

on my wards service this month a great deal of my day is spent hearing about how stupid the ER is, how everyone gets abx, a head CT, and cardiac enzymes, and every other thing i'm sure you've all heard. it's pretty funny b/c most of them don't know that i'm an EM resident.

i've come to a couple of simple but guiding principles regarding this stuff. one, who cares what you or other people do for a living as long as you're happy. two, most people love to whine about everything and complain, and the ED is an easy target. c'est la vie...after all, and it's been said, a lot of the best ep's are rarely heard from by most specialties.

being on the admitting side of things can be a giant pain in the ace, especially when the ED didn't bother to do their jobs, but in case you haven't noticed, there are crap apples in every barrel, we're not perfect and certainly don't pretend to be. we just like what we do : )

 

[Jeff698]

Everyone consults, and instead of other physicians recognizing the importance of having specialists with their specialty-specific knowledge that most physicians do not have, we seem instead to just trash other specialties for asking for help.

Bingo.

There isn't a physician alive who knows everything. There are plenty, however, who refuse to admit there's something they don't know.

I suspect the real reason most doctors bitch, moan and condescendingly laugh at all other doctors is because they're compensating for their own insecurity.

It never ceases to amaze me how physicians (among the smartest, most educated, highest paid, most successful people on the planet) still feel they have something to prove to somebody.

Maybe it's because the only way to become a physician is if mommy and daddy didn't love us when we were kids.

Take care,
Jeff

 

[Spaceman Spiff]

Easy, Cool Hand Luke; the sweatiest movie of all time...


I Don't care if it rains or freezes...

-R

As a former girlfriend used to say after seeing that movie... "Any man caught playing grab-ass spends a night in the box!" I don't think she meant it in quite the same way... Ha, ha!


Another favorite from that movie.... "Shakin' the tree here boss..."

 

[Egon]

Before EM was a specialty people got really poor care in the ER and people died because the MDs staffing were not able to handle emergencies.

You could say:
Surgeons are glorified surgical PAs
Anesthesiologists are glorified CRNAs
Cardiologists are glorified cardiology NPs
etc, etc, etc it's all silly

We're here for diagnosis, we're here to stabilize patients and save lives, and we're ready to do anything medicine calls us to do in an emergency. Yes, a lot of what comes through the door may not be an emergency, but often it is, and it's a good thing we're there and trained to deal with it.

Enjoy the field, because it changes every day and it has the most variety in medicine... and just when it feels like it's getting boring you see something new, save another life, and realize why you did EM in the first place.

 

[AmoryBlaine]

Like others have said 90% of what we do could be handled by a midlevel -- we think. In point of fact midlevels do not function indepedantly so we have very little evidence that they would be as good as we are.

Sometimes what EM docs do is alot like triage. But guess what? That saves our oh-so-busy surgical colleagues upstairs from having to staff the ED themselves. Then they really would have to see "every" case of abdominal pain.

I for one try not to get into these pissing contests about how one specialty is better than another. I certainly am glad I have colleagues in Ob to do crash sections, Neurosurg to dissect post fossa tumors, Gsurg to anastomose bowel, Peds to manage sick preemies. I will never have any of these skills and respect those who do. In return I humbly ask others to respect my growing, unique skill set.

 

[southerndoc]

In an ideal world, hospital ED's would be staffed by specialists in neurology, cardiology, general/trauma surgery, adult medicine, pediatrics, and orthopedics.

However, this is neither practical nor feasible.

 

[Spaceman Spiff]

In an ideal world, hospital ED's would be staffed by specialists in neurology, cardiology, general/trauma surgery, adult medicine, pediatrics, and orthopedics.

However, this is neither practical nor feasible.

So you've confirmed my career choice then... JOAT (Jack of All Trades (...Master of None, as some might say)).

Or as I like to say... Jack of All Trades, Master of One or Two... 😉

 

[Roy7]

So you've confirmed my career choice then... JOAT (Jack of All Trades (...Master of None, as some might say)).

Or as I like to say... Jack of All Trades, Master of One or Two... 😉

I prefer "damn good at everything" .

 

[adismo]

i love this thread.

imo, the higher and mightier the surg/orth/im/ob resident, the more they snap at the ER physician. it's a matter of ego, and ego does not forgo an opportunity to uplift itself.

since complaining about the ER is like being an armchair general after a beach landing, the residents will do it without hesitation. more so because the ED docs are too busy to take their BS seriously. so since the water is guaranteed to flow downhill and without recourse, well my friend, complain away at how bad the ER doc is.

experience has dictated that the medical universe abhorrs such douchebaggery. attendings will discipline, patients will revile, and colleagues lose respect in those who have lost touch with humanity.

ER docs are knowledgeable, approachable, and use common sense. ER was the one rotation i really loved for the pathology as well as working with the staff. 👍

 

[Old_Mil]

ER docs are knowledgeable, approachable, and use common sense.

Absolutely. Sitting through an hour long primary care case presentation as people pontificate on how a 62 year old male with acute onset of SOB superimposed on CHF and no PMH of substance abuse could - in some alternative universe in which the patient hit the powerball just before admission - be a mainfestation of cocaine use is like dying the death of a thousand cuts.

I think you've managed to summarize why I love the field. Mind if I borrow it for my personal statement? 🙂

 

[MassEDRN]

working in the ER, no, they're not "glorified triage nurses." Actually, triage nurses are now out and PA's are now the glorified triage nurses... which is completely going in the wrong direction.... in my opinion...

 

[MassEDRN]

Perhaps the comments cited in the OP come from residents who work in a hospital where they essentially do staff the ED themselves?

I have rotated through hospitals where the ED does quite a bit. My home hospital, however, has residents in every surgical subspecialty but no ER resident. Thus all positive findings result in a specialty consult, and the ED docs sleep most of the night (I'm not being dramatic, I spent a month rotating there).

Hi Tired 😴 - just sending out a greeting to ya.... and browsing about 👍

 

[docB]

I have rotated through hospitals where the ED does quite a bit. My home hospital, however, has residents in every surgical subspecialty but no ER resident. Thus all positive findings result in a specialty consult, and the ED docs sleep most of the night (I'm not being dramatic, I spent a month rotating there).

This is a fair statement. Often the use of consults is a particular hospital culture. Many community places consult a lot less and lean more toward the "Hey, I'm sending this guy to your clinic." approach.

One thing to know is that in many places with resident services the imperative to consult those services comes from the consulting departments, not the ED. Granted the ED may seem like they really relish the opportunity to torment the consult residents but there are a number of factors contributing to it. And I'll absolutely admit that EP laziness can be one of those factors.

This attitude is more prevalent in academic centers where #1 the residents on admitting and specialty services absolutley love to bitch and moan about every consult, have no financial incentive to see patients and have attendings who want to spend days ferreting out differentials that the ED "missed" and #2 all specialty services are in house all the time so it is possible for EPs to consult rather than just do it themselves. For example, where I trained, a few of the ortho residents complained so bitterly about being consulted about every fracture that we quit calling them and just splinted the patients and sent them to follow up clinic. After about 2 weeks of that the chair of ortho appeared in the ED ranting and raving about why none of these patients had the requisite ortho eval in their charts when they got to clinic. He was also angry that splints were being done with ACE wraps rather than bias (whatever). The resultant memo from the ortho dept. mandating that an ortho resident see every patient that was referred to ortho clinic (yes, including sprains and chronic arthritic pain) was quite unpopular with everyone but stuck.

 

[roja]

One thing to know is that in many places with resident services the imperative to consult those services comes from the consulting departments, not the ED.

There are two sides of this:

I have heard of private EP's basically being forced to make 'consults' to some of these large group practices (where they have multiple specialists within a group) to increase billing for the group. I have also heard of some private hospitals that do this as well.

Academically, depending on the service chair, lots of consults may be specified by the consulting service. IE, our ortho chair wanted anything that was broken (even hairlines, etc) to be seen by their residents for educational purposes. I absolutely hated calling them for simple fractures, etc but we had awesome ortho residents and we would 'fudge' sometimes and technically call and then just splint and have them follow up....

 

[QuikClot]

In an ideal world, hospital ED's would be staffed by specialists in neurology, cardiology, general/trauma surgery, adult medicine, pediatrics, and orthopedics.

However, this is neither practical nor feasible.

Honestly, I don't think that would be better, for a couple reasons. First, there's little evidence that the American fetish for specialists leads to better outcomes. Europeans are less than half as likely to see a specialist any given year, and they live longer, healthier lives for their trouble.

Secondly, I think that emergency medicine requires a different thought process than internal medicine, to which most of the above specialties are related. They work linearly in order to ensure thoroughness; we work non-linearly to arrive quickly at high-yield assessment tools and interventions.

They pursue diagnoses as a function of likelihood; we pursue diagnoses as a function of a larger set of variables including likelihood, potential to harm, potential to help, ease of confirmation, and the ability of a diagnoses to secure resources.

No one else has (or needs to the same extent) the quality of creating trust and rapport with patients with only a few moments to speak to them.

No one else has to have the watchful, supportive attitude of the great primary care physician and the confident, controlled violence of the trauma surgeon simultaneously available to every patient accord to their needs.

I don't think emergency medicine is a little of everything, even though of course the knowledge base, strictly in terms of pathology and procedures, might suggest that. I'd argue that it is its own thing, and to do it perfectly is more than being able to do what all the other specialties would do if they were there.

 

[RxnMan]

Honestly, I don't think that would be better, for a couple reasons. First, there's little evidence that the American fetish for specialists leads to better outcomes. Europeans are less than half as likely to see a specialist any given year, and they live longer, healthier lives for their trouble...

I disagree with the bolded part. The US throws an arsenal at patients that the European medical systems would not. We try to save "premies" that are allowed to die elsewhere. If the Europeans live "healthier" lives, it is because the amount of time they spend as "unhealthy" is less.

The American trend for specialists is due, in part, to the reimbursement system.

Though it is good to see QuickClot come out of the woodwork and post. And ERMudPhud...must be the weather...😀

 

[QuikClot]

I disagree with the bolded part. The US throws an arsenal at patients that the European medical systems would not. We try to save "premies" that are allowed to die elsewhere. If the Europeans live "healthier" lives, it is because the amount of time they spend as "unhealthy" is less.

Not according to the numbers I've seen. Take a look at these statistics: http://www.who.int/countries/en/

They both have more healthy years, and more years total. We do throw an large arsenal at patients, but the weapons in question are poorly guided, unreliable and the intelligence used to select targets and define objectives is a joke.

The European countries lob fewer bombs but enjoy smarter generals. [/digression ends]

PS: I'm flattered anyone remembers me. Thanks for welcome. 😉

 

[RxnMan]

...They both have more healthy years, and more years total...

And that HAS to do with the quality of the medical field, and nothing to do with greater rates of obesity, being a mobile society, and violence.

 

[8744]

Not according to the numbers I've seen. Take a look at these statistics: http://www.who.int/countries/en/

They both have more healthy years, and more years total. We do throw an large arsenal at patients, but the weapons in question are poorly guided, unreliable and the intelligence used to select targets and define objectives is a joke.

The European countries lob fewer bombs but enjoy smarter generals. [/digression ends]

PS: I'm flattered anyone remembers me. Thanks for welcome. 😉

Man. You ain't kidding. I have a large number of patients in the ICU this month for whom nothing can be done and who, even if we could save them, will have zero quality of life ever again and we continue to pour vast amounts of money into their care while their family's decide what they want to do. I am a critic of much of what our European cousins do but to their credit none of these patients would even have been admitted to the hospital over there but instead would have stayed at home to die with a little dignity and compassion. Some of the things we do are utter insanity.

 

[Lokhtar]

And that HAS to do with the quality of the medical field, and nothing to do with greater rates of obesity, being a mobile society, and violence.

But we also spend like 2x more per person.

 

[RxnMan]

But we also spend like 2x more per person.

Starting a statement with "But..." usually introduces a contrastng point/opinion. 🙄

We have a sicker population. We also do more for our sickest patients than the european states would. Naturally, both factors raise the cost of patient care. Increased cost of care does not mean we provide "worse" care.

My previous point is that there are many factors that make comparisons between systems difficult, and doctors are not responsible for all of them. Average life expectancy is just too simple of a number.

 

[AmoryBlaine]

Honestly, I don't think that would be better, for a couple reasons. First, there's little evidence that the American fetish for specialists leads to better outcomes. Europeans are less than half as likely to see a specialist any given year, and they live longer, healthier lives for their trouble.

Secondly, I think that emergency medicine requires a different thought process than internal medicine, to which most of the above specialties are related. They work linearly in order to ensure thoroughness; we work non-linearly to arrive quickly at high-yield assessment tools and interventions.

They pursue diagnoses as a function of likelihood; we pursue diagnoses as a function of a larger set of variables including likelihood, potential to harm, potential to help, ease of confirmation, and the ability of a diagnoses to secure resources.

No one else has (or needs to the same extent) the quality of creating trust and rapport with patients with only a few moments to speak to them.

No one else has to have the watchful, supportive attitude of the great primary care physician and the confident, controlled violence of the trauma surgeon simultaneously available to every patient accord to their needs.

I don't think emergency medicine is a little of everything, even though of course the knowledge base, strictly in terms of pathology and procedures, might suggest that. I'd argue that it is its own thing, and to do it perfectly is more than being able to do what all the other specialties would do if they were there.

I think EM docs pride themselves more on this than they actually display it. Many people in our field are brusque or even rude. If the issue were ever studied I doubt that a majority of patients would leave an ER and comment on how quickly the physician built "trust and rapport" with them.

 

[Spaceman Spiff]

I prefer "damn good at everything" .

YES! I like your style. I usually say "good at everything", but maybe I'm being too modest...

 

[Spaceman Spiff]

And that HAS to do with the quality of the medical field, and nothing to do with greater rates of obesity, being a mobile society, and violence.

Especially gun violence.

Not according to the numbers I've seen. Take a look at these statistics: http://www.who.int/countries/en/

They both have more healthy years, and more years total. We do throw an large arsenal at patients, but the weapons in question are poorly guided, unreliable and the intelligence used to select targets and define objectives is a joke.

The European countries lob fewer bombs but enjoy smarter generals. [/digression ends]

I think you're both right. Poorly defined objectives here, usually heroic measures for everyone. Yet a population at large that is getting fatter by the day, and treatment that keeps those with chronic disease going and going.


<digress>As for "smarter generals", I doubt. Maybe fewer, and with less toys, but just as stupid or smart. I would apply the bell curve here, as we have many more generals. </digress>





[/QUOTE]

 

[elwademd]

Ok, let me say that this comment will be controversial. It's NOT my comment, but rather a comment from various residents and attendings in other specialties. I'm personally very interested in EM, and is my top choice as a specialty right now, but was just bothered by this comment and wanted to get your take on this and how one could deal with it.

The statement: "ER docs are nothing more than glorified triage nurses." Followed by, "In a few years, I can see how it would fiscally make sense if hospitals decided to man their ERs with mid-levels, since ER docs don't do much anyways, other than be kings of referrals."

😡

I'm sure this statement has been made MANY times, especially since I've heard it from folks from the west coast to the east.

if you want to do it, don't worry about what anyone else says or thinks about it. i'm sure, if you wanted to, you could find the negative aspect of every field/specialty/subspecialty out there.

This attitude is more prevalent in academic centers where #1 the residents on admitting and specialty services absolutley love to bitch and moan about every consult, have no financial incentive to see patients and have attendings who want to spend days ferreting out differentials that the ED "missed"

Residents and fellows are notorious for moaning about admissions and consults and often will say stuff like ED physicians always consult them, never think for themselves, yada yada yada. (I actually think it's funny how they moan about it.) The funny thing is that community attendings rarely moan about this stuff. I was shocked when a community urology attending told me he was going to admit a patient known to him with a 4 mm renal stone without complications simply because he couldn't get adequate pain relief after 3 doses of morphine. No hesitation to admit whatsoever. I remember my resident days where the urology residents tried to not admit, and when an admission was indicated, they would try to turf it to medicine.

i think the financial incentive is huge, absoutely huge in the reason that community attendings don't bitch and moan, and why residents do. in fact, i had an attending tell me so, in that the very patients we hate to see as residents, we'll love to see as attendings.

medicare patient, uti with nausea and vomiting. drg is for 3 days. so, the patient will be in house for those 3 days with iv antibiotics. the attending gets paid, little may be done besides the antibiotics. in fact, the patient may be without the nausea and vomiting after the 1st night.

residents see the case and are disappointed because there's little to do, little management... patient's on the service, with little to do for him or her... can feel like a waste of time.

a community attending may see it as an opportunity to take care of an easy patient, get paid for doing very little work each day ($50-100 per day), and perhaps find a reason for an unnecesarry consult in order to scratch the back of a colleague (stable creatinine of 1.5 on an ace inhibitor, let me get a renal consult to tell me that).

its not all residents that hate it, and its not all community attendings that love it. but it would be interesting if residents were to be paid in a similar fashion to attendings. imagine a bad call night all of a sudden just paid the rent for the month.

of course its not going to happen, but i think it would be interesting nonetheless.

 

[QuikClot]

I think EM docs pride themselves more on this than they actually display it. Many people in our field are brusque or even rude. If the issue were ever studied I doubt that a majority of patients would leave an ER and comment on how quickly the physician built "trust and rapport" with them.

You may be right. Maybe I'm expressing an aspiration for the field rather than the present state of affairs. In my hospital and those outside EDs I've visited (a fair number in my years as an EMT and a medic) I've found ED docs to be better communicators than most other physicians. I speculate that the reason for this is because it's necessary in the ED to quickly form good relationships to secure the history and get patient buy-in as to the plan of care.

It could be a cultural difference, too. I'm in hippie-friendly Oregon with a lot of graduates of West-Coast EM residencies. I understand the EM cultural in the East is very different.

 

[QuikClot]

Man. You ain't kidding. I have a large number of patients in the ICU this month for whom nothing can be done and who, even if we could save them, will have zero quality of life ever again and we continue to pour vast amounts of money into their care while their family's decide what they want to do. I am a critic of much of what our European cousins do but to their credit none of these patients would even have been admitted to the hospital over there but instead would have stayed at home to die with a little dignity and compassion. Some of the things we do are utter insanity.

In my family medicine clerkship it's the same. People who clearly need scans and procedures can't get them 2/2 cost, while people with chronic somatization get tests I never knew existed. My preceptor the other day commented that he knows the imaging he ordered is unnecessary, but that if he refuses to order it, his patient will c/o more and more severe symptoms until they end up in the ED.

 

[GeneralVeers]

Man. You ain't kidding. I have a large number of patients in the ICU this month for whom nothing can be done and who, even if we could save them, will have zero quality of life ever again and we continue to pour vast amounts of money into their care while their family's decide what they want to do. I am a critic of much of what our European cousins do but to their credit none of these patients would even have been admitted to the hospital over there but instead would have stayed at home to die with a little dignity and compassion. Some of the things we do are utter insanity.

In America it's the lawyer factor. If you pull the plug on Grandpa who's 96 years old with Alzheimer's and end-stage lung cancer, the family will sue you in court and claim that "he could have gotten better and lived to see his great-grandchildren" or some such nonsense. We keep dead people alive, and order futile tests simply to prevent getting sued.

 

[WilcoWorld]

In America it's the lawyer factor. If you pull the plug on Grandpa who's 96 years old with Alzheimer's and end-stage lung cancer, the family will sue you in court and claim that "he could have gotten better and lived to see his great-grandchildren" or some such nonsense. We keep dead people alive, and order futile tests simply to prevent getting sued.

I think that it goes even deeper than legal issues into philosophical considerations. In the US many people have a view of death as something to be avaioded at all costs, regardless of the actual quality of life. Even in the absence of possible lawsuits, there are still many doctors who support continuing what is obviously futile care. Dignity in death is underappreciated by many. I think that the public needs to be educated, and that we need to stop viewing death as the most terrible thing in the world (it's surely not), and start to understand that it is a natural part of life ("Life is a terminal illness" as a brilliant and clever man once told me).

Now, I'm not suggesting we adopt Yukio Mishima's views on death, but we need some adjustment. Just think of all the health care costs we could save by not spending thousands a day on ICU care for patients without any hope of a meaningful recovery.

 

[dancindr]

Secondly, I think that emergency medicine requires a different thought process than internal medicine, to which most of the above specialties are related. They work linearly in order to ensure thoroughness; we work non-linearly to arrive quickly at high-yield assessment tools and interventions.

They pursue diagnoses as a function of likelihood; we pursue diagnoses as a function of a larger set of variables including likelihood, potential to harm, potential to help, ease of confirmation, and the ability of a diagnoses to secure resources.

No one else has (or needs to the same extent) the quality of creating trust and rapport with patients with only a few moments to speak to them.

No one else has to have the watchful, supportive attitude of the great primary care physician and the confident, controlled violence of the trauma surgeon simultaneously available to every patient accord to their needs.

I don't think emergency medicine is a little of everything, even though of course the knowledge base, strictly in terms of pathology and procedures, might suggest that. I'd argue that it is its own thing, and to do it perfectly is more than being able to do what all the other specialties would do if they were there.

this is a great way of putting our field. good job!

 

[filter07]

I don't think that Emergency Physicians are glorified triage nurses. By virtue of our common education in medical school, we all have a knowledge base and approach that is different than that of nurses. But they are triage physicians. They are kind of like the Jaguar X type or Mercedes C-class of the medical world. They carry the name brand of a physician but have significant stigma.

Emergency doctors are like back-up quarterbacks. Not quite as good as the starter, but decent enough to fill-in in a pinch. They can play a for a quarter or two while the starter rests his sprained ankle. Likewise, emergency doctors can fill-in for a while while the internists take over their long-term care, or the surgeon prepares for the operating room.

Emergency medicine residents and attendings are forever in "cross-cover" mode. Their role is to fix minor problems when they can, but mostly to keep everyone alive until the real day team arrives. They never receive any feedback during the day, rarely see the consequences of their actions, and just come back the next day without any new knowledge or experience.

 

[QuikClot]

Emergency doctors are like back-up quarterbacks. Not quite as good as the starter, but decent enough to fill-in in a pinch. They can play a for a quarter or two while the starter rests his sprained ankle. Likewise, emergency doctors can fill-in for a while while the internists take over their long-term care, or the surgeon prepares for the operating room.

Emergency medicine residents and attendings are forever in "cross-cover" mode. Their role is to fix minor problems when they can, but mostly to keep everyone alive until the real day team arrives. They never receive any feedback during the day, rarely see the consequences of their actions, and just come back the next day without any new knowledge or experience.

I think not. You're implying that the other specialties would be better at managing the ED patient were they not occupied with other tasks of greater moment, but there's no evidence that that is true. Heaven and the saints protect me from having my MI managed by a cardiologist.

Internists and surgeons think they are better because they are better at managing the patients they get. But their patients at that point are no longer the same patient that presented to the ED. They've been stabilized, interviewed, and in most cases given their diagnosis in the ED, if not in the field. Once the food has been pre-chewed, as it were, EPs hand it over to the toothless specialists who wouldn't know how to begin to work up a patient who was wheeled in on a stretcher.

At this point, we are both arguing from our experience, but I would point to the match to support my opinion. EPs are highly paid, have a three year residency, and some of the best hours out there. So why isn't it a lifestyle specialty? Why isn't it on the ROAD? (We could call them the careers to ADORE.) Why isn't it more popular than internal medicine?

Because the average internist knows he couldn't handle the job of an EP. You have to be smarter, stronger, and a little crazier than the average bear to take a job caring for whatever walks or is carried through the ED doors. Honestly, I think the people dragging their asses out of bed at 2 in the morning in their fifth year of residency to admit the EP's sloppy seconds are maybe just a bit jealous that they didn't have it in them to work on the front lines.

 

[AmoryBlaine]

I think not. You're implying that the other specialties would be better at managing the ED patient were they not occupied with other tasks of greater moment, but there's no evidence that that is true. Heaven and the saints protect me from having my MI managed by a cardiologist.

Internists and surgeons think they are better because they are better at managing the patients they get. But their patients at that point are no longer the same patient that presented to the ED. They've been stabilized, interviewed, and in most cases given their diagnosis in the ED, if not in the field. Once the food has been pre-chewed, as it were, EPs hand it over to the toothless specialists who wouldn't know how to begin to work up a patient who was wheeled in on a stretcher.

At this point, we are both arguing from our experience, but I would point to the match to support my opinion. EPs are highly paid, have a three year residency, and some of the best hours out there. So why isn't it a lifestyle specialty? Why isn't it on the ROAD? (We could call them the careers to ADORE.) Why isn't it more popular than internal medicine?

Because the average internist knows he couldn't handle the job of an EP. You have to be smarter, stronger, and a little crazier than the average bear to take a job caring for whatever walks or is carried through the ED doors. Honestly, I think the people dragging their asses out of bed at 2 in the morning in their fifth year of residency to admit the EP's sloppy seconds are maybe just a bit jealous that they didn't have it in them to work on the front lines.

1. MIs are eventually managed by a cardiologist dude, even the most bad***** EP in the world isn't doing caths. If you have an MI do you think an emergency phyisician is EVER going to provide definitive rx? Hell, the best "managed" MIs from the ED perpective are only there long enough to get an EKG, some ASA, a monitor, and hopefully a BB before those dundering cardiologists wheel them away to actually save their myocardium.

2. So what that EPs admit most patients with a working diagnosis? Usually this is a result of stat labs (in the case of MI or CHF) or easilly accesible radiological studied (which our rads colleagues then read for us in many cases). This idea that EPs are the master diagnosticians is shaky at best. If the dx is easy (CAP, MI, CHFe, GSW) then yeah, it's going to be made in the ED. Almost all other comers are "hmm, this is weird, admit to Gen Med!"

3. Alot of what we do when a patient is "wheeled in on a stretcher" is just to check every lab test on our order sheet/system. Undifferentiated complaints = broad differentials so we usually end up making our dx with a sometimes absurd amount of information. If anything an EM attending will agree with you that getting LFTs for abrupt onset LLQ pain is not indicated but then will order them anyway "just to be safe." Once again I resist the idea that emergency physicians are somehow master diagnosticians.

4. Your last statement is entirely unsupportable and a continuation of this myth that you need some sort of semi-magical, cowboy quality to be an effective emergency physician.

5. It is far more useful to respect the vital but limited role that EPs play in the overall hospital system than to suggest that our colleagues in other fields are somehow weak or inadequate for not choosing our field.

 

[Apollyon]

1. MIs are eventually managed by a cardiologist dude, even the most bad***** EP in the world isn't doing caths. If you have an MI do you think an emergency phyisician is EVER going to provide definitive rx? Hell, the best "managed" MIs from the ED perpective are only there long enough to get an EKG, some ASA, a monitor, and hopefully a BB before those dundering cardiologists wheel them away to actually save their myocardium.

Ever heard of thrombolytics?

(Although I do agree with the remaining balance of your post.)

 

[emergiQ]

1. MIs are eventually managed by a cardiologist dude, even the most bad***** EP in the world isn't doing caths. If you have an MI do you think an emergency phyisician is EVER going to provide definitive rx? Hell, the best "managed" MIs from the ED perpective are only there long enough to get an EKG, some ASA, a monitor, and hopefully a BB before those dundering cardiologists wheel them away to actually save their myocardium.

2. So what that EPs admit most patients with a working diagnosis? Usually this is a result of stat labs (in the case of MI or CHF) or easilly accesible radiological studied (which our rads colleagues then read for us in many cases). This idea that EPs are the master diagnosticians is shaky at best. If the dx is easy (CAP, MI, CHFe, GSW) then yeah, it's going to be made in the ED. Almost all other comers are "hmm, this is weird, admit to Gen Med!"

3. Alot of what we do when a patient is "wheeled in on a stretcher" is just to check every lab test on our order sheet/system. Undifferentiated complaints = broad differentials so we usually end up making our dx with a sometimes absurd amount of information. If anything an EM attending will agree with you that getting LFTs for abrupt onset LLQ pain is not indicated but then will order them anyway "just to be safe." Once again I resist the idea that emergency physicians are somehow master diagnosticians.

4. Your last statement is entirely unsupportable and a continuation of this myth that you need some sort of semi-magical, cowboy quality to be an effective emergency physician.

5. It is far more useful to respect the vital but limited role that EPs play in the overall hospital system than to suggest that our colleagues in other fields are somehow weak or inadequate for not choosing our field.

Whenever I get an obnoxious colleague (or usually just a relatively inexperienced colleague as age and experience seems to dilute the piss and vinegar) who wants to know what, really, we are beyond glorified triage nurses, or wants to whine that we miss diagnoses, yada yada yada, I point out that the one thing we do better than anyone, the real 'bread and butter' in my mind of emergency medicine, boils down to one thing:

We are the masters of resuscitation.

We have the procedural competency and at least the necessary acute medicine knowledge to resuscitate sick kids better than the average pediatrician. Same goes for the ability to resuscitate sick septic patients or a patient with thyroid storm that would not be rivaled by the average internist. Sure, the surgeons can resuscitate someone all right (and will provide the definitive care in the OR in many circumstances) but even most surgeons would struggle to match the depth of our resuscitative skills and knowledge breadth when you consider the vast majority of medical, surgical, pediatric and, frankly, undifferentiated patients.

I have never supposed that we are better than any other specialty. We're just different. But we definitely have our own specific function that no other specialty does and we shouldn't need to be apologists because most of the times when we're not resuscitating we doing a little bit of everything (the backup quarterback analogy was nice).