emergency physicians = prostitutes?

[Jeff698]

I once had a stripper come in for (guess what) PID. As I'm starting the pelvic she says to me "most guys pay me for that view". Of course I replied (before that check valve between my brain and mouth could kick in) "that's funny, most women pay me to look". (Which is true...)

- H

Wow, talk about a great payor base. Most women just pretend that they'll pay me and then stick me with an unpaid bill.

Just another reason EMTALA is a fun sucking law.

Take care,
Jeff

PS, I'll be very disappointed if nobody takes a shot at that last sentence.

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[UCLA2000]

Just another reason EMTALA is a fun sucking law.

Gotta admit that EMTALA keeps private institutes honest. No turfing of unstable/uninsured patients etc.

 

[UCLA2000]

I once had a stripper come in for (guess what) PID. As I'm starting the pelvic she says to me "most guys pay me for that view". Of course I replied (before that check valve between my brain and mouth could kick in) "that's funny, most women pay me to look". (Which is true...)

- H

 

[Castillonis]

I was told that emergency physicians are prostituting themselves. The reasons were similar both times: emergency medicine flies in the face of what good medicine should be, including a real doctor-patient relationship, preventive care, a focus on total health and wellbeing, etc.

- Ideal versus a non ideal situation.
+ Addressing urgent medical needs after normal working hours and during
normal sleeping hours.
+ Providing care to individuals who are not able to pay.
+ Physicians who have training and experience in dealing with urgent
medical situations.
+ Someone who can deal with simultanous CP and an commutated open femur
fracture. They eventually call for trauma surgeon, orthopedic, or
cardiology consult if warranted.

- MICU will not admit patients
+ I have seen a routine pattern of medicine not admitting patients because
they say they don't have time. I need to go to their area to learn
about their situation.

- Preventive care and continuity of care
+ I need to gain more time shadowing at regular primary medical practice
in order to have a well informed opinion.
+ Physicians attempt to keep visits to 15 minutes unless it is an annual
exam due to insurance compensation.
+ I have hardly seen any preventive education by physicians or nurses
in primary care clinics. This bugged me. I saw more education at the ED.
+ Instructions for medications were not adequate even when they were
dispensed to the patient during the appointment at a primary care clinic.
This bugged me.
+ If your employer changes insurance plans, you change jobs, or you move
then you continuity of care will be broken. You should have your
records transferred and the new primary care provider should speak to
your former primary care provider.

- Benefits of EM
+ Allows time for you to work at a volunteer clinic to help people who do
not have insurance. If you accept a higher level position with more
responsibility you probably will not have time to do this.
+ Allows time for clinical research or teaching.
+ Satisfaction that you did something useful after each shift.
+ You are in a position where you may learn much for the rest of your
career. You get to work with Cardiology, Orthopedics, Trauma, Surgery
Medicine, etc.

Some of the residents that I have been shadowing have extremely good interpersonal skills with the ability to put patients and patients parents at ease. I have had a very good experience with EM. I will have a better idea of what I am going to do after the third year of clinicals. Though I am leaning towards EM. I enjoy volunteering and shadowing at other clinics, but I am excited and giddy every time I get ready to go to the ED. I also have learned the most at the ED. I get to look radiographs, CTs, MRIs see pediatric cases, cancer, trauma. Very interesting place.

Also, one more point. Your attitude and desire to provide good medical
care make the biggest difference.

 

[Jeff698]

Gotta admit that EMTALA keeps private institutes honest. No turfing of unstable/uninsured patients etc.

Yeah, good thing that never happens now that we have a federal law to prevent it. It certainly didn't happen 5 times in my last shift alone.

Take care,
Jeff

 

[FoughtFyr]

Gotta admit that EMTALA keeps private institutes honest. No turfing of unstable/uninsured patients etc.

UCLA, you haven't spent much time at a tertiary center have you? Not an unfrequent conversation around here goes like "How do we tell the family of this patient (when they arrive two hours behind the helicopter) they the "head bleed" the patient was air evaced for is really motion artifact on the CT?"

An inordinate number of these patients are on medical assistance (read: welfare) But hey, they weren't dumped, they were transfered to a higher level of care.

- H

 

[UCLA2000]

UCLA, you haven't spent much time at a tertiary center have you? Not an unfrequent conversation around here goes like "How do we tell the family of this patient (when they arrive two hours behind the helicopter) they the "head bleed" the patient was air evaced for is really motion artifact on the CT?"

An inordinate number of these patients are on medical assistance (read: welfare) But hey, they weren't dumped, they were transfered to a higher level of care.

- H

I've actually spent a fair bit of time in tertiary care institutes. I've seen those "misreads" on more than one occassion. I could be wrong, but it is my understanding that there is no rule against turfing an uninsured non critical patient such as the one you describe in your scenario.

I think that the guidelines are put in place to prevent private hospitals from turfing critical patients without stabilizing them.

I'm only an M4 so please correct me if I'm wrong, but it's my understanding that EMTALA only requires that trained medical personnel (defined differently at different institutes np vs md vs rn etc) check vitals, do a physical exam, and take a patient history. If a patient is then deemed stable they can be d/c.

Is it correct that there is no "required" workup on the average stable patient beyond that?

However if the pt require life threatening interventions then the pt must be dealt with and stabilized.

I think that we can all agree that EMTALA is farrrrr from perfect, but the spirit of it is in the right place.

 

[BKN]

I've actually spent a fair bit of time in tertiary care institutes. I've seen those "misreads" on more than one occassion. I could be wrong, but it is my understanding that there is no rule against turfing an uninsured non critical patient such as the one you describe in your scenario.

I think that the guidelines are put in place to prevent private hospitals from turfing critical patients without stabilizing them.

I'm only an M4 so please correct me if I'm wrong, but it's my understanding that EMTALA only requires that trained medical personnel (defined differently at different institutes np vs md vs rn etc) check vitals, do a physical exam, and take a patient history. If a patient is then deemed stable they can be d/c.

Is it correct that there is no "required" workup on the average stable patient beyond that?

However if the pt require life threatening interventions then the pt must be dealt with and stabilized.

I think that we can all agree that EMTALA is farrrrr from perfect, but the spirit of it is in the right place.

Actually, EMTALA's purposes and rules are more complex than that. The basic requirement is that a patient cannot be transferred at all, unless for a "higher level of care". In other words no transfers for funding issues. In addition, patient must consent to transfer, receiving hospital must have facilities available and must accept the patient if they do have them. Applies to accepting physician as well. Patients must be stabilized "if possible". Otherwise, transferring physician must certify that the benefits to be gained by transfer outweigh the risks.

The medical screening exam part is a little controversial, but requires that an exam be done to the point that an emergency be ruled out. Then a wallet biopsy can be performed. You are correct in saying that there is no standard workup, but if you haven't done the same things you would have done for a paying patient and it turns out to be a life or limb-threatening condition, you're vulnerable. Honestly, by the time you're sure what you're dealing with, emergency or not, you might as well treat it.

In the face of all that, if I were by myself in a small facility with no neurosurgeon on call, and had a patient with a headache and a poor quality CT, I might want to transfer. I think it behooves the house officers at the receiving end to avoid being judgemental. They'll be there in the future.

As to whether it works, I remember the pre-EMTALA era and I don't ever want to go back there. In our town, the private places wouldn't stabilize, they didn't even bother to do an exam, just the biopsy. The following is almost verbatim from a call I got in '83 (noon, weekday):

Slimy ED Doc: "I'm sending you a lady in shock, who i think has an ectopic."
Me: ". . .What's her exam like?"
SEDD: "I couldn't do it, she's in MAST pants."
Me: "Well why don't you send her to the OR rather than put in her an ambulance!!!"
SEDDD: "Well, the ambulance has already left."
Me:". . ."

The sad thing was that SEDD was probably doing the right thing. In those days private community hospitals were run at the convenience of the attendings. It probably would have taken them two hours to get a OB, an OR and an Anesthesiologist up to do it. EMTALA changed all of this for the better.

Cheer up, it could be worse. I seem to remeber that the first laws (Code of Hammurabi) called for the cutting off of something important the first time a Doc lost a patient and death the second time. I imagine med school admissions were a lot less frenetic.

 

[turtle md]

cutting off of something important

Ouch!

 

[docB]

I disagree that the spirit of EMTALA was in the right place. If it had been then they would have funded it. As it is it's another totally unfunded federal mandate. It essentially says that private docs and private institutions must treat the uninsured for free. There is no money coming down from the feds to take care of these costs. Consequently those costs are passed on to the paying patients.
Because this is all totally unfunded the consultants (few of whom understand EMTALA) have a huge incentive to block and run. I sympathize with them. Imagine being a surgeon and you get called for something simple like an appy. You will have to do the surgery for free and all the post op care which will bump paying patients out of your clinic. My houses have no anesthesia on call so you as the surgeon have to cajole one of your gas friends to do the case for free as well. You still have the same liability for all this, they can sue you and ruin your life. They just don't have to pay for the shot.
The "spirit" of EMTALA was that the government saw a problem and rather than dealing with it decided to legislate it to be someone else's problem.

 

[BKN]

I disagree that the spirit of EMTALA was in the right place. If it had been then they would have funded it. As it is it's another totally unfunded federal mandate. It essentially says that private docs and private institutions must treat the uninsured for free. There is no money coming down from the feds to take care of these costs. Consequently those costs are passed on to the paying patients.
Because this is all totally unfunded the consultants (few of whom understand EMTALA) have a huge incentive to block and run. I sympathize with them. Imagine being a surgeon and you get called for something simple like an appy. You will have to do the surgery for free and all the post op care which will bump paying patients out of your clinic. My houses have no anesthesia on call so you as the surgeon have to cajole one of your gas friends to do the case for free as well. You still have the same liability for all this, they can sue you and ruin your life. They just don't have to pay for the shot.
The "spirit" of EMTALA was that the government saw a problem and rather than dealing with it decided to legislate it to be someone else's problem.

It's cost-shifting either way (through the public hospitals or the private). The public will bear the costs in any case and will demand care for their illnesses. If you want to wash it through the government, it's fine with me and admin costs will go down. So will your income. If you think you have no control now, imagine being in a pure governmental system. Go visit the military medicine threads if you want to understand that.

The only issue is whether the patient will be shipped in an ambulance across town, wait several hours, perf his appy and maybe die. It's back to the "its just a job" philosophy. If a person thinks so, he doesn't belong in Medicine. We are a public resource.

 

[BKN]

Oh and p.s. Where the private sector has successfully dumped on the public hospitals, the taxing entitites sell the hospitals. At this point the traditional public hospital is harder to find. At least outside of Texas and California.

When that happens, DocB the private guys really need EMTALA to allow them to send the complex cases to the university.

 

[BKN]

Oh and p.s. Where the private sector has successfully dumped on the public hospitals, the taxing entitites sell the hospitals. At this point the traditional public hospital is harder to find. At least outside of Texas and California.

When that happens, DocB the private guys really need EMTALA to allow them to send the complex cases to the university.

Finally, the private docs on call have options. If they don't think they are picking up enough paying business, they can
A) take themselves off the call schedule
B) switch hospitals, or
C) they can hold the hospital up for call coverage money.

Yeah, DocB, you really pushed my button, BKN loses it. At least the students get the of watching two attenidngs argue.

 

[UCLA2000]

Yeah, DocB, you really pushed my button, BKN loses it. At least the students get the benefit of watching two attenidngs argue.

This is the most information that I've gotten on EMTALA during the last 4 years as a med student, and 2 years of EMT work prior to that!

 

[ERMudPhud]

Finally, the private docs on call have options. If they don't think they are picking up enough paying business, they can
A) take themselves off the call schedule
.

I'm not sure how that solves any of our problems. All it means is that I am now working some nights with no ENT, hand, plastics, neurosurg, optho, or renal coverage. We have all of the above on staff at the hospital but many have "taken themselve off the call schedule" which leaves huge holes in coverage. EMTALA says that each hospital can set its call schedule to best "meet the needs" of the community. Some have decided that means it is better to still have plenty of subspecialists on staff even if none or very few will take call. The problem is that the University hospital that BKN say should be bailing me out by taking the transfer considers "no specialist on call" an invalid reason for transfer and an EMTALA violation. That leaves me in the uncomfortable position of not having the specialist I need on call and facing an EMTALA action which is not covered by my malpractice carrier if I send the patient. So, far I've always managed to work things out but I hear things are worse in California so I'm not surprised that docB is even more upset about it than I am.

 

[BKN]

. EMTALA says that each hospital can set its call schedule to best "meet the needs" of the community. Some have decided that means it is better to still have plenty of subspecialists on staff even if none or very few will take call. The problem is that the University hospital that BKN say should be bailing me out by taking the transfer considers "no specialist on call" an invalid reason for transfer and an EMTALA violation. That leaves me in the uncomfortable position of not having the specialist I need on call and facing an EMTALA action which is not covered by my malpractice carrier if I send the patient. So, far I've always managed to work things out but I hear things are worse in California so I'm not surprised that docB is even more upset about it than I am.

Yeah, that recent change in EMTALA was the private sector's response to being forced to be professional. Indeed it is a giant step backward for public good. My place isn't refusing transfers on that basis, but we know what's happening. Got a patient who needs a neurosurgeon with insurance-admit him to a PCP who will then consult somebody on staff. Got a patient who needs a neurosurgeon without insurance--sorry, nobody on call, transfer to the U. I can see how other university hospitals might refuse, when they know the community place has the capability. That doesn't help the ED doc much, but you've always managed to work it out. Sure it's annoying, move to the U and get a different set of problems.

I still say the same thing, cost shifting will occur. The demise of the tax supported hospitals was basically a war between the cities and counties and the feds. It makes no sense since the taxpayer is the real deep pocket, and it the same guy either way.

 

[docB]

It's cost-shifting either way (through the public hospitals or the private). The public will bear the costs in any case and will demand care for their illnesses. If you want to wash it through the government, it's fine with me and admin costs will go down. So will your income.

I already lose $150K/ yr in my current payor mix treating people for free. It'd be OK with me if I made less if the conditions were better (ie. malpractice and consultents).

If you think you have no control now, imagine being in a pure governmental system. Go visit the military medicine threads if you want to understand that.

I've never advocated socialized medicine. Ever.

The only issue is whether the patient will be shipped in an ambulance across town, wait several hours, perf his appy and maybe die. It's back to the "its just a job" philosophy. If a person thinks so, he doesn't belong in Medicine. We are a public resource.

And a free public resource at that. And because we're free I can't keep any specialists on call yet I'm still held to a the standard of care set by those specialists that I can't access.

Finally, the private docs on call have options. If they don't think they are picking up enough paying business, they can
A) take themselves off the call schedule
B) switch hospitals, or
C) they can hold the hospital up for call coverage money.

And that's just what they've done. ENT, URO, MaxFace, hand all left. GI, Spine, CVT surg, nephro, heme onc are not on call. The hospital pays Cards, OB/GYN and ORT a million a year just to ignore my pages.

I'm fine treating these guys for free and getting sued by them and the whole bit. We divide that ~3 million/ yr cost across the whole group. But when I have to have a knock down drag out with every consultant I call it makes my life Hell. As it is I'm transferring more stuff than ever to the county because they are the only ones with any specialists and that's only because they have soverign immunity there. I do waste lots of time and effort in the processbut oh well. The problem with EMTALA and the reason it is bad regulatory law is that it takes the burden of caring for the uninsured, a social problem, and lays it squarely on the back of the EP who is left to wheel and deal on every case individually. And if you mess it up it 50K out of pocket. What a mess.

 

[f_w]

A good part of the problem of specialists not wanting to provide charity care is the liability aspect. If the feds had a mechanism to indemnify anyone providing medically necessary care for free, people would be less scared to do it (it is stupid. if the patient receives treatment at a federally funded community health center, the physician working there is covered by federal tort liability restrictions. if the same patient goes to the local ED, whoever sees him there is fully exposed.)

EMTALA was a response to the medical professions failure to self-police. It has worked in one way, the dumping of unscreened untreated patients on the public hospitals is a thing of the past. At the same time, the treatment mandate is driving healthcare expenses through the roof by pushing primary care patients into the ED system. Can't win.

 

[BKN]

I

I've never advocated socialized medicine. Ever.

And a free public resource at that. And because we're free I can't keep any specialists on call yet I'm still held to a the standard of care set by those specialists that I can't access.

And that's just what they've done. ENT, URO, MaxFace, hand all left. GI, Spine, CVT surg, nephro, heme onc are not on call. The hospital pays Cards, OB/GYN and ORT a million a year just to ignore my pages.

I'm fine treating these guys for free and getting sued by them and the whole bit. We divide that ~3 million/ yr cost across the whole group. But when I have to have a knock down drag out with every consultant I call it makes my life Hell. As it is I'm transferring more stuff than ever to the county because they are the only ones with any specialists and that's only because they have soverign immunity there. I do waste lots of time and effort in the processbut oh well. The problem with EMTALA and the reason it is bad regulatory law is that it takes the burden of caring for the uninsured, a social problem, and lays it squarely on the back of the EP who is left to wheel and deal on every case individually. And if you mess it up it 50K out of pocket. What a mess.

You have my sympathy (for whatever that's worth). See my last post, It was working pretty well until the private sector gutted it a couple of years ago.

As for your earlier comment about "unfunded mandate":
1. We spend about 15-17% of our GDP on healthcare
2. The government (fed, states, county) is the largest payor putting down more than 1/2.
3. About 20% of the populaitons is uninsured and a another 20% underinsured.
4. Meanwhile other developed countries spend about 7-9% and cover everybody. They've got their problems, but their populace is happier than ours.

I think the average taxpayer could say that the government has already paid for an entire health system, and with the private health insurance on top, Americans pay for two whole health systems and get about 0.75 of a health system for their money.

I know you never advocated "socialized medicine". I wasn't clear, I was. I think the the American people would be better off under either a single payor system or a managed competition system (a la Clinton health plan in the early 90's). I don't think us doctors would like it much, however.

Until that happens, as long as we hold up the myth of private practice and capitalism, an EP in the private sector will have to transfer patients from a hospital that could have taken care of them and hopefully the U.H.s and the the County places will get whatever additional funding they can from the private patients transferred, because they are doing the right thing.

If you can't stand this, consider coming back to the academic sector. It has different and considerable problems, but you don't feel slimy or annoyed because people won't do their job.

P.S. We highjacked this thread. Given the thread title, it needed it, but if we're going to continue in this vein, maybe we ought to start a new one.

 

[docB]

I think this is a great discussion and I hope that the residents and students can learn from it. If nothing else everyone should be realizing that no matter what type of practice you decide on you will be affected by EMTALA. Learn as much as you can while you can and understand it as well as possible. Ignore it at your peril. That being said everyone should realize that none of us understand everything about EMTALA because many parts of it are so vague. For example the Medical Screening Exam is central to EMTALA but it's not well defined anywhere. We are doing what we think it is but the government maintains that it can decide it's something else at any time.

Maybe we are hijacking the thread and maybe we should start a new one. For now I will say I agree with FoughtFyr who said that EPs aren't prostitutes, we're sluts because we do it for free.

 

[FoughtFyr]

For now I will say I agree with FoughtFyr who said that EPs aren't prostitutes, we're sluts because we do it for free.

***Wiping away a tear of pride***

(For you newbies, praise is rare from docB)

- H

 

[FoughtFyr]

In the face of all that, if I were by myself in a small facility with no neurosurgeon on call, and had a patient with a headache and a poor quality CT, I might want to transfer. I think it behooves the house officers at the receiving end to avoid being judgemental. They'll be there in the future.

I have been there, and made the transfer. The difference is that I do not tell the family that I must transfer the patient because of a dire condition. I discuss with them the realistic limitations of the facility and the risks, alternatives (including observation and serial exams) and benefits of transfer. If we, together, elect for transfer, I execute the same after a truthful discussion with the receiving EP, often including the fact the I am transferring because of limited diagnostic ability. As such, it is rare such patients go by helicopter. And, it seems to me that the patients I transfer are far more evenly representative of the payer mix where I moonlight (as opposed to admitting the insured for observation and transferring the MA patients). But, maybe I am seeing all of this through jaded eyes...

- H

 

[UCLA2000]

4. Meanwhile other developed countries spend about 7-9% and cover everybody. They've got their problems, but their populace is happier than ours.

Also less litigious...

 

[deleted4401]

After my month in the ED as an intern, boy has my mind changed about the field.

First of all, it's not a lifestyle field. I have never been so tired! Granted, I was interviewing for rad-onc at the time and flying all over the country between shifts. My feet hurt, my head hurt, I was starving, and I was ready at the end of the shift to go right to bed. Plus, the shift switching kept me from ever feeling refreshed.

Another thing, the patient relationships are strong - at least in a major ED. Talking to an 18 yo student about his upcoming appendectomy, or a young woman with an ectopic, or a someone who is having an MI - yes, these aren't relationships that develop over the course of a year, but if you do it right, they'll never forget you. The intensity more than overrides the short length of the interraction. I saw so many letters from patients thanking their ED nurses and docs.

The other thing is the evidence-based practice - at least at Pitt - the attendings did not shotgun order tests; they totally thought about what tests to order and why. Even more so than with some of my medicine attendings. Combined with this, I felt that the acute pain management was handled much better by ED attendings compared to internists. That surprised me - I thought they just doled out narcotics.

Until you do a few months as an intern or resident, it's really hard to justify all these things older docs say. The field is it's own now, and it isn't internists and pediatricians staffing an ED for extra cash - it's ED specialists who, for what I've seen, know their stuff.

Great field, yet I can't do it. Too hard on the feet

S

 

[turtle md]

First of all, it's not a lifestyle field ... I was interviewing for rad-onc at the time and flying all over the country between shifts.

I appreciate your endorsement. Try flying "all over the country" while on a medicine or surgery block - it's impossible. So I still think EM is a lifestyle field. Most people go into it because they want time to pursue other interests.

Good luck in your match...

 

[southerndoc]

Great field, yet I can't do it. Too hard on the feet

I've gotta start sitting more often (when documenting and such).

When I worked a bunch of shifts in a row, my right ankle deltoid ligament becomes inflamed and absolutely kills me. Motrin helps, but I need to find a way to prevent this all together.