GME To Be Slashed

[futuredoc15]

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http://www.msnbc.msn.com/id/43635698/ns/politics-the_new_york_times/

Looks like in the future residents will probably be unpaid since there will not be GME money to pay them. Yikes!!!!

 

[PharmaTope]

that would pretty much stop most people from going into medicine

no way to support yourself or your family with massive debt. ya that would destroy it in this country.

now, if med school was free.....

 

[mp2100]

Do all residency programs rely on funding from Medicare? How about community hospitals and private hospitals?

 

[OncoticPressure]

Do all residency programs rely on funding from Medicare? How about community hospitals and private hospitals?

They all get funding from Medicare.

 

[cowme]

Sounds like if this goes through resident education will be cut in half. Damn.

http://online.wsj.com/article/SB10001424052702303544604576434470768158908.html

 

[McGillGrad]

Sounds like if this goes through resident education will be cut in half. Damn.

http://online.wsj.com/article/SB10001424052702303544604576434470768158908.html

I don't subscribe. Cannot see the whole article.

 

[sunset823]

First of all, I don't think they are going to either slash salaries for residents by half, cut residency positions in half, or make residents work for free. Yes, this sucks, especially with the debtload I have, but I really didn't think Medicare was the right source to fund GME in the first place. If this goes through, hospitals are going to have to pick up the slack and fund 100% instead of just the 50% they do now.

Yes, the hospitals could refuse to do this and all hell could break lose, but I doubt med students or current trainees would let that happen. A bunch of unemployed MDs does not look good for the US.

 

[McGillGrad]

WSJ: We Can't Afford to Train Fewer Doctors

Thanks.

I am not so convinced that the leaders of our nation are quite on the up-and-up when it comes to why we have such rampant overspending.

When medicaid and madicare patients are given MRIs and CT scans like candy on Halloween based on 90% arse-covering and 10% clinical judgement, money could be better saved through the elimination of frivolous lawsuits and ridiculously high payouts for legitimate cases. Cap at $250,000 and call it a day, America. Canada has already done it and pre-empted a lot of problems.

 

[cowme]

The amount of STAT head CT's I have seen ordered in the ED was absolutely absurd. 30 year old drunk guy on PCP comes in agitaged -->STAT HEAD CT. 90 year old nursing home transfer comes in because of altered mental status (which is really her baseline, but the new nurse was worried)--> STAT HEAD CT. Tension headache with no neurological signs -->STAT HEAD CT. I agree with the suggestion of tort reform, I also think there should disincentives to ED physicians who break a threshold of ordering imaging studies that turn out to show "no acute disease process."

 

[cowme]

double post

 

[Sneezing]

A NP/PA will cost about 80K in salary +/- 20K. Now when you throw in benefits that's probably an additional 20K. They work 40 hour work weeks.

Medicare pays about ~100K per resident. This covers more than our salary and more than our benefits. We also work far more than 40 hour weeks.

Midlevels and Residents on paper require the same supervision, as a resident increases they often get less.

At the end of this hiring a resident even without government funds is still a far better investment than a midlevel.

Getting the government out of GME is a great thing. Hospitals and residency programs don't need the GME welfare check.

 

[Law2Doc]

A NP/PA will cost about 80K in salary +/- 20K. Now when you throw in benefits that's probably an additional 20K. They work 40 hour work weeks.

Medicare pays about ~100K per resident. This covers more than our salary and more than our benefits. We also work far more than 40 hour weeks.

Midlevels and Residents on paper require the same supervision, as a resident increases they often get less.

At the end of this hiring a resident even without government funds is still a far better investment than a midlevel.

Getting the government out of GME is a great thing. Hospitals and residency programs don't need the GME welfare check.

The flaw in this is it presumes the residents add value from day one. Truth of the matter is that the learning curve is steep, and residents don't become profitable until several years into their training. In the first year they tend to require a lot of attending oversight and actually make the attendings less profitable. By the time they are of real value they have finished most of their three year stint in residency. By contrast once you train an NP/PA they theoretically can stay on forever, even after you get them past that initial hurdle where they are adding no value. This is the key reason residents are never the solution to the cheap labor dilemma -- by the time they are trained to do the job well, they are out the door.

 

[Coastie]

The flaw in this is it presumes the residents add value from day one. Truth of the matter is that the learning curve is steep, and residents don't become profitable until several years into their training. In the first year they tend to require a lot of attending oversight and actually make the attendings less profitable. By the time they are of real value they have finished most of their three year stint in residency. By contrast once you train an NP/PA they theoretically can stay on forever, even after you get them past that initial hurdle where they are adding no value. This is the key reason residents are never the solution to the cheap labor dilemma -- by the time they are trained to do the job well, they are out the door.

You're wrong.

A PGY-1 6 months into it is far more efficient and far, far, far more cost-effective than an NP/PA.

 

[Sneezing]

You're wrong.

A PGY-1 6 months into it is far more efficient and far, far, far more cost-effective than an NP/PA.

Yup.

 

[Osteoimperfecta]

The flaw in this is it presumes the residents add value from day one. Truth of the matter is that the learning curve is steep, and residents don't become profitable until several years into their training. In residents add value from day one.the first year they tend to require a lot of attending oversight and actually make the attendings less profitable. By the time they are of real value they have finished most of their three year stint in residency. By contrast once you train an NP/PA they theoretically can stay on forever, even after you get them past that initial hurdle where they are adding no value. This is the key reason residents are never the solution to the cheap labor dilemma -- by the time they are trained to do the job well, they are out the door.

Neither does a new PA

 

[Antibodies]

A NP/PA will cost about 80K in salary +/- 20K. Now when you throw in benefits that's probably an additional 20K. They work 40 hour work weeks.

Medicare pays about ~100K per resident. This covers more than our salary and more than our benefits. We also work far more than 40 hour weeks.

Midlevels and Residents on paper require the same supervision, as a resident increases they often get less.

At the end of this hiring a resident even without government funds is still a far better investment than a midlevel.

Getting the government out of GME is a great thing. Hospitals and residency programs don't need the GME welfare check.

Some people here keep saying that, but where is the hospital going to get that money from? Some hospitals keep afloat only because they get free labor (govt paying the residents).
For example, Mass General has ~162 IM spots (total). If there is no GME funding, where is Mass General going to find $16.2 million (assuming $100k per resident) to fund all those spots? Add in all the other spots. So the hospital will now fork over millions with absolutely no increase in revenues.

 

[HondoCrouch]

Some people here keep saying that, but where is the hospital going to get that money from? Some hospitals keep afloat only because they get free labor (govt paying the residents).
For example, Mass General has ~162 IM spots (total). If there is no GME funding, where is Mass General going to find $16.2 million (assuming $100k per resident) to fund all those spots? Add in all the other spots. So the hospital will now fork over millions with absolutely no increase in revenues.

The number of spots as a whole across the country will necessarily be cut.

Probably what will happen is that residents will be given privileges after intern year (or at whatever point they can get a full license in their respective state) and will have to work for the hospital to fund their training. There's no reason a pgy-2 couldnt do the same work as an NP/PA, and once GME funding is gone there's no reason a hospital wouldnt force them to work in that capacity.

 

[turkeyjerky]

Sounds like if this goes through resident education will be cut in half. Damn.

http://online.wsj.com/article/SB10001424052702303544604576434470768158908.html

Why'd you cite article nearly 2 weeks old in a rapidly developing issue? Anyone know if this proposal is actually in the measures being debated in congress the past few days?

 

[gutonc]

Why'd you cite article nearly 2 weeks old in a rapidly developing issue? Anyone know if this proposal is actually in the measures being debated in congress the past few days?

Is Congress actually debating anything these days other than which party is more d-bag filled?

That's a rhetorical question BTW.

 

[Gfunk6]

The way things are going, there is a 0% chance anything of substance will be cut. A last minute emergency budget and debt ceiling increase will be passed which essentially accomplishes nothing of import. Congress will pat themselves on the back and the inevitable day of reckoning will be postponed yet again.

 

[Radonkulous]

The way things are going, there is a 0% chance anything of substance will be cut. A last minute emergency budget and debt ceiling increase will be passed which essentially accomplishes nothing of import. Congress will pat themselves on the back and the inevitable day of reckoning will be postponed yet again.

Maybe we have reached that day of reckoning?

 

[Law2Doc]

Neither does a new PA

As I said above, the difference is that a PA can stay on for more than a 3 year residency, so you ultimately can get value out of them. A resident in a 3year residency is gone soon after they become useful.

 

[Law2Doc]

...

I think your comments are more applicable to specialties like medicine and surgery where there is more of a learning curve and a hierarchical structure. It is also why I have said residents should not be one pay fits all because certain specialties residents generate more revenue and more efficient than others.

sure rad onc may be the exception, although I still suggest that the attending has to teach more and accomplish less with the earlier residents, which is a cost. but the percentage of specialties my comments apply to even excluding fields like rad onc is probably 90% of residents.

 

[Osteoimperfecta]

sure rad onc may be the exception, although I still suggest that the attending has to teach more and accomplish less with the earlier residents, which is a cost. but the percentage of specialties my comments apply to even excluding fields like rad onc is probably 90% of residents.

Where in the world are you training? Must be a great institution I must say. No one holds anyone responsible for teaching.Most other places I know of, the residents learn mostly on their own and learn pretty fast,and most start adding value to the system very fast. Just gathering information, admitting and discharging is enough to justify paying residents to be on the job.

 

[Law2Doc]

Where in the world are you training? Must be a great institution I must say. No one holds anyone responsible for teaching.Most other places I know of, the residents learn mostly on their own and learn pretty fast,and most start adding value to the system very fast. Just gathering information, admitting and discharging is enough to justify paying residents to be on the job.

I think the question really is where in the world are you training, because very early residents aren't all that valuable and absolutely slow down the works in most of the places out there. Gathering information isn't really adding all that much value, a good med student can accomplish this as well. Admitting and discharging is something that interns take 3 times as long to do as the later year residents. I don't know what year you are but if you think you were equally as valuable from day one as you were on day 700, you are kidding yourself.

 

[tkim]

The amount of STAT head CT's I have seen ordered in the ED was absolutely absurd. 30 year old drunk guy on PCP comes in agitaged -->STAT HEAD CT. 90 year old nursing home transfer comes in because of altered mental status (which is really her baseline, but the new nurse was worried)--> STAT HEAD CT. Tension headache with no neurological signs -->STAT HEAD CT. I agree with the suggestion of tort reform, I also think there should disincentives to ED physicians who break a threshold of ordering imaging studies that turn out to show "no acute disease process."

When it's your ass on the line, you'll think different.

 

[goodoldalky]

The amount of STAT head CT's I have seen ordered in the ED was absolutely absurd. 30 year old drunk guy on PCP comes in agitaged -->STAT HEAD CT. 90 year old nursing home transfer comes in because of altered mental status (which is really her baseline, but the new nurse was worried)--> STAT HEAD CT. Tension headache with no neurological signs -->STAT HEAD CT. I agree with the suggestion of tort reform, I also think there should disincentives to ED physicians who break a threshold of ordering imaging studies that turn out to show "no acute disease process."

Not to belabor this post with regard to CT examples, but: 1. Alcoholics are extremely susceptible to SDH due to brain atrophy, and when one comes in on drugs and you can't get a history, even a knot on their head will make you think about a head CT, 2. You rarely know what a 90 year old patient's baseline mental status is when you're in the ED, and if the nursing home sends you a patient and tells you something is wrong with their brain, you have to listen to that, and 3. "No neurological signs" in a headache patient does not rule out a bleed or other intracranial process.

Miss one of these and you've got a great chance of being in court pronto, and your career could go anywhere from there.

When it's your ass on the line, you'll think different.

+1.

Point is, even if an EM doc thinks that the probability is low (but possible) for a positive head CT, in today's medicolegal climate, they can't afford to not order the CT. Everyone has a different degree of risk tolerance but overall it's pretty low.


One step further, neurologists deal with the same thing regarding imaging/tests in their clinics, cardiology in theirs, neurosurgeons in their clinics... etc.. the medicolegal climate these days has created this. I agree that reform, as pointed out by a previous poster, is crucial to curtailing the out-of-contol healthcare expenditure we face in this country. That's just the tip of the iceberg, but it would be a start.

 

[OncoticPressure]

Has anyone seen the legislation in its current form to see what it means for us???

 

[cowme]

3. "No neurological signs" in a headache patient does not rule out a bleed or other intracranial process.

Are you actually trying to argue that every patient with a mild headache warrants a head CT in the ED? The population in the ED is basically split between patients who use it as true emergencies, and those who use it as a family practice office. ED physicians really need to do a better job separating these 2, because a patient coming in with a mild headache, no trauma, and no risk factors for CVA, does not warrant a CT, yet I see it done all the time.

Point is, even if an EM doc thinks that the probability is low (but possible) for a positive head CT, in today's medicolegal climate, they can't afford to not order the CT. Everyone has a different degree of risk tolerance but overall it's pretty low.

This type of logic is why our health care system is doomed to fail. People use imaging as a crutch, when they ignore their clinical judgement because of that .0001 % chance it may be something else. I agree completely about tort reform helping...but if you don't acknowledge that we are just as big a part of the problem you are crazy.

 

[heech]

Has anyone seen the legislation in its current form to see what it means for us???

Much of the actual cuts won't be determined until around Thanksgiving, at the earliest. Yet another Congressional commission will be tasked with generating the cuts, which both houses of Congress must still approve.

But very simply, there won't be any sacred cows. Every federal program/agency is desperate for money, and everyone will have to face cuts of some degree. Hard to imagine GME getting through this unscathed.

 

[tkim]

Are you actually trying to argue that every patient with a mild headache warrants a head CT in the ED? The population in the ED is basically split between patients who use it as true emergencies, and those who use it as a family practice office. ED physicians really need to do a better job separating these 2, because a patient coming in with a mild headache, no trauma, and no risk factors for CVA, does not warrant a CT, yet I see it done all the time.

30 year old drunk guy on PCP comes in agitaged

90 year old nursing home transfer comes in because of altered mental status

Tension headache with no neurological signs

Which one of these is the 'mild headache'?

 

[cowme]

30 year old drunk guy on PCP comes in agitaged

90 year old nursing home transfer comes in because of altered mental status

Tension headache with no neurological signs

Which one of these is the 'mild headache'?

.....seriously?

 

[tkim]

.....seriously?

Yeah seriously, since you can predict which of these people will not have a bleed simply my looking at them. I've treated all of these people, and believe it or not, some of them have bleeds. Maybe your residency is giving you Jedi training that allows you to clear people without scans, but in the real world, there is a risk of undiagnosed bleeds in the intoxicated, the elderly, and first time headache population that presents to the ER for evaluation.

I can only guess as to what specialty you are entering as to dismiss these people in such a cavalier attitude. As I said before, when it's your ass, you'll change your tune. Or wiggle out by saying 'clinical correlation required'.

 

[Man In White]

Yeah seriously, since you can predict which of these people will not have a bleed simply my looking at them. I've treated all of these people, and believe it or not, some of them have bleeds. Maybe your residency is giving you Jedi training that allows you to clear people without scans, but in the real world, there is a risk of undiagnosed bleeds in the intoxicated, the elderly, and first time headache population that presents to the ER for evaluation.

I can only guess as to what specialty you are entering as to dismiss these people in such a cavalier attitude. As I said before, when it's your ass, you'll change your tune. Or wiggle out by saying 'clinical correlation required'.

Ya I'm sure this exact debate has been discussed ad nauseum and I'm not trying to take sides .. but essentially you are saying because someone could have a remote possibility of something .. you should scan them .. because medicolegally .. it's "your ass on the line." That's a pretty weak argument .. just sayin'.

And ya when the time comes when I find that it's "my ass on the line" and I find myself pan-labbing or pan-scanning I hope I will have the dignity to at least admit that I feel like a tool for doing it and not try to whitewash it with the medicolegal term.

 

[HondoCrouch]

Ya I'm sure this exact debate has been discussed ad nauseum and I'm not trying to take sides .. but essentially you are saying because someone could have a remote possibility of something .. you should scan them .. because medicolegally .. it's "your ass on the line." That's a pretty weak argument .. just sayin'.

And ya when the time comes when I find that it's "my ass on the line" and I find myself pan-labbing or pan-scanning I hope I will have the dignity to at least admit that I feel like a tool for doing it and not try to whitewash it with the medicolegal term.

Maybe when you see something like this :

http://blogs.courant.com/connecticut_insurance/2011/05/in-medical-malpractice-case-ju.html

and realize a "remote possibility" could cost you your entire career, everything youve worked for and destroy your future, you may feel differently.

 

[tkim]

Ya I'm sure this exact debate has been discussed ad nauseum and I'm not trying to take sides .. but essentially you are saying because someone could have a remote possibility of something .. you should scan them .. because medicolegally .. it's "your ass on the line." That's a pretty weak argument .. just sayin'.

And ya when the time comes when I find that it's "my ass on the line" and I find myself pan-labbing or pan-scanning I hope I will have the dignity to at least admit that I feel like a tool for doing it and not try to whitewash it with the medicolegal term.

The three scenarios mentioned - ALOC intoxicated, PCP man, elderly NH lady with ALOC, 'tension' headache - bad enough that the present to the ER. Those are not 'remote possibility' - those are people who, if you cannot confidently attribute ALOC to something other than bleed, you should scan. People come it with headaches all the time without focal deficit and they say that it's worst of their life, that they figured it was a 'tension' headache, but geez, they're 60 y/o and never had a migraine or tension HA before. These are people you worry about.

I've sent my fair share of 'bumped heads' home. I've talked lots of parents out of scanning their kid's squashes. But altered, agitated, possibly drunk man or confused old NH lady, you bet.

 

[Man In White]

Look I'm not the one you should be trying to convince - you can scan all you want - it's money out of all of our pockets.

I'm just saying that the opposite side has already made up their minds just as you have. This debate isn't going to end anywhere productive and you might as well just suck it up and say - "ya, this is a ridiculous waste of resources, and it's NOT GOOD medicine but it's the way it has to be practiced these days."

And the other side can say .. "fine, glad you see that it is a gigantic waste, let's try to solve the problem", etc.

Ya fairy tale scenario, right? Probably, because our egos are ridiculously gigantic as well - too busy fighting amongst ourselves instead of the real problem ..

 

[Man In White]

Oh and btw, the argument of "residents being of little value initially" to hospitals - that's fine. But as noted the hospitals get paid back in FULL and much more after the first few months. Yes, residents leave after their "short stints" and that's why you ALWAYS have MORE residents to replace them as they leave. There is a continuous supply which makes the "value" of a resident HIGH and on AVERAGE constant throughout time.

The healthcare system in its current state would completely and utterly cease to function without residents.

We can live without NPs and PAs for the moment.

 

[3dtp]

A bit of history on how Medicare came to fund the residencies:

In the early to mid 1980s, back to the days when residents worked q2/q3 and 7 days a week, for 30 hours at a time, 108-110 hours a week, the predecessor to CMS, then known as HCFA (Health Care Financing Agency) made a determination that hospitals would be compensated on a diagnosis related group bases or DRG. The DRGs were theoretically established such that hospitals would receive a fixed prospective fee based on diagnosis codes. If the patient cost the hospital less to treat, the hospital won. If not, the government won.

This prospective payment system was implemented in 1984 and soon the University hospitals screamed that they were "teaching" hospitals, and residents cost them money and as government contractors, they were entitled to be "compensated" for the costs they incurred, over and above the PPS/DRG.

So HCFA decided that teaching hospitals were right, and soon the government feeding trough was filled to overflowing. Government cost accounting pays for a.) Direct costs of employment (wages, benefits, insurance, etc), b.) general indirect costs (office space, equipment, pencils, supervision, etc) which are the "overhead percentage" times the direct costs, c.) general administrative costs (costs of marketing, executives, etc) which are the "G&A percentage * everything below it".

By the late 1980s this became a very tidy profit center for the teaching hospitals, and since initially, there was no cap to the number of residents an institution could bring on, residencies grew and hospitals prospered. Finally, HCFA eventually figured out they had been had, but by then it was too late. A cap on "funded" residency slots was instituted in the late 1990s (I think). The institutions howled, but not much.

Then came the lengthening of residencies. A noted chair of a prestigious department of a Tier I research university who is now an executive leader in a specialty association started a drive to extend residencies at his university and managed to succeed in several residency programs, thus increasing the funding. I remember him saying, "if we can extend the residency program by a year, calling it a "research" year, we can easily get HCFA to increase the funding and we get a free year of research work out of the residents that we don't have to tap grants for." Which is exactly what happened.

Now, the government is finally figuring it out. The teaching institutions will howl louder, but it is a change that does need to happen. Residency training has for too long, been abused by institutions as a source of free/cheap labor.

Unfortunately, the government is taking over post-GME practice and coming soon to a clinic near you, will be vast changes as Obama-care exerts its influence. It is ironic that Law2Doc points out the economic fallacy of indentured servitude in the residency side of the equation, and now the United States proposes to have physicians enter into indentured servitude for the first time, I think since the Kansas-Nebraska Act and the Dred Scott Decision. It is doubly ironic that our potential enslavement is led by a man of our president's personal background and culture.

 

[Socrates25]

A bit of history on how Medicare came to fund the residencies:

In the early to mid 1980s, back to the days when residents worked q2/q3 and 7 days a week, for 30 hours at a time, 108-110 hours a week, the predecessor to CMS, then known as HCFA (Health Care Financing Agency) made a determination that hospitals would be compensated on a diagnosis related group bases or DRG. The DRGs were theoretically established such that hospitals would receive a fixed prospective fee based on diagnosis codes. If the patient cost the hospital less to treat, the hospital won. If not, the government won.

This prospective payment system was implemented in 1984 and soon the University hospitals screamed that they were "teaching" hospitals, and residents cost them money and as government contractors, they were entitled to be "compensated" for the costs they incurred, over and above the PPS/DRG.

So HCFA decided that teaching hospitals were right, and soon the government feeding trough was filled to overflowing. Government cost accounting pays for a.) Direct costs of employment (wages, benefits, insurance, etc), b.) general indirect costs (office space, equipment, pencils, supervision, etc) which are the "overhead percentage" times the direct costs, c.) general administrative costs (costs of marketing, executives, etc) which are the "G&A percentage * everything below it".

By the late 1980s this became a very tidy profit center for the teaching hospitals, and since initially, there was no cap to the number of residents an institution could bring on, residencies grew and hospitals prospered. Finally, HCFA eventually figured out they had been had, but by then it was too late. A cap on "funded" residency slots was instituted in the late 1990s (I think). The institutions howled, but not much.

Then came the lengthening of residencies. A noted chair of a prestigious department of a Tier I research university who is now an executive leader in a specialty association started a drive to extend residencies at his university and managed to succeed in several residency programs, thus increasing the funding. I remember him saying, "if we can extend the residency program by a year, calling it a "research" year, we can easily get HCFA to increase the funding and we get a free year of research work out of the residents that we don't have to tap grants for." Which is exactly what happened.

Now, the government is finally figuring it out. The teaching institutions will howl louder, but it is a change that does need to happen. Residency training has for too long, been abused by institutions as a source of free/cheap labor.

Unfortunately, the government is taking over post-GME practice and coming soon to a clinic near you, will be vast changes as Obama-care exerts its influence. It is ironic that Law2Doc points out the economic fallacy of indentured servitude in the residency side of the equation, and now the United States proposes to have physicians enter into indentured servitude for the first time, I think since the Kansas-Nebraska Act and the Dred Scott Decision. It is doubly ironic that our potential enslavement is led by a man of our president's personal background and culture.

Good post. Here's the next step: state laws that mandate that all doctors have to accept Medicaid/Medicare/state insurance program as a condition of medical licensure in that state.

Crazy right? Massachusetts already has a bill in the works that does exactly that.

 

[Socrates25]

I think the question really is where in the world are you training, because very early residents aren't all that valuable and absolutely slow down the works in most of the places out there. Gathering information isn't really adding all that much value, a good med student can accomplish this as well. Admitting and discharging is something that interns take 3 times as long to do as the later year residents. I don't know what year you are but if you think you were equally as valuable from day one as you were on day 700, you are kidding yourself.

While its true that first day interns are not very efficient, your larger point about residents being sinks for cost and slowdown of attending labor is inaccurate.

I'm a chief resident and our attendings bitch and moan whenever we pull a resident off their service, even if its a lowly intern. Its only August, and we've had to pull 2nd month interns off services for scheduling issues and I immediately get a dozen emails and phone calls from angry attendings.

The attendings wouldnt be calling/emailing me if the interns/residents were making their lives harder by slowing them down.

Every attending I know would rather have a resident on their team than not have one.

 

[alwaysaangel]

Look I'm not the one you should be trying to convince - you can scan all you want - it's money out of all of our pockets.

I'm just saying that the opposite side has already made up their minds just as you have. This debate isn't going to end anywhere productive and you might as well just suck it up and say - "ya, this is a ridiculous waste of resources, and it's NOT GOOD medicine but it's the way it has to be practiced these days."

And the other side can say .. "fine, glad you see that it is a gigantic waste, let's try to solve the problem", etc.

Ya fairy tale scenario, right? Probably, because our egos are ridiculously gigantic as well - too busy fighting amongst ourselves instead of the real problem ..

Even without the medical legal, CYA medicine issue. There is the point of unacceptable misses.

How many missed MIs are ok? 1/100? 10/100? The general consensus of EM is none, because its not that hard to run people on a treadmill. Its pretty poor form to send someone home and have them go into V-fib and die because you missed an atypical MI presentation.

How many SAH/subdural misses are ok? Is it ok to send the tension HA home and have her come back herniated because you missed the small bleed that later completely ruptured? How many times out of 100 is that ok? On my current rotation we are about to harvest the organs of a VERY young woman who was told by urgent care she had a "tension" headache - even though it was sudden onset and was VERY atypical for her. 2 small bleeds and an complete rupture later - she's brain dead. If someone had scanned her in the first place she would still be alive.

You may think the ED is just scanning everyone - but I guarantee you there was something in that history that triggered the CT. Atypical HA, sudden onset, and yes, even N/V if the patient has not had migraines in the past.

 

[McGillGrad]

On my current rotation we are about to harvest the organs of a VERY young woman who was told by urgent care she had a "tension" headache - even though it was sudden onset and was VERY atypical for her. 2 small bleeds and an complete rupture later - she's brain dead. If someone had scanned her in the first place she would still be alive.

You may think the ED is just scanning everyone - but I guarantee you there was something in that history that triggered the CT. Atypical HA, sudden onset, and yes, even N/V if the patient has not had migraines in the past.

If you want an honest answer, she is the victim of faulty genes and bad luck. No good doctor would scan her head looking for a bleed. It is a waste of time and resources. Is it unfortunate for this patient and her family? ABSOLUTELY. Is it the fault of the urgent care centre...not by a country mile. They did nothing medically wrong.

 

[alwaysaangel]

If you want an honest answer, she is the victim of faulty genes and bad luck. No good doctor would scan her head looking for a bleed. It is a waste of time and resources. Is it unfortunate for this patient and her family. ABSOLUTELY. Is it the fault of the urgent care centre...not by a country mile. They did nothing medically wrong.

I disagree. Sudden onset, atypical headache is an EASY scan. For any well trained EM doc. She was not the one in a million miss. She was an obvious potential bleed.

I'm curious what triggers you guys think should be scanned. Seems unless the patient is already posturing with altered mental status you wouldn't dare scan them. Again, I ask you - how many is it ok to miss?

 

[McGillGrad]

I disagree. Sudden onset, atypical headache is an EASY scan. For any well trained EM doc. To me she was not the 1 in a million miss. She was an obvious potential bleed.

I'm curious what triggers you guys think should be scanned. Seems unless the patient is already posturing with altered mental status you wouldn't dare scan them.

A "very young" patient with no personal/family history does not prompt a secondary work-up. Maybe pain relief and observation and that is playing it conservatively. Hindsight can cloud your judgement and make it 'obvious' that she should have been scanned.

Was it initially described as "sudden and unilateral?" Was there a history of headache? Only the notes would tell, not the parents after hearing all kinds of mumbo jumbo from your hospital in the aftermath.

People die. It's not malpractice if nature takes its course.

edit- how many ok to miss? I would say as many that happen to present atypically and would not warrant a work-up by a qualified doctor.

 

[alwaysaangel]

A "very young" patient with no personal/family history does not prompt a secondary work-up. Maybe pain relief and observation and that is playing it conservatively. Hindsight can cloud your judgement and make it 'obvious' that she should have been scanned.

Was it initially described as "sudden and unilateral?" Was there a history of headache? Only the notes would tell, not the parents after hearing all kinds of mumbo jumbo from your hospital in the aftermath.

People die. It's not malpractice if nature takes its course.

edit- how many ok to miss? I would say as many that happen to present atypically and would not warrant a work-up by a qualified doctor.

Well very young is relative - I was talking 30s which I think is very young to be dead. And yes it was presented as sudden onset, and she did not have a history of headaches. Again, easy scan.

EM has a different perspective. Its the ED's job to catch those things. The number of SAHs which present atypically is very high and something like 40% have no neuro symptoms. You're talking about missing a significant percentage of SAHs.

Anyway, like mentioned before chances are no one's mind is going to change here. EM has a very different perspective than most other specialties. Everyone assumes its CYA medicine. My point its its not, its the nature of the specialty which is supposed to catch all the bad stuff. Not just for medico-legal issues but also because its what the ED is supposed to do.

 

[McGillGrad]

Well very young is relative - I was talking 30s which I think is very young to be dead. And yes it was presented as sudden onset, and she did not have a history of headaches. Again, easy scan.

oh, you have her notes from the initial visit?

 

[MJB]

All these things that supposedly present to the ED "all the time"...and yet I can't tell you how many times I've worked ED's and watched hundreds of thousands of negative tests be ordered.

SOMEONE IS PAYING THAT BILL.

I just can't convince myself that every schmoe that walks into an ED is about to die and must be ruled out with expensive, high radiation (in many cases), and all too often useless tests.

As for the drunk PCP dude vs. the LOL in NAD. I'd scan her first...probably because I'd feel bad if I missed something in her. Drunk PCP dude obviously doesn't give a damn.

 

[cowme]

Even without the medical legal, CYA medicine issue. There is the point of unacceptable misses.

How many missed MIs are ok? 1/100? 10/100? The general consensus of EM is none, because its not that hard to run people on a treadmill. Its pretty poor form to send someone home and have them go into V-fib and die because you missed an atypical MI presentation.

How many SAH/subdural misses are ok? Is it ok to send the tension HA home and have her come back herniated because you missed the small bleed that later completely ruptured? How many times out of 100 is that ok? On my current rotation we are about to harvest the organs of a VERY young woman who was told by urgent care she had a "tension" headache - even though it was sudden onset and was VERY atypical for her. 2 small bleeds and an complete rupture later - she's brain dead. If someone had scanned her in the first place she would still be alive.

You may think the ED is just scanning everyone - but I guarantee you there was something in that history that triggered the CT. Atypical HA, sudden onset, and yes, even N/V if the patient has not had migraines in the past.

They're not scanning everyone...just almost everyone. Missing 1/100 MI's is bad. But running troponins are not as wasteful as doing a CT.

I must have seen 100 CT scans in my 4 weeks in the ED to "Rule out pancreatitis" which is a friggin CLINICAL diagnosis. I understand getting a scan on the patient who looks very ill and/or is febrile, but any mild, vague abdominal pain with a lipase on the upper end of normal seemed to go straight to CT.

 

[MJB]

They're not scanning everyone...just almost everyone. Missing 1/100 MI's is bad. But running troponins are not as wasteful as doing a CT.

Not to mention radiation exposure.


30 years from now there will be some "miracle study" showing rates of cancer increasing...and they'll wonder why. I have to believe it will be in part because we are frying people with CT.

We seem to act like this is a benign test (and don't get me wrong, I think they are great when needed), but I hope the outcome isn't as bad down the road as I'm anticipating.