Got fired by locums within 10 minutes for requesting the ED physician to not admit patient before being assessed

[Señor S]

After it happened I turned to a few lawyers and at best got a single reply, then got too busy. Absolutely nothing more to story.

IANAL but it sounds like you got your answer: they don't think it's a worthwhile case, probably because the amount of money involved is trivial. If you offer to pay out of pocket to fund litigation and are willing to shell out an amount in the low six figures because your sense of justice demands it, well, that's your prerogative and you can probably find a lawyer to take the case but I wouldn't recommend it. Ditto the state medical board: if you want to fight the good fight go ahead and do so but there are a lot of potential pitfalls there, as others have outlined.

I'm not a locums but I know a fair number of them and this seems to me the catch-22 of that life: by definition you're working at places that can't get somebody permanent. In some cases that's just because they're in some small town nobody wants to live in, but in other cases it's because of a toxic environment that pushes people away. Your case seems to be the latter. I also agree with @chessknt that a big part of IM, in all its fields but especially as a hospitalist, is getting along with people and putting your ego aside. We're not neurosurgeons or orthopods who can get hospitals to bow to our whims; we're just not that valuable.

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[Señor S]

Re: that Minnesota ruling, my sense reading the coverage at the time was that it was a novel (landmark?) ruling and it's still unclear what the practical implications will be. It also is state-specific so unclear whether it will spread beyond MN...but I wouldn't be shocked to see more suits like that going forward. Anecdotally I think we're entering a new malpractice environment and we should all expect to be sued more frequently, for larger sums, and for more ticky-tacky reasons than our predecessors were. And of course any name that appears anywhere in the chart is at pretty high likelihood to end up as a defendant in a malpractice suit.

 

[chessknt]

What if you say not to put their name in the chart as its a discussion and not a formal recommendation?

Also how does one stop them from just saying they discussed with you and consultant was ok with it even if you said something different?

It doesnt. Where I live this is common practice because of a massive shortage of multiple specialties and access to puln/neurosurgery/ctsx etc etc are so hard for most people that if you decline to give advice you are doing a serious disservice to these outlying centers that truly are doing the best they can with minimal resources. Transport of medical patients can be life-threatening (Transplant Team Dies in Jet Crash; Mechanical Problems Suspected (Published 2007) for example) and forcing the healthcare system to take on a 6 figure transport and put the pilot/medical team at risk just because I didnt want to tell the provider over the phone that it was OK to not transfer for lytics in a stable large burden PE seems wasteful to me. I tell them straight up to xfer if I think they need it. I could just hang up the phone but I am only a dick online

 

[HemeOncHopeful19]

Also how does one stop them from just saying they discussed with you and consultant was ok with it even if you said something different?

I had this problem a few times in fellowship where a certain ER midlevel would just do whatever they wanted (usually admit a patient that didn’t need to be admitted) and document that I told them to admit.

I don’t know if there is a solution if you’re not in the system to write your own note, you have to rely on a “recorded line” that probably is not actually recorded or backed up with any regularity and will certainly be “lost” if the hospital ever needs it to be.

I think it is an ethical dilemma as Chessknt has stated above hard to say where your “duty” to the community begins and ends, and why the other hospitals seem to not feel the need to pay for coverage when you’re effectively on call for them via the transfer center.

 

[anonperson]

As for medmal -- to my knowledge, you are not legally responsible for a patient you do not assume care over. Assessing a patient and determining, again, based on sound medical judgement and standard of care, that the patient should not be admitted does not designate you legally as the physician who assumes care over patient and therefore, you can't make decisions regarding this patient's disposition etc. That is left to the ED MD. Obviously, it leaves ED in a less convenient spot because now they might have to do some additional workup and risk stratification (i.e. what they should've done

Now, is reality that everyone ****s on hospitalist and nothing can be done about it other than quit or go private? Sure. I'm not new to game and that wasn't why posted. My question was more specific. I.e. I did what I did, followed contract and medical board, only asked to assess the patient before being admitted -- didn't even refuse patient yet. Yet ED and locums responded way they did. Despite widely accepted knowledge of hospitalist being **** on etc, anyone has similar experience / knowledge / educated advice regarding next steps to take? Got some already and seems like concensus is to get money for work I've already completed and forget about rest / weak recommendation to report ED MD in addition.

To your point regarding med mal if you don't assume care.

That isn't true. Let's say you evaluated the patient and wrote that they are not a candidate for admission. The ED physician let's them go. Patient becomes septic and dies at home 12 hours later, you and the ED physician will be eating $hit. Any malpractice lawyer will take that case and it will be easy money.

Look, at the end of the day, I'm sure you were clinically correct in your assessment and they didn't need admission. You won the battle but lost the war.

Regarding what to do:

Get your payment for shifts already completed
Try to get paid for the cancelled shift per your contract but understand that you may have to let that go.

For the ED physician on a power trip:

As a locums, you have little influence or power. If you try to go the state medical board route, it won't go anywhere and they can easily lob a grenade back at you that will make your life more difficult.

You can complain to the chair of the ED department or the chief of staff or CMO. But if this guy is well established he probably is well connected.

If this was your actual job, I would be more likely to recommend action but as a locums in this situation, I just don't think it's going to result in any meaningful action.

 

[rokshana]

Uh huh. I get phone calls from hospitals I have no way of leaving a note in asking me about ****. I hope for the best but yea--leave a note and if you are calling someone to ask their opinion dont be a ****ing tool and put their name or document the phone call at all if they cant or arent asked to leave a note.

How are you getting consulted if you don’t have privileges at the hospital ?

 

[chessknt]

How are you getting consulted if you don’t have privileges at the hospital ?

I am getting phone calls from hospitalists or er docs calling our central transfer line asking to opine on any number of ccm or pulm issues. I work at a central referral center for an enormous area that dozens of smaller hospitals/critical access centers feed in to when needed. Sometimes they get stuck with someone sick and can't travel due to weather and need help. Sometimes they just need someone to hold their hand and help them put their grown up pants on. And sometimes they need to be told that they are 100% right that a xfer is needed and not a crazy idea. Sometimes these phone calls or on a recorded line but sometimes they just get my number directly from the on call list through emtala.

When I worked at an academic center it was a very black white to transfer call, the real world is much messier especially when there is a dearth of help.

 

[HemeOncHopeful19]

I am getting phone calls from hospitalists or er docs calling our central transfer line asking to opine on any number of ccm or pulm issues. I work at a central referral center for an enormous area that dozens of smaller hospitals/critical access centers feed in to when needed. Sometimes they get stuck with someone sick and can't travel due to weather and need help. Sometimes they just need someone to hold their hand and help them put their grown up pants on. And sometimes they need to be told that they are 100% right that a xfer is needed and not a crazy idea. Sometimes these phone calls or on a recorded line but sometimes they just get my number directly from the on call list through emtala.

When I worked at an academic center it was a very black white to transfer call, the real world is much messier especially when there is a dearth of help.

Reminds me of a time in fellowship when I was rounding with our department chair and they got one of these calls

“I’m sorry but I’m not on call for your hospital, what did your Hematologist say about this?”

“Oh we don’t have Hematologists at our hospital.”

“Yes you do. One of them is XYZ. She was my fellow last year and put me down as a reference when your facility hired her.”

 

[doctorsun]

That isn't true. Let's say you evaluated the patient and wrote that they are not a candidate for admission. The ED physician let's them go. Patient becomes septic and dies at home 12 hours later, you and the ED physician will be eating $hit. Any malpractice lawyer will take that case and it will be easy money.

Not certain about that unless it is an official consult and even then, not sure how significant your liability will be compared to admitting and discharging and something happens. If there's a medical law practitioner around that can clarify, that would be helpful to forum.

Disregarding litigation, even though I don't think it should be that way and that ED physician should do their job like they're supposed to rather than shop around for admission and do incomplete initial workup/management then demand you admit without assessing, that's not going to happen.
I consider being liable for recommending discharge from ED, assuming you have input into workup in ED (and they don't tell you "stop ordering tests for nothing") and are "allowed" to assess patient before admission -- the lesser of two evils.

On the other hand, I do know that if ED admitted without hospitalist even seeing patient and something happens to patient on way to floor -- both ED and hospitalist may be on the hook. Had a colleague that was sued for a patient that coded and expired on way to floor from ED after ED admitted. In this case, hospitalist was busy rounding and just waited for patient to arrive on floor before assessing.

 

[doctorsun]

IANAL but it sounds like you got your answer: they don't think it's a worthwhile case, probably because the amount of money involved is trivial. If you offer to pay out of pocket to fund litigation and are willing to shell out an amount in the low six figures because your sense of justice demands it, well, that's your prerogative and you can probably find a lawyer to take the case but I wouldn't recommend it.

I am not understanding how litigating for breach of contract stating 30-day notice before cancellation is my sense of justice demanding it. Especially considering others in the forum stated that such litigation is taken seriously under some circumstances. I mean, if you can afford letting go of $30k+ and consider litigation for wage theft "sense of justice" I'm glad for you. Nor do I understand how assessing patient and refusing admissions based on well established criteria a "whim." In fact, not applying such criteria and sound clinical judgement may be considered a whim and one that can be costly. But no need to dwell on it.

As for getting along, this ED MD obviously did not intend to get along with me and didn't provide me with many chances to get along with him. This happened to him recently with at least one more hospitalist regarding another of his fraudelant admissions. His reply to my question "how severe is pneumonia based on PSI" was "do you know who I am!? I am your superior" and despite that I made several attempts to return the conversation to professional realm to no avail. Mind you, it so happens he already has TMB citation for not reporting DUI, BUI, resistance to arrest, and battery. I have no reason to act out of ego -- he was shouting nonsense across the hall and I was just enjoying the show. They terminated my services? I'd pay them more to get me out of there a day earlier.

Some of the replies here, beyond veering off the topic, are projections of their submissive tendencies (which they may be correct to have). "that's reality. it's just the way it is. welcome to the party. there are no rules or contracts." Ok. That's the way you think hospital medicine is or should be, and you think that being that way is the best way to practice hospital medicine and safest for your livelihood etc. We got it. And based on your response, I am assuming that you consider request to assess patient before admitting a revolution in medicine. Good. So my questions was -- I dared to ask to see patient before admitting and once saw patient and realized how BS admit is, broke free from my shackles and refused admission. What next? Seems like there's a pretty decent concensus on no action. Thanks for all input.

 

[Señor S]

I am not understanding how litigating for breach of contract stating 30-day notice before cancellation is my sense of justice demanding it. Especially considering others in the forum stated that such litigation is taken seriously under some circumstances. I mean, if you can afford letting go of $30k+ and consider litigation for wage theft "sense of justice" I'm glad for you.

As for getting along, this ED MD obviously did not intend to get along with me and didn't provide me with many chances to get along with him. This happened to him recently with at least one more hospitalist regarding another of his fraudelant admissions. His reply to my question "how severe is pneumonia based on PSI" was "do you know who I am!? I am your superior" and despite that I made several attempts to return the conversation to professional realm to no avail. I have no reason to act out of ego -- he was shouting nonsense across the hall and I was just enjoying the show. They terminated my services? I'd pay them more to get me out of there a day earlier.

Some of the replies here, beyond veering off the topic, are projections of their submissive behavior. "that's reality. it's just the way it is. welcome to the party. there are no rules or contracts." Ok. That's the way you think hospital medicine is or should be, and you think that being that way is the best way to practice hospital medicine and safest for your livelihood etc. We got it. And based on your response, I am assuming that you consider request to assess patient before admitting a revolution in medicine. Good. So my questions is -- I dared to ask to see patient before admitting and once saw patient and realized how BS admit is, broke free of my shackles and refused admission. What next?

If you can’t find a lawyer willing to take the contingency then that’s there way of telling you that they either don’t think you have a case or that the damages you would get would be too small to make it worth their time. What a bunch of doctors on an internet message board think is irrelevant.

I have no idea what a “fraudulent admission” is but if it means calculating a PSI prior to admission (which I have never done) then I’ve probably done a lot of them myself. Where I work IM has no right of refusal.

What’s next I (and others) have already told you. One option is to invest a lot of time/money into pursuing these guys. Call more lawyers, tell them you want to hire them at their hourly rate to take your case. Submit a claim to your state’s labor division for wage theft (something that can be done on the internet in my state). File a complaint with the state medical board (again, in my state it’s an online form you fill out).

Or just let it go. You’ve heard from many (including me) who have actual experience trying to fight large organizations about how that process can play out and why we think it may not be a good idea. You said lawyers aren’t returning your phone calls. If you think we’re all wrong well maybe we are. Only one way to find out.

 

[doctorsun]

If you can’t find a lawyer willing to take the contingency then that’s there way of telling you that they either don’t think you have a case or that the damages you would get would be too small to make it worth their time. What a bunch of doctors on an internet message board think is irrelevant.

I think you are confusing. I didn't try to lawyer up for this case based on input from you and others in this forum. They recommended to lawyer up for wage theft on a different occasion.

As for fraudulent admission, I admitted a bunch of negative PSI and curb65 as well because they had significant relevant chronic comorbidities, had other acute issues that called for admission despite negative stratification, clinical judgement etc. I don't know about you, but ED ordering CT abdomen for pneumonia.... without young patient having symptoms that are specific for pneumonia and recent diagnosis of treated pneumonia, breathing and satting perfect on room air, relying on CT abd finding without having proof that it is a new finding, and treating patient with flagyl and zosyn (strange combo, especially for CAP) -- shady to say the least. Now if that was a single occurrence, alas, but it is a pattern. This case doesn't constitute fraud by itself and didn't mean to state that this specific case is by itself all that is necessary to prove fraud. Unfortunately, when you had multiple recent hospitalists claiming inappropriate admissions, when ED documentation cites findings that were never there and use those findings to admit only to be later reversed once hospitalist note is in (and they don't always reverse), when locums rep herself admits issues with admissions they're working on resolving, and so on, you have a better case. Also, again, I am not a lawyer but accepting physician has to put admission order, When you admit a patient before discussing with accepting physician--inappropriate, fraud, call it as you may.

We can continue discussing even though these are pretty reasonable, lawful, contractual, and standards of care. You can choose to ignore them for your reasons to "get along with other physicians" etc but having reviewed medical cases for medical board and from personal experience, not sure it is a better alternative.

 

[Señor S]

If they owe you a significant sum of money then you should talk to an employment lawyer (more than one if necessary) to try to get what you’re owed. Also would recommend talking to the state labor board (might be worth doing that first since it can be handled online).

Regarding the ED guy, he sounds like an idiot, a cocky old timer(?) with a God complex, but he can always come up with some after-the-fact justification. A lot of doctors around me do stuff I think is weird and dumb and unnecessary but that’s just how medicine is sometimes ime. I’ve had people to admit to me without sign out before; I was upset but I don’t think it’s fraud since they have admitting privileges. If you think this truly rises to the level of malpractice then go ahead and report to the state medical board. I’ve also seen cases in my state of people being reported to the board for unprofessional conduct vis-a-vis colleagues (and being sanctioned for it) so that’s another angle to play. The downsides of all of the above remain the same.

 

[dozitgetchahi]

I am getting phone calls from hospitalists or er docs calling our central transfer line asking to opine on any number of ccm or pulm issues. I work at a central referral center for an enormous area that dozens of smaller hospitals/critical access centers feed in to when needed. Sometimes they get stuck with someone sick and can't travel due to weather and need help. Sometimes they just need someone to hold their hand and help them put their grown up pants on. And sometimes they need to be told that they are 100% right that a xfer is needed and not a crazy idea. Sometimes these phone calls or on a recorded line but sometimes they just get my number directly from the on call list through emtala.

When I worked at an academic center it was a very black white to transfer call, the real world is much messier especially when there is a dearth of help.

Yeah, this is something that happens at big centers. I used to get a lot of these “outside curbsides” when carrying the department pager on call as a rheumatology fellow. One of the strangest examples of this happened one of the first times I was on call - I got paged to a random number in the US Virgin Islands. I wondered if this was some sort of scam…but nevertheless I called back. It was some ER doctor in the USVI who basically demanded I teach him how to manage a vasculitis patient who had just shown up in his ER.

 

[The kitchen sink]

Conversation becoming less focused and more presumtive than intended but don't care -- info may come useful to others. I was not at all looking at this black / white. I had multiple very soft admissions throughout week and had conversation over phone with locums rep after they attempted to admit for "husband took low blood pressure at home" admitting they've had issues with that in past with multiple other physicians and working on it. Yet, some justified OBS IMO so I admitted. In some instances, told ED physician this is borderline but if you think should be admitted, will take to OBS -- after assessing the patient. I've been working in the grey zone throughout my time there. If it was black and white, 95% of patients I've encountered there would not be admitted. In fact, only about 5% of my patients were inpatients during my tenure there, and one was already refused by insurance.

As for medmal -- to my knowledge, you are not legally responsible for a patient you do not assume care over. Assessing a patient and determining, again, based on sound medical judgement and standard of care, that the patient should not be admitted does not designate you legally as the physician who assumes care over patient and therefore, you can't make decisions regarding this patient's disposition etc. That is left to the ED MD. Obviously, it leaves ED in a less convenient spot because now they might have to do some additional workup and risk stratification (i.e. what they should've done to begin with) to let patient go or attempt transfer. The alternative? You putting all the work and risk on yourself. Admitting and transfering from floor more difficult than ED to ED. Or admitting drug seeking patient not qualifying, this time hoping quasinurse doing shopping on amazon doesn't give wrong medication/dose or that you yourself don't mess up dealing with all the BS around and relying on inaccurate medication reconciliation. You can't admit every person arriving to ED because you might find something wrong during stay. That's not how it works. Nor can you admit every patient the ED physician is, at best, worried about discharging or as in most cases, prefers to dump on you rather than take other steps that take a little more time -- that is a problem for your patient and for you. Whether you choose to still do it and align with them disregarding medical practice, contracts, etc-- your choice and based on feedback, perhaps a choice many make. This hospital has a high turnover of physicians because, reportedly, they chose similarly to me.

In a better though not perfect medical world, I don't have to apply ED criteria to determine if the patient should be admitted like HEART etc. I received several calls from ED to admit HEART 6-7 and I don't even have cardiology. The ED physician should apply them. Some (or many in my experience) of them choose not to do it because they are aware patients meet no criteria and just want to dump and/or hospitalist has no choice but to admit. ED dumps all time. let's not pretend we're in a vacuum in which poor ED physician trying to do right thing and admitting physician denies admission for no reason, nor in a world in which transfer from ED is more complicated than transfer from floor. ED work can be hard though in most cases, especially rural, they're just lazy, don't do nearly appropriate initial workup or management, and do criteria-shopping to dump the patient.

Now, is reality that everyone ****s on hospitalist and nothing can be done about it other than quit or go private? Sure. I'm not new to game and that wasn't why posted. My question was more specific. I.e. I did what I did, followed contract and medical board, only asked to assess the patient before being admitted -- didn't even refuse patient yet. Yet ED and locums responded way they did. Despite widely accepted knowledge of hospitalist being **** on etc, anyone has similar experience / knowledge / educated advice regarding next steps to take? Got some already and seems like concensus is to get money for work I've already completed and forget about rest / weak recommendation to report ED MD in addition.

A lot of valid points and greivances. Hospitalist medicine is tough as hell. The ED docs do attempt to dump quite a bit from my experience with very incomplete workups I agree. That is why documentation is important

I am not understanding how litigating for breach of contract stating 30-day notice before cancellation is my sense of justice demanding it. Especially considering others in the forum stated that such litigation is taken seriously under some circumstances. I mean, if you can afford letting go of $30k+ and consider litigation for wage theft "sense of justice" I'm glad for you. Nor do I understand how assessing patient and refusing admissions based on well established criteria a "whim." In fact, not applying such criteria and sound clinical judgement may be considered a whim and one that can be costly. But no need to dwell on it.

As for getting along, this ED MD obviously did not intend to get along with me and didn't provide me with many chances to get along with him. This happened to him recently with at least one more hospitalist regarding another of his fraudelant admissions. His reply to my question "how severe is pneumonia based on PSI" was "do you know who I am!? I am your superior" and despite that I made several attempts to return the conversation to professional realm to no avail. Mind you, it so happens he already has TMB citation for not reporting DUI, BUI, resistance to arrest, and battery. I have no reason to act out of ego -- he was shouting nonsense across the hall and I was just enjoying the show. They terminated my services? I'd pay them more to get me out of there a day earlier.

Some of the replies here, beyond veering off the topic, are projections of their submissive tendencies (which they may be correct to have). "that's reality. it's just the way it is. welcome to the party. there are no rules or contracts." Ok. That's the way you think hospital medicine is or should be, and you think that being that way is the best way to practice hospital medicine and safest for your livelihood etc. We got it. And based on your response, I am assuming that you consider request to assess patient before admitting a revolution in medicine. Good. So my questions was -- I dared to ask to see patient before admitting and once saw patient and realized how BS admit is, broke free from my shackles and refused admission. What next? Seems like there's a pretty decent concensus on no action. Thanks for all input.

No one disagrees with allowing hospitalist to assess a patient and decide whether to admit or recommend discharge. It should be simple and straight forward. If there are social issues they will probably end up being admitted.

In this case, it is unanimous that ppl agree that the ED doc was beyond unprofessional and you have many routes to report and escalate it if you choose to do so. My personal opinion is to report your findings objectively to your leadership as a safety issue for the working environment.

As for your comment on ‘submissive tendencies’, i think even if you are borderline superficially red pilled you can understand the position of a hospitalist is difficult. Your value is derived from admitting and discharging. Most people derive a simple cost benefit analysis of each admission and decide which ‘battles’ are worthy of fighting.

For some a borderline pneumonia is an easy slam dunk admit to obs and 24 hour dc.

I would personally choose to battle the attempts at surgical dumps from PACU or ER rather than a simple medical admission.

AGAIN however, it does NOT excuse this individuals behavior and there should be some reprimand for this because it truly does disrupt the professional work place balance

Good luck and let us know how it plays out

 

[Osteoth]

I am slowly learning that rural hospital medicine might suck

Pay is great, but you’re constantly squeezed by the hospital to take more patients to fill their beds, but when something bad happens everyone asks you why you admitted the patient.

 

[The kitchen sink]

I am slowly learning that rural hospital medicine might suck

Pay is great, but you’re constantly squeezed by the hospital to take more patients to fill their beds, but when something bad happens everyone asks you why you admitted the patient.

What do you mean something bad happens?

 

[doctorsun]

Pay is great, but you’re constantly squeezed by the hospital to take more patients to fill their beds, but when something bad happens everyone asks you why you admitted the patient.

To add insult to injury, pay was horrible. 30% less than usual pay in larger hospitals. ED dump patients, improper workups, locums has in writing instructions for hospitalist "don't order tests in ED when you know patient is going to be admitted anyway" then patient comes to floor, you order test, no subspecialty, transfer. "Why did you admit to begin with!?"

Also they push discharges and when patient, who ED physician promised 3 night stay for nursing home though patient shouldn't be anything near hospitalized, husband brings patient back two hours after discharge and ER nurse comes to floor demanding admission because "husband measured low blood pressure at home. Why did you discharge so quickly!? Not admitting!? I'm calling your locums" Then I have to spend another hour over phone with another dumb nurse turned C-something why I don't care about her interqual suggesting this patient is inpatient. Is there anybody in US who doesn't qualify for admission based on interqual? Not to mention they added "findings" to push them in.

 

[doctorsun]

What do you mean something bad happens?

Exactly. I think that some of the comments here derive from not having much experience with rural hospital medicine and therefore were somewhat surprised about me "sticking to my guns" requesting to assess patient before admission. I worked in academic centers and larger hospitals. Did I see every patient before arrival to floor? Not nearly. Nor did I care that much because admissions, staff, resources were, for the most part, appropriate. This hospital has RT two days a week, no pharmacy, no subspecialty, FM as EM MDs (except for that ED MD prick who's IM turned EM), high turnover of nurses, etc. A LOT can go wrong and has gone wrong when admitting patients who should not be admitted. For example, I admitted a patient for ADHF (kinda... though progressive for weeks, breathing satting well on room air, BNP mildly elevated....). Treated appropriately though no cardio. Well, day nurse thought cough for 3 weeks = pneumonia. Told her no. She still signed out to night nurse patient has pneumonia. Night nurse calls ED MD who wants to just be left alone, works up pneumonia, started IVF, steroids (?, against IDSA recs, they threw methylpred at every patient coming in with something on CXR, even flu), antibiotics. Following day, patient luckily still room air though borderline sats, crackles worse, BNP 1K. You discharge a patient? no hospital follow up, limited PCP clinics in area, limited to no subspecialty clinics in area, on top of population that tends to see a doctor once a decade.

 

[dozitgetchahi]

Exactly. I think that some of the comments here derive from not having much experience with rural hospital medicine and therefore were somewhat surprised about me "sticking to my guns" requesting to assess patient before admission. I worked in academic centers and larger hospitals. Did I see every patient before arrival to floor? Not nearly. Nor did I care that much because admissions, staff, resources were, for the most part, appropriate. This hospital has RT two days a week, no pharmacy, no subspecialty, FM as EM MDs (except for that ED MD prick who's IM turned EM), high turnover of nurses, etc. A LOT can go wrong and has gone wrong when admitting patients who should not be admitted. For example, I admitted a patient for ADHF (kinda... though progressive for weeks, breathing satting well on room air, BNP mildly elevated....). Treated appropriately though no cardio. Well, day nurse thought cough for 3 weeks = pneumonia. Told her no. She still signed out to night nurse patient has pneumonia. Night nurse calls ED MD who wants to just be left alone, works up pneumonia, started IVF, steroids (?, against IDSA recs, they threw methylpred at every patient coming in with something on CXR, even flu), antibiotics. Following day, patient luckily still room air though borderline sats, crackles worse, BNP 1K. You discharge a patient? no hospital follow up, limited PCP clinics in area, limited to no subspecialty clinics in area, on top of population that tends to see a doctor once a decade.

Look, sounds to me like you’re learning about the type of crap that can happen during a locums job. You’ve also learned that this particular hospital sucks, and that rural medicine is a “special flavor” out here in America. I get that you’re pissed with all of this, but at some point it’s time to chalk this up to a learning experience and move on to better jobs.

 

[doctorsun]

As for your comment on ‘submissive tendencies’, i think even if you are borderline superficially red pilled you can understand the position of a hospitalist is difficult. Your value is derived from admitting and discharging. Most people derive a simple cost benefit analysis of each admission and decide which ‘battles’ are worthy of fighting.

For some a borderline pneumonia is an easy slam dunk admit to obs and 24 hour dc.

I would personally choose to battle the attempts at surgical dumps from PACU or ER rather than a simple medical admission.

This case was not borderline pneumonia. It was no pneumonia. It was nothing. Drug seeker presenting for diffuse pain. If the ED physician would've suspected pneumonia, he would not order an abdominal CT and start treatment somewhat consistent w/ intraabdominal infection. The only reason I mentioned pneumonia was because that was the reason for admission based on an incapable ED MD. And if it was pneumonia, if I can't assess the patient and after assessment use my clinical judgement + two widely accepted stratification scores to determine outpatient vs inpatient (rather than "borderline") I am not sure what I can do to disqualify it as "borderline."

As for remaining reply, I've been trying to avoid getting into this topic considering it seems like a sensitive subject but keep being pulled back in so might as well join the discussion.

Listen, you can tell yourselves stories about why you let people crap on you, admit patients who shouldn't be admitted (accomplice to fraud whether willingly or because you are afraid of retribution doesn't really matter) cost benefit analyses, deciding which battles, job security, and so on. Personally, I find such behavior overly submissive and harmful in the long run not only to you (because, for example, if you mess up nobody's going to back you up) but to patients (who in best case scenario, get medical bills they shouldn't be getting), hospital medicine, and medicine in general. Do I go into a hospital and proclaim "there's a new sheriff in town"? No. I know my place in the hierarchy and the misfortunes of being a hospitalist, much owing to the notion that "it's just the way it is." Also, I saw some comments "now you know what rural medicine is, it's a learning experience" as if this is my first job in rural medicine or my predicament is a common occurence in rural medicine. It is not. In fact, I've worked all week in that hospital doing just what I did with that ED MD, and a couple of times even had to change disposition based on additional workup I requested that should've been a no brainer to an ED MD. Presenting what happened as a commonality, "that's way it is" is another example of normalization of kneeling before your masters.

As for your value being admissions and discharge, funny thing is that based on metrics, I and other colleagues I've come across who knew what they're doing made the most money to the hospital despite having a backbone. During my very short tenure in this hospital, I reportedly had highest patient turnover. Yet this and other hospitals choose to act the way they do even to high performing physicians not because of your value or your quality as a physician, so let's not pretend that their choice is based on value. Sure, being a modern slave or whatever you wish to call it will increase chances of getting and keeping a job and if this is a price you're willing to pay, all the best.

In any case, thank you for all the useful advice and discussion, everyone who participated. Hopefully my predicament and the information that followed helps someone.

 

[rokshana]

I think you are confusing. I didn't try to lawyer up for this case based on input from you and others in this forum. They recommended to lawyer up for wage theft on a different occasion.

As for fraudulent admission, I admitted a bunch of negative PSI and curb65 as well because they had significant relevant chronic comorbidities, had other acute issues that called for admission despite negative stratification, clinical judgement etc. I don't know about you, but ED ordering CT abdomen for pneumonia.... without young patient having symptoms that are specific for pneumonia and recent diagnosis of treated pneumonia, breathing and satting perfect on room air, relying on CT abd finding without having proof that it is a new finding, and treating patient with flagyl and zosyn (strange combo, especially for CAP) -- shady to say the least. Now if that was a single occurrence, alas, but it is a pattern. This case doesn't constitute fraud by itself and didn't mean to state that this specific case is by itself all that is necessary to prove fraud. Unfortunately, when you had multiple recent hospitalists claiming inappropriate admissions, when ED documentation cites findings that were never there and use those findings to admit only to be later reversed once hospitalist note is in (and they don't always reverse), when locums rep herself admits issues with admissions they're working on resolving, and so on, you have a better case. Also, again, I am not a lawyer but accepting physician has to put admission order, When you admit a patient before discussing with accepting physician--inappropriate, fraud, call it as you may.

We can continue discussing even though these are pretty reasonable, lawful, contractual, and standards of care. You can choose to ignore them for your reasons to "get along with other physicians" etc but having reviewed medical cases for medical board and from personal experience, not sure it is a better alternative.

Not worth haggling with the ED person… it’s like the blue line…they will never admit that there is a terrible ED doc out there practicing.

 

[Osteoth]

I guess the question is OP, was it worth it?

 

[dozitgetchahi]

This case was not borderline pneumonia. It was no pneumonia. It was nothing. Drug seeker presenting for diffuse pain. If the ED physician would've suspected pneumonia, he would not order an abdominal CT and start treatment somewhat consistent w/ intraabdominal infection. The only reason I mentioned pneumonia was because that was the reason for admission based on an incapable ED MD. And if it was pneumonia, if I can't assess the patient and after assessment use my clinical judgement + two widely accepted stratification scores to determine outpatient vs inpatient (rather than "borderline") I am not sure what I can do to disqualify it as "borderline."

As for remaining reply, I've been trying to avoid getting into this topic considering it seems like a sensitive subject but keep being pulled back in so might as well join the discussion.

Listen, you can tell yourselves stories about why you let people crap on you, admit patients who shouldn't be admitted (accomplice to fraud whether willingly or because you are afraid of retribution doesn't really matter) cost benefit analyses, deciding which battles, job security, and so on. Personally, I find such behavior overly submissive and harmful in the long run not only to you (because, for example, if you mess up nobody's going to back you up) but to patients (who in best case scenario, get medical bills they shouldn't be getting), hospital medicine, and medicine in general. Do I go into a hospital and proclaim "there's a new sheriff in town"? No. I know my place in the hierarchy and the misfortunes of being a hospitalist, much owing to the notion that "it's just the way it is." Also, I saw some comments "now you know what rural medicine is, it's a learning experience" as if this is my first job in rural medicine or my predicament is a common occurence in rural medicine. It is not. In fact, I've worked all week in that hospital doing just what I did with that ED MD, and a couple of times even had to change disposition based on additional workup I requested that should've been a no brainer to an ED MD. Presenting what happened as a commonality, "that's way it is" is another example of normalization of kneeling before your masters.

As for your value being admissions and discharge, funny thing is that based on metrics, I and other colleagues I've come across who knew what they're doing made the most money to the hospital despite having a backbone. During my very short tenure in this hospital, I reportedly had highest patient turnover. Yet this and other hospitals choose to act the way they do even to high performing physicians not because of your value or your quality as a physician, so let's not pretend that their choice is based on value. Sure, being a modern slave or whatever you wish to call it will increase chances of getting and keeping a job and if this is a price you're willing to pay, all the best.

In any case, thank you for all the useful advice and discussion, everyone who participated. Hopefully my predicament and the information that followed helps someone.

I think you’ve misunderstood me.

Part of the power you have as a physician is the ability to choose where you work. There are some places in America where I absolutely will not work for any amount of money. For instance, I had a rheumatology job at a multispecialty practice in rural Alabama which involved all you describe and much, much more - at least your despised ED doc wasn’t doing drugs in his office, groping patients and staff while on shift, living in his office and banging random women there at night and leaving used condoms under his desk, and engaging in grossly fraudulent billing that brought in CMS for a major crackdown (but I digress). I promise you, it can get MUCH worse than what you’re describing. The other docs at this practice were way out of control.

I didn’t “submit to my masters” in Alabama in that ****ty job, I GTFO and moved far away and won’t work there ever again. Rural America is often a ****show - rural American *medicine*, even more so. As one doctor, you are not going to have the power or the desire to even remotely clean any of this up. So just get away from it, for the sake of your own sanity and livelihood.

 

[doctorsun]

I guess the question is OP, was it worth it?

Yes, but that is a personal choice and a personal dealing with the consequences. As you can see, there are different "approaches" to practicing hospital medicine, though safe to state the conversation here shows you how grim hospital medicine is, part of the reason most do whatever the can to avoid it, and that it is likely to get worse owing to its complacent population whether because of its submissiveness, priorities, morals, personal experience, reasoning, etc. Summing up the responses -- contracts, medical board, law (btw I think there is a multi-state wide litigation against corporate involvement in medicine in states in which there are already non-applied laws against such involvement, something you should consider supporting), reason, professionalism, your and patient's well being, etc don't matter. Even in ghost town community hospitals. Let me know if you can sum it better.

In this specific case.... I practiced medicine in a rational manner, based on standards of care, and the only way I know and am willing to practice medicine. Could I have admitted patient without assessing and admit a patient that's not supposed to be and hoped for best? Sure. Would something have happened that could've risked patient or myself? Yes but unlikely in single occurrence. You keep doing that -- something will happen for certain and you will pay for it possibly dearly, and sometimes all it takes is one time to derail your career and livelihood. So I did what I did, consequences were some delusional small town idiot who thinks he owns me coming to the realization he does not while I witness it, which was somewhat entertaining. Me being fired for it though only 1 day of service left, which was less entertaining but not a big deal and I couldn't wait to get out of that dump. Also, thanks to the extra time I had after being fired, had time to do some stock analysis, resulting in investing and making $80k nearly overnight. So taking everything into consideration, a resounding YES.

 

[doctorsun]

Rural America is often a ****show

I worked in academic and large hospitals in the past five years. The reason I decided to go locums and rural was my experience in such environments. I am not sure at all that medicine in these large institutions, with all the politics and major league corruption, is that much better if at all, especially for hospitalists. Physician turnover, for example, is highest in academia and for a reason. On the other hand, lowest in private local physician groups, again, for a reason.

 

[mszzeta]

In my previous hospital, the ED to medicine admission is solely decided by the ED physician, and the hospitalist cannot refuse. I thought this would be the norm for all hospitals......

Of course, the hospitalist can just see the patient and discharge right after that......

 

[dozitgetchahi]

I worked in academic and large hospitals in the past five years. The reason I decided to go locums and rural was my experience in such environments. I am not sure at all that medicine in these large institutions, with all the politics and major league corruption, is that much better if at all, especially for hospitalists. Physician turnover, for example, is highest in academia and for a reason. On the other hand, lowest in private local physician groups, again, for a reason.

I agree that there are many structural problems with American medicine as a whole. Don’t even get me started on how I feel about academic medicine. At the end of the day, you have to kinda pick your poison and go with what works best for you, with all its pros and cons. I currently work for a local private group and it’s the best experience I’ve had yet. The last private group I described above…wasn’t. My first job out of fellowship was a hospital job that was horrible - invasive micromanagement by admin, really bad office staff, low pay, etc etc.

 

[Osteoth]

In my previous hospital, the ED to medicine admission is solely decided by the ED physician, and the hospitalist cannot refuse. I thought this would be the norm for all hospitals......

Of course, the hospitalist can just see the patient and discharge right after that......

It’s not the easy ones that get you, it’s the sick ones.

 

[VA Hopeful Dr]

I am slowly learning that rural hospital medicine might suck

Pay is great, but you’re constantly squeezed by the hospital to take more patients to fill their beds, but when something bad happens everyone asks you why you admitted the patient.

There's a reason rural hospitals need so much locums coverage.

 

[doctorsun]

It’s not the easy ones that get you, it’s the sick ones.

Yea... in general. But try to admit a 22yo for something outpatient (for example, one of my admissions this past week was for panic disorder with completely negative workup otherwise for chest pain they admitted overnight without my presence), then medical error and they're in ICU (if there is one). That might draw a lot more attention than the 85yo with multiple comorbidities who gets on your floor without your knowledge and ends in ICU.

Had a youngish 40ish with fulminant hepatic failure. ED didn't even bother consulting GI or checking for toxins, just called me, omitted a few important findings while I was busy rounding. One minute she's mildly drowsy, Ox3, stable, room air, but icteric. A couple of hours later apneustic in a community hospital with quasi-ICU and CC visiting physician who couldn't even discriminate afib from SVT. Consulted GI the moment I saw her labs, and despite her and her multiple family members denying suicide attempt repeatedly, "Are you sure? Pain meds? Tylenol? This will make a big difference and possibly save her life," found out later she attempted to commit suicide at least twice in past. By time we took tylenol level it was low, but GI still thought it was the case (and it may have been.) Gave her NAC, she expired within a couple of hours. There were approximately 30 family members who demanded explanations to what had happened to their "perferctly healthy" relative. The conference room could barely fill them.

 

[doctorsun]

Federal Bankruptcy Court Stays Envision Healthcare Litigation in California | Insights | Holland & Knight

Envision Healthcare Corp. and certain of its subsidiaries recently filed voluntary Chapter 11 petitions in the U.S. Bankruptcy Court for the Southern District of Texas.

www.hklaw.com

Do you remember the last time something good came out of California? Who knows, it might happen....

 

[michaelrack]

Federal Bankruptcy Court Stays Envision Healthcare Litigation in California | Insights | Holland & Knight

Envision Healthcare Corp. and certain of its subsidiaries recently filed voluntary Chapter 11 petitions in the U.S. Bankruptcy Court for the Southern District of Texas.

www.hklaw.com

Do you remember the last time something good came out of California? Who knows, it might happen....

I remember Ronald Reagan coming out of California to win the Presidency (I was a child living in southern california at the time).

 

[doctorsun]

Update: Received first paycheck from them that was a few hundred dollars short but wasn't worth fretting about. Second paycheck - nearly $2k short, I haven't communicated or sought litigation up until now, but inquired them regarding truncated compensation and will take them to small claims if not compensated for my work.