Hot Take: Emergency Medicine should cease to exist as a specialty

[EctopicFetus]

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EM is a failed model because of the way it's been morphed by the health care system as a dumping ground for all it's own inadequacies. So in that sense it's incomplete. But the idea of a true emergency department that only really deals with emergencies is in theory a good idea.

My idea(s) for changing EM are either
1) change EMTALA. You can't go to an ER and ask for a medical screening exam 24/7/365. It has to be reworded.
AND / OR
2) rename all Emergency Departments into "Critical Access Department". It's therefore not an Emergency Department, hence not subject to EMTALA. The only way to get in there is via referral. Can't walk in off the street. So EMS can call to see if we will allow them to bring the drunk person they found in the parking lot (no). Or the 68M with chest pain and EKG changes (yes).
AND / OR
3) ER doctors actually become specialists on call and we can be consulted. We no longer see all the chitt that comes in. The ER themselves can be staffed with dopey IM, FP, NP's, PA's, or anyone else who wants to take the medico-legal responsibility, and the ER doctor who is there can be "consulted" for challenging or real emergency cases.

80% of what we do is chronic disease management and we learn so little of that in residency. Just have us deal with emergencies. unfortunately my ideas above would put a lot of ER doctors out of work.

Discussed this with my resident yesterday. Patient with biliary colic. Seen at outside hospital told outpt follow up.. comes to my ED and wants surgery.

I told said resident the patient wants this cause it is convenient for them. It is inconvenient for the surgeon, the OR staff and is unfair to patient who need urgent/emergent surgery. He felt bad about this and I told him people come here all the time cause they want a knee MRI for 2 years of knee pain. It is not our job to do this for them.

 

[JacobMcCandles]

Discussed this with my resident yesterday. Patient with biliary colic. Seen at outside hospital told outpt follow up.. comes to my ED and wants surgery.

I told said resident the patient wants this cause it is convenient for them. It is inconvenient for the surgeon, the OR staff and is unfair to patient who need urgent/emergent surgery. He felt bad about this and I told him people come here all the time cause they want a knee MRI for 2 years of knee pain. It is not our job to do this for them.

I think it’s all about expectations. Some people just don’t know emergent joint MRIs don’t happen in the ED. Professional athletes don’t even get them. Some people understand once you explain it and some people still remain unreasonable and think they need/deserve one. By far the most frustrating is when someone gets referred to the ED for one by someone else in healthcare, typically urgent care. I’ve called them before to explain we don’t do emergent joint MRIs but then they just complain so you can’t even give these places feedback on your own capabilities so they’re not wasting the patient’s time and money.

 

[deleted239798]

https://www.sciencedirect.com/science/article/pii/S2688115225000086

This is the article. I know it is common in Iowa, we have them in TN. Texas has them..

That study says ‘attending’ coverage so they’re including places that have shifts that are a moonlighting resident only in that 7%. I have heard of some places that only have a midlevel on but they are ultra low volume sites. The idea that because a 1k visit a year place in rural Idaho is NP only at night, the entire field’s going to be replaced by midlevels en masse is just not a real fear.

 

[Torsion]

The cognitive dissonance expressed on this board that A) IM/FM physicians working in the ED are slow and outdated on EM practice and are generally of inferior quality and B) ABEM certified EM physicians are going to be fully replaced with NPs with an online degree, is something to behold.

 

[alpinism]

I mean if we're all being honest EM has already ceased to exist as a distinct specialty for physicians.

Hard truth but people still call it EM cause it sounds cool but in reality it hasn't been EM for many years.

Read any of the history books on EM and it was originally intended to be specialist in resuscitation for staffing the resuscitation room of a hospital who's available for the occasional actively dying crashing patient to start immediate treatment. The whole argument to have it be a specialty was based on the fact that previously hospitals had random docs often with minimal resuscitation knowledge or experience that would see all of these cases and then have to call down a bunch of on call specialists to do all the procedures. The problem with that was that in the meantime patients would often died from treatable causes while they waited for the specialists. The most common examples given were car accident victims with significant traumatic injuries that affected the ABCs such as an occluded airway or tension pneumothorax that could be treated.

So in summary EM was intended to be a specialist in resuscitation that could focus on the crashing patients and lifesaving procedures for the relatively quick timeframe (30 to 60min) before the specialist on call arrived for specialty care (labs and scans) before their admission.

That is quite literally the complete opposite of how EM functions at community hospitals.

 

[alpinism]

Regarding why EM has ceased to exist its complicated and someone could quite literally write a whole text book on the many reasons but the bottom line is that sick patients are not well reimbursed vs not sick patients are well reimbursed. This has lead to a situation where at the moment there is no financial incentive for all the community hospitals to have a specialist that functions to focus on sick patients.

 

[alpinism]

I'm not an EM MD, but I do consult there, so I like to track this board. The whole NP preoccupation is on every board, but here's the thing...there are no NP only emergency departments or inpatient psych units or ORs. The simple fact of the matter is that we didn't go to school forever to deal with simple stuff and the VAST majority of what we see in any specialty is indeed the simple stuff. We're still needed for when that more complex stuff comes in.

The University of Iowa EM department has a NP fellowship program that is literally designed for them to independently work at rural hospitals.

 

[deleted239798]

I mean if we're all being honest EM has already ceased to exist as a distinct specialty for physicians.

Hard truth but people still call it EM cause it sounds cool but in reality it hasn't been EM for many years.

Read any of the history books on EM and it was originally intended to be specialist in resuscitation for staffing the resuscitation room of a hospital who's available for the occasional actively dying crashing patient to start immediate treatment. The whole argument to have it be a specialty was based on the fact that previously hospitals had random docs often with minimal resuscitation knowledge or experience that would see all of these cases and then have to call down a bunch of on call specialists to do all the procedures. The problem with that was that in the meantime patients would often died from treatable causes while they waited for the specialists. The most common examples given were car accident victims with significant traumatic injuries that affected the ABCs such as an occluded airway or tension pneumothorax that could be treated.

So in summary EM was intended to be a specialist in resuscitation that could focus on the crashing patients and lifesaving procedures for the relatively quick timeframe (30 to 60min) before the specialist on call arrived for specialty care (labs and scans) before their admission.

That is quite literally the complete opposite of how EM functions at community hospitals.

Community hospitals? As in the hospitals that don’t have specialist coverage and often have only an emergency med doc in house at night? Where there’s literally nobody to consult for the actual emergencies that come in and you handle it by yourself? I agree we spend the majority of our time not doing high level resuscitation but community hospitals are exactly where you DO get to practice actual EM. And I think your argument extends to any generalist field. IM was not conceived of as a specialty where you are responsible for placing bedbound patients in SNFs. FM was not conceived of as a specialty where you spend hours of your day chasing prior auths. That’s life… not every moment of work is going to be the super awesome exciting stuff, in ANY job.

 

[JacobMcCandles]

I mean if we're all being honest EM has already ceased to exist as a distinct specialty for physicians.

Hard truth but people still call it EM cause it sounds cool but in reality it hasn't been EM for many years.

How has it ceased to exist as its own distinct specialty? What other specialty is trained to do it well? If none then I think that’s the argument that it’s its own distinct specialty. Sure, there’s overlap with other specialties but that’s true for nearly every specialty.

What would you call it instead?

 

[AlmostAnMD]

How has it ceased to exist as its own distinct specialty? What other specialty is trained to do it well? If none then I think that’s the argument that it’s its own distinct specialty. Sure, there’s overlap with other specialties but that’s true for nearly every specialty.

What would you call it instead?

"Convenience medicine"

It's convenient for the dying. It's convenient for homeless needing snacks. Or a pcp that doesn't want to deal with low risk chest pain on a Friday.

 

[JacobMcCandles]

"Convenience medicine"

It's convenient for the dying. It's convenient for homeless needing snacks. Or a pcp that doesn't want to deal with low risk chest pain on a Friday.

I figured that would be the suggestion. While you’re not wrong, I can’t get on board until it officially gets renamed the “Convenience Department”.

 

[Lexdiamondz]

The cognitive dissonance expressed on this board that A) IM/FM physicians working in the ED are slow and outdated on EM practice and are generally of inferior quality and B) ABEM certified EM physicians are going to be fully replaced with NPs with an online degree, is something to behold.

It isn't cognitive dissonance

NPs and PAs are cheaper than physicians and that's the biggest motivator to hire them. An IM or FM doc is still a doc and at the end of the day, so you can't get away with paying them much less than an ABEM certified EM doc.

An IM or FM doc staffing your ER means you're paying the same for something that is generally inferior.

A midlevel staffing your ER means you're getting something inferior, but at least you are paying less for it.

 

[deleted239798]

Hospital I’m at now used to be double or triple coverage. Then Covid happened and now it’s single coverage all day, with either 1 or 2 midlevels. Volume is back to pre COVID but it’s stayed that way. That happened all over the country. My point is, the great midlevel takeover ALREADY happened. Yes there are still some hospitals that maybe could pare back doc coverage some, but they already figured out the minimal doc supervising 1 or 2 PA model and instituted it. You’re a few years late on this particular brand of dooming. Those of you saying it’ll go farther and we’ll have 25k/year sites that do not have surgery in house at night, do not have anesthesia at night, etc, but there’ll be a midlevel who is seeing 2 pph for 12 hours, treating multiple high acuity patients simultaneously, handling airways, taking care of trauma drop offs… I mean it’s detached from reality. All I can guess is that people saying this either work in academics and like many specialists can’t wrap their heads around busy sites that don’t have specialists that you can pawn stuff off on (where yes, an NP could replace a doc, maybe) or work in some very cushy places where they still have robust doc staffing models.

 

[RustedFox]

The cognitive dissonance expressed on this board that A) IM/FM physicians working in the ED are slow and outdated on EM practice and are generally of inferior quality and B) ABEM certified EM physicians are going to be fully replaced with NPs with an online degree, is something to behold.

Is it that far out, though?
Take into account corporate greed and discard all quality standards.

 

[Apollyon]

The cognitive dissonance expressed on this board that A) IM/FM physicians working in the ED are slow and outdated on EM practice and are generally of inferior quality and B) ABEM certified EM physicians are going to be fully replaced with NPs with an online degree, is something to behold.

I would show you exactly that, but I would dox myself.

 

[thegenius]

I would show you exactly that, but I would dox myself.

dox a grifting furu
none of these terms make sense.

first I thought you were going to give yourself doxycycline. Why would you do that if an NP was going to replace you? 🤓

 

[TooMuchResearch]

I think it’s all about expectations. Some people just don’t know emergent joint MRIs don’t happen in the ED. Professional athletes don’t even get them. Some people understand once you explain it and some people still remain unreasonable and think they need/deserve one. By far the most frustrating is when someone gets referred to the ED for one by someone else in healthcare, typically urgent care. I’ve called them before to explain we don’t do emergent joint MRIs but then they just complain so you can’t even give these places feedback on your own capabilities so they’re not wasting the patient’s time and money.

Professional athletes get them same day at the specialist that manages the team injuries.

 

[Apollyon]

Professional athletes get them same day at the specialist that manages the team injuries.

And, when I was a resident, one of the guys a year behind me knew an NHL goalie from his hometown, and got him an MRI on a Sunday, at Duke. I don't know if Duke Ortho saw him or not (it was a knee).

 

[TooMuchResearch]

The truth is, even a lowly EP such as myself can get a same day MRI at one of multiple local full service orthopedic walk in clinics.

 

[JacobMcCandles]

Professional athletes get them same day at the specialist that manages the team injuries.

That goes against pretty much all news reports we see, especially in the NFL. Injury happens on Sunday then get MRI and results on Monday. I’m sure there have been some that have gotten same day MRIs but that doesn’t seem to be the norm.

 

[DeadCactus]

The hospitals and communities are happy to have my group in the smaller towns, providing emergent services and arranging safe dispositions.

Of course they're happy. They'd probably be even happier if there were so many of us that it started becoming economically viable to have physician response vehicles in every EMS system. They would be happy to have dermatologists and cardiologists too. But dermatology didn't ramp up production to make sure every critical access hospital can have a dermatologist on-call and cardiology isn't pushing for a 3 year training program to increase the number of Comprehensive Cardiac Centers in rural areas. Our specialty suffered because we became a community specialty available everywhere rather than a specialist field only available at referral centers. We have been left clamoring to work nights, weekends, and holidays under the constant threat of violence and disrespect without the pay or geographic control of similarly challenging specialties.

It's fair to ask, "But what about patient care?" Personally, I don't think the answer is as simple as having an emergency physician in every emergency department would clearly be the best for patient care. By not branding ourselves as a specialist, we've taken a back seat in our own field. No one cares what we think. They ask trauma about trauma issues, cardiology about cardiology topics, anesthesia about airway, etc. The house of medicine throws our opinions into the same bucket as primary care providers and probably even PA/NP's; generalist medical providers with no real expertise or authority. I really question if patient care would not have ultimately been better by having emergency physicians only at major "Certified Emergency Care Centers" (or whatever we would brand it) and used that institutional authority to better influence patient care along the entire emergency care chain.

I say this all as someone who still views emergency medicine positively as profession. But I think we are underappreciated by society and the broader medical profession. The first step toward fixing that is respecting ourselves and that starts with viewing ourselves as a high quality, limited resource.

 

[AlmostAnMD]

The first step toward fixing that is respecting ourselves and that starts with viewing ourselves as a high quality, limited resource.

Soft disagree

that, I'm sure is a part of the equation

but the bigger issue, as I previously mentioned, is EM being on an island. Other people--admin, insurance, nurses--do not view us as a high quality, limited resource. They clearly view us as an expendable quantity. Perception is largely guided by how others perceive you, not necessarily how you perceive yourself. Getting other people to buy into the vision is the real hill to climb. And how that's accomplished I can only shrug my shoulders.

 

[xaelia]

Imagine, say, a future in which Medicare decides it will pay crappy ol' NP rates for all ED care, excepting it will pay full RVUs to an emergency physician for patients meeting criteria for critical care time (or some permutation such as this). All of a sudden, the staff makeup and model of care for an ED would change dramatically.

Play around with the financial levers in play, you can change who delivers, and how care is delivered.

 

[comp1]

https://www.sciencedirect.com/science/article/pii/S2688115225000086

This is the article. I know it is common in Iowa, we have them in TN. Texas has them..

This is a great article. It shows there are literally 10 EDs (0.2% of responding) in the country that didn't have 24/7 access to an MD. I think it supports my point that NPs are not running EDs by themselves. I definitely would like to know more about the structure of those 10, but I think it's also reasonable to guess that the directors' answers might simply be erroneous.

 

[DeadCactus]

Soft disagree

that, I'm sure is a part of the equation

but the bigger issue, as I previously mentioned, is EM being on an island. Other people--admin, insurance, nurses--do not view us as a high quality, limited resource. They clearly view us as an expendable quantity. Perception is largely guided by how others perceive you, not necessarily how you perceive yourself. Getting other people to buy into the vision is the real hill to climb. And how that's accomplished I can only shrug my shoulders.

I mean that's my point. We put out 3,000 emergency physicians a year trained in the least amount of time possible. Those choices were driven, or at least supported, by the idea that every emergency department needed to be staffed by emergency physicians. If every emergency department is staffed by emergency physicians, then there is nothing special about emergency physicians. We are a widget, a role to be filled as cheaply as possible as part of doing business. No different than the electrical bill or the janitorial team.

But put out 300 emergency physicians a year? Now you've made it so only a fraction of emergency departments can be full staffed by emergency physicians. Make the training 4 or 5 years so we're more akin to anesthesia, neurology, psychiatry, etc. and the house of medicine views us as experts instead of in the same pool as family medicine, pediatrics, and internal medicine. Now hospital A can advertise their emergency department is fully staffed by specialty emergency experts and hospital B can't. Maybe they can get a special certification for it. Maybe their ability to be a level 1 trauma center, comprehensive cardiac center, or comprehensive stroke center depends on keeping a full emergency medicine staff. Now suddenly it affects revenue and prestige and patient recruitment; now suddenly emergency medicine matters.

 

[EctopicFetus]

I mean that's my point. We put out 3,000 emergency physicians a year trained in the least amount of time possible. Those choices were driven, or at least supported, by the idea that every emergency department needed to be staffed by emergency physicians. If every emergency department is staffed by emergency physicians, then there is nothing special about emergency physicians. We are a widget, a role to be filled as cheaply as possible as part of doing business. No different than the electrical bill or the janitorial team.

But put out 300 emergency physicians a year? Now you've made it so only a fraction of emergency departments can be full staffed by emergency physicians. Make the training 4 or 5 years so we're more akin to anesthesia, neurology, psychiatry, etc. and the house of medicine views us as experts instead of in the same pool as family medicine, pediatrics, and internal medicine. Now hospital A can advertise their emergency department is fully staffed by specialty emergency experts and hospital B can't. Maybe they can get a special certification for it. Maybe their ability to be a level 1 trauma center, comprehensive cardiac center, or comprehensive stroke center depends on keeping a full emergency medicine staff. Now suddenly it affects revenue and prestige and patient recruitment; now suddenly emergency medicine matters.

Any of the downstream asks wont happen. Nothing in it for the hospitals. Everyone has an opinion on some special award if there are EM trained people there. That being said what you are asking is for hospitals to police themselves and make things harder on themselves. Thats not realistic.

They want to clamp down on docs yet be as free as possible to do what they want while they maximize $$.

 

[EctopicFetus]

This is a great article. It shows there are literally 10 EDs (0.2% of responding) in the country that didn't have 24/7 access to an MD. I think it supports my point that NPs are not running EDs by themselves. I definitely would like to know more about the structure of those 10, but I think it's also reasonable to guess that the directors' answers might simply be erroneous.

The article they did sucks cause they included residents being on as some inferior person to attendings which shunted the numbers. Thats being said the number isnt 10. This is a significant number of EDs in Iowa, South Dakota etc.

Also, based on their attending physician model I can tell you the data is off. I now of hospitals in Nevada that will staff an NP only and I am sure there are plenty where residents moonlight alone meaning no way the number is 0.

 

[DeadCactus]

Any of the downstream asks wont happen. Nothing in it for the hospitals. Everyone has an opinion on some special award if there are EM trained people there. That being said what you are asking is for hospitals to police themselves and make things harder on themselves. Thats not realistic.

They want to clamp down on docs yet be as free as possible to do what they want while they maximize $$.

I’m asking for the market to police hospitals. Hospitals clamor for all sorts of merit badges or advertising claims to separate themselves from the competition and draw in patients and referrals. Emergency medicine would be one of those if we weren’t so ubiquitous.

 

[RustedFox]

This is a great article. It shows there are literally 10 EDs (0.2% of responding) in the country that didn't have 24/7 access to an MD. I think it supports my point that NPs are not running EDs by themselves. I definitely would like to know more about the structure of those 10, but I think it's also reasonable to guess that the directors' answers might simply be erroneous.

Yeah bro, there's 10 in one state that I know of alone.

 

[comp1]

Yeah bro, there's 10 in one state that I know of alone.

Name and shame. I'd love to see what their websites say.

 

[RustedFox]

Name and shame. I'd love to see what their websites say.

Look around Pennsylvania.
That's all I'm gonna say.
I got reasons.

 

[EctopicFetus]

I’m asking for the market to police hospitals. Hospitals clamor for all sorts of merit badges or advertising claims to separate themselves from the competition and draw in patients and referrals. Emergency medicine would be one of those if we weren’t so ubiquitous.

Nah.. it’s convenience and the perception of quality. No one is worried if you are a chest pain center or anything else. We just had a traumatic eye injury sent in by a doctor. He asked for them to see ophtho.. we have no ophtho.. Even physicians have no idea.. the general public is even more clueless.

 

[xaelia]

We just had a traumatic eye injury sent in by a doctor. He asked for them to see ophtho.. we have no ophtho.. Even physicians have no idea.. the general public is even more clueless.

'round these parts, if a GP sends a patient to the ED to see ophtho ... and they didn't call ophtho ahead of time to accept the referral, they get a demerit.

(not literally)

(but they'll get Constructive Feedback)

 

[dozitgetchahi]

I actually disagree with you on this. One of the things that makes AI different from previous technologies is that you can actually train it on visual data. Feed it 10,000 interviews of patients and tell it which patients are in distress or not, and I guarantee it's going to be able to pick out the subtle visual cues indicating if "something is going on". It could be much more accurate than most of us given enough data and "training". It can even count respirations, look at facial expressions etc. Simultaneously while interviewing the patient it can review the chart for past visits/imaging and make a plan in real time while.

In theory, yea.

In reality, this is way off at best.

 

[xaelia]

In theory, yea.

In reality, this is way off at best.

Here you go:

Hospitalization prediction from the emergency department using computer vision AI with short patient video clips - npj Digital Medicine

In this study, we investigate the performance of computer vision AI algorithms in predicting patient disposition from the emergency department (ED) using short video clips. Clinicians often use “eye-balling” or clinical gestalt to aid in triage, based on brief observations. We hypothesize that...

www.nature.com

 

[Old_Mil]

The face you make when you realize that the move to a four year residency is driven by the desire to have more warm bodies, cheaper, for longer.

🤔

The fundamental disconnect in the specialty is that the training is focused on emergency medicine while hospital administrators want the maximum volume of meat moved by the conveyor belt for the lowest cost.