How often does EM diagnose?

[3bamboo]

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Obviously I have a long way before residency but I am curious about the chain of events in the emergency room/ hospital.

Let say a kid presents with a semi-rare disorder that is causing a moderate amount of problems (take your pick). Is the purpose of the EM to stabilize him as much as possible and spend a good deal of time ruling out common and rare disorders. Or is the purpose to stabilize him, then after ruling out only the most common disorders, admit him.

If it is the latter, then who takes over after the kid has been admitted? Does the EM doc just send him away and assign a particular specialist take over?

 

[WilcoWorld]

I diagnose many diseases per shift. The really fun ones are the zebras I catch that others have missed. I'd bet ED docs are better at diagnosing undifferentiated things like altered mental status or "found down" than any other service. That being said, diagnosis is not my top priority. Disposition is my top priority. If I can't get the diagnosis within a timely ED stay, then I'm not going to get the diagnosis. You'll have to be OK with that if you want to have longevity in EM.

 

[Arcan57]

Obviously I have a long way before residency but I am curious about the chain of events in the emergency room/ hospital.

Let say a kid presents with a semi-rare disorder that is causing a moderate amount of problems (take your pick). Is the purpose of the EM to stabilize him as much as possible and spend a good deal of time ruling out common and rare disorders. Or is the purpose to stabilize him, then after ruling out only the most common disorders, admit him.

If it is the latter, then who takes over after the kid has been admitted? Does the EM doc just send him away and assign a particular specialist take over?

We rule out the life-threatening things and resuscitate if needed. If kid is sick enough to be admitted, then care is transferred over to the doctor that will be the attending as an in-patient. If pediatric in-patient or specialists services are not available at your hospital, they get transferred to a hospital that does have those services.

Some semi-rare or rare diseases cause immediate threats to life or limb. Some of these diseases are readily apparent by history and physical and basic lab tests (epiglottitis, DKA, etc), others we need to initiate treatment or move to higher level of care prior to having an actual diagnosis (suspected bacterial meningitis, neonatal fever, undiagnosed urea cycle defects,etc).

There's no one that's going to tell you that the kid has to stay in the ED until a definitive diagnosis has been made (in fact, in contrast to the adult side, pediatricians' first instinct is to get very sick patients out of the ED), although people will get upset if you haven't started resuscitation or checked/treated the more common causes of severe pediatric illness (sepsis, hypovolemia, hypoglycemia,etc.)

 

[la gringa]

semi-rare disorders? if it can't be diagnosed on the H&P, blood work that comes back in the ED, US, or CT... very rarely.

i do often diagnose things other providers have missed. not often rare things, usually just common things that people aren't describing well, or that are becoming clearer with time or lack of response to treatment.

 

[Colbert]

I'd say we're pretty damn good at diagnosis. That being said, there are a lot of tests, blood and otherwise, that don't return within the 4 hour time frame that most ER patients are expected to be disposed by. Like others said, my main priority is where is this patient going to go? I don't loose a minute of sleep at night admitting a patient who is ill but I don't know why or discharging someone who's very unconcerning complaint I can't answer. That's the reason that inpatient doctors and outpatient follow up exist.

 

[e30ftw]

EM docs probably make more overall diagnoses than any other physician. Sometimes it's "chest pain without evidence of acute MI" or "abdominal pain" but often it's specific dx that determine future management.

as said above though, dispo is king. If my 20 labs, cxr, ekg, head ct, LP, etc don't show a specific diagnosis on an AMS patient and the patient is still altered, they're getting admitted under "altered mental status". Most of the time these never get figured out anyway, but either way it doesn't bother me in the slightest not figuring it out because I still knew enough to admit the patient and there are many patients still to be seen.

PE and aortic dissection are diseases w/ relatively low overall prevalence but should be "common" to EM because we're looking for them.. same goes for a lot of other less common but high morbidity pathologies.

The whole host of rare chronic non-life threatening disorders which may affect daily life but have no time limitations or emergent risk I honestly don't care about ever diagnosing or really knowing about except in how it affects my evaluation of emergent disease (ie, knowing that if a pt w/ cp has anti-phospholipid ab d/o they need closer PE consideration).

 

[dotcb]

We do make a lot of diagnoses, but to me that is not what is most satisfying in the field - it's stabilizing the patient and getting them what they need. If that's me - great, but if it's a specialist - hey, that's great too.

If your goal is to diagnose rare diseases, I'd suggest an internal med or peds subspecialty, neurology, or pathology. Personally, I find it a better strategy to choose your field by which bread and butter you like.

gallbladders, hernias, appendix
acne, rosacea. skin cancer
runny noses, growth monitoring, vaccinations
stroke, seizure
tonsils, ear tubes, nasal polyps
elderly weak and dizzy, diabetes, hypertension
depression, anxiety, stress
broken ankles, wrists, and hips
boob jobs, tummy tucks, skin lesion removal
intoxicated people, trauma, _____ pain (that's us)

 

[goodoldalky]

gallbladders, hernias, appendix, runny noses, stroke, seizure, elderly weak and dizzy, diabetes, hypertension, depression, anxiety, broken ankles, wrists, and hips, intoxicated people, trauma, _____ pain (that's us)

Fixed for you

 

[dotcb]

True dat - thanks.

 

[Xerxes1729]

You will make more definitive diagnoses as you become more of a subspecialist. The reason you do that is not because you're smarter or better but because, on their way to see you, patients pass through the hands of many other physicians who rule out everything that's outside your area of expertise.

Let's say someone calls his internist because he's passed out three times today. The internist listens to the story, thinks it sounds concerning, and tells him to go to the ED. I do my H&P, and agree. I can rule out PE, anemia, severe electrolyte abnormalities, obvious EKG findings, associated traumatic injuries, and establish that the episodes aren't likely to be seizures, but if I'm concerned for cardiogenic syncope, I admit the patient. The hospitalist will monitor him on telemetry for further arrhythmias and order an echocardiogram. The cardiologist who reads the echo rules out HOCM, and takes a more detailed family history which is concerning. He refers the patient to an electrophysiologist who gives the patient flecainide in the EP lab and demonstrates that he has type I Brugada syndrome. Sure, the electrophysiologist "made" the diagnosis, but she only got to see the patient because everyone else along the chain did their job.

People like to rag on emergency physicians as being "glorified triage nurses", but the only reason we are able to tell someone that he needs to see a neurosurgeon and not a urologist for his urinary retention is because we're able to sort through huge numbers of possible diagnoses and eliminate a hell of a lot of them.

 

[Bostonredsox]

I diagnose many diseases per shift. The really fun ones are the zebras I catch that others have missed. I'd bet ED docs are better at diagnosing undifferentiated things like altered mental status or "found down" than any other service. That being said, diagnosis is not my top priority. Disposition is my top priority. If I can't get the diagnosis within a timely ED stay, then I'm not going to get the diagnosis. You'll have to be OK with that if you want to have longevity in EM.

this.

as one of the ed attendings told me here when he was giving me a patient I at that time in my youthful career felt was not properly worked up..."its not my job to figure out whats wrong with him, Its my job to figure out whether he can go home or whether he needs to come in. He needs to come in. Its your job to figure out the rest."

sort of a gross generalization of a poor ED doc, but in general, IMO, ED docs stabilize unstable pts as best as can be in the dept, find the pts that have something wrong that can kill them, send the pts that do not have acute problems that require inpt treatment or observation home, and anything in the grey zone they ask for the hospitalists opinion and we come to a mutual decision of safe to go home or yeah i agree with you i'll admit him. If during the workup they discover a new diagnosis thats great and a testament to a good physician, but its not the main goal.

classic example is shortness of breath 71 year old. Typical ed docs eval will look for the things that will kill a pt. PTX, PE, MI, dissection, impending arrest from hypercarbic failure. from there, ok its not a lethal issue, but this dyspnea is concerning and may need inpt treatment. H/O COPD and CHF. Film is a bit wet but shes wheezy as all get out. slight fever. wbc up. no infiltrate but story fits for PNA.

Bam done. this patient meets most all admission criteria and I will accept this pt without question. ED doc may not know yet exactly what the true source is but hes excluded alot of major things that can kill the pt and narrowed the diagnosis down to help me guide treatment. So to answer your question, sometimes the complete dx is elucidated. CHF is florid pulmonary edema, pt is sitting up 90 degress gasping, BNP is 2k and prior echo in computer has ef 30%. Boom acute decompensated chf. other times its like i described. maybe a touch of diastolic failure, defininte COPD exac, but high prob of pna too.

both of them get admitted. and IMO both have been worked up effectively. The full dx is not always there though and thats ok.

 

[Arcan57]

this.

as one of the ed attendings told me here when he was giving me a patient I at that time in my youthful career felt was not properly worked up..."its not my job to figure out whats wrong with him, Its my job to figure out whether he can go home or whether he needs to come in. He needs to come in. Its your job to figure out the rest."

sort of a gross generalization of a poor ED doc, but in general, IMO, ED docs stabilize unstable pts as best as can be in the dept, find the pts that have something wrong that can kill them, send the pts that do not have acute problems that require inpt treatment or observation home, and anything in the grey zone they ask for the hospitalists opinion and we come to a mutual decision of safe to go home or yeah i agree with you i'll admit him.

Actually, anything in the grey zone we decide what needs to be done and disposition the patient accordingly. I haven't worked in a hospital since residency that had the ability to block an admit from the ED. It's not the hospitalist that's useful in helping me with the decision (I'm well aware of the resources available to the patient in-house) but whether the PCP can provide appropriate outpt care, FWIW.

 

[Apollyon]

this.

as one of the ed attendings told me here when he was giving me a patient I at that time in my youthful career felt was not properly worked up..."its not my job to figure out whats wrong with him, Its my job to figure out whether he can go home or whether he needs to come in. He needs to come in. Its your job to figure out the rest."

sort of a gross generalization of a poor ED doc

Aren't you a PGY-2? Your career is STILL youthful (unless you are 1 month into PGY-3 - same applies).

Your commonly-held opinion that it is a poor EM physician who says that it is not his/her job that says that their place is not to figure out what is wrong, but binarily to decide admit or DC, is misplaced. You might disagree with the words, but you sound as if you are not happy with doing the diagnosing. When I was a resident, the IM program director asked my PD to not have us be so thorough, because we weren't leaving his residents with anything to do besides babysit and find articles.

Sometimes, I will present you with a pt with a big bow on them, but not always, and to say I am poor at my job because I don't have all of the nuances is disingenuous.

Are you familiar with the golf analogy? We tee off (see the patients). We want to stay on the course, and no go out of bounds or into the rough, and get the ball (the patient) to the green, and someone else comes in to putt. Occasionally, we'll hole out, but not always, but we have to get on to the next hole, and we don't usually have time to 3 or 5 putt.

I don't have the luxury of a hospitalist, or a resident on whom I can dump liberally. I get crusty old IM docs that want to retire, but also want to squeeze as much money out as they can at the end, so I have to fight and fight for the right thing to be done (and, when I couldn't admit an ultrasound-proven cholecystitis - because of no fever or white count in an 82 year old guy, and who came back 2 days later and got admitted - I realized HOW crusty some of these guys are), and still have to kiss PG butt. So, even when I DO make the diagnosis, it's like when Hannibal beat the Romans - they just would NOT surrender. Even when I am right, it doesn't matter.

 

[Bostonredsox]

Aren't you a PGY-2? Your career is STILL youthful (unless you are 1 month into PGY-3 - same applies).

Your commonly-held opinion that it is a poor EM physician who says that it is not his/her job that says that their place is not to figure out what is wrong, but binarily to decide admit or DC, is misplaced. You might disagree with the words, but you sound as if you are not happy with doing the diagnosing. When I was a resident, the IM program director asked my PD to not have us be so thorough, because we weren't leaving his residents with anything to do besides babysit and find articles. Sometimes, I will present you with a pt with a big bow on them, but not always, and to say I am poor at my job because I don't have all of the nuances is disingenuous.
Are you familiar with the golf analogy? We tee off (see the patients). We want to stay on the course, and no go out of bounds or into the rough, and get the ball (the patient) to the green, and someone else comes in to putt. Occasionally, we'll hole out, but not always, but we have to get on to the next hole, and we don't usually have time to 3 or 5 putt.

I don't have the luxury of a hospitalist, or a resident on whom I can dump liberally. I get crusty old IM docs that want to retire, but also want to squeeze as much money out as they can at the end, so I have to fight and fight for the right thing to be done (and, when I couldn't admit an ultrasound-proven cholecystitis - because of no fever or white count in an 82 year old guy, and who came back 2 days later and got admitted - I realized HOW crusty some of these guys are), and still have to kiss PG butt. So, even when I DO make the diagnosis, it's like when Hannibal beat the Romans - they just would NOT surrender. Even when I am right, it doesn't matter.

Not sure what you inferred from my post, but clearly you missed the message.

Yes I am youthful, I am a PGY3, and I was pointing that out to the OP so he would understand that my opinion was that of someone with limited experience thus far.

The entire point of my post was that it is very common for EM to not make the diagnosis. And thats ok. Thats why I have a job. Sometimes the dx is clearly made and thats great, but usually it isnt and thats fine. As I stated its not your job to make the dx, its your job to determine if the pt needs to be admitted or not and anything else you do just helps me out that much more.

honestly do not know what to make of your post. It really does not make any sense to me. In know way, shape or form was I saying I expect a "big bow" on the patients. In fact I have come to expect the opposite. However, even if the ED docs here were good, I still wouldnt expect a big bow, as thats not your job...which is fine.

Again, not really sure what the hell your talking about.

 

[Bostonredsox]

Actually, anything in the grey zone we decide what needs to be done and disposition the patient accordingly. I haven't worked in a hospital since residency that had the ability to block an admit from the ED. It's not the hospitalist that's useful in helping me with the decision (I'm well aware of the resources available to the patient in-house) but whether the PCP can provide appropriate outpt care, FWIW.

I suppose thats facility dependent. Here, when the ED docs are on the fence about sending home vs bringing in they usually ask us to see the pt and see what we think. 9/10 the patient was admitted. Administration put a stop to that because they want every pt admitted. They actually incentivize the ED docs here based on their admission #s. Its all about revenue generation here, to hell with patient care. So now ED determines all admissions and we just take what were handed. I am primarily in the ICU and rarely on wards so all of the pts I admit are obviuosly the real deal but it does get a bit annoying admitting a 58 y/o with CP who had a negative lexi cardiolyte 2 months ago just so the hospital can collect for his observation stay.

 

[Groove]

Last I checked, I need an ED diagnosis on my charts to get coded and billed properly. I can't remember the last admission where I told the hospitalist " yo man, it's ED cowboy here, I don't know wtf, but dude can't go home, you cool with a full admit or you wanna obs this cat? " 😀

 

[KLPM]

Obviously I have a long way before residency but I am curious about the chain of events in the emergency room/ hospital.

Let say a kid presents with a semi-rare disorder that is causing a moderate amount of problems (take your pick). Is the purpose of the EM to stabilize him as much as possible and spend a good deal of time ruling out common and rare disorders. Or is the purpose to stabilize him, then after ruling out only the most common disorders, admit him.

If it is the latter, then who takes over after the kid has been admitted? Does the EM doc just send him away and assign a particular specialist take over?

EM doctors make diagnosis like every other doc. All docs make diagnoses it's just different conditions prevail within different specialties. When rotating through ED you see conditions from head-to-toe BUT the role of ED is to decide wherever the customer currently has a potentially life-threatening problem (hence the triage list). The reason EM docs consult other specialties is not just to consolidate clinical impressions but also because management plans may involve the expertise of another doc. The great people of ED stabilise the patient and give everyone else a starting point.

I am not sure why you said "semi-rare disorder". Do you want a specialty where you can find loads of zebras? Then you are probably better off in pathology, radiology or neurology. Is neuroblastoma rare enough? We had a kid coming through ED a while ago with that. I have seen many EM docs catch rare disorders and many miss rare disorders but hey that's just life and applies to everyone.

 

[Arcan57]

I suppose thats facility dependent. Here, when the ED docs are on the fence about sending home vs bringing in they usually ask us to see the pt and see what we think. 9/10 the patient was admitted. Administration put a stop to that because they want every pt admitted. They actually incentivize the ED docs here based on their admission #s. Its all about revenue generation here, to hell with patient care. So now ED determines all admissions and we just take what were handed. I am primarily in the ICU and rarely on wards so all of the pts I admit are obviuosly the real deal but it does get a bit annoying admitting a 58 y/o with CP who had a negative lexi cardiolyte 2 months ago just so the hospital can collect for his observation stay.

If the residents have a clinic where they can guarantee outpatient f/u (or at least its availability) then having them involved in a discussion about whether to admit the borderline cases has some value. If a patient currently doesn't have the ability to care for their condition at home, having a hospitalist tell me they won't admit but also can't/won't offer another alternative is not so useful. We're trained to make correct dispositions, and pawning that decision off on a doctor that has no pre-existing relationship with the patient (and thus no unique knowledge of the patient's situation) is an abdication of our role as emergency physicians.

In regards to the chest pain r/o's, what's the negative predictive value of a neg. cardiolyte scan 2 months ago on whether the patient's chest pain today is cardiac in nature? And does that drop the pre-test probability of death, MI, revascularization below 1%? There are definitely places and situations where everyone is ok with ruling out infarction and the ischemia w/u can be done as an outpatient. But that's completely system dependent. In Texas, I'm all over sending home poor stories with 2 sets of neg. cardiac markers in the ED with urgent outpt f/u. In a lot of the country the standard of care is still to rule out ischemia (hence getting all those useless stress tests in the first place) in the hospital, and thus you have frequent re-admissions because our ability to r/o unstable angina without a recent normal cath is too poor to take the medicolegal risk of sending out 5% of patients who will come back with one of the triple-composite endpoints.

 

[deleted547339]

Last I checked, I need an ED diagnosis on my charts to get coded and billed properly. I can't remember the last admission where I told the hospitalist " yo man, it's ED cowboy here, I don't know wtf, but dude can't go home, you cool with a full admit or you wanna obs this cat? " 😀

I had an admit that was somewhat like this one night this weekend, lol. Something along the lines of "I don't know what's wrong with cancer guy, but homeboy needs to come in."

 

[docB]

Last I checked, I need an ED diagnosis on my charts to get coded and billed properly. I can't remember the last admission where I told the hospitalist " yo man, it's ED cowboy here, I don't know wtf, but dude can't go home, you cool with a full admit or you wanna obs this cat? " 😀

I actually do this quite a bit. For example the 80 yo with acute onset of too weak to get OOB. They look like crap. Work up is a little off but not enough to explain the acute change. UA ok, lytes ok mostly, CTH ok, CXR nl. I'll call the hospitalists and say "I don't know what it is but they're sick."

I have a really good relationship with most of my hospitalists so they know if I'm saying that the guy really does look sick and an appropriate work up was done so it works out.

 

[WilcoWorld]

It took me awhile to become comfortable with not knowing exactly what was wrong with a patient. ("What do you mean the diagnosis is 'headache"?) But after I started routinely following up on patients I admitted without a clear diagnosis, I realized that a lot of patients will be discharged without a clear diagnosis. Syncope patients will get an echo, a head CT, 24 hours on tele, a Neuro and a Cardiology consult, and their final diagnosis is "syncope and collapse". Septic patients who I admitted to the ICU get an ID consult, their cultures get 72 hours to grow, and several days to declare themselves. But you read the discharge summary, and what does it say, in essence? "The patient got better and we sent her home."

So be warned, while the folks upstairs like to act as if the ED docs are the only ones who "don't diagnose", it's actually done by every specialty that doesn't have the luxury of refusing to see any patient that isn't pre-packaged and served up with an MRI-confirmed diagnosis.

 

[e30ftw]

So be warned, while the folks upstairs like to act as if the ED docs are the only ones who "don't diagnose", it's actually done by every specialty that doesn't have the luxury of refusing to see any patient that isn't pre-packaged and served up with an MRI-confirmed diagnosis.

Exactly. I frequently look up the DC summary of patient's I've admitted without figuring out what was going on.. most of the time the admitting team didn't figure it out either, and the patient just ended up with a bunch of CSF studies for arbo/entero/hanta viruses and a bunch of send out labs that were all negative and then after 2 days in the hospital when back at baseline the patient is just discharged with a diagnosis of "likely viral encephalitis" or something like that.

The most common "exact" diagnosis I get after looking up inpatients is probably from MRI results in patient's with nonspecific neuro symptoms that could be lacunar/thalamic infarct or MS/psych, etc. Of course, I order the MRI in the ED and then it's done the next day showing the diagnosis. I guess if medicine wants to get fancy they can order the bubble study but usually i just order that on the admit orders as well...

the problem is not that EM physicians aren't smart enough to figure out which labs/imaging to order. Most of the time we know the next step in getting to a diagnosis. The problem is time constraints. If the patient has been taking up an ER bed for 3 hours, they need to either be admitted or sent home. There are too many other patients in the waiting room who could crump at any minute for someone to hold in the ED waiting for another round of labs to result. i don't have time to be worried by "not getting the exact diagnosis in 3 hours" because I'm too focused on the sick patients who are still completely undifferentiated coming in by ambulance/triage.

 

[evilbooyaa]

It took me awhile to become comfortable with not knowing exactly what was wrong with a patient. ("What do you mean the diagnosis is 'headache"?) But after I started routinely following up on patients I admitted without a clear diagnosis, I realized that a lot of patients will be discharged without a clear diagnosis. Syncope patients will get an echo, a head CT, 24 hours on tele, a Neuro and a Cardiology consult, and their final diagnosis is "syncope and collapse". Septic patients who I admitted to the ICU get an ID consult, their cultures get 72 hours to grow, and several days to declare themselves. But you read the discharge summary, and what does it say, in essence? "The patient got better and we sent her home."

So be warned, while the folks upstairs like to act as if the ED docs are the only ones who "don't diagnose", it's actually done by every specialty that doesn't have the luxury of refusing to see any patient that isn't pre-packaged and served up with an MRI-confirmed diagnosis.

Some diagnoses are essentially matters of exclusion. If someone has syncope in the ED, they generally get admitted for a w/u. If the w/u is negative and doesn't show cardiogenic/neurologic/orthostatic syncope, you leave it as idiopathic syncope. Pts in florid sepsis patients admitted to the ICU generally get treated with Abx, and blood cultures will give a diagnosis. Not sure what you're going for there.

 

[Arcan57]

Some diagnoses are essentially matters of exclusion. If someone has syncope in the ED, they generally get admitted for a w/u. If the w/u is negative and doesn't show cardiogenic/neurologic/orthostatic syncope, you leave it as idiopathic syncope. Pts in florid sepsis patients admitted to the ICU generally get treated with Abx, and blood cultures will give a diagnosis. Not sure what you're going for there.

That we don't have to feel bad about admitting patients without a clear cut diagnosis because it's not uncommon that they leave the hospital without a clear cut diagnosis.

And my experience tracks with Wilco and e30ftw's. When I look at the H&P, labs, diagnostic tests, and read the d/c summary on the cases that stumped me in the ED it's rare that there was any significant deviation in the plan of care I had in my head when I was writing the admit orders.

 

[WilcoWorld]

Not sure what you're going for there.

Arcan got it right. My post wasn't a criticism of inpatient services, it was an observation on the typical clinical course of patient's who get admitted without a clear diagnosis.

 

[Bostonredsox]

If the residents have a clinic where they can guarantee outpatient f/u (or at least its availability) then having them involved in a discussion about whether to admit the borderline cases has some value. If a patient currently doesn't have the ability to care for their condition at home, having a hospitalist tell me they won't admit but also can't/won't offer another alternative is not so useful. We're trained to make correct dispositions, and pawning that decision off on a doctor that has no pre-existing relationship with the patient (and thus no unique knowledge of the patient's situation) is an abdication of our role as emergency physicians.

In regards to the chest pain r/o's, what's the negative predictive value of a neg. cardiolyte scan 2 months ago on whether the patient's chest pain today is cardiac in nature? And does that drop the pre-test probability of death, MI, revascularization below 1%? There are definitely places and situations where everyone is ok with ruling out infarction and the ischemia w/u can be done as an outpatient. But that's completely system dependent. In Texas, I'm all over sending home poor stories with 2 sets of neg. cardiac markers in the ED with urgent outpt f/u. In a lot of the country the standard of care is still to rule out ischemia (hence getting all those useless stress tests in the first place) in the hospital, and thus you have frequent re-admissions because our ability to r/o unstable angina without a recent normal cath is too poor to take the medicolegal risk of sending out 5% of patients who will come back with one of the triple-composite endpoints.

We have excellent outpt followup. An FP resident clinic....across the street from the ED doors....an IM resident clinic, very receptive cardiologists who will see the 2 negative set clean ekg in 48 hours. Regardless of this, they all get admitted. The reason is simple. The hospital doesnt get paid for that followup in clinic tomorrow. They get paid if they get admitted for observation. They want cheddar. standard of care and best practice are irrelevant here. not the ed docs fault, though the more recent ones who are much better doc IMO actually stand up to admin and say no, this pt meets no criteria for admission, im sending them home. Its nice to see that.

 

[3bamboo]

very useful information thanks guys!

 

[evilbooyaa]

Arcan got it right. My post wasn't a criticism of inpatient services, it was an observation on the typical clinical course of patient's who get admitted without a clear diagnosis.

Ah, OK. Initially sounded to me like inpatient docs don't do anything besides sit around then discharge the patient with the same diagnosis they came in with. My bad. Carry on.