I have an emergency! Five o'clock okay?

[BlackDynamite]

---

Members don't see this ad.

Sent from my iPhone using SDN mobile

 

[alpinism]

Welcome to modern american "emergency" medicine.

 

[IH8ColdWeath3r]

you can check in online too, kind of like going to the barber...you know...the true emergencies

 

[Angry Birds]

This is such complete BS.

 

[engineeredout]

If they took emergency departments out of their inconvenient locations at the bottom of hospitals and put them in malls, we could give out those round pagers that you get in restaurants so we wouldn't interrupt shopping

 

[The White Coat Investor]

If they took emergency departments out of their inconvenient locations at the bottom of hospitals and put them in malls, we could give out those round pagers that you get in restaurants so we wouldn't interrupt shopping

No you wouldn't. You wouldn't have a wait time. That's the first step in attracting convenience care purchasers.

 

[RustedFox]

The look on the gal's face in the pic.... "I don't let chest pain get in the way of my shoe shopping, Lulz!!11!"

 

[NurWollen]

That hospital is a core rotation site for AZCOM. I have friends who rotated there. They have FM, IM, and General Surgery residencies. I've probably shopped at that mall too.

 

[realemergency911]

This is what happens when ACEP resists any effort to divert patients from the ED. Does anyone who has ever worked in an ED actually believe that 92% of patients have "a real medical emergency"?

 

[RustedFox]

If you have the time to consider wether to check in for your ER visit before or after hitting up "Crate and Barrel", then you're not having an emergency. If you take a selfie at any point...

 

[GeneralVeers]

This is what happens when ACEP resists any effort to divert patients from the ED. Does anyone who has ever worked in an ED actually believe that 92% of patients have "a real medical emergency"?

It has nothing to do with resisting efforts to divert. It's all about money. ACEP is owned by the CMGs. The CMGs want more emergency visits, because they can take their skim off the top. As such they will never recommend reducing ER usage, and in fact will only recommend increasing usage.

 

[Zebra Hunter]

It has nothing to do with resisting efforts to divert. It's all about money. ACEP is owned by the CMGs. The CMGs want more emergency visits, because they can take their skim off the top. As such they will never recommend reducing ER usage, and in fact will only recommend increasing usage.

Why exactly would the boots on the ground be opposed to increasing ED utilization? The BS complaints are the reason we are in such high demand.

 

[Apollyon]

With the allergic reactions, I tell them that there are very few true emergencies, where we can do everything right, in a timely manner, and pts still die. These include cardiac arrest (primary, not as a result of the following), anaphylaxis, airway obstruction, and nec fasc. Oh, and precipitated delivery of a distressed fetus. Oh, and meningococcal meningitis. These are seconds to minutes. Most of what we do is hours to days before badness. You might include STEMI or PE in there, but, the PE is a gradual progression, as per the physics, and STEMI can still go up to 3 hours.

 

[coachB]

Why exactly would the boots on the ground be opposed to increasing ED utilization? The BS complaints are the reason we are in such high demand.

Because some people feel they have a greater responsibility that involves being a steward of resources. Some people are concerned about more than just making more money. Perhaps some even recognize that this is a completely unsustainable system and it is bound to collapse. I understand the people on here who say, "hey, just more money for me." It's also clear that most of these people gave up any sort of idealism or interest in "doing the right thing" long ago. And maybe EPs would be better at their jobs if they actually focused on what they train for. Yes, this could reduce demand, but I think many would see a significant increase in job satisfaction and be better at what they do. I have to laugh at the people who say the medicine is easy after a few years. It might be easy if you don't think about the potential harms of your decisions. It might be easy if you don't bother to keep up with the changing evidence and continue to do things exactly the way you were trained. But I guarantee you, no matter how well trained you are, if you care about doing the right thing, care about actually what is best for your patients, not most convenient or best for you, it's often not all that easy.

 

[deleted547339]

If you have the time to consider wether to check in for your ER visit before or after hitting up "Crate and Barrel", then you're not having an emergency. If you take a selfie at any point...

I dunno, I've seen people with chest tubes take selfies.....

Our patient population is.....lets just call them "special."

 

[The White Coat Investor]

Because some people feel they have a greater responsibility that involves being a steward of resources. Some people are concerned about more than just making more money. Perhaps some even recognize that this is a completely unsustainable system and it is bound to collapse. I understand the people on here who say, "hey, just more money for me." It's also clear that most of these people gave up any sort of idealism or interest in "doing the right thing" long ago. And maybe EPs would be better at their jobs if they actually focused on what they train for. Yes, this could reduce demand, but I think many would see a significant increase in job satisfaction and be better at what they do. I have to laugh at the people who say the medicine is easy after a few years. It might be easy if you don't think about the potential harms of your decisions. It might be easy if you don't bother to keep up with the changing evidence and continue to do things exactly the way you were trained. But I guarantee you, no matter how well trained you are, if you care about doing the right thing, care about actually what is best for your patients, not most convenient or best for you, it's often not all that easy.

If you let the crazy system you work in get you down or if you try to change it singlehandedly by doing the right thing when the system is not to designed to do that, you'll end up burnt out or crazy. Besides, the right thing for one person or the system isn't necessarily the right thing for your patient, to whom you owe a primary duty. The patient comes to do you with a little ditzel abscess that could certainly have gone to an urgent care or even waited a week to be seen in primary care. What's the right thing? Tell them, "Hose off, that's not an emergency. Go see your primary doctor." Or drain their abscess? I'll tell you what I'm going to do every time, and I'm doing it for the following reasons:
1) It will help the patient get better faster
2) I know the patient will get the care they need
3) It pays me better
4) It increases patient satisfaction
5) It reduces my liability
6) It pays my partner, the hospital, better.

Multi-faceted. I'm not going to martyr myself on the altar of "resource steward." I'm not the resource steward. I'm the emergency physician. I get no additional pay, recognition, reduced liability, patient appreciation or anything for being the resource steward. My duties are to my patients, my family, my business, my malpractice insurer, and my partners. I have no duty whatsoever to the system or society aside from EMTALA.

Now, if I can do all that and still be a resource steward, fine. I'll do it. But it's not my job to educate patients about how to quit wasting their health care dollars. They want to come see me with their bug bites, fine, I'll take their $150 and send my kids to college with it.

Besides, imagine a world with EDs where all they did was take care of emergencies. True emergencies. Instead of 10 EDs in the city, there's now only one and many cities don't have any. And it's too far away to actually save most of the people with emergencies. And since there are only 1/10th the EDs, there are only 1/10th the EM residencies. You didn't even match into EM. You're doing family practice or anesthesia somewhere.

Now, come back to the real world. Joe Schmoe is a 50 year old fat dude sitting on his couch at home having chest pain. Should he go to the ED? Yes he should. Even though when he gets there and stays for 6 hours and spends $4K and then has a negative stress the next day and in the end it's just reflux. It wasn't an emergency. But that doesn't mean it didn't belong in an ED.

The right thing is in the eye of the beholder. Yes, I still throw the drug-seekers and sandwich-seekers out. No, I don't admit everyone who meets admission criteria. But I certainly am not going to throw myself onto the grenade to save the system. It'll get along just fine without me and it doesn't seem to care about me, my family, or my patients anyway as near as I can tell.

 

[deleted480308]

If you let the crazy system you work in get you down or if you try to change it singlehandedly by doing the right thing when the system is not to designed to do that, you'll end up burnt out or crazy. Besides, the right thing for one person or the system isn't necessarily the right thing for your patient, to whom you owe a primary duty. The patient comes to do you with a little ditzel abscess that could certainly have gone to an urgent care or even waited a week to be seen in primary care. What's the right thing? Tell them, "Hose off, that's not an emergency. Go see your primary doctor." Or drain their abscess? I'll tell you what I'm going to do every time, and I'm doing it for the following reasons:
1) It will help the patient get better faster
2) I know the patient will get the care they need
3) It pays me better
4) It increases patient satisfaction
5) It reduces my liability
6) It pays my partner, the hospital, better.

Multi-faceted. I'm not going to martyr myself on the altar of "resource steward." I'm not the resource steward. I'm the emergency physician. I get no additional pay, recognition, reduced liability, patient appreciation or anything for being the resource steward. My duties are to my patients, my family, my business, my malpractice insurer, and my partners. I have no duty whatsoever to the system or society aside from EMTALA.

Now, if I can do all that and still be a resource steward, fine. I'll do it. But it's not my job to educate patients about how to quit wasting their health care dollars. They want to come see me with their bug bites, fine, I'll take their $1500 and send my kids to college with it.

Besides, imagine a world with EDs where all they did was take care of emergencies. True emergencies. Instead of 10 EDs in the city, there's now only one and many cities don't have any. And it's too far away to actually save most of the people with emergencies. And since there are only 1/10th the EDs, there are only 1/10th the EM residencies. You didn't even match into EM. You're doing family practice or anesthesia somewhere.

Now, come back to the real world. Joe Schmoe is a 50 year old fat dude sitting on his couch at home having chest pain. Should he go to the ED? Yes he should. Even though when he gets there and stays for 6 hours and spends $4K and then has a negative stress the next day and in the end it's just reflux. It wasn't an emergency. But that doesn't mean it didn't belong in an ED.

The right thing is in the eye of the beholder. Yes, I still throw the drug-seekers and sandwich-seekers out. No, I don't admit everyone who meets admission criteria. But I certainly am not going to throw myself onto the grenade to save the system. It'll get along just fine without me and it doesn't seem to care about me, my family, or my patients anyway as near as I can tell.

exactly.....treat ethically/properly and get paid.....I'm not sacrificing those on principle to change the world that isn't changing

 

[Tenk]

She's gonna get a flare up of her fibromyalgia carrying her bag like that...

 

[GeneralVeers]

In principle we should be good stewards. I used to get frustrated and tried to change the system. Now I just punch my shifts and collect $$$.

That being said, I still don't order extra tests/scans that I don't feel are clinically warranted.

 

[WilcoWorld]

Because some people feel they have a greater responsibility that involves being a steward of resources. Some people are concerned about more than just making more money. Perhaps some even recognize that this is a completely unsustainable system and it is bound to collapse. I understand the people on here who say, "hey, just more money for me." It's also clear that most of these people gave up any sort of idealism or interest in "doing the right thing" long ago. And maybe EPs would be better at their jobs if they actually focused on what they train for. Yes, this could reduce demand, but I think many would see a significant increase in job satisfaction and be better at what they do. I have to laugh at the people who say the medicine is easy after a few years. It might be easy if you don't think about the potential harms of your decisions. It might be easy if you don't bother to keep up with the changing evidence and continue to do things exactly the way you were trained. But I guarantee you, no matter how well trained you are, if you care about doing the right thing, care about actually what is best for your patients, not most convenient or best for you, it's often not all that easy.

If you let the crazy system you work in get you down or if you try to change it singlehandedly by doing the right thing when the system is not to designed to do that, you'll end up burnt out or crazy. Besides, the right thing for one person or the system isn't necessarily the right thing for your patient, to whom you owe a primary duty. The patient comes to do you with a little ditzel abscess that could certainly have gone to an urgent care or even waited a week to be seen in primary care. What's the right thing? Tell them, "Hose off, that's not an emergency. Go see your primary doctor." Or drain their abscess? I'll tell you what I'm going to do every time, and I'm doing it for the following reasons:
1) It will help the patient get better faster
2) I know the patient will get the care they need
3) It pays me better
4) It increases patient satisfaction
5) It reduces my liability
6) It pays my partner, the hospital, better.

Multi-faceted. I'm not going to martyr myself on the altar of "resource steward." I'm not the resource steward. I'm the emergency physician. I get no additional pay, recognition, reduced liability, patient appreciation or anything for being the resource steward. My duties are to my patients, my family, my business, my malpractice insurer, and my partners. I have no duty whatsoever to the system or society aside from EMTALA.

Now, if I can do all that and still be a resource steward, fine. I'll do it. But it's not my job to educate patients about how to quit wasting their health care dollars. They want to come see me with their bug bites, fine, I'll take their $150 and send my kids to college with it.

Besides, imagine a world with EDs where all they did was take care of emergencies. True emergencies. Instead of 10 EDs in the city, there's now only one and many cities don't have any. And it's too far away to actually save most of the people with emergencies. And since there are only 1/10th the EDs, there are only 1/10th the EM residencies. You didn't even match into EM. You're doing family practice or anesthesia somewhere.

Now, come back to the real world. Joe Schmoe is a 50 year old fat dude sitting on his couch at home having chest pain. Should he go to the ED? Yes he should. Even though when he gets there and stays for 6 hours and spends $4K and then has a negative stress the next day and in the end it's just reflux. It wasn't an emergency. But that doesn't mean it didn't belong in an ED.

The right thing is in the eye of the beholder. Yes, I still throw the drug-seekers and sandwich-seekers out. No, I don't admit everyone who meets admission criteria. But I certainly am not going to throw myself onto the grenade to save the system. It'll get along just fine without me and it doesn't seem to care about me, my family, or my patients anyway as near as I can tell.

Forgive my presumptuousness, but I think that you two aren't actually disagreeing.
CoachB is claiming that the systematic appeal to convenience over emergently-indicated care is bad for the system, and, via downstream effects, bad for everyone.
WCI is claiming that the individual patient encounter is not the place to sort this out.
You're both right, of course.

But c'mon WCI - you've got to admit that the featured image, with a perfectly well-appearing person deciding whether her symptom(s) warrant(s) a shopping break is almost certainly not experiencing a life, limb or sight-threatening condition (i.e. an emergency).

 

[Siggy]

It's also clear that most of these people gave up any sort of idealism or interest in "doing the right thing" long ago.

If "doing the right thing" would save my patient $5, then great! If "doing the right thing" results in the hospital CEO or insurance company board member making $5 more as a bonus at the end of the year, then why should I care? If physicians are going to be blamed for ruining the health care system despite being a tiny overall percentage of expenditure, why shouldn't we try to milk the cow for as much money as we can get out of it?

The nurse isn't saying, "I make enough money, give my raise back to the patients."

The CEO isn't saying, "I make enough money, give my bonus to the patients"

The insurance company stock holder isn't saying, "I made enough money, give my dividend back to the patients."

Only the physician... the person who invested their 20s and $250k + in debt to get to where they are are the ones who are expected to say, "Naw, I got enough money... give my piece of the healthcare pie back to the patient."

 

[alpinism]

Because some people feel they have a greater responsibility that involves being a steward of resources. Some people are concerned about more than just making more money. Perhaps some even recognize that this is a completely unsustainable system and it is bound to collapse. I understand the people on here who say, "hey, just more money for me." It's also clear that most of these people gave up any sort of idealism or interest in "doing the right thing" long ago. And maybe EPs would be better at their jobs if they actually focused on what they train for. Yes, this could reduce demand, but I think many would see a significant increase in job satisfaction and be better at what they do. I have to laugh at the people who say the medicine is easy after a few years. It might be easy if you don't think about the potential harms of your decisions. It might be easy if you don't bother to keep up with the changing evidence and continue to do things exactly the way you were trained. But I guarantee you, no matter how well trained you are, if you care about doing the right thing, care about actually what is best for your patients, not most convenient or best for you, it's often not all that easy.

This might be the best forum post I've seen all year.

Sincerely,

An idealistic resident.

 

[goodoldalky]

This type of advertising and pandering to insured well to do patients is somewhat sickening (although done for obvious reasons). However, if all EDs only took care of emergencies only, we'd all be making half of what we are now, and there'd be half of us. You cannot sustain a department based on dying patients. It takes all the abscesses and other urgencies and ailments to even keep the lights on (assuming some of these can pay).

Stewards of resources... I am not a steward of resources in the sense of deciding who gets care in my ed. The system relies on me. The primary physicians, can't see them til next week. The patient has no doc. No money. Their FP doc isn't comfortable with that laceration. Whatever. I'm there to take care of whatever comes through the door and most of the time it's not an emergency. Sometimes it's an emergency and sometimes it's an emergency that doesn't seem like an emergency and that's my job to figure it out. Call me a steward of resources for the head CTs I order, fine, but the system is busted, and I'm needed to do work, so I do it.

Also... Next time someone gives you this argument, you can remind them that all ED care across the United States accounts for 2% of all healthcare costs in this country. In many ways we are the only part of the system that actually works. Everything else is just so broken that you might not see it that way.

 

[emergentmd]

Please forgive my choice of words but docs who thinks FSEDs, EM advertising, steward of resources, and EDs only caring for true emergencies need to get their heads out of the sand and are full of crap.

Seriously, why are Docs and esp EM docs held to a higher standard. We live in America, everyone's goal should be to profit. That is what drives our country. Every business in America has its top priority to make a profit, and the more the better. If you can do this while bettering everyone's lives, doing it efficiently without being a detriment to others, and sprinkle in charity/austerity then great. But the number one purpose of Most businesses is to make money, otherwise you would be called a charity. The only business that does not make money are either corrupt government agencies or charities.

1. FSED - Why should EM docs be the only ones not to own a business in the medical community? Surgeons open surgical centers, Most docs have offices, Pathologists own labs, Nephrologist owns dialysis centers, Rads own imagine centers. They ALL advertise. Why are we not allowed to profit? Do you think plastics do boob jobs to better the world? If someone is willing to use the service, pay for it, then why can't we profit?

2. EM advertising - So what? Are we so special that we can't advertise for profit? FSEDs are providing a needed service. In most cities where there are 2-3 hr waits, shoddy EM docs with Midlevels seeing everything, Nurses that don't really care and overworked, imaging taking hours for a CT; I would go to a FSED in a heartbeat. I work hard, have insurance, and I would rather go to a FSED where the majority are well trained EM docs with tons of experience without seeing a midlevel, get labs/imaging in 1 hr. For most EM care (emergencies, and non emergencies alike), FSEDs do a much better job. Even if I required an admission, I would be better off having care in 1 hr, and then transferred to a bed in another hour rather than taking 3-4 hrs to be worked up in a hospital ED, waiting 2 hrs for the hospitalist to write orders, and then another 2 hrs for nursing to transport me up there. So Yes, FSED including the needed advertising fills a hole missing in hospital based EDs for people who are insured wanted better service. EVERY field and industry provide better service for those that can pay.

3. Steward of resources - Give me a break. This is not our job to save resources, no one really cares about saving resources. Even if I ordered half the labs/CT, I would just get more headaches and no one would care that I ordered less. They probably would be more pissed that the hospital could not bill as much and I would be called out. I would be brought to QA with missed appendicitis, etc and no one would give me a pass b/c I used my clinical judgment and missed appy are part of using my clinical judgement.

4. Caring for only Emergencies in the ED - This might sound great, but NO one would want this to happen. Which EM doc here would want to do a 10 hr shift where every pt is sick, crashing, need admission, or need a full workup? No other field would want to only deal with sick pts. What cardiolgist would want their clinics filled with bad pathology? What internist would want every office visit to be filled with sick, old, complicated pts requiring an hour each visit? I hear EM docs complain all the time about why a pt didn't just go to a clinic or that it was not an emergency. Give me all of these layups all day, throw in a few sick pts to make the day interesting and I am a happy man. Give me shift where I am admitting 60%, dealing with crash pts all day and I would quit in a week. MOST here would. Not to mention you would get paid probably 1/2-2/3 your current rate b/c there would be 10 docs begging for your job.



Be THANKFUL for a system that has set EM docs to be a scarce commodity, high pay, work place choices. Stop complaining that this is not what you signed up for, because you have it better than your ideal world.

 

[Brahnold Bloodaxe]

If you let the crazy system you work in get you down or if you try to change it singlehandedly by doing the right thing when the system is not to designed to do that, you'll end up burnt out or crazy. Besides, the right thing for one person or the system isn't necessarily the right thing for your patient, to whom you owe a primary duty. The patient comes to do you with a little ditzel abscess that could certainly have gone to an urgent care or even waited a week to be seen in primary care. What's the right thing? Tell them, "Hose off, that's not an emergency. Go see your primary doctor." Or drain their abscess? I'll tell you what I'm going to do every time, and I'm doing it for the following reasons:
1) It will help the patient get better faster
2) I know the patient will get the care they need
3) It pays me better
4) It increases patient satisfaction
5) It reduces my liability
6) It pays my partner, the hospital, better.

Multi-faceted. I'm not going to martyr myself on the altar of "resource steward." I'm not the resource steward. I'm the emergency physician. I get no additional pay, recognition, reduced liability, patient appreciation or anything for being the resource steward. My duties are to my patients, my family, my business, my malpractice insurer, and my partners. I have no duty whatsoever to the system or society aside from EMTALA.

Now, if I can do all that and still be a resource steward, fine. I'll do it. But it's not my job to educate patients about how to quit wasting their health care dollars. They want to come see me with their bug bites, fine, I'll take their $150 and send my kids to college with it.

Besides, imagine a world with EDs where all they did was take care of emergencies. True emergencies. Instead of 10 EDs in the city, there's now only one and many cities don't have any. And it's too far away to actually save most of the people with emergencies. And since there are only 1/10th the EDs, there are only 1/10th the EM residencies. You didn't even match into EM. You're doing family practice or anesthesia somewhere.

Now, come back to the real world. Joe Schmoe is a 50 year old fat dude sitting on his couch at home having chest pain. Should he go to the ED? Yes he should. Even though when he gets there and stays for 6 hours and spends $4K and then has a negative stress the next day and in the end it's just reflux. It wasn't an emergency. But that doesn't mean it didn't belong in an ED.

The right thing is in the eye of the beholder. Yes, I still throw the drug-seekers and sandwich-seekers out. No, I don't admit everyone who meets admission criteria. But I certainly am not going to throw myself onto the grenade to save the system. It'll get along just fine without me and it doesn't seem to care about me, my family, or my patients anyway as near as I can tell.

If "doing the right thing" would save my patient $5, then great! If "doing the right thing" results in the hospital CEO or insurance company board member making $5 more as a bonus at the end of the year, then why should I care? If physicians are going to be blamed for ruining the health care system despite being a tiny overall percentage of expenditure, why shouldn't we try to milk the cow for as much money as we can get out of it?

The nurse isn't saying, "I make enough money, give my raise back to the patients."

The CEO isn't saying, "I make enough money, give my bonus to the patients"

The insurance company stock holder isn't saying, "I made enough money, give my dividend back to the patients."

Only the physician... the person who invested their 20s and $250k + in debt to get to where they are are the ones who are expected to say, "Naw, I got enough money... give my piece of the healthcare pie back to the patient."

Please forgive my choice of words but docs who thinks FSEDs, EM advertising, steward of resources, and EDs only caring for true emergencies need to get their heads out of the sand and are full of crap.

Seriously, why are Docs and esp EM docs held to a higher standard. We live in America, everyone's goal should be to profit. That is what drives our country. Every business in America has its top priority to make a profit, and the more the better. If you can do this while bettering everyone's lives, doing it efficiently without being a detriment to others, and sprinkle in charity/austerity then great. But the number one purpose of Most businesses is to make money, otherwise you would be called a charity. The only business that does not make money are either corrupt government agencies or charities.

1. FSED - Why should EM docs be the only ones not to own a business in the medical community? Surgeons open surgical centers, Most docs have offices, Pathologists own labs, Nephrologist owns dialysis centers, Rads own imagine centers. They ALL advertise. Why are we not allowed to profit? Do you think plastics do boob jobs to better the world? If someone is willing to use the service, pay for it, then why can't we profit?

2. EM advertising - So what? Are we so special that we can't advertise for profit? FSEDs are providing a needed service. In most cities where there are 2-3 hr waits, shoddy EM docs with Midlevels seeing everything, Nurses that don't really care and overworked, imaging taking hours for a CT; I would go to a FSED in a heartbeat. I work hard, have insurance, and I would rather go to a FSED where the majority are well trained EM docs with tons of experience without seeing a midlevel, get labs/imaging in 1 hr. For most EM care (emergencies, and non emergencies alike), FSEDs do a much better job. Even if I required an admission, I would be better off having care in 1 hr, and then transferred to a bed in another hour rather than taking 3-4 hrs to be worked up in a hospital ED, waiting 2 hrs for the hospitalist to write orders, and then another 2 hrs for nursing to transport me up there. So Yes, FSED including the needed advertising fills a hole missing in hospital based EDs for people who are insured wanted better service. EVERY field and industry provide better service for those that can pay.

3. Steward of resources - Give me a break. This is not our job to save resources, no one really cares about saving resources. Even if I ordered half the labs/CT, I would just get more headaches and no one would care that I ordered less. They probably would be more pissed that the hospital could not bill as much and I would be called out. I would be brought to QA with missed appendicitis, etc and no one would give me a pass b/c I used my clinical judgment and missed appy are part of using my clinical judgement.

4. Caring for only Emergencies in the ED - This might sound great, but NO one would want this to happen. Which EM doc here would want to do a 10 hr shift where every pt is sick, crashing, need admission, or need a full workup? No other field would want to only deal with sick pts. What cardiolgist would want their clinics filled with bad pathology? What internist would want every office visit to be filled with sick, old, complicated pts requiring an hour each visit? I hear EM docs complain all the time about why a pt didn't just go to a clinic or that it was not an emergency. Give me all of these layups all day, throw in a few sick pts to make the day interesting and I am a happy man. Give me shift where I am admitting 60%, dealing with crash pts all day and I would quit in a week. MOST here would. Not to mention you would get paid probably 1/2-2/3 your current rate b/c there would be 10 docs begging for your job.



Be THANKFUL for a system that has set EM docs to be a scarce commodity, high pay, work place choices. Stop complaining that this is not what you signed up for, because you have it better than your ideal world.

Preach! Our job is to treat people's medical conditions to the best of our abilities and to get paid as much as possible while doing so. There are already plenty of people out there working full time to ensure that we make as little money as possible, and it's not part of our job description to aid them in that effort.

 

[PlutoBoy]

That hospital is a core rotation site for AZCOM. I have friends who rotated there. They have FM, IM, and General Surgery residencies. I've probably shopped at that mall too.

And?

 

[cbrons]

 

[TheComebacKid]

4. Caring for only Emergencies in the ED - This might sound great, but NO one would want this to happen. Which EM doc here would want to do a 10 hr shift where every pt is sick, crashing, need admission, or need a full workup? No other field would want to only deal with sick pts. What cardiolgist would want their clinics filled with bad pathology? What internist would want every office visit to be filled with sick, old, complicated pts requiring an hour each visit? I hear EM docs complain all the time about why a pt didn't just go to a clinic or that it was not an emergency. Give me all of these layups all day, throw in a few sick pts to make the day interesting and I am a happy man. Give me shift where I am admitting 60%, dealing with crash pts all day and I would quit in a week. MOST here would. Not to mention you would get paid probably 1/2-2/3 your current rate b/c there would be 10 docs begging for your job.

Be THANKFUL for a system that has set EM docs to be a scarce commodity, high pay, work place choices. Stop complaining that this is not what you signed up for, because you have it better than your ideal world.

I have a hard time following this line of thought. I really think that the "true emergencies" are the reasons why EM docs get paid and will continue to get paid in the future. Your extensive investment in your education and training gave you the ability to manage crashing patients and is what separates you from say, an NP or a PA. It seems to me that the "layups" you are referring to are already increasingly being handed off to other providers. I agree that an EM doc who drains an uncomplicated abscess is performing a service and should be compensated. I just don't think the service you are providing requires a unique skill set that can't be done by somebody else. Given the number of people that are capable of draining an abscess, I hardly think that makes EM docs a scarce commodity. Isn't what makes EM docs a commodity their ability to find the ticking time bomb in the waiting room, to make decisive and swift decisions in those 1% of patients that have a "true emergency"?

 

[The White Coat Investor]

Forgive my presumptuousness, but I think that you two aren't actually disagreeing.
CoachB is claiming that the systematic appeal to convenience over emergently-indicated care is bad for the system, and, via downstream effects, bad for everyone.
WCI is claiming that the individual patient encounter is not the place to sort this out.
You're both right, of course.

But c'mon WCI - you've got to admit that the featured image, with a perfectly well-appearing person deciding whether her symptom(s) warrant(s) a shopping break is almost certainly not experiencing a life, limb or sight-threatening condition (i.e. an emergency).

Of course. It's a stupid ad with a model in it trying to show that going to the ED is cool, especially if you can get some shopping in too. But the people who use that ED aren't going to be like her. It's like all those depression medication commercials on TV. They're all models romping through the tulips, right? Who romps through tulips? Nobody. But if you're depressed, you might think, Wow, Celexa looks great! Just like a potential ED user looks at that ad and says, "Wow! That looks like a great ED when I need an ED." It's just marketing.

Did you expect them to put a real patient in an ad?

 

[discongruent]

I have a hard time following this line of thought. I really think that the "true emergencies" are the reasons why EM docs get paid and will continue to get paid in the future. Your extensive investment in your education and training gave you the ability to manage crashing patients and is what separates you from say, an NP or a PA. It seems to me that the "layups" you are referring to are already increasingly being handed off to other providers. I agree that an EM doc who drains an uncomplicated abscess is performing a service and should be compensated. I just don't think the service you are providing requires a unique skill set that can't be done by somebody else. Given the number of people that are capable of draining an abscess, I hardly think that makes EM docs a scarce commodity. Isn't what makes EM docs a commodity their ability to find the ticking time bomb in the waiting room, to make decisive and swift decisions in those 1% of patients that have a "true emergency"?

What would be preclude staffing ED with mostly NP/PAs and only 2-3 MD, in sort of CRNA-type model of 5-1. They are also doing "light" cases in the OR. Is that where the trend is pointing to? So much for scarce commodity if you can staff the entire ED with midlevels you have to supervise. Stuff of my nightmares.

 

[Perrotfish]

Seriously, why are Docs and esp EM docs held to a higher standard. We live in America, everyone's goal should be to profit. That is what drives our country. Every business in America has its top priority to make a profit, and the more the better..

I think the feeling is that, ethics aside, EDs are being poor stewards of their own credibility resources in the legal/legislative battle for compensation. The ED bills at several times the rate of a clinic because of the assumption that they are not, in fact, a clinic.. If EDs are too unscrupulous about deliberately pulling in what are really clinic patients, so as to charge insurers and the government several times a clinic's cost for what is really a clinic service (an effectively unsupervised NP doing a 5 minute checkup for a sneezing patient and telling them that they have the sniffles) then payers will eventually push compensation down to clinic levels and it will be worse for everyone over the long term.

To quote Rounders: "You can shear a sheep many times, but you can only skin him once".

 

[alpinism]

4. Caring for only Emergencies in the ED - This might sound great, but NO one would want this to happen. Which EM doc here would want to do a 10 hr shift where every pt is sick, crashing, need admission, or need a full workup? No other field would want to only deal with sick pts. What cardiolgist would want their clinics filled with bad pathology? What internist would want every office visit to be filled with sick, old, complicated pts requiring an hour each visit? I hear EM docs complain all the time about why a pt didn't just go to a clinic or that it was not an emergency. Give me all of these layups all day, throw in a few sick pts to make the day interesting and I am a happy man. Give me shift where I am admitting 60%, dealing with crash pts all day and I would quit in a week. MOST here would. Not to mention you would get paid probably 1/2-2/3 your current rate b/c there would be 10 docs begging for your job.

You can’t be serious.

I don't know about you but I went into emergency medicine to take care of emergency patients, not urgent care patients and certainly not primary care patients.
So, yes I’d be more than happy to take care of sick crashing patients all shift. That being said I'm on the crazy side since I enjoy working in chaotic inner city ERs.

 

[WilcoWorld]

There is a difference between finding advertisement of convenience care in the ED setting distasteful and saying that FSED's should be illegal. There's also a difference between being eager to pander to well-insured patients and insisting that EP's open themselves up to lawsuits in order to save "the system".

You can’t be serious.

I don't know about you but I went into emergency medicine to take care of emergency patients, not urgent care patients and certainly not primary care patients.
So, yes I’d be more than happy to take care of sick crashing patients all shift. That being said I'm on the crazy side since I enjoy working in chaotic inner city ERs.

If I didn't have to worry about apologizing to three-fers for their wait, and if I could focus on my sick patients for more than 5 minutes at a time, instead of hustling from room to room to keep my survey recipients (i.e. those who will be discharged) happy - then yes, I'd love to have a shift with nothing but real pathology.

 

[GeneralVeers]

I just want $$$. Whatever maximizes that I am fine with.

 

[emergentmd]

I have a hard time following this line of thought. I really think that the "true emergencies" are the reasons why EM docs get paid and will continue to get paid in the future. Your extensive investment in your education and training gave you the ability to manage crashing patients and is what separates you from say, an NP or a PA. It seems to me that the "layups" you are referring to are already increasingly being handed off to other providers. I agree that an EM doc who drains an uncomplicated abscess is performing a service and should be compensated. I just don't think the service you are providing requires a unique skill set that can't be done by somebody else. Given the number of people that are capable of draining an abscess, I hardly think that makes EM docs a scarce commodity. Isn't what makes EM docs a commodity their ability to find the ticking time bomb in the waiting room, to make decisive and swift decisions in those 1% of patients that have a "true emergency"?

The skills of an EM doc has more to do with figuring out sick vs not sick, and less to do with treating the sick. I could train a med student in 6 months on how to treat most medical issues/do procedures once I tell them what the diagnosis is.

Take chest pain. Out of 10, maybe 2 are serious can't miss. So the rest are noncardiac/nonpulmonary and essentially Layups. But a skilled EM doc would have to see all those to find the 2 that requires more workup/admission. But in essence, 8 of 10 are layups.

 

[emergentmd]

You can’t be serious.

I don't know about you but I went into emergency medicine to take care of emergency patients, not urgent care patients and certainly not primary care patients.
So, yes I’d be more than happy to take care of sick crashing patients all shift. That being said I'm on the crazy side since I enjoy working in chaotic inner city ERs.

No I am dead on serious and once your have been through it like I, you will gain the appreciation. We all have had shifts where most pts are sick and crap hits the fan left and right. Those shifts will wear anyone out. Good luck on working at a job like that.

I trained at one of the busiest inner city hospitals. Been there, done that. Even then, most of these pts are layups and should never have stepped foot in the ED.

Give me 80 percent layups and 20 percent real ED pts and I am happy with such a mix. I doubt you could find more than 1 percent of ED docs who would want 100% real ED pts.

 

[emergentmd]

I think the feeling is that, ethics aside, EDs are being poor stewards of their own credibility resources in the legal/legislative battle for compensation. The ED bills at several times the rate of a clinic because of the assumption that they are not, in fact, a clinic.. If EDs are too unscrupulous about deliberately pulling in what are really clinic patients, so as to charge insurers and the government several times a clinic's cost for what is really a clinic service (an effectively unsupervised NP doing a 5 minute checkup for a sneezing patient and telling them that they have the sniffles) then payers will eventually push compensation down to clinic levels and it will be worse for everyone over the long term.

To quote Rounders: "You can shear a sheep many times, but you can only skin him once".

How difficult is it to understand that hospital based EDs have to charge more than clinic rate b/c they are required to see all pts including 50% + government/uninsured pts?

If they paid EDs clinic rates, then you would never be able to staff the ED with EM docs and hospitals would go bankrupt across the country. EDs usually are not profit centers even with the current higher rates, imagine if you chopped their legs off with clinic rates.........

 

[TheComebacKid]

The skills of an EM doc has more to do with figuring out sick vs not sick, and less to do with treating the sick. I could train a med student in 6 months on how to treat most medical issues/do procedures once I tell them what the diagnosis is.

Take chest pain. Out of 10, maybe 2 are serious can't miss. So the rest are noncardiac/nonpulmonary and essentially Layups. But a skilled EM doc would have to see all those to find the 2 that requires more workup/admission. But in essence, 8 of 10 are layups.

So you are saying sifting through all the "not sicks" is part of what a good EM doc does. I can get on board with that. And it works for your example of chest pain.

Your chest pain example is one example where it's possible that there could be an underlying "can't miss" diagnosis. But what about drug seekers? Kids with mosquito bites (do you really need a "skilled" EM doc to rule out malaria?)? Frat kid who is just plain old drunk? While there are cases where the diagnosis may be elusive, a lot of the time, the diagnosis is very straight forward i.e. alcohol intoxication, UTI, radial fracture, benign insect bite, simple laceration, uncomplicated abscess, allergic rhinitis, conjunctivitis, etc. etc. I agree that the chest pain, headache, SOB, AMS patients require the expertise of a trained EM doc, but a lot of the BS med refills and stupid complaints do not require our services.

Whenever an EM doc gives reassurance to a mom regarding their kid's diaper rash, it's a complete waste. It's like making a Formula 1 driver work for Uber. If what an EM doc is doing is so easy a monkey could do it, before we know it, ED's will be staffed by monkeys who become great at doing layups.

I completely understand the profit motive and the desire to get paid and be fairly compensated for your work. I just wonder if working in an environment where you see straightforward layups all the time devalues EM docs in the long run.

 

[WilcoWorld]

With all this talk of lay ups I gotta admit, I'm terrible at basketball. That's why I went to med school.

 

[emergentmd]

With all this talk of lay ups I gotta admit, I'm terrible at basketball. That's why I went to med school.

Layups for well trained EM docs are a free throw or three pointer for a midlevel. That is where the difference lies.

We all deal with 80% layups every shift, while a midlevel seeing the same would feel like playing Jordan's Bulls

 

[The White Coat Investor]

So you are saying sifting through all the "not sicks" is part of what a good EM doc does. I can get on board with that. And it works for your example of chest pain.

Your chest pain example is one example where it's possible that there could be an underlying "can't miss" diagnosis. But what about drug seekers? Kids with mosquito bites (do you really need a "skilled" EM doc to rule out malaria?)? Frat kid who is just plain old drunk? While there are cases where the diagnosis may be elusive, a lot of the time, the diagnosis is very straight forward i.e. alcohol intoxication, UTI, radial fracture, benign insect bite, simple laceration, uncomplicated abscess, allergic rhinitis, conjunctivitis, etc. etc. I agree that the chest pain, headache, SOB, AMS patients require the expertise of a trained EM doc, but a lot of the BS med refills and stupid complaints do not require our services.

Whenever an EM doc gives reassurance to a mom regarding their kid's diaper rash, it's a complete waste. It's like making a Formula 1 driver work for Uber. If what an EM doc is doing is so easy a monkey could do it, before we know it, ED's will be staffed by monkeys who become great at doing layups.

I completely understand the profit motive and the desire to get paid and be fairly compensated for your work. I just wonder if working in an environment where you see straightforward layups all the time devalues EM docs in the long run.

Lower acuity does not equal less skill required. I find some of my trickiest patients are the squirrels, because squirrels get sick too. Yes, they're nuts, but that doesn't mean they don't have a PE too.

You will be a lot happier if you quit thinking of some of your patients as "stupid complaints." Just think of them as "$200 for my kid's college" and it'll bother you less. They're coming in because they think they have an emergency. Sometimes you take care of an emergency. Sometimes you tell them they don't have an emergency. But it all pays the same. If every patient had a life threatening emergency it would be kind of boring anyway. How hard is it to recognize a sick person when they're all sick?

 

[The White Coat Investor]

EDs usually are not profit centers even with the current higher rates, imagine if you chopped their legs off with clinic rates.........

There's a myth that ought to be taken into the corner and have an anvil dropped on it. Do you really believe that? I know of 500 free-standing EDs that would argue with you about that.

 

[Brahnold Bloodaxe]

We currently have X emergency physicians across the country seeing patients of whom let's say only 20% "belong" in the ED. For the life of me I cannot understand how any actively practicing EM doc can be in favor of pruning access to the ED only to the 20% of patients who are suffering from real emergencies, given what such a change would do to their own livelihoods. Talk about "pathological altruism."

 

[emergentmd]

There's a myth that ought to be taken into the corner and have an anvil dropped on it. Do you really believe that? I know of 500 free-standing EDs that would argue with you about that.

I should have clarified myself. I should have said Most Hospital Based EDs are money losing. I know that most FSED are money cows. Trust me, I know.

WCI, you should know me better. My posts shows that I have been around the block many times over. I know where the money in EM medicine is, I have been in all positions.

To all EM docs, EM is a business. Make your money because if anyone can make a profit off from you, they will and you will be thrown to the wasteside.

I am just as happy pulling in 500/hr seeing layups.

 

[emergentmd]

We currently have X emergency physicians across the country seeing patients of whom let's say only 20% "belong" in the ED. For the life of me I cannot understand how any actively practicing EM doc can be in favor of pruning access to the ED only to the 20% of patients who are suffering from real emergencies, given what such a change would do to their own livelihoods. Talk about "pathological altruism."

Again, EM docs who thinks that we should only see real emergencies are ignorant or dumb. Thats like telling a Lawyer to take only cases that really require their expertise and just use Leaglzoom. Or a CPA telling 90% of their clients that they should just buy Turbo Tax.

I truly hate it when docs think we should have a Midlevel or even a doc in the front who turns pts away that are not true emergencies. Geezzzzz.....

There is no reason I should not be paid to exclude an emergency. That is what you are paying me for, not for giving you penicillin for your dental pain.

 

[gman33]

I should have clarified myself. I should have said Most Hospital Based EDs are money losing. I know that most FSED are money cows. Trust me, I know.

In most places, virtually every admission comes via the Er. If the hospital profits from admissions, the Er is not losing money.

Depends how you do the math.

The door at Starbucks doesn't make any money, but they make a lot once they get you inside.

 

[coachB]

I really wonder what motivated some of you to go into medicine since you can't seem to think beyond yourselves and your own income. And then you wonder why the profession doesn't get the respect that it used to or why you have become just a cog in the machine.

 

[gman33]

I'm glad to see non emergencies.
Usually easy to deal with as long as the patient is halfway reasonable.

I used to get upset at these patients.
Now I just try to find out what they want and help them the best I can.

If they want something I can't provide, I try to explain why and just dc.

 

[MSmentor018]

Of course. It's a stupid ad with a model in it trying to show that going to the ED is cool, especially if you can get some shopping in too. But the people who use that ED aren't going to be like her. It's like all those depression medication commercials on TV. They're all models romping through the tulips, right? Who romps through tulips? Nobody. But if you're depressed, you might think, Wow, Celexa looks great! Just like a potential ED user looks at that ad and says, "Wow! That looks like a great ED when I need an ED." It's just marketing.

Did you expect them to put a real patient in an ad?

true, it's just marketing. The hospital want to increase the volume so they can can make money. It makes sense doesn't it? Sell the convenience of healthcare at their timetable so therefore more people comes in. Now were emptying out the waiting room and corralling them in other places to make it look empty in the front but busy in the back, the magic of Disney ! Don't get me wrong I don't mind taking care of the easy patients, it's nice to have less stress on a shift or two but I think were giving patient false expectations (and entitlement) that their healthcare is the same as a bed bath and beyond coupon

 

[TheComebacKid]

Lower acuity does not equal less skill required. I find some of my trickiest patients are the squirrels, because squirrels get sick too. Yes, they're nuts, but that doesn't mean they don't have a PE too.

You will be a lot happier if you quit thinking of some of your patients as "stupid complaints." Just think of them as "$200 for my kid's college" and it'll bother you less. They're coming in because they think they have an emergency. Sometimes you take care of an emergency. Sometimes you tell them they don't have an emergency. But it all pays the same. If every patient had a life threatening emergency it would be kind of boring anyway. How hard is it to recognize a sick person when they're all sick?

I don't know how it is in FSEDs or low acuity community shops... But at the bigger centers and inner city ED's, the "worried well" are very stressful to take care of. In those places, it's not $200 for your kids college, it's a huge malpractice case because you are taking away time from other patients who may have real problems. It's a "I'm dealing with this high maintenance patient who wants a sandwich, instead of the low risk chest pain who MAY have ACS." In this respect, resource allocation is important because it can affect outcomes.

You are completely right that these low acuity patients are the ones we need to be most vigilant about because they are the ones who will crunk when you least expected them to. And those patients can be challenging, and they are $200 well earned. But there are clearly patients who have no business being there. While in the short term it may seem like taking care of these patients equals "cha-ching", in the long term I wonder if EM docs are going to get pushed aside because we cost so much for a job that someone else who is less qualified can do for half the cost.

People in this thread are talking about America and the profit incentive, and how profit is great and we should all want to get paid. I agree with that premise. But a big part of making profit when you are talking about business is cutting costs. EM docs spending a huge chunk of their time taking care of patients who are straight forward, who want some Tylenol, who just need to "metabolize to freedom" etc. Why are hospitals/groups going to keep paying EM docs top dollar when as someone else stated, you could train a med student to do most of this in 6 months?

To clarify, I know the importance of having EM docs for ruling out ACS in patients with low risk chest pain, for making sure that one HA is not a SAH etc. We are needed for those cases and you can't train your average person to manage those cases.