My doctor said to just go to the ER.

[RustedFox]

When I hear a patient say this, I lose my damned mind.

It generally goes like this:

"Well, I waited all weekend with these nonspecific and nonemergent symptoms. SO, I called my doctor, but they said to just go to the ER because they don't have any time to see me today."

Really?!

As if I'm not already seeing 2.5 patients/hour and a sepsis alert is coming in via ambulance in 12 minutes.

We don't have the time for you, but the ER will have the time for you.

SPOILER ALERT!: WE DON'T.

ATTENTION, PRIMARY CARE:

You need to... PRIMARY CARE.

I get that you don't have a "slot" for the patient on your map, but the answer to that isn't "just go to the ER".

Do the medicines.

---

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[Zebra Hunter]

Keep in mind that patients lie and exaggerate. Most of the time when I ask the patient to clarify, they state that it was the secretary or nurse answering the phone that recommended coming to the ER rather than the actual doctor. And they were usually told this after the patient said something ridiculous like “this can’t wait, I need to see someone.” In which case they get the response “well if you feel it needs to be seen immediately, then go to the ER.” Or after telling the patient they have no availability that day, they add on at the end “but if you feel this is an emergency, you can always go to the ER”. I will sometimes call these PCPs that patients swear told them to come in, only for the PCP to state “I have literally not talked to that patient in months, and they have missed several appointments.”

Where I get annoyed is when we get sent patients directly from their office without so much as a call to give a heads up, or at least ask for advice about whether they need to come to the ER.

 

[thegenius]

on the flip side, hey, they pay the bills. 90% of these visits are generally quite easy. 1/4 of your pay is from these nonsense visits.

I know it's annoying - but I agree with Zebra it's rarely the doc actually sending the patient to the ED (however when when they do, especially for something non-emergent, it's really annoying!)

 

[Alvarez13]

Meh. I'm now on an RVU pay setup. I want a busy dept and these asx HTN are easy, hell, can become level 4/5 bills if needing chest pain r/o or CC if a dose of IV labetalol is needed. Busy means more pay and faster shifts. My triage RNs are good about spotting the real sickos and getting them back. The whiners about wait times can whine, I don't feel as stressed about it anymore. Send these ones to my ED all night long.

 

[TooMuchResearch]

We have really well documented phone and online conversations, so I can definitely tell you that at least here often it's a triage nurse, other times it's the patient's primary care doctor (or NP/PA). Chest pain in a 20 year old that's been worked up beyond belief the past few months? Go to the ER. I know this clinic can work this person up for their beyond low risk chest pain. Listen, a lot of these are easy patients for me, but I don't think the clinics are doing these patients any useful service by sending them to see me. I guess other than that I'll greet them with a smile and will always make the time for them (unless they leave without being seen).

Keep in mind that patients lie and exaggerate. Most of the time when I ask the patient to clarify, they state that it was the secretary or nurse answering the phone that recommended coming to the ER rather than the actual doctor. And they were usually told this after the patient said something ridiculous like “this can’t wait, I need to see someone.” In which case they get the response “well if you feel it needs to be seen immediately, then go to the ER.” Or after telling the patient they have no availability that day, they add on at the end “but if you feel this is an emergency, you can always go to the ER”. I will sometimes call these PCPs that patients swear told them to come in, only for the PCP to state “I have literally not talked to that patient in months, and they have missed several appointments.”

Where I get annoyed is when we get sent patients directly from their office without so much as a call to give a heads up, or at least ask for advice about whether they need to come to the ER.

 

[thegenius]

We have really well documented phone and online conversations, so I can definitely tell you that at least here often it's a triage nurse, other times it's the patient's primary care doctor (or NP/PA). Chest pain in a 20 year old that's been worked up beyond belief the past few months? Go to the ER. I know this clinic can work this person up for their beyond low risk chest pain. Listen, a lot of these are easy patients for me, but I don't think the clinics are doing these patients any useful service by sending them to see me. I guess other than that I'll greet them with a smile and will always make the time for them (unless they leave without being seen).

I agree they are not helping patients at all. Making them spend more money, and a lot more insurance / govt money. Thank goodness people can't read minds because if they could read mine after I walk out of the room, they would punch me.

All the more reason why people need to start paying for health care, not govt's and insurance companies. They would stop coming to the ED when we tell them, for the third time: "you are not sick enough for me to care about you - OK you can go home now."

 

[alpinism]

Regardless of the complaint we're talking at least 10min start to finish and that's if you don't have to sit there and explain why they don't need treatment with IV labetolol STAT for their blood pressure of 160/80 for another 10min. Believe it or not those 10min can add up fast during a shift and before you know it you've spent 1 hour of your 8 hour shift dealing with this nonsense everyday. That's time you could have spent checking on that septic shock patient on pressors or talking with the family members about end of life planning. Don't forget that you could also maybe god forbid find some free time for eating a snack or taking a restroom break. But hey if all you care about in your life is making bank and having job security then go ahead and see them all and we can become official 24/7 all hours primary care doctors.

If that's the case I have just one request. Can we at least set aside a few doctors and nurses to focus on those patients with actual emergencies. We can train them in acute medical resuscitation and give them the tools and resources for those patients who need help the most so that they can provide the best quality care for patients. I'll call them emergency physicians.

 

[cyanide12345678]

Meh. I'm now on an RVU pay setup. I want a busy dept and these asx HTN are easy, hell, can become level 4/5 bills if needing chest pain r/o or CC if a dose of IV labetalol is needed. Busy means more pay and faster shifts. My triage RNs are good about spotting the real sickos and getting them back. The whiners about wait times can whine, I don't feel as stressed about it anymore. Send these ones to my ED all night long.

It's critical care time if you give a dose of labetalol?!?!?

 

[gamerEMdoc]

Most of the time when someone says they talked to their doctor and they said go to the ED, they talked to a secretary or nurse whose default line is “go to the ED”.

Where I really get annoyed though is when a doc sends someone in from their office bc they are too sick to be worked up as an outpatient. But then you call the same doc to admit the patient and they say they don't need admitted and can followup as an outpatient.

 

[VA Hopeful Dr]

Where I get annoyed is when we get sent patients directly from their office without so much as a call to give a heads up, or at least ask for advice about whether they need to come to the ER.

As a PCP, I can't speak for everyone but if I'm not calling to give you a heads up it's because I used to and got sick of some of the EPs giving me a hard time about it.

I was working UC at once point and would send 1-2 people over per shift (out of the 60+ I saw each day). Two of the EPs there would routinely say I obviously had no business doing UC if I couldn't handle these patients myself.

Some of those patients: bowel obstruction, cholecystitis, cellulitis not responding to PO meds, COPD with O2 sat of 85 percent after duoneb in the office.

After that last one I basically said "**** those guys" and never called them again.

Now I'm not saying lots of PCPs don't suck because there are lots who absolutely do (I also love cleaning up their bad care). Just offering another perspective.

 

[Tenk]

As a PCP, I can't speak for everyone but if I'm not calling to give you a heads up it's because I used to and got sick of some of the EPs giving me a hard time about it.

I was working UC at once point and would send 1-2 people over per shift (out of the 60+ I saw each day). Two of the EPs there would routinely say I obviously had no business doing UC if I couldn't handle these patients myself.

Some of those patients: bowel obstruction, cholecystitis, cellulitis not responding to PO meds, COPD with O2 sat of 85 percent after duoneb in the office.

After that last one I basically said "**** those guys" and never called them again.

Now I'm not saying lots of PCPs don't suck because there are lots who absolutely do (I also love cleaning up their bad care). Just offering another perspective.

Yeah, it’s actually a pet peeve of mind when someone wants to send in a patient and the ED doc gives them flak about it. Sorry that happened. Sometimes I think medicine would be a lot more fun if we all just treated each other as friends and tried to help each other out.

 

[Porfirio]

Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!

 

[AMEHigh]

I agree they are not helping patients at all. Making them spend more money, and a lot more insurance / govt money. Thank goodness people can't read minds because if they could read mine after I walk out of the room, they would punch me.

All the more reason why people need to start paying for health care, not govt's and insurance companies. They would stop coming to the ED when we tell them, for the third time: "you are not sick enough for me to care about you - OK you can go home now."

I know a lot of people that can’t afford the copays or medications or testing recommended so they don’t go to the doctor. So your wish has already come true about avoiding medical care due to inability to pay :/

As far as the OP goes if doctor’s really are saying "go to the ED" for non-emergent complaints is it because you don’t have urgent care in your area? The nurses take most of the triage calls where I am now, but when I used to take call myself and if our office was closed like on the weekends I’d suggest they go to urgent care if they insisted they couldn’t wait to be seen for non-emergent complaints.

I honestly hate sending people to the ED unless it’s clear the patient is having an MI or something, but do it anyway for the best patient care. ED physicians complain, it costs the patient more money, it costs the healthcare system more money, etc.

 

[Brigade4Radiant]

Don’t mind if PCPs complain about you you will end up in trouble

 

[BoardingDoc]

It's critical care time if you give a dose of labetalol?!?!?

Intravenous cardiac meds to treat tachycardia or hypertensive urgency/emergency = critical care time.

Dilt for afib with RVR? CC time
Adenosine for SVT? CC time.
Lopressor for hypertensive emergency? CC time.
Nitro gtt? CC time
etc etc etc.

That said, if you're giving lopressor for HTN and they are basically there for HTN with no symptoms at all and normal labs... that's not cc time if you bill it. That's fraud.

 

[VA Hopeful Dr]

Yeah, it’s actually a pet peeve of mind when someone wants to send in a patient and the ED doc gives them flak about it. Sorry that happened. Sometimes I think medicine would be a lot more fun if we all just treated each other as friends and tried to help each other out.

Thankfully its quite rare, in the 7 years I've been out of residency those 2 guys were literally the only ones I've ever had any trouble with. Both of them also were notorious among the hospitalists (my wife was one at the same hospital) for weak admissions, half-assed work ups, and just being generally unpleasant to work with.

One of them was the director of that particular ED, so that's a plus.

 

[gutonc]

Yeah, it’s actually a pet peeve of mind when someone wants to send in a patient and the ED doc gives them flak about it. Sorry that happened. Sometimes I think medicine would be a lot more fun if we all just treated each other as friends and tried to help each other out.

When I'm sending someone to the ER (rarely from the office, usually at night/weekends when I'm on call) or get a call about a patient that showed up in the ER, I've found a simple, honest, "thanks for your help", even when they're being d**ks about it, goes a long way to putting everyone back on the same team.

 

[TooMuchResearch]

I don't care what they're sending in. Every time: Sounds good. Happy to take care of them.

Occasionally I ask if they would rather directly admit the patient. If that's the case, I get them connected with the admission line.

Thankfully its quite rare, in the 7 years I've been out of residency those 2 guys were literally the only ones I've ever had any trouble with. Both of them also were notorious among the hospitalists (my wife was one at the same hospital) for weak admissions, half-assed work ups, and just being generally unpleasant to work with.

One of them was the director of that particular ED, so that's a plus.

 

[ShockIndex]

As a PCP, I can't speak for everyone but if I'm not calling to give you a heads up it's because I used to and got sick of some of the EPs giving me a hard time about it.

I was working UC at once point and would send 1-2 people over per shift (out of the 60+ I saw each day). Two of the EPs there would routinely say I obviously had no business doing UC if I couldn't handle these patients myself.

Some of those patients: bowel obstruction, cholecystitis, cellulitis not responding to PO meds, COPD with O2 sat of 85 percent after duoneb in the office.

After that last one I basically said "**** those guys" and never called them again.

Now I'm not saying lots of PCPs don't suck because there are lots who absolutely do (I also love cleaning up their bad care). Just offering another perspective.

Typically, these types of situations are best handled by a phone call between the UC and ED directors where specific cases can be discussed offline for QI. The idea being that effective communication and handoff is good for patients and minimizing everyone’s liability. However, you are describing a situation where the ED director is part of the problem. In that case, I’d escalate to the hospital CMO and the CMG leadership if it’s a large group. The fact that your wife is on staff and can vouch for similar behavior from a different angle should make a resolution even faster.

To my EM colleagues at tertiary referral centers - I get it. You are tired of calls from Derka Derkastan where the signout is, “Patient too sick for vitals...many drips...many drips.” Just member that the vast majority of these patients where a doctor is actually calling you need to be seen pretty quick. Granted, there are times where we can politely redirect care to more appropriate environments, but these instances should be the minority. If they’re not and every call is an argument, then you are probably doing it wrong. Also, thanking the referring provider for an interesting case goes a long way to making other doctors think that you are awesome and not a douche.

 

[erdoc00]

Nearly all of the issues that are causing our dissatisfaction are due to the fact that our system is beyond broken and yet we continue to try and work within it. But rather than address the difficult problems, we lash out at our colleagues. Family practice docs are overworked, surgeons are overworked, hospitalists are overworked, radiologists are overworked, er docs are overworked... But doctors are a passive group of people so they continue to eat **** and take it out on each other rather than address the actual issues.

The system is broken and we are in a crisis. Im not sure if a solution exists but fighting amongst ourselves only makes things worse for us. If anything we need an actual physician union so we can unify and fight the ridiculousness that has become American healthcare.

 

[emergentmd]

Op, I don't know why these complaints ever bother ER docs. Similar to coming to the ER for admission. Similar to Pt needs Lab rechecks b/c office closed.

#1 - They are easy and slam dunks
#2 - Nice to have easy patients to balance the sick patients
#3 - Job Security.
#4 - Keep a good relationship with PCP/specialists. If you help them out, they will help you out in many ways.

If Non emergent patients all went to UC, PCP, or stayed home my hospital volume would go from 150 to 40/dy

#1 - I would be single coverage doing 12 hr shifts with 3-4 spikes in the shift where I am dealing with multiple sick/crashing pts
#2 - We would go from a 6 doc day to a 2 doc day
#3 - My rate would be cut by 25% because there will be an an oversupply of ER docs or I would have to find a job somewhere in the sticks
#4 - I would be burned out quickly when all my shifts reminds me of the time when I had to handle 3 intubations, 1 unresponsive kid, 2 central lines that came in a span of 15 minutes.

I am at the point in my career where I don't need all of the excitement and critical care patients. I am much happier doing my 8 hr shift when all I am seeing stable patients or QC patients.

 

[emergentmd]

As a PCP, I can't speak for everyone but if I'm not calling to give you a heads up it's because I used to and got sick of some of the EPs giving me a hard time about it.

I was working UC at once point and would send 1-2 people over per shift (out of the 60+ I saw each day). Two of the EPs there would routinely say I obviously had no business doing UC if I couldn't handle these patients myself.

Some of those patients: bowel obstruction, cholecystitis, cellulitis not responding to PO meds, COPD with O2 sat of 85 percent after duoneb in the office.

After that last one I basically said "**** those guys" and never called them again.

Now I'm not saying lots of PCPs don't suck because there are lots who absolutely do (I also love cleaning up their bad care). Just offering another perspective.

I have had some pretty weak ER referrals but I always say, "No Problem I will take care of them, do you want a call back?". I don't even care if the PCP/UC didn't call first. Saves me 2 minutes, and I can call them if I have any questions. Just send the pt with the visit note.

I am not in their office and will not judge. It is much easier to be pleasant than grill another doctor. I have had plenty of weak admissions just because the pt can't go home. I don't want to be grilled by the hospitalist and ruin my shift. I will never grill another doctor or a midlevel who wants to send the pt over. Hell, I have had ER docs in my same system send pts to my ER b/c they can't handle it and I say, "Great, Ill take care of them and likely send them home"

Give me your patients. Give me work to do. Keep me seen as valuable.

I will dare to say that I hope the healthcare systems do not get smart enough to open a bunch of UCs right next to all ERs and take away all the Easy patients. God forbid that the HC systems become efficient and decrease ER utilization. God forbid that there are enough PCPs where they don't need to go to the ER. God forbid that the PCPs become efficient where they can order all the labs/xrays in the same visit.

I want to keep my job with high pay. I want to be seen as a rare commodity.

I doubt any plumber would tell their customers "Why are you calling me to fix your toilet stopper" while he is collecting his $175 fee spending 10 minutes putting in a new stopper. Much better than spending 2 hrs making $300 doing a complicated job.

 

[VA Hopeful Dr]

Typically, these types of situations are best handled by a phone call between the UC and ED directors where specific cases can be discussed offline for QI. The idea being that effective communication and handoff is good for patients and minimizing everyone’s liability. However, you are describing a situation where the ED director is part of the problem. In that case, I’d escalate to the hospital CMO and the CMG leadership if it’s a large group. The fact that your wife is on staff and can vouch for similar behavior from a different angle should make a resolution even faster.

The UC director was a partner in that ED group (SDG I later learned) before he semi-retired so he was of no help (he actually told me that maybe I needed more UC CME). My wife was pregnant at the time so we didn't want to rock the boat in any way that might have made it tougher for her to go on maternity leave.

The easy solution was that I left that job a few months later, then we both left town about 1 year later. Not long after that, the hospital system was bought out completely.

 

[thegenius]

As a PCP, I can't speak for everyone but if I'm not calling to give you a heads up it's because I used to and got sick of some of the EPs giving me a hard time about it.

I was working UC at once point and would send 1-2 people over per shift (out of the 60+ I saw each day). Two of the EPs there would routinely say I obviously had no business doing UC if I couldn't handle these patients myself.

Some of those patients: bowel obstruction, cholecystitis, cellulitis not responding to PO meds, COPD with O2 sat of 85 percent after duoneb in the office.

After that last one I basically said "**** those guys" and never called them again.

Now I'm not saying lots of PCPs don't suck because there are lots who absolutely do (I also love cleaning up their bad care). Just offering another perspective.

yea I'm not surprised.

 

[thegenius]

Yeah, it’s actually a pet peeve of mind when someone wants to send in a patient and the ED doc gives them flak about it. Sorry that happened. Sometimes I think medicine would be a lot more fun if we all just treated each other as friends and tried to help each other out.

I agree with this overall sentiment. The frustrating thing is that in almost all of medicine, doctors can control their workflow. For instance, you need an appointment to see one. Some aren't working enough and want more business.

The ED is the only place you can just walk in and be seen and it's taken advantage of. So when we are packed to the brim and we get PCP's sending us asthma that just requires like 4 more hours of nebs and obs it does get frustrating. Just to be clear, that is NOT the PCP's fault.

But I guess it's the life we choose.

 

[thegenius]

Op, I don't know why these complaints ever bother ER docs. Similar to coming to the ER for admission. Similar to Pt needs Lab rechecks b/c office closed.

#1 - They are easy and slam dunks
#2 - Nice to have easy patients to balance the sick patients
#3 - Job Security.
#4 - Keep a good relationship with PCP/specialists. If you help them out, they will help you out in many ways.

If Non emergent patients all went to UC, PCP, or stayed home my hospital volume would go from 150 to 40/dy

#1 - I would be single coverage doing 12 hr shifts with 3-4 spikes in the shift where I am dealing with multiple sick/crashing pts
#2 - We would go from a 6 doc day to a 2 doc day
#3 - My rate would be cut by 25% because there will be an an oversupply of ER docs or I would have to find a job somewhere in the sticks
#4 - I would be burned out quickly when all my shifts reminds me of the time when I had to handle 3 intubations, 1 unresponsive kid, 2 central lines that came in a span of 15 minutes.

I am at the point in my career where I don't need all of the excitement and critical care patients. I am much happier doing my 8 hr shift when all I am seeing stable patients or QC patients.

The singular reason why we complain about this is we can't control our environment. For an ER doctor, we have to see every single patient who comes in.

So nobody is happy when the non-sick comes to the ED.
- the patient waits 3-5 hours to be seen, they get pissed off;
- the ER doctor can't fully treat the pt's condition, or doesn't give them a definitive diagnosis for their problem. Pt's wait 8 hours to be told the ER doc doesn't know what's causing their abd pain
- the PCP gets frustrated
- other patients get their care delayed
- everything falls apart



Believe me, if I were sitting around seeing 1/hr you can send me anybody. I don't care if their tooth itches. I'll see them and not complain.

The complaints about these things all stem from being overworked and in unpredictable manner.

 

[TheComebacKid]

I don't mind if a PCP sends a patient to the ED. But if you are sending them to the ED, for the love of god, CALL AHEAD and give your thought process. I had a patient who said "I feel fine, but the oncologist sent me here." as I observe his unstable vital signs on the monitor. 10 minutes later get a call from the oncologist: "sorry I was late giving you guys a call. This guy was in clinic hypoxic satting 84% on RA and complaining of crushing chest pain. I'm concerned either he has a PE or pneumonia or something else going on, do you mind taking a look?"

I will echo the sentiment that overall health literacy is low amongst patients and they have zero idea why their physician would send them to the ED.

Agree that the majority of transfers to EDs that are inappropriate by "doctors" are actually from nurse exchange/hotlines etc.

At an academic center, the best ED visits are from the patients who say "I have had this abdominal pain for 8 months. Nobody has ever been able to figure it out. My primary care physician said to drive 6 hours to come here and you would have a specialist who would figure it out today. I've had 8 abdominal MRIs. Oh, I had no idea that the images would be helpful to you guys... Can't you just admit me?"

 

[Alvarez13]

Intravenous cardiac meds to treat tachycardia or hypertensive urgency/emergency = critical care time.

Dilt for afib with RVR? CC time
Adenosine for SVT? CC time.
Lopressor for hypertensive emergency? CC time.
Nitro gtt? CC time
etc etc etc.

That said, if you're giving lopressor for HTN and they are basically there for HTN with no symptoms at all and normal labs... that's not cc time if you bill it. That's fraud.

BuT mY prEssUrE aT hOmE waS iN thE 160s! tHe 160s! tHAt's hIgH foR mE dOc.

 

[thegenius]

At an academic center, the best ED visits are from the patients who say "I have had this abdominal pain for 8 months. Nobody has ever been able to figure it out. My primary care physician said to drive 6 hours to come here and you would have a specialist who would figure it out today. I've had 8 abdominal MRIs. Oh, I had no idea that the images would be helpful to you guys... Can't you just admit me?"

You work at an academic center? Does this happen rarely like 1/month, or frequently? I've always wondered about that.

 

[emergentmd]

The singular reason why we complain about this is we can't control our environment. For an ER doctor, we have to see every single patient who comes in.

So nobody is happy when the non-sick comes to the ED.
- the patient waits 3-5 hours to be seen, they get pissed off;
- the ER doctor can't fully treat the pt's condition, or doesn't give them a definitive diagnosis for their problem. Pt's wait 8 hours to be told the ER doc doesn't know what's causing their abd pain
- the PCP gets frustrated
- other patients get their care delayed
- everything falls apart



Believe me, if I were sitting around seeing 1/hr you can send me anybody. I don't care if their tooth itches. I'll see them and not complain.

The complaints about these things all stem from being overworked and in unpredictable manner.

I rather be busy than slow. Our jobs are dependent on the ER being busy, otherwise they will start to slash shifts and bring the pph to 2/hr.
I rather worry about being busy and making more $$ than being slow and worrying about getting shipped out to an outlying ER or having my shifts cut back by 25%

 

[thegenius]

I rather be busy than slow. Our jobs are dependent on the ER being busy, otherwise they will start to slash shifts and bring the pph to 2/hr.
I rather worry about being busy and making more $$ than being slow and worrying about getting shipped out to an outlying ER or having my shifts cut back by 25%

I hear what you are sayin. I would rather there be the right balance. Too slow is a problem, and too busy is a problem too. People don't get good care when it's too busy. H&P's get sloppy, they get over-tested, over-treated, don't get explanations, wait too long, etc. Patients are harmed when you, the ER doc, are too busy at work.

 

[TheSingularity]

I accept most "referrals" without a battle.

However, I refuse to be dumped on.

I will not accept transfer of an unstable patient to Podunk Hospital from Even More Podunk Hospital, especially when the respective subspecialist hasn't even been called. This is inappropriate. Get the patient to the academic center that's down the highway.

I will also always give a hard time to Jenny McJennerson, NP, BSN, MS about "referring" asymptomatic hypertension. There is no role for this in 2019.

TL/DR: Do your ****ing job and leave me out of it.

Sent from my Pixel 3 using SDN mobile

 

[RuralEDDoc]

I will not accept transfer of an unstable patient to Podunk Hospital from Even More Podunk Hospital, especially when the respective subspecialist hasn't even been called. This is inappropriate. Get the patient to the academic center that's down the highway.

I hear you on that! Train wrecks from the sticks needs to go to the big city, not to another **** hole hospital also in the sticks.

To the main point of the thread: this stuff used to piss me off as well. Then everywhere I worked figured it out and did split model flow with low, mid, and high acuity. I choose to work high acuity and rarely deal with stupid stuff. Works out nicely. Most mid to large EDs do this now.

 

[VA Hopeful Dr]

So this is timely.

Had a guy come to the office today for an INR check. Came back >8. The last time this happened it was our machine being wrong so I sent his sample to the hospital lab for confirmation. I told my staff that I would check the lab tonight and then call the patient. Somehow, they heard "patient needs to go to the ED".

I sent the EP who saw him a message apologizing for the screw up and thanking him for taking care of the guy.

 

[CajunMedic]

And for all that is good and holy, if you are sending them for abnormal labs or imaging results, tell them why and make sure they understand. Because, I probably should not be the one to tell them that their PET scan shows significant, diffuse metastatic cancer.

 

[RustedFox]

Wow. This got a of lot replies that I didn't expect. But a lot of them are really good.

To be clear, my original complaint was with those who won't even entertain the idea of an outpatient workup and just blindly "send to the ER" when the patient tries to do the right thing, and go to their PMD, under the idea that "the ER will see you quicker; I don't have time". I assure you, PMD, that my ER is far busier than your office.

 

[gutonc]

And for all that is good and holy, if you are sending them for abnormal labs or imaging results, tell them why and make sure they understand.

You're so cute. I'm usually surprised if my patients can find their way back to the front door of the clinic.

 

[GeneralVeers]

I hate when they send a prescription with their dream work-up spelled out. If you send them to me, then leave it up to me what workup I do. I don't like having to argue and disagree with patients when their idiot PCP wants a non-indicated head CT or some other BS test.

 

[RuralEDDoc]

I hear ya Veers. Every football season we get a dozen kids a week sent for “rule-out concusssion”. Rule out concussion? What the **** are you talking about? I guess I’ll just get my magic concussion wand and rule that out real quick.

 

[thegenius]

I hear ya Veers. Every football season we get a dozen kids a week sent for “rule-out concusssion”. Rule out concussion? What the **** are you talking about? I guess I’ll just get my magic concussion wand and rule that out real quick.

That is so stupid. They are just sending them in to get a head CT

The old “rule out” phrase. Such an interesting one. Nobody ever send someone in to “rule-in” disease. It’s always “rule - out”.

 

[jw3600]

Meh. I'm now on an RVU pay setup. I want a busy dept and these asx HTN are easy, hell, can become level 4/5 bills if needing chest pain r/o or CC if a dose of IV labetalol is needed. Busy means more pay and faster shifts. My triage RNs are good about spotting the real sickos and getting them back. The whiners about wait times can whine, I don't feel as stressed about it anymore. Send these ones to my ED all night long.

Are you actually giving IV labetalol to these people?

 

[EctopicFetus]

I get the frustration but honestly its dumb. It’s like the surgeon who doesn’t want to operate. We literally put food on our table by seeing patients. Send them all. Sure some suck.. some suck really bad. I wish I had a mulligan 1-2 patients per shift. That being said if a patient has a pcp who sends them to me that means they have insurance (or are on public aid) and that means money that will eventually go into my bank account.

As I always said I dont mind any patients as long as they are polite and reasonable. Being annoyed makes no sense to me. Harming patients is another issue and to me is the bigger issue when it comes to these things.

 

[RustedFox]

I get the frustration but honestly its dumb. It’s like the surgeon who doesn’t want to operate. We literally put food on our table by seeing patients. Send them all. Sure some suck.. some suck really bad. I wish I had a mulligan 1-2 patients per shift. That being said if a patient has a pcp who sends them to me that means they have insurance (or are on public aid) and that means money that will eventually go into my bank account.

As I always said I dont mind any patients as long as they are polite and reasonable. Being annoyed makes no sense to me. Harming patients is another issue and to me is the bigger issue when it comes to these things.

I hear you. But when you "don't even try to medicine" and just punt.... You lose. You're the reason why our system is broken. Or at least a big part of it.

 

[EctopicFetus]

I hear you. But when you "don't even try to medicine" and just punt.... You lose. You're the reason why our system is broken. Or at least a big part of it.

I agree. But to be honest they system is f-ed and many of those same PCPs are employees of a hospital system who would abuse them to the max extent possible. Their overlords dont care about them one iota. They would take take and take more if it was an option. You have to set limits. It’s not like the old days where it was your practice and you had real skin in the game. Now a huge majority are just saps employed by hospItals or other leeches.

They will take all their blood, like parasites will keep taking until the host is dead and then just move onto the next one.

In an ideal setting yes. I agree. I have had the luxury to work with private PCPs they are infinitely better at this than those who aren’t. Those systems make up some terrible system to try to limit this such as walk in clinics staffed by *****s (usually MLPs) who dont know anything.

 

[RuralEDDoc]

That is so stupid. They are just sending them in to get a head CT

The old “rule out” phrase. Such an interesting one. Nobody ever send someone in to “rule-in” disease. It’s always “rule - out”.

Which is why it’s stupid. If you’re a pediatrician you should know PECARN or have at least gestalt guiding you. Not just “I feel a little dizzy the day after football practice”. I understand why they send vomiting kids or kids that look bad but the well appearing kids with a mild headache is just a liability duck while encouraging over utilization of CT.

 

[RustedFox]

Op, I don't know why these complaints ever bother ER docs. Similar to coming to the ER for admission. Similar to Pt needs Lab rechecks b/c office closed.

#1 - They are easy and slam dunks
#2 - Nice to have easy patients to balance the sick patients
#3 - Job Security.
#4 - Keep a good relationship with PCP/specialists. If you help them out, they will help you out in many ways.

If Non emergent patients all went to UC, PCP, or stayed home my hospital volume would go from 150 to 40/dy

#1 - I would be single coverage doing 12 hr shifts with 3-4 spikes in the shift where I am dealing with multiple sick/crashing pts
#2 - We would go from a 6 doc day to a 2 doc day
#3 - My rate would be cut by 25% because there will be an an oversupply of ER docs or I would have to find a job somewhere in the sticks
#4 - I would be burned out quickly when all my shifts reminds me of the time when I had to handle 3 intubations, 1 unresponsive kid, 2 central lines that came in a span of 15 minutes.

I am at the point in my career where I don't need all of the excitement and critical care patients. I am much happier doing my 8 hr shift when all I am seeing stable patients or QC patients.

I don't know where you work, homey.
And I like a LOT of your posts/contributions here,
but my ER is plenty more busy than any FP office during season.
And "season" is here.

And I work in a "rich boomer shop" on the 'right' side of the tracks.
My average acuity/day is far more radical than the FP docs'/day.
Yet, they say: "I can't see you today; the ER will see you faster."

NO, D!CKBREATH! I'm already busy enough with all the rest of the things you send me, plus the influx of seniors from NY/NY and all points northeast.

Don't send me "patient felt funny; might want a med refill, said his pee-pee tingled and that's not normal for him" when you haven't seen it in the office setting first.
If I did that, I'd kick my own ass.

If it's "Hey doc, my chest hurts when I breathe fast and I get dizzy", I get it.
When its not, and in 99% of cases, they don't even know because they didn't even talk to them...

Then, its not

 

[RustedFox]

I hear ya Veers. Every football season we get a dozen kids a week sent for “rule-out concusssion”. Rule out concussion? What the **** are you talking about? I guess I’ll just get my magic concussion wand and rule that out real quick.

I hate this too, if only for the reason that the parent wants to know (immediately) when their kid can be *Cleared To Play!* again.
As if the phrase "CLEARED to PLAY!" was some Aegis that absolved everything and made them a SuperRunningBack!

Watch OUT! My boy is CLEARED TO PLAY! WHOOO! Watch him get all Emmitt Aikman (sic) up on this field now! Whaaawww!

I want to grab 99.99% of these parents by their ears and say:

"Listen; your kid isn't going to make it to D-1, let alone the NFL. Now, knock it off and stop living vicariously thru your son."
"When is he *CLEARED to PLAY!* ? - I don't care. Now, eff off."

Oh, and by the way; your son hates football anyways. He likes saxophone and marijuana.

 

[RustedFox]

I hate when they send a prescription with their dream work-up spelled out. If you send them to me, then leave it up to me what workup I do. I don't like having to argue and disagree with patients when their idiot PCP wants a non-indicated head CT or some other BS test.

Yep.
They might as well write:

"Here; do the medicines because I can't/don't want to. Its 4:47 pm and I'm out of the office in ten minutes, but you're open ALL the TIME and HAVE to see your patients in :20 minutes or less."

 

[TheComebacKid]

You work at an academic center? Does this happen rarely like 1/month, or frequently? I've always wondered about that.

4th year resident. Fellow next year. Probably continuing on in academics after that if I can land a decent gig.

It happens fairly frequently at the ivory tower/quaternary referral centers. These places are (incorrectly) viewed as being "great hospitals" based on US News and world report rankings.

It's always somewhat humorous when you see a well to do patient drive 6 hours for "the top care in the nation" only to be told they have to sit in the waiting room for 6 hours before being seen.

 

[BoardingDoc]

I don't know where you work, homey.
And I like a LOT of your posts/contributions here,
but my ER is plenty more busy than any FP office during season.
And "season" is here.

And I work in a "rich boomer shop" on the 'right' side of the tracks.
My average acuity/day is far more radical than the FP docs'/day.
Yet, they say: "I can't see you today; the ER will see you faster."

NO, D!CKBREATH! I'm already busy enough with all the rest of the things you send me, plus the influx of seniors from NY/NY and all points northeast.

Don't send me "patient felt funny; might want a med refill, said his pee-pee tingled and that's not normal for him" when you haven't seen it in the office setting first.
If I did that, I'd kick my own ass.

If it's "Hey doc, my chest hurts when I breathe fast and I get dizzy", I get it.
When its not, and in 99% of cases, they don't even know because they didn't even talk to them...

Then, its not

How you get compensated must play a large influence on how people feel about this topic. I'm compensated based on productivity. You can send em to me all day long. Either I can go a bit faster and make yet more money, or I'm already flying and they sit in the waiting room for 4 hours because it's nonsense. They'll either get sick of waiting and leave, or they'll eventually come back and I get paid more. Win win.

If I were hourly, I would probably be standing next to @RustedFox with my megaphone.