My ER Experience

[RxBoy]

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So I been pretty quiet lately because I spent this entire month working in the ER. I thought I would share what I observed and tie it in to the current political discussions.

After working in the ER I must say, I have never seen such an abused and inefficient system in my life. I think all Obama needs to do is spend 3 days in any busy city ER and see exactly why our healthcare costs are spinning out of control.

Reasons that were appalling to witness:

1) REPEATED visits by the same patients for the same symptoms in order to get PAIN MEDS. There were many other malingering reasons as well. Such as this homeless guy who admitted that he faked his chest pains to get a "ride" to the hospital through EMS and didn't want to stay for a cardiac workup… at least he was honest.

2) REPEATED visits by the same patients for primary care problems. "Doc it's been burning every time I urinate. I had the same symptoms last month until I came to the ER and got some antibiotics". 1 patient had racked up a $13k tab with the hospital for repeated PCP type visits to the ER. Of course he simply refused to pay his medical bills (lost money to that hospital) but we still had to repeatedly treat him. Honestly the first 2 reasons mentioned above compromise at least 70% of the total ER visits.

3) Using clinical guidelines too tightly and getting a full work up on every 25 year old with obvious acid reflux type chest pain. Admitting just about EVERYONE who appears even slightly discomforted out of fear of litigation.

4) Using labs, radiography and consults inefficiently. We were using them too readily when patients didn't need them. We were not using them readily enough when patients seriously DID need them. This was mostly because the system was overwhelmed with all the prior unneeded orders.

5) Noncompliant patients who got the 5k workup for their PUD but refused to take their PPI's or f/u, rushed to the ER with a perforation. CHF exacerbation, Asthma exacerbation, Uncontrolled Diabetes, list goes on and on. This compromised another 20% of the patients I saw in the ER. Almost all could of been avoided if they took their meds (and no I'm not talking about state of the art chemo drugs, simple $5 scripts at any walmart). This of course, is not even discussing the ones who refuse to change their social habits (diet, EtOH, Tob, IDU, coke, ect.).

6) Patients with a GCS score of 3 on a vent, feeding tube and foley, transported to the ER because the nursing home noticed a "fever".I could understand if these patients had recently fell into a coma, but all of these patients were chronic (months to years). They always seem to send these patients with no family members making you hunt endlessly for PMH records as well as an endless workup with full admission to find the source of the fever. Lets not forget about the costs to maintain, transport, and re-establish lines on these patients. Not to sound rude, but I think its time to rethink treatment when your treating an oversized petri dish. I know this is completely opinion but I would never want my body disgraced with diapers, tubes, and repeated physical exams like that.... which is why I'll be sure to keep a loaded gun handy.

6) I could continue naming 1000 other flaws I noticed. I have seen similar abuses in other units (ICU's, floors, PCP offices, ect.) but I have never seen it in such a raw and glourious view as I did in the ER.

Do I blame the ER Doctor? NO

They have to simultaneously write every note to assure proper reimbursement all while working up every minor complaint as a major one and documenting it to safeguard themselves from greedy litigation lawyers. They have very little room to make their own clinical decisions.

WIth all this said, I just wanted to say… don't be fooled into thinking our salaries, our work ethic, or our expertise are the reasons for the current health care crisis…

It's because we are FORCED to practice defensive medicine on an increasingly abused and unrationed health care system. PERIOD.

My ER experience was all the evidence I needed. No matter how much money you dump into the system or how much salary/staff cuts you make, the problems will not go away. Until politicians understand these basic premises, you will continue seeing health care costs spin out of control.

Sorry about the rant, just had to let that out.

 

[YouISee]

Your experience is something I can agree with. Will the Dems look at this and try to fix it pragmatically? Or will they slash the already low reimbursement rates to fund some mythical everybody lives forever medicine?

1.) Repeated PCP-like visits from the same few individuals just shows how irresponsible Americans have become. I hope the new administration actually includes provisions to outright deny care to repeated offenders. Yeah, it's cruel, but I don't feel that a responsible taxpayer should keep paying for an idiot, upper, middle, or lower class.

2.) Lawyers and people like Mikulski (HHS nominee I believe) who don't want to cap malpractice need to be openly attacked by the AMA. These people think the *****s in #1 deserve to continue to behave the way they do, and when something doesn't go right, they should be able to take money from people/system so they can probably do more *****ic things with a whole lot of money. Or have the family cash in on the death. Maybe the Obamanation needs to add a provision that civil lawsuits can only be carried out when dependents are involved.

3.) Petri dish is probably one of the best terms I have ever heard. These individuals are just bio material with tubing. They are not people anymore, but in a God-less society, we can't let them go to the unknown beyond. Will Obama cap care on those meeting certain criteria that represent no return? I think it's reasonable that an 80 year old doesn't live for another 4 months vent/trach/pegged so that funding can be diverted to maybe something like free vaccines.

In the end, our cultural views have to change if we are going to change US medicine.

 

[brianmartin]

3) Using clinical guidelines too tightly and getting a full work up on every 25 year old with obvious acid reflux type chest pain. Admitting just about EVERYONE who appears even slightly discomforted out of fear of litigation.

Usually practitioners who are staying close to treatment guidelines on questionable patients have been burned before, they aren't just blindly following protocol for no reason. But you are right, many resources are wasted, and usually on certain presentations. Headaches come to mind. As for admitting people who are uncomfortable, hospitalists and internists need to speak up if their service is being abused. It's not like that everywhere. All the criticisms you have of the ER and the medical system are valid and we should all work to improve the system. Sometimes that's impossible though, when you are handed a crap records system, high patient volume, and not enough staff.

In the end, our cultural views have to change if we are going to change US medicine.

This is insightful and likely, true.

 

[coprolalia]

You guys "get" it.

Now, are you going to be part of the solution? Or, continue to be part of the problem?

Start to think about solutions. Real solutions.

-copro

 

[Planktonmd]

You guys "get" it.

Now, are you going to be part of the solution? Or, continue to be part of the problem?

Start to think about solutions. Real solutions.

-copro

OK,
Here is some solutions:
1- For patients who use the ER as their PCP:
I am sure they don't do that because they love spending 12 hours at the ER waiting room to get blood pressure medicine, so unfortunately the only solution is to give all of them free health care since they are getting it anyway and since it seems that the rest of the world thinks that humans should not be allowed to die on the streets for lack of health care in civilized countries.
2- For physicians that are afraid of lawyers and practicing defensive medicine:
Change the laws and make it mandatory for any malpractice suit to be first evaluated by a committee of experts (not paid by the plaintiff) to see it has merit, then if it goes to court it should not be in the hands of lay juries that think all doctors are rich bastards and the actual judgment, if there is one, should make sense and not reward people for abusing the system.
3- For physicians that don't know when to order the right labs or do the right intervention:
Make sure that people who go to medical school are learning medicine not only memorizing keywords so they can pass exams.
There you have it, solutions for all the problems the OP mentioned.
😀

 

[jwk]

It’s because we are FORCED to practice defensive medicine

Yet I've never seen this mentioned by Obama as a source of the problem. Why? Because Democrats, frequently scumbag lawyers themselves, don't go for tort reform.

 

[fakin' the funk]

1) REPEATED visits by the same patients for the same symptoms in order to get PAIN MEDS.

2) REPEATED visits by the same patients for primary care problems.

3) Using clinical guidelines too tightly and getting a full work up on every 25 year old with obvious acid reflux type chest pain.

4) Using labs, radiography and consults inefficiently. We were using them too readily when patients didn't need them. We were not using them readily enough when patients seriously DID need them.

5) Noncompliant patients who got the 5k workup for their PUD but refused to take their PPI's or f/u, rushed to the ER with a perforation. CHF exacerbation, Asthma exacerbation, Uncontrolled Diabetes, list goes on and on.

6) Patients with a GCS score of 3 on a vent, feeding tube and foley, transported to the ER because the nursing home noticed a "fever".

I think you make several excellent points, particularly the fact that these problems are front-and-center in the ED even though you deal with them in microcosm in every inpt and outpt setting.

There are really 2 types of problems here: ones physicians CAN do something about, and ones they can't.

Problems 3, 4, and 6 physicians absolutely can at least do their part to remedy. This means evidence-based guidelines (and their appropriate interpretation) leading to appropriate use of diagnostics and treatments hopefully not guided by fear or CYA medicine. Problem 6 is a relatively easy one for the PCPs, geriatricians, etc out there: every demented or NH-resident pt should have a clear and REASONABLE living will, DPOA, or at least have discussed end-of-life issues before the NH gomers come into the ED and ICU with urosepsis to die and rack up a $100K bill. The VA computer system nicely uses alerts to let the provider know to update the pt's code status etc. To me, defensive medicine and inappropriate cultural expectations for end-of-life care are a HUGE part of healthcare costs.

Problems 1, 2, and 5 physicians really can't do that much about personally. You can use the opioid tracking system or take that minute or 2 to do pt education, but you won't change the level of intelligence, education, or expectations that the majority of ED players have. You can't make the CHFer adhere to their diet, or make the pt get and see their PCP -- but you can try.

 

[Trisomy13]

3.) Petri dish is probably one of the best terms I have ever heard. These individuals are just bio material with tubing. They are not people anymore, but in a God-less society, we can't let them go to the unknown beyond. Will Obama cap care on those meeting certain criteria that represent no return? I think it's reasonable that an 80 year old doesn't live for another 4 months vent/trach/pegged so that funding can be diverted to maybe something like free vaccines.

In the end, our cultural views have to change if we are going to change US medicine.

Are you implying that non-believers or atheists are responsible for maintaining life support on the persistent vegetative patients? Either I misinterpreted this statement, or you are seriously muddying the waters with an unnecessary interjection of your own religious beliefs here. I'm godless, and I say cut 'em loose. ASAP. Send them home to baby jesus, or the big worm pile in the sky, or wherever they think they go when cerebral perfusion pressure becomes terminally inadequate 🙄

But i'm with you on the general sentiment.

 

[YouISee]

....so unfortunately the only solution is to give all of them free health care since they are getting it anyway and since it seems that the rest of the world thinks that humans should not be allowed to die on the streets for lack of health care in civilized countries...

Should people be allowed to die for their choices? Possibly. I'm not saying that we need to universally shun people who can't afford services, but there is a huge spectrum in the group who says they can't afford it. A person who legitimately cannot pay for services and doesn't participate in activity that is destructive (ex: illicit drugs, gang fights) should be treated in the ER. Such people do exist, which makes me feel that situations decide who a person is going to be is BS. Poor folks don't all act like idiots while not so poor folks can act like idiots all the time. What about that blue collar worker buying an expensive cell phone plan, paying for cable TV versus OTA, purchasing a car with low MPG, etc. living above their means who then shows up for freebies?

#1 is a serious problem where we allow abuse rather than letting them just die on the streets. That might just send a point. Why not? They beat people for spitting gum in the streets of Singapore. Might explain why the sidewalks are clean. Wonder how their healthcare system works? 🙄

For Trisomy13: I have found patient's family belief system has profoundly impacted their choices. I had quite an intense ICU experience where I spoke with 2 to 3 families per call night about end of life issues. That's quite a lot, and you start seeing something that really only observation can explain. I can't find you a randomized controlled trial on it, but once again, new American culture enters into the picture.

 

[DO4lifer]

Yet I've never seen this mentioned by Obama as a source of the problem. Why? Because Democrats, frequently scumbag lawyers themselves, don't go for tort reform.

a lot of anti-dem stuff in here blaming them for the system. 😡

About half of our congress has been dem and half republican. The president for the past EIGHT years was republican. The system IS NOT BROKEN because of one side or the other...its broken because the people making decisions on health care ARE NOT DOCTORS.

don't bash democrats. if it wasn't for them and their public assistance + education agenda, i'd still be living on the streets with my mom instead of entering residency as an anesthesiologist. 😱

THANK YOU! 👍

 

[proman]

don't bash democrats. if it wasn't for them and their public assistance + education agenda, i'd still be living on the streets with my mom instead of entering residency as an anesthesiologist. 😱

THANK YOU! 👍

Mind sharing your story? I'm curious what programs helped you?

 

[jwk]

a lot of anti-dem stuff in here blaming them for the system. 😡

About half of our congress has been dem and half republican. The president for the past EIGHT years was republican. The system IS NOT BROKEN because of one side or the other...its broken because the people making decisions on health care ARE NOT DOCTORS.

don't bash democrats. if it wasn't for them and their public assistance + education agenda, i'd still be living on the streets with my mom instead of entering residency as an anesthesiologist. 😱

THANK YOU! 👍

I know, you're one of those guys that thinks Republicans hate poor people. They don't. And don't think for a second that Democrats like poor people - they like them only as far as they think making them dependent on the government will buy them a vote in the next election. Don't you attribute at least some of your success to your own willpower and sense of responsibility, or did that come from the Democrats too?

I agree that much of the problem stems from non-doctors making medical decisions. But tort reform is almost always opposed by Democrats. Defensive medicine is practiced largely because of the possibility of a lawsuit, even if the chances are remote. How many billions upon billions of dollars are wasted because of this? How much of RxBoy's original post could be chalked up to defensive medicine? Repeated or unnecessary labs, xrays, scans, etc., all fall in this category. How many talented people avoid the medical field altogether because they don't want to mess with the legal climate?

Much of the rest of the problems lie with the individuals and the poor choices they make. Smoking, alcohol, and drugs, take a tremendous toll. How many healthcare dollars are wasted treating conditions related to substance abuse?

 

[coprolalia]

OK,
Here is some solutions:
1- For patients who use the ER as their PCP:
I am sure they don't do that because they love spending 12 hours at the ER waiting room to get blood pressure medicine, so unfortunately the only solution is to give all of them free health care since they are getting it anyway and since it seems that the rest of the world thinks that humans should not be allowed to die on the streets for lack of health care in civilized countries.

In theory, this sounds good. However, remember this isn't "free" care. People are sent a bill, whether or not they pay it is a separate issue. There is not a huge incentive to fix this system on the administrative level because hospitals charge a premium for ER visits (i.e., less likely to be part of the solution) and they can write-off their losses for those who don't pay.

Secondly, the EMTALA regulations currently hand-tie practitioners from refusing care. What is intended to be "stabilize the patient" turns into "treat every patient" in our ERs, regardless as to whether or not they can and/or are willing to pay.

I believe what needs to happen is rapid triage and refusal to provide care without pay if the patient is not (as is true in many if not most cases) really having an "emergency". Of course, you won't be able to refuse the malingerers (people who say they are having chest pain just to get seen when they are not), but you don't then treat the other co-morbid condition (e.g., earache) that they are really there to get seen.

Lastly, I don't think you can fix people who have been programmed to go to the ER when they are finally really sick. People are, generally, lazy procrastinators. (How many of you have done your taxes already... and this is not a representative group, remember...). Fact is there is a ton of cheap, affordable care at the primary level out there that people are, quite frankly, just not seeking because they don't know how to access it.

Remove the ease and incentive of going to the ER, and refuse care to those who don't really need it there without pay up front, is the only way you can fix this problem

2- For physicians that are afraid of lawyers and practicing defensive medicine:
Change the laws and make it mandatory for any malpractice suit to be first evaluated by a committee of experts (not paid by the plaintiff) to see it has merit, then if it goes to court it should not be in the hands of lay juries that think all doctors are rich bastards and the actual judgment, if there is one, should make sense and not reward people for abusing the system.

Many states already require "mandatory binding arbitration" before proceeding to the court system. Generally, this doesn't work.

Until you require plaintiffs lawyers to work on retainer and not on a contingency basis, I don't know how you effectively change this. The plaintiffs attorneys lobby is just too strong right now to make an effective change in this arena.

3- For physicians that don't know when to order the right labs or do the right intervention:
Make sure that people who go to medical school are learning medicine not only memorizing keywords so they can pass exams.
There you have it, solutions for all the problems the OP mentioned.
😀

Well, again, this is a systematic problem. We are moving more and more to "protocol" type medicine, and less away from individualization of care. You can blame JCAHO and other organizations that push "standardization" over clinical acumen. Not sure how you change this problem either.

-copro

 

[Trisomy13]

For Trisomy13: I have found patient's family belief system has profoundly impacted their choices. I had quite an intense ICU experience where I spoke with 2 to 3 families per call night about end of life issues. That's quite a lot, and you start seeing something that really only observation can explain. I can't find you a randomized controlled trial on it, but once again, new American culture enters into the picture.

We obviously had different ICU family encounters. I also had plenty of end-of-life discussions over at least 6 months of ICU rotations, and the ones that stick in my mind are the families who let grandma rot in the ICU until her skin was falling off (prompting, of course, a derm consult - LOVE academia 🙄), because "God will get her through this".

And for the record, there's nothing new about atheism in American culture 😉

I'll stop hijacking this thread now.

 

[geogil]

OK,
Here is some solutions:
1- For patients who use the ER as their PCP:
I am sure they don't do that because they love spending 12 hours at the ER waiting room to get blood pressure medicine, so unfortunately the only solution is to give all of them free health care since they are getting it anyway and since it seems that the rest of the world thinks that humans should not be allowed to die on the streets for lack of health care in civilized countries.
2- For physicians that are afraid of lawyers and practicing defensive medicine:
Change the laws and make it mandatory for any malpractice suit to be first evaluated by a committee of experts (not paid by the plaintiff) to see it has merit, then if it goes to court it should not be in the hands of lay juries that think all doctors are rich bastards and the actual judgment, if there is one, should make sense and not reward people for abusing the system.
3- For physicians that don't know when to order the right labs or do the right intervention:
Make sure that people who go to medical school are learning medicine not only memorizing keywords so they can pass exams.
There you have it, solutions for all the problems the OP mentioned.
😀

I'm no lawyer, but it's my understanding that plaintiff's attorneys present a case to an expert, usually an MD in the field in question, to see if a potential case has merit. What would be easier than legislating the problem would be to regulate this in house so to speak. If state medical boards were to require that a physician only testify or give opinions concerning the specialty in which they are board certified, that would reduce the number of sleazbag doctors selling their opinions on subjects on which they may not be qualified. This in turn would reduce the number of cases going to court, which would remove the incentive for a plaintiff's attorney to get into court, and eventually, remove the fear of litigation (hopefully). Additionally, state medical boards should be empowered to enact stricter sanctions on physician mis-behavior, the way that state bar associations have, I think it would reduce the requirement to use the court system to 'discipline' a physician, thus reducing the fear of expensive litigation.

There is an interesting thread here about this.

 

[RxBoy]

The system IS NOT BROKEN because of one side or the other...its broken because the people making decisions on health care ARE NOT DOCTORS.

I agree with this the most... I am sick of having to choose between the lesser of two evils. Politicians are the problem, they have no insight into the havoc we call healthcare. Right now, dems seem to be the greater evil. I also read that article discussed in the other thread:
http://www.cnn.com/2009/HEALTH/03/27/india.medical.travel/index.html

and one quote that made me sick to my stomach was the Indian neurosurgeon saying:
"In the U.S. people are making careers out of carrying laptops and documenting things that are not really useful in the long term for the patient."

I could not believe the bias in that statement. This Indian neurosurgeon actually thinks we as doctors WANT to document every aspect of the encounter. What he does not understand is that we are FORCED to spend countless hours documenting charts to safegaurd against litigation. I am sure in India he could of killed the woman during surgery and everything would of went on as usual... no litigation, no years in court. Unfortunately we don't have that luxury. Endless documention is not something we choose.

Example, I had to do so many pelvic exams for those vaginal discharge women even though I could of gave them those 2 dollar antibiotics and sent them on their way. Reason: insurance wouldn't reimburse the ER encounter if we didn't document a Pelvic exam. I remember after one of the pelvic exams, a 22 yo woman had mild adnexal tenderness. So what did we do? Order a U/S pelvic exam. U/S was clean. So my attending orders a pelvic ct r/o mass... comes back clean. Now he can document that he worked up the patient as well as ordered culture sensitivity to insure it was gon or chl that we treated. In India I am sure they would just give her antibiotics, send her home and if she got worse come back. No documentation, no litigation. In the US on the other hand you send them home and that 1 in a million chance they have a tumor or PID... well you are going to court. It's absurd. How many extra dollars did we spend on such an easy and treatable encounter for just that one patient? Multiply that on a grand scale and you can see prices sky rocketing.


People don't understand medicine is defense. We have to fight both litigation and reimbursement issues.

A lawyer's argument is that litigation itself is a minor percentage cost in health care therefore is not the problem. For that arguement, I have this analogy:
In past 70 years the US and other foreign countries began building nuclear missiles. As Russian nuclear missiles inventory increased, US had to respond by building more missiles (deterrence). Russian responded by increasing their stockpiles, and the US responded with increasing theirs. Around and around the vicious cycle began costing billions.

A rationalist would say hey, why not just stop building missiles in both countries to stop the increasing danger and spinning cost of producing nuclear missiles.

A lawyer/politician would argue, nuclear missiles are not dangerous and they cost the taxpayers very little because they have only been used twice and those 2 bombs cost a couple mil. What they fail to realize is the threat itself forces US to produce larger and larger stockpiles costing tax payers a hell of a lot then a "couple mil". The threat is more dangerous than the use.

This is the same dilemma with medicine. The actual cost of litigation itself is minuscule compared to the threat of litigation. Keep threatening doctors, and they'll keep ordering extra, non essential studies. Any rationalist could understand this, but its too bad a "rational politician" is nothing more than an oxy"*****".

 

[Planktonmd]

I'm no lawyer, but it's my understanding that plaintiff's attorneys present a case to an expert, usually an MD in the field in question, to see if a potential case has merit.

They do, but that "expert" is usually paid by the plaintiff and his only purpose is to sign an affidavit saying that he thinks that the physician being sued was negligent which is all these lawyers need to proceed with the law suit in all states.
If that expert does not do what they want him to do (accuse a colleague of negligence) the lawyers won't give him business next time and he will not make money.
After a plaintiff's "expert" says that a case has merit a whole blackmail process starts and the physician is subjected to different stages of litigation nightmare that could take many years and even if ultimately the case is dismissed or the court finds the doctor not liable he would have already wasted valuable time, effort and was subjected to a very stressful experience that he will not be compensated for.
All this starts by some doctor getting paid to sign a paper saying that he thinks his colleague was negligent and most of times that doctor's job ends there because if the case goes to court they are not going to use the guy who signs an affidavit for a few hundred dollars as their main expert witness, at that point they will get more highly paid and credible experts who make a good chunk of their living by testifying against other doctors.
It's a dirty game and unfortunately they don't teach you enough about it in medical school.

 

[dfk]

Remove the ease and incentive of going to the ER, and refuse care to those who don't really need it there without pay up front, is the only way you can fix this problem

-copro

tell me how you can explain the answer to this. problem is, it can't happen. obviously, you see people everyday that fall in to the "go to the ER b/c ..." scenario. it will never end.

refuse care? obviously unethical and unobtainable, if you will.

i can understand what you are saying, but there's no way this can happen and have a society feel right about this.

on a side note, this is why we've developed an urgent care system, but no matter.. there's still people who won't/don't get it, and don't see that actually a nose cold can wait (for example).

 

[geogil]

tell me how you can explain the answer to this. problem is, it can't happen. obviously, you see people everyday that fall in to the "go to the ER b/c ..." scenario. it will never end.

refuse care? obviously unethical and unobtainable, if you will.

i can understand what you are saying, but there's no way this can happen and have a society feel right about this.

on a side note, this is why we've developed an urgent care system, but no matter.. there's still people who won't/don't get it, and don't see that actually a nose cold can wait (for example).

whoa, whoa, whoa there cowboy. I needs my antiobiotics for that, and I needs them now!

 

[jwk]

I'm no lawyer, but it's my understanding that plaintiff's attorneys present a case to an expert, usually an MD in the field in question, to see if a potential case has merit. What would be easier than legislating the problem would be to regulate this in house so to speak. If state medical boards were to require that a physician only testify or give opinions concerning the specialty in which they are board certified, that would reduce the number of sleazbag doctors selling their opinions on subjects on which they may not be qualified. This in turn would reduce the number of cases going to court, which would remove the incentive for a plaintiff's attorney to get into court, and eventually, remove the fear of litigation (hopefully). Additionally, state medical boards should be empowered to enact stricter sanctions on physician mis-behavior, the way that state bar associations have, I think it would reduce the requirement to use the court system to 'discipline' a physician, thus reducing the fear of expensive litigation.

There is an interesting thread here about this.

A lawyer can always find a ***** somewhere.

 

[lfesiam]

Nice post rxboy. I will post my rant soon. I am working in a Thai SICU on my international rotation (changed my rotation from Anes to pure SICU). Boy, we can learn a thing or two from international medicine.

Made me apprecitate the things we take for granted.... Many things are insignificant when compared to the suffering I am seeing here in the patients and their family members.

 

[radslooking]

Actually, our system is so screwed that I don't feel bad for our current health care crisis. It has to happen in order for it to change. Apparently we will have to wait until healthcare makes our businesses completely uncompetitive to foriegn ones, or bankrupts our nation before it will change. Whatever, change is coming either way.

You can't have it all. You can't live forever. People need to start internalizing these things. We fight mortality far too much in this field.

Workups should be thoughtful and regard both cost and efficacy. "Gold standard" treatment isn't gold standard if it's prohibitively expensive.

At the end of the day, we will need to start rationing care, and cutting off sick and dying from unnecessary tests. No one wants to dictate who gets care or doesn't, but it has to happen. Whether that's this year, or 10 years from now, it has to happen. You can't be doing head ct's, renal workups, ICU admissions for people with end stage cancer. There's just no sense in it.

Also, only until you start protecting physicians from lawsuits will you see defensive medicine improve. There is no incentive to practice good medicine because it leaves you exposed.

We have to accept that by not doing full workups on everybody, and not taking everyone for a ride in the ambulance, that some people will get hurt. That's a fact. Some people will be overlooked. That's the price of covering everyone and drawing a line about how much care we will provide. Our leaders need to communicate to the public that no way will ever be perfect. In order to cover everyone, and keep costs down, sacrifices will need to be made. If you want the million dollar workup, you are going to have to pay for it out of your own pocket.

We can either learn these lessons now, or later. But they will be learned.

So I been pretty quiet lately because I spent this entire month working in the ER. I thought I would share what I observed and tie it in to the current political discussions.

After working in the ER I must say, I have never seen such an abused and inefficient system in my life. I think all Obama needs to do is spend 3 days in any busy city ER and see exactly why our healthcare costs are spinning out of control.

Reasons that were appalling to witness:

1) REPEATED visits by the same patients for the same symptoms in order to get PAIN MEDS. There were many other malingering reasons as well. Such as this homeless guy who admitted that he faked his chest pains to get a "ride" to the hospital through EMS and didn't want to stay for a cardiac workup… at least he was honest.

2) REPEATED visits by the same patients for primary care problems. "Doc it's been burning every time I urinate. I had the same symptoms last month until I came to the ER and got some antibiotics". 1 patient had racked up a $13k tab with the hospital for repeated PCP type visits to the ER. Of course he simply refused to pay his medical bills (lost money to that hospital) but we still had to repeatedly treat him. Honestly the first 2 reasons mentioned above compromise at least 70% of the total ER visits.

3) Using clinical guidelines too tightly and getting a full work up on every 25 year old with obvious acid reflux type chest pain. Admitting just about EVERYONE who appears even slightly discomforted out of fear of litigation.

4) Using labs, radiography and consults inefficiently. We were using them too readily when patients didn't need them. We were not using them readily enough when patients seriously DID need them. This was mostly because the system was overwhelmed with all the prior unneeded orders.

5) Noncompliant patients who got the 5k workup for their PUD but refused to take their PPI's or f/u, rushed to the ER with a perforation. CHF exacerbation, Asthma exacerbation, Uncontrolled Diabetes, list goes on and on. This compromised another 20% of the patients I saw in the ER. Almost all could of been avoided if they took their meds (and no I'm not talking about state of the art chemo drugs, simple $5 scripts at any walmart). This of course, is not even discussing the ones who refuse to change their social habits (diet, EtOH, Tob, IDU, coke, ect.).

6) Patients with a GCS score of 3 on a vent, feeding tube and foley, transported to the ER because the nursing home noticed a "fever".I could understand if these patients had recently fell into a coma, but all of these patients were chronic (months to years). They always seem to send these patients with no family members making you hunt endlessly for PMH records as well as an endless workup with full admission to find the source of the fever. Lets not forget about the costs to maintain, transport, and re-establish lines on these patients. Not to sound rude, but I think its time to rethink treatment when your treating an oversized petri dish. I know this is completely opinion but I would never want my body disgraced with diapers, tubes, and repeated physical exams like that.... which is why I'll be sure to keep a loaded gun handy.

6) I could continue naming 1000 other flaws I noticed. I have seen similar abuses in other units (ICU's, floors, PCP offices, ect.) but I have never seen it in such a raw and glourious view as I did in the ER.

Do I blame the ER Doctor? NO

They have to simultaneously write every note to assure proper reimbursement all while working up every minor complaint as a major one and documenting it to safeguard themselves from greedy litigation lawyers. They have very little room to make their own clinical decisions.

WIth all this said, I just wanted to say… don't be fooled into thinking our salaries, our work ethic, or our expertise are the reasons for the current health care crisis…

It's because we are FORCED to practice defensive medicine on an increasingly abused and unrationed health care system. PERIOD.

My ER experience was all the evidence I needed. No matter how much money you dump into the system or how much salary/staff cuts you make, the problems will not go away. Until politicians understand these basic premises, you will continue seeing health care costs spin out of control.

Sorry about the rant, just had to let that out.

 

[radslooking]

IExample, I had to do so many pelvic exams for those vaginal discharge women even though I could of gave them those 2 dollar antibiotics and sent them on their way. Reason: insurance wouldn't reimburse the ER encounter if we didn't document a Pelvic exam. I remember after one of the pelvic exams, a 22 yo woman had mild adnexal tenderness. So what did we do? Order a U/S pelvic exam. U/S was clean. So my attending orders a pelvic ct r/o mass... comes back clean. Now he can document that he worked up the patient as well as ordered culture sensitivity to insure it was gon or chl that we treated. In India I am sure they would just give her antibiotics, send her home and if she got worse come back. No documentation, no litigation. In the US on the other hand you send them home and that 1 in a million chance they have a tumor or PID... well you are going to court. It’s absurd. How many extra dollars did we spend on such an easy and treatable encounter for just that one patient? Multiply that on a grand scale and you can see prices sky rocketing.
.

That's a nice example. Happens every day in a million different scenarios. Add in to that that some doctors have a financial incentive to order more tests, and you have a useless, test-ordering orgy, that only serves to harm the patient.

Incentives. it all comes down to incentives.

 

[radslooking]

We obviously had different ICU family encounters. I also had plenty of end-of-life discussions over at least 6 months of ICU rotations, and the ones that stick in my mind are the families who let grandma rot in the ICU until her skin was falling off (prompting, of course, a derm consult - LOVE academia 🙄), because "God will get her through this".

And for the record, there's nothing new about atheism in American culture 😉

I'll stop hijacking this thread now.

I favor a 3 member (or whatever number) physician panel that can decide whether further ICU care or hospital care will be provided. Despite family wishes. If they want to pay for it out of pocket after a consensus "no", that's their wish.

If expert medical personnel determines that further care is futile we should abide by that decision.