Negatives of EM as a Specialty

[spyderdoc]

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Ask your EM attendings who are 10 or more years out how close they are to retiring.

9 yrs out of residency, and not even close to close. And that is with a 2 doc salary. My wife and I had total of $400+k med school debt. We live in NoCal/SF Bay area with a mortgage payment that is more than most people's salary. We have 2 kids (I was 40 when my 1st was born) , bills, preschool, etc. It is just staggering how much money goes out every month. Granted, I am saving like crazy now for kids college funds and my SEP-IRA, and did a refi to a 15yr mortgage so I can be able to cut back at 59yo when my mortgage is paid off..

Right now, I do 12-15 eight hour shifts, so my big plan is to keep working this workload until I hit 60, then cut back to 6-8 shifts/mo....That is about the time my kiddos will be ready to start college, so assuming the money has appreciated appropriately, I won't have to work more to put them through college at that age.....

We'll see.......But, in no way am I financially ready to retire in 1 year..

 

[NYRN]

👍👍👍 To all the great ideas on here. That would be awesome to have that number code at triage to document how busy it is. I was at one deposition where the lawyer did ask me how busy it was that night, and honestly I couldn't remember. It was a Tuesday, which can go either way.

Another thing that I see ED docs have to deal with that drives me nuts, is when patients are sent to the ED for testing and treatment that could be done outpatient. Why? Just because the patient complains that they have to wait a few days for a CT at an outpatient center, or something ridiculous like that. If the ED doc determines that this scan or any other thing on the laundry list that the PMD wants is not appropriate use of ED resources, it becomes a problem. You don't see primary care MD's sending patients to other private MD offices and demanding that they are seen there that moment. Just another way that ED docs are abused, and I can't stand it!

 

[otacon88]

- and here is the kicker.

- Everyone in the department, in the HOSPITAL knows "Christina Diabetica". She's 26, and has had as many ICU/SICU admits. She's just not willing to admit that she needs to be vigilant about her blood glucose, and it shows. Whenever she feels '****ty', which is every two weeks... she comes into the ED, gets a central line, gets her potassium/glucose/acidosis corrected, and goes home.

- We (residents) all know Christina. We all salivate over getting the central line/intubation. But she's singlehandedly bankrupting the system. Again. and Again. and Again.

- Anyone want to let her die next time ?

#braveryandhonestyblog.

#socialresponsibilityblog.

#dontwanttobeadickblog.

I am a total noob when it comes to all this healthcare business. Can you or anyone please expand on how that one patient is bankrupting the system? Doesn't she have to pay her ED bills when the $5000 bill arrives at her door?

And while I'm on the topic, I read in another post that many people don't pay their ED bills? How in the world does that work? How can people bypass something like that...isn't it just like not paying your credit card bill? And how does having insurance vs no insurance affect all this?

 

[ccfccp]

I am a total noob when it comes to all this healthcare business. Can you or anyone please expand on how that one patient is bankrupting the system? Doesn't she have to pay her ED bills when the $5000 bill arrives at her door?

And while I'm on the topic, I read in another post that many people don't pay their ED bills? How in the world does that work? How can people bypass something like that...isn't it just like not paying your credit card bill? And how does having insurance vs no insurance affect all this?

Don't feel bad. You're one of the lucky few people out there who haven't had their attitudes spoiled by seeing this repeatedly every single day.

If you or I do not pay our ED bills, the hospital sends us angry letters. Eventually they turn it over to collections. They call with angry phone calls. Eventually, they sue us for the difference. Throughout this time, our credit is being ruined. We don't like that, so we tend to pay our bills.

However, there are lots of ways of getting around this. The first, easiest, and probably most common is: just don't have anything. If you have no assets, and your credit sucks anyway, what's the harm in not paying your bills? It's not like they can take anything from you. You can't draw water from a stone. They can call and call all they want, but you don't have anything, so why should you worry. And if you've done this to a hospital once, what's the harm in doing it 10 times a month for repeatedly minor or ridiculous claims. The hospital can't turn you away. And you've found if your irritating enough, usually docs will just give in to what you want to get you out of their department. If you can convince enough doctors of your pain, you can manage a nice little cash only unregistered-narcotics-delivering-side-practice. Now... it's cash only so no one could ever prove you make more than the residents who see you several times a week... allegedly.

That doesn't even cover the folks who give false identification when checking in. It seems strange that all these bills for Jon Smith at 1234 Penis Road keep coming back. Hmmmm...

[/rant]

For what it's worth... it was kind of cathartic to write that. A lot of it was tongue firmly in cheek, but there's some truth in it too. Hope it helps.

 

[otacon88]

Don't feel bad. You're one of the lucky few people out there who haven't had their attitudes spoiled by seeing this repeatedly every single day.

If you or I do not pay our ED bills, the hospital sends us angry letters. Eventually they turn it over to collections. They call with angry phone calls. Eventually, they sue us for the difference. Throughout this time, our credit is being ruined. We don't like that, so we tend to pay our bills.

However, there are lots of ways of getting around this. The first, easiest, and probably most common is: just don't have anything. If you have no assets, and your credit sucks anyway, what's the harm in not paying your bills? It's not like they can take anything from you. You can't draw water from a stone. They can call and call all they want, but you don't have anything, so why should you worry. And if you've done this to a hospital once, what's the harm in doing it 10 times a month for repeatedly minor or ridiculous claims. The hospital can't turn you away. And you've found if your irritating enough, usually docs will just give in to what you want to get you out of their department. If you can convince enough doctors of your pain, you can manage a nice little cash only unregistered-narcotics-delivering-side-practice. Now... it's cash only so no one could ever prove you make more than the residents who see you several times a week... allegedly.

That doesn't even cover the folks who give false identification when checking in. It seems strange that all these bills for Jon Smith at 1234 Penis Road keep coming back. Hmmmm...

[/rant]

For what it's worth... it was kind of cathartic to write that. A lot of it was tongue firmly in cheek, but there's some truth in it too. Hope it helps.

thanks for the quick version. But, if that's the case, why can't hospitals turn them away? Or just say no, i'm not gonna do anything for that drug seeker that comes in every 5 days? What can they do that makes it so we still have to treat them, other than our oath that we take? They don't have the money or the means to sue or anything, and we all know they are abusing the system?

And how does patient's not paying affect an EMP salary? Is it the less ppl that pay, the less ED docs get paid, or would they not be affected and the hospital takes the hit?

 

[DrMom]

thanks for the quick version. But, if that's the case, why can't hospitals turn them away? Or just say no, i'm not gonna do anything for that drug seeker that comes in every 5 days? What can they do that makes it so we still have to treat them, other than our oath that we take? They don't have the money or the means to sue or anything, and we all know they are abusing the system?

Just a little federal law.

 

[Arcan57]

thanks for the quick version. But, if that's the case, why can't hospitals turn them away? Or just say no, i'm not gonna do anything for that drug seeker that comes in every 5 days? What can they do that makes it so we still have to treat them, other than our oath that we take? They don't have the money or the means to sue or anything, and we all know they are abusing the system?

And how does patient's not paying affect an EMP salary? Is it the less ppl that pay, the less ED docs get paid, or would they not be affected and the hospital takes the hit?

DrMom covered your first paragraph quite well. The issue of unreimbursed care is handled differently by different groups. Some groups are "eat what you kill" and you receive nothing for a patient that doesn't pay. Some groups pay based on RVU's, so the whole group takes a hit but you still get something for every patient you see. Some are straight salary and avoid the issue altogether. The key is not to be stuck in a model that doesn't fit your payor mix. If you see mostly uninsured patients, "eat what you kill" doesn't make a lot of sense from the physician's standpoint. If you are straight salary at a place that is chock full of privately insured patients, then there is likely serious money being left on the table.

 

[Birdstrike]

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[Arcan57]

I've heard interpretations of EMTALA that include pain as an emergency condition. Which if strictly applied means that almost no one shows up to the ED without an emergent condition.

 

[NSAIDAllergy]

I've heard interpretations of EMTALA that include pain as an emergency condition. Which if strictly applied means that almost no one shows up to the ED without an emergent condition.

Not really. That may be an acute symptom, but it does not necessarily constitute an emergent condition. For example, a 24 year old male comes into the ED with acute lower back pain, but vitals are normal, neurologic exam & CV exam are unremarkable; he can ambulate. There aren't any urinary symptoms. The patient does not have a history of connective tissue disorders or a history of hypertension. He can probably follow up outpatient & manage symptoms with OTC meds.

Just because someone shows up to the ED does not mean they are entitiled to have imaging, mediciations or an admission.

 

[docB]

I've heard interpretations of EMTALA that include pain as an emergency condition. Which if strictly applied means that almost no one shows up to the ED without an emergent condition.

Not really. That may be an acute symptom, but it does not necessarily constitute an emergent condition. For example, a 24 year old male comes into the ED with acute lower back pain, but vitals are normal, neurologic exam & CV exam are unremarkable; he can ambulate. There aren't any urinary symptoms. The patient does not have a history of connective tissue disorders or a history of hypertension. He can probably follow up outpatient & manage symptoms with OTC meds.

Just because someone shows up to the ED does not mean they are entitiled to have imaging, mediciations or an admission.

Medically I agree with NSAID but I too have heard, frequently and from reliable sources like risk managers, that pain can be considered an "emergent condition" in and of itself.

I'm frequently told that anyone with a pain of 5 or higher has "an emergency." It's actually really humorous and absurd and goes to show everyone the silliness of medicine in a highly regulated environment. We have taken the notoriously unreliable pain scale and picked an arbitrary number and are using that to make regulations that drive medical decision making.

One thing to remember about EMTALA is that the government wants hospitals treating these people for free. They view any attempt to limit that carte blanch as in violation of the spirit of the law. The spirit of the law is that people without the ability to pay will be given mandated free care at EDs so that the politicians don't have to raise taxes to actually fund that care. EMTALA care costs are passed on to paying healthcare customers so the public gets stuck with it of course but almost no one makes the connection between those high costs and the politicians. Thus, with deft slight of hand, the government passes off the hatred generated by the high costs of EMTALA to the hospitals and doctors. This is not an unintended consequence. This was, is and will continue to be the primary goal.

 

[WhyOhWhy]

- and here is the kicker.

- Everyone in the department, in the HOSPITAL knows "Christina Diabetica". She's 26, and has had as many ICU/SICU admits. She's just not willing to admit that she needs to be vigilant about her blood glucose, and it shows. Whenever she feels '****ty', which is every two weeks... she comes into the ED, gets a central line, gets her potassium/glucose/acidosis corrected, and goes home.

- We (residents) all know Christina. We all salivate over getting the central line/intubation. But she's singlehandedly bankrupting the system. Again. and Again. and Again.

- Anyone want to let her die next time ?

#braveryandhonestyblog.

#socialresponsibilityblog.

#dontwanttobeadickblog.

You've just become my new favorite person.

 

[Powdermonkey]

...

One thing to remember about EMTALA is that the government wants hospitals treating these people for free. They view any attempt to limit that carte blanch as in violation of the spirit of the law. The spirit of the law is that people without the ability to pay will be given mandated free care at EDs so that the politicians don't have to raise taxes to actually fund that care. EMTALA care costs are passed on to paying healthcare customers so the public gets stuck with it of course but almost no one makes the connection between those high costs and the politicians. Thus, with deft slight of hand, the government passes off the hatred generated by the high costs of EMTALA to the hospitals and doctors. This is not an unintended consequence. This was, is and will continue to be the primary goal.

Is there anything we can do about this? I'm still a student, but I want to be involved in the political side of things because I absolutely HATE the fact that things like above happen day in and day out. And I want to do something about it so practice for me and future generations can be better.

 

[Birdstrike]

.

 

[TrumpetDoc]

EM:
"Love it for what it could be,
Frustrated by what it is,
And sickened by what it is becoming"


Not at all in regards to "what we do" but more in regard to or getting continually bent over by hospitals and Govt.