The opposite of "emergency"

[quickfeet]

Just a student, but I want to know how some of you who have been in the game a long time deal with those people who come in for utter non-sense. 2 quick examples:

30 y/o female shows up at 12am with complaint of "I can't sleep." No other complaints at all, and doesn't even want any drugs. Just "I can't sleep."

20 something y/o male shows up one day after work because he is "dehydrated." He walks in with a bottle of water in his hand and clutching his chest in panic, saying he is dehydrated. "Are you having chest pain or SOB or have you fainted or anything?" "No, I'm dehydrated." Really? U come to the hospital because ur thirsty?

Have only seen 1 relatively older attending (65) take some of these people to task by saying things, "So you feel good about yourself wasting a community resource for a problem that could handled with common sense?" Younger attendings + residents just get annoyed but don't complain. Me... I just laugh, because really what else can you do in such a stupid broken system that allows these dingbats to get away with this.

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[alpinism]

The thing that pisses me off even more is that EMTALA does not in any way require non emergency treatment.

It only requires an emergency screening exam.

The problem is that too many physicians are too scared to speak up and too many hospitals see these patients as nothing but $$.

We created this problem ourselves.

Both patients =
Any other complaints? No? okay
How are your vital signs? Normal? great
Listen to heart and lungs, press on belly, and watch them walk out the door.

Takes less than 5 min. That's all they should ever get.

 

[DocEspana]

The thing that pisses me off even more is that EMTALA does not in any way require non emergency treatment.

It only requires an emergency screening exam.

The problem is that too many physicians are too scared to speak up and too many hospitals see these patients as nothing but $$.

We created this problem ourselves.

Both patients =
Any other complaints? No? okay
How are your vital signs? Normal? great
Listen to heart and lungs, press on belly, and watch them walk out the door.

Takes less than 5 min. That's all they should ever get.

With the correct attending I'm a very pro EMTALA resident. At least very pro "the letter of the law". Give the legal minimum and dispo to correctly seleced patients. If there is nothing but BS from the patient I give them a screening exam and start their discharge note. I've managed to turn a patient around in 7 minutes door-to-dispo time once (my record. Which is good considering I actually talk to them and the dispo note takes 3-4 minutes to write). And a few at 8, 9 and 10 minutes. but it has to be clear and absolute BS for me to not go and give a real exam.

 

[Hercules]

The thing that pisses me off even more is that EMTALA does not in any way require non emergency treatment.

It only requires an emergency screening exam.

The problem is that too many physicians are too scared to speak up and too many hospitals see these patients as nothing but $$.

We created this problem ourselves.

Both patients =
Any other complaints? No? okay
How are your vital signs? Normal? great
Listen to heart and lungs, press on belly, and watch them walk out the door.

Takes less than 5 min. That's all they should ever get.

How does performing an MSE ever benefit a physician? The hospital benefits and can say a physician saw them and felt there was no medical emergency and discharged them without utilizing any hospital resources (all while absorbing the liability of any bad outcome). But how does that benefit the physician? I don't ever perform MSE. If I take my time to see you then you have just had a physician encounter. I'm going to document an ED visit not an MSE. I may choose to do nothing and discharge you on the spot, but I'm not doing an MSE for the hospital's benefit. If the hospital wants to start doing MSEs they can empower their triage nurses to do them and the hospital can absorb the liability without wasting my time. Very few hospitals choose to do this and that should tell you something.

 

[msgsk]

We have a fast track that takes care of these during the day. Recently our group started putting a doc up there during the day to try to speed things up. So much of this kind of stuff comes in (insect bite, morphine refill, methadone refill, etc). If you're in a place that looks at metrics these kind of cases are great - like the OP said quick turnaround. But how can you change public perception about what constitutes an emergency? You can't.

 

[Arcan57]

You could have ads on TV that ridicule non-emergent use of the ED (there's a viral video of one from Australia that pops up occasionally on FB). The problem is that there's almost no disincentive to utilizing ED care besides the financial hit. If you look at the target metrics for door to doc and LOS for most non-county hospitals, you'll see that they start to compare reasonably with a scheduled appointment at many offices. And UCs typically demand money up front so they're not going to be siphoning off these visits.

In regards to MSEs, you have to pay the doc some nominal rate if RVU based otherwise there's no incentive to screen out regardless of medical merit.

 

[cbrons]

You could have ads on TV that ridicule non-emergent use of the ED (there's a viral video of one from Australia that pops up occasionally on FB).

Id love to see this if someone has the link

 

[dotcb]

With these two patients, I would spend a few minutes talking with them. Likely wouldn't do any tests or provide any specific treatment, then write the charts and discharge them. While these cases might be a little frustrating, they're also pretty easy and you get paid a little bit to do the assessment. I support anything that steers clear of redlining doctors' emotions. You've got to pick your battles, and these are not one of them. If it bothers you that much, place a provider to work in triage. You shouldn't get angry about this kind of thing. Just move on. Next patient…

 

[turkeyjerky]

How does performing an MSE ever benefit a physician? The hospital benefits and can say a physician saw them and felt there was no medical emergency and discharged them without utilizing any hospital resources (all while absorbing the liability of any bad outcome). But how does that benefit the physician? I don't ever perform MSE. If I take my time to see you then you have just had a physician encounter. I'm going to document an ED visit not an MSE. I may choose to do nothing and discharge you on the spot, but I'm not doing an MSE for the hospital's benefit. If the hospital wants to start doing MSEs they can empower their triage nurses to do them and the hospital can absorb the liability without wasting my time. Very few hospitals choose to do this and that should tell you something.

I suppose the main benefit of doing an MSE would be if one were not RVU based (although I wonder how much you could really bill for these encounters, likely a level 3 at best, right?), but did have an administration focused on patient satisfaction scores--so that these two patients wouldn't get a survey. With the way the OP presented the patients, I really don't think there's any liability involved whatsoever

 

[SuckySurgeon7]

Id love to see this if someone has the link

This is the one I saw yesterday

 

[Birdstrike]

Just a student, but I want to know how some of you who have been in the game a long time deal with those people who come in for utter non-sense. 2 quick examples:

30 y/o female shows up at 12am with complaint of "I can't sleep." No other complaints at all, and doesn't even want any drugs. Just "I can't sleep."

20 something y/o male shows up one day after work because he is "dehydrated." He walks in with a bottle of water in his hand and clutching his chest in panic, saying he is dehydrated. "Are you having chest pain or SOB or have you fainted or anything?" "No, I'm dehydrated." Really? U come to the hospital because ur thirsty?

Have only seen 1 relatively older attending (65) take some of these people to task by saying things, "So you feel good about yourself wasting a community resource for a problem that could handled with common sense?" Younger attendings + residents just get annoyed but don't complain. Me... I just laugh, because really what else can you do in such a stupid broken system that allows these dingbats to get away with this.

It doesn't matter what you do with these über-non-emergent patients as long as you:

1-Do it efficiently,

2-Don't let them frustrate you (since these non-emergencies are bread and butter "emergency" medicine, and they will never, ever, ever, go away or reduce in numbers.)

3-Do it relatively politely (since your bosses will likely consider an invalid complaint from one of these people during a time you were trying to manage a rollover bus-load of kids on coumadin, equally as important as a very valid compliant levied by a dying or critically ill patient or their family. This is unfortunate, but true.)

 

[TheBlueBlazer]

I'm still probably coasting on my non-jaded-yet, resident naivete, but one of my attendings said "because they're an idiot" is a certainly a reasonable answer for the question "why did they choose the ED TODAY?" but is an answer (in a stand-alone form) of exclusion. I just ask people point blank specifically what they want to accomplish and why they think this needs to be handled right here and now. Sometimes I get some *****ic answers, sometimes it's something legitimizing, sometimes they're motivated by food/shelter, but usually it's "because I just wanted to make sure everything was ok." I assure them that everything is indeed ok, do 2 minutes of counseling, tell them this is a job for the doc that knows them better than I do, if they don't have one they get our referral number "because it's really important to have a primary care doc to take care of issues like this" and they're out the door in 10 minutes. People are generally pretty satisfied, and I have way more important things to get worried about. If this is really bugging you that much, you need to examine if this is the right career, or if your Burnout-O-Meter is higher than you think it is.

 

[Jonassen]

Why not have an ED fellowship track for primary care physicians if such a high proportion of ED visits are the "opposite of emergency"? It really doesn't make sense that a sniffle in clinic is reimbursed $60, while the same sniffle in the ED is reimbursed double that plus hundreds of dollars in facility fees.

CMS and the federal government are basically incentivizing hospital systems to have patients go to the ED for minor problems and open more freestanding EDs. Is this good public policy or even sustainable in the long run? I thought the whole point of our trillion dollar health care reform was to reduce ED visits? What a cluster.

 

[WilcoWorld]

Why not have an ED fellowship track for primary care physicians if such a high proportion of ED visits are the "opposite of emergency"? It really doesn't make sense that a sniffle in clinic is reimbursed $60, while the same sniffle in the ED is reimbursed double that plus hundreds of dollars in facility fees.

CMS and the federal government are basically incentivizing hospital systems to have patients go to the ED for minor problems and open more freestanding EDs. Is this good public policy or even sustainable in the long run? I thought the whole point of our trillion dollar health care reform was to reduce ED visits? What a cluster.

You're making two points here.

Your first point is that, because primary care problems present to EDs, PCP's should be able to staff EDs. I disagree. The fact that emergencies sometimes present to office practices does not qualify me to be a primary care doc.

Your second point is that the current US healthcare system insentivizes higher-cost care, and that this is creating/worsening our healthcare cost crisis. I agree.

 

[Greenbbs]

...:but, what if non-emergent patients (your colds, preg tests, yada yadda) are MSE'd appropriately and then triaged to a primary care setting/follow up clinic staffed by FP's but run by the ED?

Our ED has a huge number of no-pcp patients and establishing follow up is a bitch. You could kill 2 birds- get them the urgent type care they need while not killing the ED and tying up EP's AND establishing care in a primary care setting

 

[RustedFox]

...:but, what if non-emergent patients (your colds, preg tests, yada yadda) are MSE'd appropriately and then triaged to a primary care setting/follow up clinic staffed by FP's but run by the ED?

Our ED has a huge number of no-pcp patients and establishing follow up is a bitch. You could kill 2 birds- get them the urgent type care they need while not killing the ED and tying up EP's AND establishing care in a primary care setting

Love this idea, but this miiiight require them to pay up front for their visit, which is a big reason why many of the self-pay-no-pay crowd show up to the ED in the first place; the perception of "free care".
I frequently groan when I hear patients ask me for a Rx for (motrin, children's tylenol, benadryl) because "its free if you write the Rx". Now, you're going to have family-care-triaged patients arguing to be re-triaged to the ED.

 

[Jonassen]

You're making two points here.

Your first point is that, because primary care problems present to EDs, PCP's should be able to staff EDs. I disagree. The fact that emergencies sometimes present to office practices does not qualify me to be a primary care doc.

Exactly, you're not a primary care doc, yet a majority of your patients have primary care concerns and need primary care follow-up. Isn't this a problem?

And if anesthesiologists, surgeons, medicine docs, EPs can all go into the ICU with a fellowship, there's no reason ED fellowships can't provide the additional training for PCPs and vice versa. PCPs have done significant MICU and floor rotations during residency. Many have logged more clinical hours in residency than ED residents. Their scope of training is far greater than what a lot of ED physicians give them credit for. It's kind of warped that ED docs are training ED NPs to see the Level 3 cases rather than providing an ED fellowship path for PCPs.

 

[Greenbbs]

Love this idea, but this miiiight require them to pay up front for their visit, which is a big reason why many of the self-pay-no-pay crowd show up to the ED in the first place; the perception of "free care".
I frequently groan when I hear patients ask me for a Rx for (motrin, children's tylenol, benadryl) because "its free if you write the Rx". Now, you're going to have family-care-triaged patients arguing to be re-triaged to the ED.

But, if it's run under the auspices of the ED, then you can likely handle it as more of an urgent care situation rather than an FP situation. They get the same care, and built in follow up.

That's what I'd hope for in that situation.

 

[Jonassen]

But, if it's run under the auspices of the ED, then you can likely handle it as more of an urgent care situation rather than an FP situation. They get the same care, and built in follow up.

That's what I'd hope for in that situation.

That's kind of the model in Canada, where primary care is run more like urgent care, but they are staffed by general practitioners, not ED docs or NPs, and they have follow-up clinic. I feel if we go into this model, then you can't shut out the PCPs. Otherwise you'll just have a bunch of NPs staffing urgent cares doing immunizations, buddy taping, giving ankle stirrups and rapid strep tests. It's not sufficient scope for primary care.

Like I said above, PCPs have done significant MICU and floor rotations during residency, and that training is very relevant to being a good ED doc. There's a certain arrogance from ED docs that primary care physicians aren't capable or cannot be additionally trained to handle the ED. Their scope of training is far greater than what a lot of ED physicians give them credit for.

 

[Arcan57]

Like I said above, PCPs have done significant MICU and floor rotations during residency, and that training is very relevant to being a good ED doc. There's a certain arrogance from ED docs that primary care physicians aren't capable or cannot be additionally trained to handle the ED. Their scope of training is far greater than what a lot of ED physicians give them credit for.

You keep saying that last sentence like it means something. I can't quite tell if you're using PCP to refer to FP residency trained physicians or to the entire spectrum of docs that provide primary care. Your line of reasoning suggests the former as most IM docs don't feel like they have to justify having received enough inpatient training. I'm pretty sure there aren't a lot of FP programs that do 5 unit months during their 3 years of residency. Also, unit months are quite useful for seeing concentrated severe pathology and (depending on setup) developing procedural skills but a packaged ICU pt /= undifferentiated sick ED patient and treating them as such greatly increases the risk of missing a time sensitive diagnosis. In short, I do agree that PCPs are capable of working in an ED with additional training. It's just that the additional training is an EM residency.

 

[Jonassen]

You keep saying that last sentence like it means something. I can't quite tell if you're using PCP to refer to FP residency trained physicians or to the entire spectrum of docs that provide primary care. Your line of reasoning suggests the former as most IM docs don't feel like they have to justify having received enough inpatient training. I'm pretty sure there aren't a lot of FP programs that do 5 unit months during their 3 years of residency. Also, unit months are quite useful for seeing concentrated severe pathology and (depending on setup) developing procedural skills but a packaged ICU pt /= undifferentiated sick ED patient and treating them as such greatly increases the risk of missing a time sensitive diagnosis. In short, I do agree that PCPs are capable of working in an ED with additional training. It's just that the additional training is an EM residency.

This is the exact kind of arrogance I'm talking about.

http://www.westsuburbanmc.com/resid...cy-program/curriculum/curriculum-summary.aspx
Many family medicine programs do 3-4 months of ICU, with a rotation in every year of residency. The idea that an FP should still have to do a 3 year ED residency from scratch to be board certified in the ED is kind of ludicrous when at least 60% of the training in residency overlap, from pedi to OBGYN to the unit and to the medical and surgical floors. The only reason you favor this is to keep your job market closed off from other physicians in the future even as demand for urgent and emergent care increases (which ends up just meaning more and more midlevel encroachment since someone has to meet the demand).

We hire midlevels with very little training in their specialty for on the job training often doing the same work as senior residents and attendings, essentially making a farce in our overextended residency training process already. Instead of trying to streamline our residency education process to be more adaptive to changing times, you want to make the barrier of entry even higher, especially for other physicians. I hope you enjoy even more midlevels taking your jobs for half the pay like the CRNAs instead of incorporating more actual physicians to meet the demand.

 

[TheBlueBlazer]

OK let's compromise then, if you've done 3-4 months of ICU, and OB, and probably a couple months of ED, then you can do a 2 year fellowship on top of your 3-year residency and be certified to work in the ED, and I think that's being generous. We SPECIFICALLY have cut medical and surgical floor months TO ZERO from our training program because they're just not useful in doing what we do. You don't get credit for those. You also don't get credit for inpatient or outpatient peds, but I'll give you credit if it's peds ED. Your 60% overlap number is coming from where, exactly? 75% of my residency is in the ED, because that's where you learn Emergency Medicine. We've streamlined our residency process, like you've accused us of not doing, because you need that amount of time in the ED, taking care of ED patients to be good at what we do. The barrier for entry is high, because the stakes are high, and if someone sick hits your door and you're not prepared for it, PEOPLE DIE. The midlevels in our shop are not seeing the sickest patients and places where they are seeing the higher acuity folks, it's with a tremendous amount of oversight, if they're not decades deep into their career.

This is the exact kind of arrogance I'm talking about.

http://www.westsuburbanmc.com/resid...cy-program/curriculum/curriculum-summary.aspx
Many family medicine programs do 3-4 months of ICU, with a rotation in every year of residency. The idea that an FP should still have to do a 3 year ED residency from scratch to be board certified in the ED is kind of ludicrous when at least 60% of the training in residency overlap, from pedi to OBGYN to the unit and to the medical and surgical floors. The only reason you favor this is to keep your job market closed off from other physicians in the future even as demand for urgent and emergent care increases (which ends up just meaning more and more midlevel encroachment since someone has to meet the demand).

We hire midlevels with very little training in their specialty for on the job training often doing the same work as senior residents and attendings, essentially making a farce in our overextended residency training process already. Instead of trying to streamline our residency education process to be more adaptive to changing times, you want to make the barrier of entry even higher, especially for other physicians. I hope you enjoy even more midlevels taking your jobs for half the pay like the CRNAs instead of incorporating more actual physicians to meet the demand.

 

[Xerxes1729]

The NHS in the UK has a national campaign regarding appropriate usage of the ED (or A&E there):

Now obviously this can't be done in the US, since it relies on having a unified health care system that wants to reduce overall expenditures.

 

[Birdstrike]

...:but, what if non-emergent patients (your colds, preg tests, yada yadda) are MSE'd appropriately and then triaged to a primary care setting/follow up clinic staffed by FP's but run by the ED?

Our ED has a huge number of no-pcp patients and establishing follow up is a bitch. You could kill 2 birds- get them the urgent type care they need while not killing the ED and tying up EP's AND establishing care in a primary care setting

The MSE and triage concept is a shell game. The EM doc is forced to see them and "rule out an emergency" which is the essence of 99% of what EPs do. Then, after including all the liability of any other patient encounter while performing that service for free, the patient is jettisoned to some primary care setting, where not only do they have to waste their time, being evaluated a second time, they still get a charge. The intent is to be a deterrent which is futile. If waiting in a crazy loud, crowded ED at 3 am wasn't enough of a deterrent, then some cute little "system" designed to "educate" them on appropriate ED use is going to be futile. Also, the concept that the primary care charge is "cheaper" is a scam. Sure it's cheaper. It's cheaper to the hospital because they get to steal EPs services for free while also dumping the liability of the patient-physician relationship upon the EP. Then the EP is told he gets some RVU credit for evaluation & management, but it's funny money that's never backed up by any collections received from the patient and their insurance company. There's not one penny collected by the EP or his employer to go towards any collections account that would be available for physician salaries or bonuses.

The real kicker comes when one of these patients who "can't possibly be sick" ends up having a migraine which is really a SAH, chronic back pain which is an epidural abscess, or chest pain in a 15 yr old that turns out to be a PE with familial hypercoaguability. Then, you're the fall guy and no one has any sympathy for you when you explain that you kicked the patient out, who now has a KNOWN misdiagnosed emergency, to save $100 for "the system."

The MSE concept is simply away to convince you to incur liability while giving away your services free ultimately for free, to the patient and the hospital.

 

[WilcoWorld]

Now obviously this can't be done in the US, since it relies on having a unified health care system that wants to reduce overall expenditures.

Exactly. The problem is that our hospital administrators don't want people not to come to the ED.

 

[RustedFox]

The MSE and triage concept is a shell game. The EM doc is forced to see them and "rule out an emergency" which is the essence of 99% of what EPs do. Then, after including all the liability of any other patient encounter while performing that service for free, the patient is jettisoned to some primary care setting, where not only do they have to waste their time, being evaluated a second time, they still get a charge. The intent is to be a deterrent which is futile. If waiting in a crazy loud, crowded ED at 3 am wasn't enough of a deterrent, then some cute little "system" designed to "educate" them on appropriate ED use is going to be futile. Also, the concept that the primary care charge is "cheaper" is a scam. Sure it's cheaper. It's cheaper to the hospital because they get to steal EPs services for free while also dumping the liability of the patient-physician relationship upon the EP. Then the EP is told he gets some RVU credit for evaluation & management, but it's funny money that's never backed up by any collections received from the patient and their insurance company. There's not one penny collected by the EP or his employer to go towards any collections account that would be available for physician salaries or bonuses.

The real kicker comes when one of these patients who "can't possibly be sick" ends up having a migraine which is really a SAH, chronic back pain which is an epidural abscess, or chest pain in a 15 yr old that turns out to be a PE with familial hypercoaguability. Then, you're the fall guy and no one has any sympathy for you when you explain that you kicked the patient out, who now has a KNOWN misdiagnosed emergency, to save $100 for "the system."

The MSE concept is simply away to convince you to incur liability while giving away your services free ultimately for free, to the patient and the hospital.

Yeah. I never, ever MSE anybody. Period.

 

[Birdstrike]

Exactly. The problem is that our hospital administrators don't want people not to come to the ED.

As evidenced by the billboard on the highway advertising <30 min wait times driving more business to your overwhelmed ED.

 

[Brigade4Radiant]

This is the exact kind of arrogance I'm talking about.

http://www.westsuburbanmc.com/resid...cy-program/curriculum/curriculum-summary.aspx
Many family medicine programs do 3-4 months of ICU, with a rotation in every year of residency. The idea that an FP should still have to do a 3 year ED residency from scratch to be board certified in the ED is kind of ludicrous when at least 60% of the training in residency overlap, from pedi to OBGYN to the unit and to the medical and surgical floors. The only reason you favor this is to keep your job market closed off from other physicians in the future even as demand for urgent and emergent care increases (which ends up just meaning more and more midlevel encroachment since someone has to meet the demand).

We hire midlevels with very little training in their specialty for on the job training often doing the same work as senior residents and attendings, essentially making a farce in our overextended residency training process already. Instead of trying to streamline our residency education process to be more adaptive to changing times, you want to make the barrier of entry even higher, especially for other physicians. I hope you enjoy even more midlevels taking your jobs for half the pay like the CRNAs instead of incorporating more actual physicians to meet the demand.

There are ED fellowships in family medicine they are 1 year long. Jackson TN has them. You can work in the ED as a FM doc about half of the docs in the ED are not ER trained or certified.

 

[RustedFox]

There are ED fellowships in family medicine they are 1 year long. Jackson TN has them. You can work in the ED as a FM doc about half of the docs in the ED are not ER trained or certified.

Just because you caaaan doesn't mean that you shouuuld.

 

[RustedFox]

Doing an inpatient ped's or gen med month is not the same as th ED. It doesn't make them worse doctors, just not able to handle the ED as effectively or efficiently.

Also -3 months critical care? I do 10 months in my residency. Plus, ED months are more valuable than critical care months, in my opinion.

Sorry about brevity, from phone

Regarding ED months being more valuable than CC months.... there are several reasons why this is very largely true. When I was training, we got rid of our second-year SICU rotation because it ended up being little more than rounding and watching surgeons argue with one another.

 

[alpinism]

This is the exact kind of arrogance I'm talking about.

http://www.westsuburbanmc.com/resid...cy-program/curriculum/curriculum-summary.aspx
Many family medicine programs do 3-4 months of ICU, with a rotation in every year of residency. The idea that an FP should still have to do a 3 year ED residency from scratch to be board certified in the ED is kind of ludicrous when at least 60% of the training in residency overlap, from pedi to OBGYN to the unit and to the medical and surgical floors. The only reason you favor this is to keep your job market closed off from other physicians in the future even as demand for urgent and emergent care increases (which ends up just meaning more and more midlevel encroachment since someone has to meet the demand).

We hire midlevels with very little training in their specialty for on the job training often doing the same work as senior residents and attendings, essentially making a farce in our overextended residency training process already. Instead of trying to streamline our residency education process to be more adaptive to changing times, you want to make the barrier of entry even higher, especially for other physicians. I hope you enjoy even more midlevels taking your jobs for half the pay like the CRNAs instead of incorporating more actual physicians to meet the demand.

And many FM residencies do not have ICU rotations every year.

U Washington is widely considered to be the best FM program in the country and they only do 4 weeks MICU + 2 weeks NICU the entire residency.

Not to mention they only spend 6 weeks on adult EM and 2 months on peds EM.

That's a huge difference from your average EM residency which does 5+ months of ICU and 20+ months of EM.

 

[Arcan57]

There are ED fellowships in family medicine they are 1 year long. Jackson TN has them. You can work in the ED as a FM doc about half of the docs in the ED are not ER trained or certified.

That's absolutely true. I've worked in that environment and the quality of ED care is substantially different than in shops with EM trained docs.

 

[Jonassen]

That's absolutely true. I've worked in that environment and the quality of ED care is substantially different than in shops with EM trained docs.

That's not my contention here. I believe that you can easily create an ED fellowship for IM/FM trained physicians that will match to the same quality of care as current EM residents. You can ensure quality while not shutting down an in-demand primary access field that used to be open to all specialties from other fields, a field that even most of you will admit is full of "the opposite of emergencies."

 

[Jonassen]

We SPECIFICALLY have cut medical and surgical floor months TO ZERO from our training program because they're just not useful in doing what we do.

This actually sounds like a horrible way to train ED docs. You only get to see the pre-admission but have no perspective of whether such consult or admission was even warranted. Basically you call to admit only based on what your ED attending or protocol tells you, and not at all from the perspective of people taking care of the patient on the other side. It's like a surgeon who never sees his post-ops; he can't really learn or improve, to him every surgery hopefully helped.

 

[TooMuchResearch]

That's not my contention here. I believe that you can easily create an ED fellowship for IM/FM trained physicians that will match to the same quality of care as current EM residents. You can ensure quality while not shutting down an in-demand primary access field that used to be open to all specialties from other fields, a field that even most of you will admit is full of "the opposite of emergencies."

Design that fellowship, including the didactics, time in the ED, procedural skills, and time to unlearn all of the traditional medicine teaching about all the stuff that is not pertinent to the ED visit and greatly extends length of stay.

It "used to be open to all specialties from other fields" when the other fields considered staffing the ED to be a terrible burden and no one believed anyone could work there as their medical practice.

 

[littlejuan]

This actually sounds like a horrible way to train ED docs. You only get to see the pre-admission but have no perspective of whether such consult or admission was even warranted. Basically you call to admit only based on what your ED attending or protocol tells you, and not at all from the perspective of people taking care of the patient on the other side. It's like a surgeon who never sees his post-ops; he can't really learn or improve, to him every surgery hopefully helped.

Sounds like you have no idea how the ED functions. Yes, some things are protocol driven, as are things on the floors, but to insinuate that most/many admissions are essentially protocol driven is just wrong.This sounds like a roundabout way of calling us glorified triage nurses. I think this also shows how people really don't understand EM or how an EM residency functions. I tell my attending my plan for a patient and my reasoning. If he doesn't agree we speak about it, but generally admission is based on me. I manage my patients and my attending oversees me, I really don't know how else to explain it but it's completely different than how residents function on the floors or ICUs. Also, when he stated that floor months have been cut out, he is not talking about the ICU. General medicine/surgery floors are completely useless and a waste of time for us. We follow up on our patient's quite a bit, and have follow-up rounds all the time. There is no need to spend months on a general floor when you can just talk about the patients you saw in the ED in a very focused manner.

 

[engineeredout]

That's not my contention here. I believe that you can easily create an ED fellowship for IM/FM trained physicians that will match to the same quality of care as current EM residents. You can ensure quality while not shutting down an in-demand primary access field that used to be open to all specialties from other fields, a field that even most of you will admit is full of "the opposite of emergencies."

How about this as a wild idea:

If you want to be an emergency physician, do an emergency medicine residency.

If you want to be a family practitioner, do a family practice residency.

If you want to do both, do both residencies

 

[RustedFox]

Jonassen sounds like he is missing one important detail: you can't tease out all those IM details about whether or not X, Y, or Z is "warranted" in the 3-4 hours that a patient stays in the ED for. Hell, you can't even sit down for 10-15 minutes at a click to thoroughly review X, Y, and Z because of the constant carousel of interruptions (EMS runs, acute changes in condition, patient demands, etc. etc.)

 

[naus]

Jonassen sounds like he is missing one important detail: you can't tease out all those IM details about whether or not X, Y, or Z is "warranted" in the 3-4 hours that a patient stays in the ED for. Hell, you can't even sit down for 10-15 minutes at a click to thoroughly review X, Y, and Z because of the constant carousel of interruptions (EMS runs, acute changes in condition, patient demands, etc. etc.)

Whoa you don't actually think IM and surgical residents sit on their arses all day long and spend hours on a patient? Almost every resident in our hospital don't have time to sit down for 10-15 minutes without 5 interruptions from nurses, case managers, attendings and consults. It's pretty clear to me that EM residents need more real IM and surgery rotations than just floor scut, because you guys clearly don't get it. Many of us get 10-15 consults in a single 12 hour period (often bunched up together when the EM residents switch shifts) while also taking care of any floor issues. You don't work any harder than the rest of us, the only difference is you never get consulted and don't even have a clue how crappy of a job you did for your initial evaluation. The number of times that I get "oh I haven't seen the patient yet, I just came on shift" or "I haven't looked at the X-ray myself" while you're consulting me is more than I can count every single week. Now I finally understand how this keeps happening year after year, because you don't even know your reputation of shoddy half-assed work in the entire hospital, since you have little experience with being the consultant to the ED.

There is no need to spend months on a general floor when you can just talk about the patients you saw in the ED in a very focused manner.

You're kidding me right? You can focus till your eyes pop out and you still don't have that feedback loop if you don't actually see what happens to the patient after they are admitted or even know if it was appropriate to force an admit in the first place.

 

[littlejuan]

You're kidding me right? You have no feedback loop.

We take care of critically ill patient's in the ICUs. We don't need to know how to manage non-critical patient's past the acute setting. It is an absolute waste of time and energy to do floor months just 'to understand whether a consult or admission was even warranted.' There are so many better ways to learn how to efficiently and properly consult for/admit patients.

 

[TooMuchResearch]

Whoa you don't actually think IM and surgical residents sit on their arses all day long and spend 3-4 hours on a patient? Almost every resident in our hospital don't have time to sit down for 10-15 minutes without 5 interruptions from nurses, case managers, attendings and consults. It's pretty clear to me that EM residents need more real IM and surgery rotations than just floor scut, because you guys clearly don't get it.


You're kidding me right? You can focus till your eyes pop out and you still don't have that feedback loop.

Why do I need floor (non-ICU) months?

Edit: No one said other specialties spend 3-4 hours on one patient.

 

[RustedFox]

Whoa you don't actually think IM and surgical residents sit on their arses all day long and spend hours on a patient? Almost every resident in our hospital don't have time to sit down for 10-15 minutes without 5 interruptions from nurses, case managers, attendings and consults. It's pretty clear to me that EM residents need more real IM and surgery rotations than just floor scut, because you guys clearly don't get it. Many of us get 10-15 consults in a single 12 hour period (often bunched up together when the EM residents switch shifts) while also taking care of any floor issues. You don't work any harder than the rest of us, the only difference is you never get consulted and don't even have a clue how crappy of a job you did for your initial evaluation. The number of times that I get "oh I haven't seen the patient yet, I just came on shift" or "I haven't looked at the X-ray myself" while you're consulting me is more than I can count every single week. Now I finally understand how this keeps happening year after year, because you don't even know your reputation of shoddy half-assed work in the entire hospital, since you have little experience with being the consultant to the ED.

The vitriol has that eau de insecure about it. At no point do I imply that we work "harder".

Yes, you have your interruptions, too. You also have the luxury of time after the patient has been stabilized and the initial workup completed to take it all in on the floor/unit/etc. The difference is "this patient isn't going anywhere soon", versus "this patient needs to go somewhere soon."

- and I'm all for additional IM/surg months... if they're useful. The majority of time chasing around renal functions and replacing lytes... is not useful.

 

[TheBlueBlazer]

That's not my contention here. I believe that you can easily create an ED fellowship for IM/FM trained physicians that will match to the same quality of care as current EM residents. You can ensure quality while not shutting down an in-demand primary access field that used to be open to all specialties from other fields, a field that even most of you will admit is full of "the opposite of emergencies."

Like I said before, a 2 year-fellowship on top of your 3 year residency would conceivably give you enough additional training to do what we do. But it's obvious from your other comments that you have NO IDEA what working in the ED really means. Talking about protocols? PROTOCOLS? That would be nice. And acting as if I have no idea what is going on when a patients is admitted is just plain asinine. You know I did spend an almost entire 2 full years doing medical school clerkships not all that long ago. I'm not claiming I could be an inpatient doc or a primary care doc by any means, but to suggest I don't understand the inpatient side of things at all is a *****ic statement.

 

[EMIM2011]

So, does this mean I can do a 1 year FM-fellowship and be a PCP ;-)?!

 

[Druggernaut]

That's not my contention here. I believe that you can easily create an ED fellowship for IM/FM trained physicians that will match to the same quality of care as current EM residents. You can ensure quality while not shutting down an in-demand primary access field that used to be open to all specialties from other fields, a field that even most of you will admit is full of "the opposite of emergencies."

I believe you can easily create an orthopedic surgery fellowship for EM trained physicians that will match to the same quality of care as current orthopedic surgery residents. I mean, the EM guys already know how to diagnose orthopedic problems, they already do reductions (and can even handle the sedation to cut the anesthesiologist out of the picture!), and any monkey can be trained how to do a procedure. We'll make it a year long, since it's essentially just carpentry and those guys don't even have to go to school.

Sounds pretty ridiculous, doesn't it? But that's pretty much what you're suggesting here. There's a lot of nuances that go into being a specialist that aren't appreciated by people outside the field. They are also trained to think about things differently. The patients the FM/IM guys are seeing in the clinic or on the floors have a significantly different skew of pathology. 6-12 more months of EM isn't going to make them "think EM" on the same level as someone who does 26 months of it.

And that's ignoring that everyone's crying we need more PCPs, which would only be worsened by what you suggest.

And ignoring that historically, all you had to do was an internship to hang a shingle and be a general practitioner, but that the board certified IM and FM guys are closing it off to all the other medical graduates. Times change, and the volume of knowledge required to practice EM, IM, and FM has grown to the point that you should really do a residency in it if you want to do it.

And ignoring publications that indicate that only a small percentage of complaints presenting to the ED are "the opposite of emergencies."

Whoa you don't actually think IM and surgical residents sit on their arses all day long and spend hours on a patient? Almost every resident in our hospital don't have time to sit down for 10-15 minutes without 5 interruptions from nurses, case managers, attendings and consults. It's pretty clear to me that EM residents need more real IM and surgery rotations than just floor scut, because you guys clearly don't get it. Many of us get 10-15 consults in a single 12 hour period (often bunched up together when the EM residents switch shifts) while also taking care of any floor issues. You don't work any harder than the rest of us, the only difference is you never get consulted and don't even have a clue how crappy of a job you did for your initial evaluation. The number of times that I get "oh I haven't seen the patient yet, I just came on shift" or "I haven't looked at the X-ray myself" while you're consulting me is more than I can count every single week. Now I finally understand how this keeps happening year after year, because you don't even know your reputation of shoddy half-assed work in the entire hospital, since you have little experience with being the consultant to the ED.

Great, another person who doesn't practice emergency medicine has come to enlighten us on how terrible all emergency physicians are, and how we should do things. We really appreciate it. I know I'm a better man for having read this informative piece.

 

[RustedFox]

So, does this mean I can do a 1 year FM-fellowship and be a PCP ;-)?!

I thought about posting this earlier; but I got distracted by the hockey game. I'm glad someone else followed thru on this.

 

[Promethean]

I just talked a co-worker out of going to the ED to have a zit inside her nose popped.

"But it REALLY hurts."

That is unfortunate. But it isn't an emergency. If they have any decency, they will quickly screen you and discharge you with instructions to follow up with your PCP. If they are having a really bad day, they will stick you in a corner exam room, or more likely, a hall bed, and ignore you for as long as possible, hopefully at least 12 hours, while attending to more urgent matters, while keeping you NPO. Then they will discharge you with instructions to follow up with your PCP.

 

[Daiphon]

Wow... this escalated quickly.

One argues that the ED knows nothing about being a consultant... I would argue the opposite.

1) one learns how/why/when to consult during residency. If one of my consultants thinks I'm off base, then we talk and come to an accord. Most times, it's because we're looking at the same problem from different perspectives. Sometimes I'm being a twit. Sometimes they are. However, I know my limits & what I'm capable of accomplishing... and of the skewed perspective of what's most likely to kill you vs. what's probably going on.

2) clinic dumps. Ever sent an asymptomatic hypertensive patient to the ED because "the pressure is too high?" If you answer no, then I call mierda de toro. Clinics send quasi - acute stuff *all the time* for a de facto ED "consult" to make sure there is not an emergency. THIS is our consultancy. Chest pain? Don't even try to get an appointment, go to the ED. Cough for 6 months? Go make sure you don't have TB or cancer.

So, don't give EPs any crap for consulting, because PCP'S do it all the time.

3) I am a consultant in Medical Toxicology, so deal with crazy consults all the time. Most times, there's no question or thought on the part of the inpatient team... and by the time they call me, they've often bollocksed up the scenario.

What I've learned from being a consultant is to *always* have a question to frame the discussion.

tl;dr - everyone consults, and everyone makes questionable calls sometimes... but if you think you're batting 1.000, you're sorely misinformed and possibly delusional... and need a psych consult yourself.

-d

 

[Jonassen]

1) one learns how/why/when to consult during residency. If one of my consultants thinks I'm off base, then we talk and come to an accord.

Most of us are polite and just take the consult (unless it's truly egregious), and avoid making a scene in the ED, or we have departments that just accept every consult by policy (our department is like that, and I don't know how the ED residents learn when to consult in a setup like that). I've found ED residents to be very aggressive and belligerent in pushing for inane consults, backed up by your attending next to you. And unfortunately in the academic setting you have the upper hand in the power dynamic because your attending is right beside you, while our attending is often at home sleeping and cannot easily back us up at 2 in the morning, and the ED loves to pull the "I can call your attending if you would like" card. I also understand that you have a ton of people in the waiting room and you need to dispo your patients even if it's a weak admit; in the end you just need to clear your beds.

Clinics send quasi - acute stuff *all the time* for a de facto ED "consult" to make sure there is not an emergency. THIS is our consultancy. Chest pain? Don't even try to get an appointment, go to the ED. Cough for 6 months? Go make sure you don't have TB or cancer.

So, don't give EPs any crap for consulting, because PCP'S do it all the time.

PCPs do it because there often isn't the imaging and lab resources in clinic that EDs have, not because they don't know how to do an ACS workup. Clinics don't have instant troponin labs. EDs have all that resources at their disposal and yet we still get a huge proportion of inane consults from the ED. Chest pain that's not GERD or obvious palpable tenderness is almost universally worked up in the ED because the ED has the STAT labs and cardiologists on call. That isn't an inane consult.

My point still stands that if you only admit and never see the criticism from the other side (and proud of the fact that you do 0 weeks of inpatient medicine or surgery), then you are like the surgeon who never sees any of his own postops. At the end of the day, he can only hope that he did some good, but he can't really ever know or refine his method. And if he were to hear some criticism, he would think he is personally attacked because he has never seen his postop complications and failures himself.

 

[Daiphon]

Most of us are polite and just take the consult (unless it's truly egregious), and avoid making a scene in the ED, or we have departments that just accept every consult by policy (our department is like that, and I don't know how the ED residents learn when to consult in a setup like that). I've found ED residents to be very aggressive and belligerent in pushing for inane consults, backed up by your attending next to you. And unfortunately in the academic setting you have the upper hand in the power dynamic because your attending is right beside you, while our attending is often at home sleeping and cannot easily back us up at 2 in the morning, and the ED loves to pull the "I can call your attending if you would like" card. I also understand that you have a ton of people in the waiting room and you need to dispo your patients even if it's a weak admit; in the end you just need to clear your beds.




PCPs do it because there often isn't the imaging and lab resources in clinic that EDs have, not because they don't know how to do an ACS workup. Clinics don't have instant troponin labs. EDs have all that resources at their disposal and yet we still get a huge proportion of inane consults from the ED. Chest pain that's not GERD or obvious palpable tenderness is almost universally worked up in the ED because the ED has the STAT labs and cardiologists on call. That isn't an inane consult.

My point still stands that if you only admit and never see the criticism from the other side (and proud of the fact that you do 0 weeks of inpatient medicine or surgery), then you are like the surgeon who never sees any of his own postops. At the end of the day, he can only hope that he did some good, but he can't really ever know or refine his method. And if he were to hear some criticism, he would think he is personally attacked because he has never seen his postop complications and failures himself.

Dude. You're missing the point.

You claim that the ED pushes for "inane" consults while dismissing the fact that the clinics do the same. Goose & gander, my friend.

As for inpatient floor months, we're going to have to disagree. One doesn't need to put in the scut in order to benefit from feedback; I was in the last class in my residency to do floor surgery & medicine and the only true benefit I received was getting to know the residents to whom I admit my patients better.

I will concede your point that followup is important; however, inpatient floors are not the most efficient way... plus, the most germane feedback is on the patients I admit. If I'm in the ED, then I'm not managing this patient on the floor. So, yes, we should follow up on the patients we admit (like the surgeon seeing their postops)... but your attempt to utilize this scenario is a logical fallacy.

Furthermore, if you feel that you're being bullied by the ED, and you're getting the "attending card" pulled too often, then it's likely for one of 3 reasons:

1) you're at a community site, where consults are your attending's bread & butter and should be called per institutional ethos. Sucks, but needs to be done. Stop tilting at the windmills.

2) you have an EM residency where they're not really teaching the art of selling... if true, then I'm sorry.

3) you're being pathologically obstructive & the ED feels they need to speak with someone with more experience. FWIW, at least you get this warning - I just call the attending if I feel it's warranted; I don't give a heads up to the resident. Luckily, I can count on 1 hand the number of times I've had to do this, but still...

Oh, and just as I don't expect my off-service residents to understand the breadth & scope of EM after 4 weeks (if they rotate with us at all), you shouldn't push the idea that a brief period of floor work will do the same for IM. It belittles & cheapens your specialty and does nothing to bolster your arguments.