Uncomplicated diverticulitis?

[deleted109597]

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It's funny. I'm still a resident. But I've heard so many people complain (both IRL and on here) about the groups losing contracts at hospitals. You would think they would encourage their CMG leaders to do almost anything to protect a contract. It seems there is no winning?

The contract matters nothing to the people working. Occasionally the director will leave, but everyone else usually stays around. Their checks just come from another place. Ask anyone that's worked in one place for a decade or longer, and I'm sure they've done at least once transition.

 

[WildcatS11]

The contract matters nothing to the people working. Occasionally the director will leave, but everyone else usually stays around. Their checks just come from another place. Ask anyone that's worked in one place for a decade or longer, and I'm sure they've done at least once transition.

Interesting. I always thought there was this perpetual fear that if you worked at a newer-contracted job, it may disappear overnight.

 

[GeneralVeers]

The contract matters nothing to the people working. Occasionally the director will leave, but everyone else usually stays around. Their checks just come from another place. Ask anyone that's worked in one place for a decade or longer, and I'm sure they've done at least once transition.

Correct. I don't care who holds the contract as long as I get paid the same. The problem is that the directors, regional VPs, etc of the CMG want to hold onto the contract tooth and nail, and will ***** themselves (and the other doctors) out to hospital administration.

 

[emergentmd]

It seems like the most important thing to you in the practice of medicine is what is easiest for you.

I bet you are a newbie attending or resident. Work 15 yrs, be a director for 6, work Community ER, indigent ER. You will not say such an ignorant statement if you did.

 

[goodoldalky]

I bet you are a newbie attending or resident. Work 15 yrs, be a director for 6, work Community ER, indigent ER. You will not say such an ignorant statement if you did.

No need to be defensive, was my observation incorrect? You said as much yourself, probably a dozen times on this forum.

 

[emergentmd]

Interesting. I always thought there was this perpetual fear that if you worked at a newer-contracted job, it may disappear overnight.

Today, EM docs holds a great deal of the Cards. I am a good, efficient doc. Newer docs at my shop are concerned about their metrics, pph, etc. They jump when a pt is available to see.

Me? After 15 yrs, I know an extra pt seen does not make my check much bigger. I know that unless I am 2 standard deviation from the norm or an exceptionally PIA, I will never get fired.

So even when contracts changes hands, pay most of the time doesn't change much b/c they know we will jump ship and they can't find similarly good docs on the cheap. Plus we have so many employment options that they hold very little cards with me.

 

[emergentmd]

No need to be defensive, was my observation incorrect? You said as much yourself, probably a dozen times on this forum.

Your observation if very far from correct. I practice good medicine, still love going to work, and happy when I am at work. I still have great joy improving people's lives.

But that does not mean I have my head in the sand about where my place in the EM universe is. EM docs are still a commodity and as such we need to look out for ourselves. I understand I could be the best doc today and follow all of the rules, but if they could find a cheaper doctor then I would be out the door. Its business and as such, I realize that each EM doc must look out for themselves. I have seen it over and over.

I also realize that admin/CMGs will not protect my back when they can save a few bucks. This is what I have seen.

#1 - all complaints, even the stupidest, are sent to me to evaluate when I was director. If they really cared, they would screen out the 90% crap and throw it out. But that is way too much work
#2 - we have no input on our work flow and EMR. They once told us to evaluate 2 different EMR, we picked the one we wanted. Next day, they gave us the crappier one b/c it was cheaper. Who cares that it slows us down and creates discontent.
#3 - Instead of fixing the real problems with flow and admitted pts out of the ED, all they care about are Sat scores, time metrics. So instead of fixing the hard inpatient issues, they want to put a PA in triage so our door to provider is 1 minute.
#4 - When I practice good medicine and deny drug seekers, I get complaints to admin. I get Board complaints that I have to prove that they are drug seeking. Instead of doing alittle research, they just throw the complaint at me to answer.

I can go on and on. But the bottom line is this, take giving abx. If I give amoxil to 100% of my virals, and they all leave happy that took me 2 minutes vs giving no abx to 100% of my virals and getting 25% complaints requiring 10 minutes to explain then YES.... I am taking the self preserving path.

At the end of the day, I try to practice good medicine but realize that the only person watching out for me is myself. Good luck to all of the "always appropriate docs", you will eventually see that its not worth the head banging.

 

[coachB]

Your observation if very far from correct. I practice good medicine, still love going to work, and happy when I am at work. I still have great joy improving people's lives.

But that does not mean I have my head in the sand about where my place in the EM universe is. EM docs are still a commodity and as such we need to look out for ourselves. I understand I could be the best doc today and follow all of the rules, but if they could find a cheaper doctor then I would be out the door. Its business and as such, I realize that each EM doc must look out for themselves. I have seen it over and over.

I also realize that admin/CMGs will not protect my back when they can save a few bucks. This is what I have seen.

#1 - all complaints, even the stupidest, are sent to me to evaluate when I was director. If they really cared, they would screen out the 90% crap and throw it out. But that is way too much work
#2 - we have no input on our work flow and EMR. They once told us to evaluate 2 different EMR, we picked the one we wanted. Next day, they gave us the crappier one b/c it was cheaper. Who cares that it slows us down and creates discontent.
#3 - Instead of fixing the real problems with flow and admitted pts out of the ED, all they care about are Sat scores, time metrics. So instead of fixing the hard inpatient issues, they want to put a PA in triage so our door to provider is 1 minute.
#4 - When I practice good medicine and deny drug seekers, I get complaints to admin. I get Board complaints that I have to prove that they are drug seeking. Instead of doing alittle research, they just throw the complaint at me to answer.

I can go on and on. But the bottom line is this, take giving abx. If I give amoxil to 100% of my virals, and they all leave happy that took me 2 minutes vs giving no abx to 100% of my virals and getting 25% complaints requiring 10 minutes to explain then YES.... I am taking the self preserving path.

At the end of the day, I try to practice good medicine but realize that the only person watching out for me is myself. Good luck to all of the "always appropriate docs", you will eventually see that its not worth the head banging.

You have shown your cards repeatedly, although historically you often contradict yourself. I totally understand why you choose to practice the way you do. As you and others point out, that's the system we are in. But don't say in the same breath that you "practice good medicine." Clearly, you do not. You have indicated this over and over again, including in this post. You do what is easy and self-serving regardless of potential harm. Again, I understand your actions in the context of the system, but it's this lack of professional responsibility that reinforces many of the systemic issues discussed here.

 

[WilcoWorld]

If I give amoxil to 100% of my virals, and they all leave happy that took me 2 minutes vs giving no abx

I'm no saint, and I will admit to taking the path of least resistance on occasions when the fight does not seem worth it. But I have to disagree with the above statement.

A lot of the patients who are gonna be pissed if I don't Rx ABX are going to be pissed no matter what. If I Rx ABX then they just find something else to be pissed about.

 

[gro2001]

I don't think emergentmd was saying he ACTUALLY gives antibiotics to 100% of his virals. I think he was just comparing the two extremes. I don't give antibiotics willy nilly, but there have been occasions when I have given them because there was no convincing them. I doubt all of your who are criticizing really can't relate.

For the residents who are criticizing emergent for picking the path of least resistance: patients will often really want something. It's not just antibiotics. Sometimes it's ridiculous/impossible (MRI for their twisted ankle). Sometimes it's possible, but would cause legit harm (CT for their kid who bumped his head). Sometimes its a little bit harmful (Zpack for their likely viral bronchitis). Sometimes its not really harmful, but I've determined it's not necessary (ultrasound for their swollen legs). Often they will be open to reasoning, but often enough they will not. Will you really deny ALL of their requests you don't agree with ALL the time? Or will you pick your battles?

Denying antibiotics is not the hill I want to die on. I'll give it my best shot, but I'd rather spend my energy explaining to parents why their kid doesn't need a CT scan. Or why I am/am not admitting their dad for chest pain. Those are more important discussions for me.

 

[emergentmd]

You have shown your cards repeatedly, although historically you often contradict yourself. I totally understand why you choose to practice the way you do. As you and others point out, that's the system we are in. But don't say in the same breath that you "practice good medicine." Clearly, you do not. You have indicated this over and over again, including in this post. You do what is easy and self-serving regardless of potential harm. Again, I understand your actions in the context of the system, but it's this lack of professional responsibility that reinforces many of the systemic issues discussed here.

I hesitate to dirty myself responding to this and I will not get into personal attacks. You don't know me to even question if I practice good medicine. If you step back, I can bet most docs would think you practice bad medicine too. I am sure you order way too many labs, order way too many imaging, prescribe way too many narcotics. But I will step away from personal attacks.

My point is the system sets EM docs to be in a no win situation.

#1 - We need pts seen in 5 minutes and get great pt sats while allowing every nonemergent case come to the ER
#2- Antibiotics is overused and creates multi resistance while pushing 1hr abx for sepsis criteria when the pts has a viral infection.
#3 - We overprescribe narcs and have created a country of junkies while wanting every pt in the ED to be Pain free. Stupid Pain scale, everyone is a 10/10.

I can go on and on. I am sure I have been in medicine much longer than you and have seen it all. I have seen EM and other specialists shown the door when it doesn't fit their needs.

I am happy having a balanced medical practice where I will give abx for some known virals to avoid the long fight with the patients. If I had an 100% insured outpt practice, I would never give abx to virals b/c the pts are educable and I can see them in follow up. Most of my pts who comes for virals are uninsured and have no clue when I explained them viral vs bacterial.

Early in my career, I had the prolonged 2 min viral vs bacterial abx education. They nod like they know what I am talking about and then when I tell them they will be discharged, they usually say, "So am I getting abx"?

But go ahead and sit on your high horse. You will be knocked off eventually and see what is practical EM medicine vs Book EM medicine.

Oh BTW, I almost never draw blood on kids or scan them for head trauma. I know many EM docs that do.

 

[emergentmd]

You have shown your cards repeatedly, although historically you often contradict yourself. I totally understand why you choose to practice the way you do. As you and others point out, that's the system we are in. But don't say in the same breath that you "practice good medicine." Clearly, you do not. You have indicated this over and over again, including in this post. You do what is easy and self-serving regardless of potential harm. Again, I understand your actions in the context of the system, but it's this lack of professional responsibility that reinforces many of the systemic issues discussed here.

I just read the Panscan thread. You better go over there and bash them too much radiation.

 

[DeadCactus]

There is a difference between proactively offering antibiotics for viral illnesses vs. limiting the energy you put into dissuading them. It's unclear what camp you fall into based on your posts.

 

[hundreddaysoff]

I have. Ay ay ay but walking around normally, on cell phone until i come in and magically in distress, unremarkable story, pan positive ros, normal vitals, benign belly. This is scott weingart, with the emcrit podcast, saying bye bye.

I would scan that, once, just for provider communication purposes. One normal scan in our system = future silly belly complaints written off as silly. Will save lots of people a ton of time when she comes back.

And you just know she will come back.