Putting the Myths of EM Docs to Rest!!

[Hernandez]

and imagines the level of care the patient needs (at most places I've been anyway. [Spontaneous pneumo, that's a level 5 (low), nose bleed, thats a 2 (high)])

We must have rotated at the same hospitals

---

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[Doowai]

the IM docs would pissing their pants while trying to kill themselves with their stupid bow ties to avoid the pain. Have you ever seen an ED doc wear a bow tie????

James Bond wears a bow tie
Bat Masterson wore a bow tie
Wyatt Earp wore a bow tie
Their image = bad ass.

ER docs can be pretty bad ass. A good friend of mine is 3rd year EM resident at Maricopa in Arizona. Former collegiate champion wrestler, and a number of other bad things - so yeah there are some badasses. Even though he is a really nice guy with a tender heart, and super sweet and patient with his wife and 5 children.

Where I did my EM rotation though I could not help but think all the docs but one (who played college Div 1 football as linebacker) were pencil neck pansies. But it was not a level 1 trauma ER. Today I substitute taught at a local high school as a PE coach, and had 2 weight lifting classes. I was called "the machine" after they watched me put so many 45 LB plates on the bar that it would not hold anymore (did not use collars so I could fit more plates on the bar), and then deadlift it. I was state kickboxing champ twice, state AAU wrestling champion once, have been in virtually every martial arts magazine there is (in the 90's) and security in a bar for 6 years when I was in my twenties......I wear a bow tie sometimes. Yesterday I went shopping for a new Tuxedo, and of course looked at the bowties. I love the James Bond look.

 

[DJ LACTULOSE]

bow ties aren't cool unless it's on a tux. i would cite an article but the clinical trial is still in progress.

 

[Dr. Will]

Great, one more person using this dumba$$ argument.

Listen, when you argue that another person's experience is too limited to draw conclusions (ie - "you n is too low"), you don't get to draw the opposite conclusion unless your "n" is much higher.

Duh.

Considering I work in the field of EM, did multiple rotations during medical school, have >20 classmates that matched in EM, >20 upperclassmen friends that have matched in EM, my n IS much larger. Should I go on, cuz I have many other interactions with EM docs. Did you even read the rest of my post when I specifically stated that I can't entirely back up what I said anymore than Fineline can? Or did you happen to skip that part?

 

[Dr. Will]

Exactly. You guys gotta understand that the EM doc is there to make sure the patient is stable and then get help from other docs for the definitive care of the patient...unless it's for things that most docs should be able to manage without help anyway. That's why docs trained in some other specialties (FM, IM, General Surgery) can cover the ER and do almost anything as well as a pure EM doc. And that's where, dare I say, the insecurity of a good number of people in EM comes from...that they know the old stereotype of them being a glorified triage nurse has a fair amount of truth to it.

It's funny how most of the lawsuits in EM are against the non-EM trained/board certified docs doing what you just described above. Guess just about anbody can work in the ED, right?

 

[awdc]

I don't really agree with the OP's stereotyping. I'm also not crazy about all the criticisms of EM. Basically, for every one of the ER horror stories, there's a medicine/surgery horror story. Just tonight, some of my co-residents got together and were venting about all the mismanagement of patients by medicine, surgery, peds, etc. that we've seen on our off-service rotations. Then there's also the horror stories of the non-EM moonlighters at the community or VA ED's. As we all know, there are good and bad docs in every specialty. Many times, it's not even about the doctor but just a matter of perspective or not having certain information.

Lots of issues about emergency physicians being the docs who transfers care, as if it's a bad thing. Well, it's probably a bad thing up on the floors. However, in the ED, if we can't transfer definitive care of a sick patient, the ED grinds to a halt, and sick people become sicker in the waiting room, ambulances get diverted, etc. It may be a foreign concept to other specialties but as EM physicians we have a responsibility to the community that emergencies get taken care of. And if the department is full of patients and EMS is lining up out to the ambulance bay, and if a stabilized patient's definitive work-up can be completed on the floor, patient is going to the floor. We're not going to make the truly sick patients (that we may not have even seen yet) wait another hour or two or divert our attention away from them just to package a patient for the floor. Nor are we going to have a system where emergent/critical patients cannot be seen because all ED beds and hallways are full because the work up hasn't been completed on patients stable enough to be out of the ED.

Our job isn't to follow every single one of our patients from triage to discharge. We identify the sick, make the most likely diagnosis given the (lack of) info and time we have, and make sure the appropriate treatments are initiated and the patient is on their way to recovery whether it be via the OR, floors, ICU, etc. And to all the admitting services, that's only about 20-25% of the patients that were in the ED. We didn't even call you on the other 75% that we discharged.

 

[Idiopathic]

It's funny how most of the lawsuits in EM are against the non-EM trained/board certified docs doing what you just described above. Guess just about anbody can work in the ED, right?

Data, please.

 

[AlternateSome1]

>> Originally Posted by Dr. Will
>>It's funny how most of the lawsuits in EM are against the non-EM >>trained/board certified docs doing what you just
>>described above. Guess just about anybody can work in the
>>ED, right?

Data, please.

Data, AND the study demonstrating that the disproportionate number of lawsuits against these docs from other primary specialties is not due to lawyers being more willing to sue when they can say "Dr X was not even board certified in EM!"

 

[elwademd]

James Bond wears a bow tie
Bat Masterson wore a bow tie
Wyatt Earp wore a bow tie
Their image = bad ass.

steve urkel wore a bow tie

his image... not bad ass.

 

[tkim]

It's funny how most of the lawsuits in EM are against the non-EM trained/board certified docs doing what you just described above. Guess just about anbody can work in the ED, right?

Data, please.

>> Originally Posted by Dr. Will
>>It's funny how most of the lawsuits in EM are against the non-EM >>trained/board certified docs doing what you just
>>described above. Guess just about anybody can work in the
>>ED, right?



Data, AND the study demonstrating that the disproportionate number of lawsuits against these docs from other primary specialties is not due to lawyers being more willing to sue when they can say "Dr X was not even board certified in EM!"

Not exactly what people have specified, but not a bad start either:

http://www.ingentaconnect.com/content/els/07364679/2000/00000019/00000002/art00218

Malpractice occurrence in Emergency Medicine: Does residency training make a difference?1
Authors: Branney S.W.1; Pons P.T.; Markovchick V.J.; Thomasson G.O.

Source: Journal of Emergency Medicine, Volume 19, Number 2, August 2000 , pp. 99-105(7)

Abstract:

We evaluated the effects of Emergency Medicine (EM) residency training, EM board certification, and physician experience on the occurrence of malpractice claims and indemnity payments. This was a retrospective review of closed malpractice claims from a single insurer. Outcome measures included the occurrence of claims resulting in indemnity, indemnity amounts, and defense costs. Differences in the outcome measures were compared based on: EM residency training, EM board certification, EM residency training versus other residency training, and physician experience using both univariate and multivariate analyses. There were 428 closed EM claims with indemnity paid in 81 (18.9%). Indemnity was paid in 22.4% of closed claims against non-EM residency-trained physicians, and in only 13.3% against EM residency-trained physicians (p = 0.04). The total indemnity was $6,214,475. Non-EM trained physicians accounted for $4,440,951 (71.5%), EM residency-trained physicians accounted for $1,773,524 (28.5%). The average indemnity was $76,721 and the average defense cost was $17,775. There were no significant differences in the mean indemnity paid per closed claim or the mean cost to defend a closed claim when comparing EM-trained and non-EM residency-trained physicians. The total cost (indemnity + defense costs) per physician-year of malpractice coverage was $4,905 for non-EM residency-trained physicians and $2,212 for EM residency-trained physicians. EM residency-trained physicians account for significantly less malpractice indemnity than non-EM residency-trained physicians. This difference is not due to differences in the average indemnity but is due to significantly fewer closed claims against EM residency-trained physicians with indemnity paid. This results in a cost per physician-year of malpractice coverage for non-EM residency-trained physicians that is over twice that of EM residency-trained physicians.

 

[Doowai]

steve urkel wore a bow tie

his image... not bad ass.

Steve Urkel did not wear a bow tie. I don't think you can find one image of him wearing a bow tie...his schtick was suspenders.


http://images.google.com/images?hl=en&q=steve+urkel&um=1&ie=UTF-8&sa=N&tab=wi


Bow ties are bad ass

 

[jessica84]

Steve Urkel did not wear a bow tie. I don't think you can find one image of him wearing a bow tie...his schtick was suspenders.


http://images.google.com/images?hl=en&q=steve+urkel&um=1&ie=UTF-8&sa=N&tab=wi


Bow ties are bad ass

Not Steve Urkel, but here's a look-alike for all to enjoy.

http://www.flickr.com/photos/namishion/394467219/

Ooh! Ooh! Here's another bow tie picture.

http://www.nightmarefactory.com/BB469.jpg
One of my professors wore a bow tie every day to work (and he was young, early 30s). Nice guy...but I never got the bow tie thing. Weird.

 

[Doowai]

Jack Dempsey wore a bow tie
http://martin_bradford.tripod.com/boxing/dempswet.jpg

As did Winston Churchill.

Both bad ass.

Sure you will find goobers like Urkel or your nerdy young professor who take something badass and make it look silly,the same thing is true in all areas of life. Wake up when you smell the toothpaste, open your eyes and reflect on the type of person that makes medicine look silly. Someone ought to curbcheck the guys pictured in the links for denigrating the reputation of the bow tie.

 

[deleted50478]

Here is the biggest crux of the argument. If other docs could do it, why does every clinic end up sending somebody to the ED to treat something they aren't handled to treat? How many times have we gotten the falls, chest pains, abdominal pains, rectal bleeds, and the rest from IM, FM, and surgery clinics?

Docs in clinics send patients to the ER because that's the pathway to hospital admission, many diagnostic studies, possibly surgical intervention, etc., NOT to take advantage of the superior management or diagnostic skills of the ER doc.

 

[Top Gun]

Exactly. You guys gotta understand that the EM doc is there to make sure the patient is stable and then get help from other docs for the definitive care of the patient...unless it's for things that most docs should be able to manage without help anyway. That's why docs trained in some other specialties (FM, IM, General Surgery) can cover the ER and do almost anything as well as a pure EM doc. And that's where, dare I say, the insecurity of a good number of people in EM comes from...that they know the old stereotype of them being a glorified triage nurse has a fair amount of truth to it.

OK, you're basically doing the same thing as EM Doc. The only difference is that you're defending FM, IM, and General Surgery instead of EM. Let's agree that physicians in each of those specialties have certain skills unique to each specialty, and therefore all of those physicians are essential. How about that?

 

[AlternateSome1]

Interesting article, but this line is pretty telling.
"As a marker of physician experience, we evaluated the years since completion of medical school training at the time of the closed claim to attempt to compare individuals with no residency training, just an internship, or residency training of various lengths."

I was pretty taken in until I saw that. I can't find a table which details the actual specialties of the "non EM trained physicians". With the inclusion of an unspecified (though I could EASILY have missed it) number of non-residency trained physicians, I am left questioning the results of the entire study.

There are also a few letters to the editor that rip the article apart for multiple reasons.

Not exactly what people have specified, but not a bad start either:

http://www.ingentaconnect.com/content/els/07364679/2000/00000019/00000002/art00218

Malpractice occurrence in Emergency Medicine: Does residency training make a difference?1
Authors: Branney S.W.1; Pons P.T.; Markovchick V.J.; Thomasson G.O.

Source: Journal of Emergency Medicine, Volume 19, Number 2, August 2000 , pp. 99-105(7)

Abstract:

We evaluated the effects of Emergency Medicine (EM) residency training, EM board certification, and physician experience on the occurrence of malpractice claims and indemnity payments. This was a retrospective review of closed malpractice claims from a single insurer. Outcome measures included the occurrence of claims resulting in indemnity, indemnity amounts, and defense costs. Differences in the outcome measures were compared based on: EM residency training, EM board certification, EM residency training versus other residency training, and physician experience using both univariate and multivariate analyses. There were 428 closed EM claims with indemnity paid in 81 (18.9%). Indemnity was paid in 22.4% of closed claims against non-EM residency-trained physicians, and in only 13.3% against EM residency-trained physicians (p = 0.04). The total indemnity was $6,214,475. Non-EM trained physicians accounted for $4,440,951 (71.5%), EM residency-trained physicians accounted for $1,773,524 (28.5%). The average indemnity was $76,721 and the average defense cost was $17,775. There were no significant differences in the mean indemnity paid per closed claim or the mean cost to defend a closed claim when comparing EM-trained and non-EM residency-trained physicians. The total cost (indemnity + defense costs) per physician-year of malpractice coverage was $4,905 for non-EM residency-trained physicians and $2,212 for EM residency-trained physicians. EM residency-trained physicians account for significantly less malpractice indemnity than non-EM residency-trained physicians. This difference is not due to differences in the average indemnity but is due to significantly fewer closed claims against EM residency-trained physicians with indemnity paid. This results in a cost per physician-year of malpractice coverage for non-EM residency-trained physicians that is over twice that of EM residency-trained physicians.

 

[deleted109597]

Docs in clinics send patients to the ER because that's the pathway to hospital admission, many diagnostic studies, possibly surgical intervention, etc., NOT to take advantage of the superior management or diagnostic skills of the ER doc.

So what you're saying is that you're too stupid to perform a direct admit? Can't get studies as an inpatient? Can't send someone to the OR without stopping by to see the ED?

No, it is because they are too ****ing lazy to do the work themselves, so they make the ED do it. The ED is treated like a residency position in that they are always there, so might as well make them do something that you could do yourself. Someone calls your call line complaining of something? Don't ask them questions or call in a med, send them to the ED. Someone in your clinic sick? Don't slow down clinic to work with them, call an ambulance to send them to the ED. I've had people come from surgery clinics to have lacerations sewn. I've had people have to come back to the ED to have sutures removed from their surgery because the clinic couldn't find the time to have a nurse remove them.

 

[Museless]

Originally Posted by nolagas
Docs in clinics send patients to the ER because that's the pathway to hospital admission, many diagnostic studies, possibly surgical intervention, etc., NOT to take advantage of the superior management or diagnostic skills of the ER doc.

So what you're saying is that you're too stupid to perform a direct admit? Can't get studies as an inpatient? Can't send someone to the OR without stopping by to see the ED?

If you have a legitimately ill patient - this month I've sent a hypotensive new-onset afib with RVR and a crushing chest pain to the ED - who drove themselves to their appt that day (and most of my patients do drive themselves), you can't very well have them drive to the hospital. They're getting there via ambulance, and when you call EMS for one, their protocol dictates the patient goes to the ED. EMTs don't take patients to the floor. I'd prefer direct admits, and so would patients. They're cheaper and easier on the patient and family.

 

[f_w]

and when you call EMS for one, their protocol dictates the patient goes to the ED. EMTs don't take patients to the floor.

Must be a local issue.

 

[lucky_deadman]

If you have a legitimately ill patient - this month I've sent a hypotensive new-onset afib with RVR and a crushing chest pain to the ED - who drove themselves to their appt that day (and most of my patients do drive themselves), you can't very well have them drive to the hospital. They're getting there via ambulance, and when you call EMS for one, their protocol dictates the patient goes to the ED. EMTs don't take patients to the floor. I'd prefer direct admits, and so would patients. They're cheaper and easier on the patient and family.

This is an example of a legitimate use of the EMS system and the ED. It's the whole bus load of patients on Friday afternoon that really irritate. When asked what we can do for them the reply is "My doctor told me to come to the ER". It's usually something like a sore throat. Or worse yet, "my doctor told me I could get my MRI done today without waiting till next week if I came to the ER".

There are abuses on both sides. I just ask that people use their heads for more than a stethoscope hanger and consider what happens to really sick folk for whom there is not a bed due to every room, hallway, and closet filled with people waiting on their MRIs.

 

[deleted109597]

If you have a legitimately ill patient - this month I've sent a hypotensive new-onset afib with RVR and a crushing chest pain to the ED - who drove themselves to their appt that day (and most of my patients do drive themselves), you can't very well have them drive to the hospital.

Yes, then the ED serves a purpose, and you are arguing with the OP in saying that there is a need for people trained to take care of patients with high acuity. Unstable SVT, ACS, you name it, this is bread and butter emergency medicine.

They're getting there via ambulance, and when you call EMS for one, their protocol dictates the patient goes to the ED. EMTs don't take patients to the floor. I'd prefer direct admits, and so would patients. They're cheaper and easier on the patient and family.

You can't direct admit using an ambulance? What planet do you live on? If they need advanced life support, then maybe they should stop in the ED to be stabilized. If they don't, one can have the men with badges roll that stretcher right through the front door, up the elevator, and to the room one has obtained for them previously if one isn't a lazy bastard.

 

[Winged Scapula]

There are abuses on all sides...just as the ED hates it when the Friday afternoon bus rolls in, we used to refer to ourselves as the "Friday afternoon consult service" when we would get boatloads of surgical consults between 4-7 pm on a Friday, especially if it were a holiday weekend.

However, as noted above there are legitimate reasons for sending a patient to the ED from the clinic.

I have sent hypotensive patients with EKG changes to the ED from the surgical clinic because I was pretty sure their problem was not surgical; I have sent patients over for a CT scan because even the nurses will tell you, they don't want the patient sitting in clinic after hours (while they have to stay with them) waiting for the scan. I have sent patients over who have had syncopal episodes with residual weakness in clinic.

Does that mean I need to the ED to work them up? Not necessarily, sometimes I do, sometimes I don't. I'm not a medicine doctor and it would be presumptuous of me to assume that "everything is ok". To imply that all patients that come from the clinic are inappropriate is to overgeneralize.

 

[Winged Scapula]

I've had people come from surgery clinics to have lacerations sewn. I've had people have to come back to the ED to have sutures removed from their surgery because the clinic couldn't find the time to have a nurse remove them.

Well, that's obviously a system problem at your institution because I've never heard of such ridiculousness.

 

[deleted109597]

Well, that's obviously a system problem at your institution because I've never heard of such ridiculousness.

Lots of places have system problems, and lots of places abuse whatever group doesn't have the best representation at the table. Really medicine needs to as a whole stop the "me against the world" idea, and work together before other groups take over because there isn't a unified front.

 

[lucky_deadman]

Lots of places have system problems, and lots of places abuse whatever group doesn't have the best representation at the table. Really medicine needs to as a whole stop the "me against the world" idea, and work together before other groups take over because there isn't a unified front.

Here, Here!!! Enough of this infighting and backbiting (unless it's b/n consenting adults). We need to attack the real enemy.

 

[Homunculus]

But the biggest PITAs, IMHO during medical school and residency, were the Pediatricians. That doesn't mean that all Pediatricians are that way, it was just my experience.

i must admit, that's a first. pediatricians the biggest PITAs? some of us are gunshy after being burned too many times by otherwise adult oriented folks trying to kill our patients (my most recent experience was a DKA in the ED) but i think the average @sshole quotient for peds is lower than everyone else

--your friendly neighborhood friendly caveman

 

[AwesomO]

Sorry OP but if you think any job in medicine is going to give you a bad ass persona you are mistaken. You want to be a marine then join the corps. No one in the general public is ever going to mistake you for a bad ass by going into medicine no matter what residency you do.

Quite frankly you sound like "someone in the basement playing zelda and dungeons and dragons while trading magic cards" who's hoping that a career in EM will transform you into some kind of stud.

 

[Dr Serenity]

Lots of places have system problems, and lots of places abuse whatever group doesn't have the best representation at the table. Really medicine needs to as a whole stop the "me against the world" idea, and work together before other groups take over because there isn't a unified front.

Here, Here!!! Enough of this infighting and backbiting (unless it's b/n consenting adults). We need to attack the real enemy.

The most sensible quotes I've seen on this thread!

Okay, back to the flame wars! [Dr Serenity puts on flame ******ent Kevlar suit as he leaves the room]

 

[Faebinder]

Sorry OP but if you think any job in medicine is going to give you a bad ass persona you are mistaken. You want to be a marine then join the corps. No one in the general public is ever going to mistake you for a bad ass by going into medicine no matter what residency you do.

Quite frankly you sound like "someone in the basement playing zelda and dungeons and dragons while trading magic cards" who's hoping that a career in EM will transform you into some kind of stud.

For God's sake!! There is nothing wrong with D&D and Zelda damn it!!!

 

[elwademd]

Steve Urkel did not wear a bow tie. I don't think you can find one image of him wearing a bow tie...his schtick was suspenders.


http://images.google.com/images?hl=en&q=steve+urkel&um=1&ie=UTF-8&sa=N&tab=wi


Bow ties are bad ass

here's a you tube clip of an episode of family matters, where steve urkel is wearing a bow tie!

http://www.youtube.com/watch?v=1qqYWDalS8k

another non bad ass wearer of the bow tie would have been carlton, from fresh prince of bel air. granted, he didn't wear the bow tie at all times.

 

[awdc]

That's why docs trained in some other specialties (FM, IM, General Surgery) can cover the ER and do almost anything as well as a pure EM doc. And that's where, dare I say, the insecurity of a good number of people in EM comes from...that they know the old stereotype of them being a glorified triage nurse has a fair amount of truth to it.

The ironic thing is that you'd have to be very secure with yourself to do EM. We recognize that we are not cardiologists, surgeons, neurologists, or any of the other specialists we consult. As a result, we are constantly looked at with very critical eyes. Yet, we are comfortable in our role and enjoy the work we do.

We never deny that there is always a specialty that can do something we can. However, no other single specialty is trained to do everything we are able to do. Imagine having to staff an ED with a boat load of specialists 24/7. FM physicians (seeing how they are comfortable with infants, kids, adults, geriatric, ob/gyn) are probably the closest specialty that can do our job but their emphasis isn't exactly in identifying and managing the breadth of emergent/critical presentations, trauma, and the practice of certain procedures.

 

[AwesomO]

For God's sake!! There is nothing with D&D and Zelda damn it!!!

Meh I haven't liked Zelda since it went 3D. Theres nothing wrong with playing them, my point was that the OP is just insecure in himself and thinks getting a spot in ER is magically going to transform him into the hot shot in the hospital.

 

[jessica84]

here's a you tube clip of an episode of family matters, where steve urkel is wearing a bow tie!

http://www.youtube.com/watch?v=1qqYWDalS8k

another non bad ass wearer of the bow tie would have been carlton, from fresh prince of bel air. granted, he didn't wear the bow tie at all times.

Well done, elwademd! Way to use those research skills. A+ to you! Also, good work on the discussion part, mentioning Carlton's inconsistency in the bow ties, though I do not believe that weakens the positive correlation between the geekyness and the bow tie? No?

 

[tkim]

Interesting article, but this line is pretty telling.
"As a marker of physician experience, we evaluated the years since completion of medical school training at the time of the closed claim to attempt to compare individuals with no residency training, just an internship, or residency training of various lengths."

I was pretty taken in until I saw that. I can't find a table which details the actual specialties of the "non EM trained physicians". With the inclusion of an unspecified (though I could EASILY have missed it) number of non-residency trained physicians, I am left questioning the results of the entire study.

It's easy to dismiss a study on a few lines taken out of context. Here's the full paragraph:

"It has been suggested that physician experience plays a large role in the occurrence of malpractice closed claims, with fewer closed claims occurring as physicians gain experience. As a marker of physician experience, we evaluated the years since completion of medical school training at the time of the closed claim to attempt to compare individuals with no residency training, just an internship, or residency training of various lengths. There was a statistically significant difference between the EM residency-trained group (10.5 years to closed claim) and the non-residency-trained group (14.6 years to closed claim). However, the interpretation of these data is not clear. Some of the difference is due to older individuals in the non-residency-trained group, as well as those who practiced in other areas of Medicine before pursuing careers in Emergency Medicine."

Actually, two paragraphs up they make specific comparison between EM-residency trained and other residency trained but with 5 years of EM experience:

"Although the non-residency-trained physicians accounted for only 5.7% more physician-years of malpractice insurance coverage, they generated 71.5% of the indemnity paid out and had 66% more closed claims where indemnity was paid. Both the ratios of defense costs and indemnity paid per physician-year of malpractice coverage for non-residency-trained emergency physicians were twice as great as for those physicians with EM residency training.

These differences hold true even when comparing individuals with EM residency training to those with residency training in another specialty and Emergency Department experience (PTC-Physicians). The PTC-physician group accounted for 74% more closed claims where indemnity was paid than did the EM residency-trained physicians, a difference that was also statistically significant. Residency training in EM was associated with fewer malpractice closed claims in which indemnity was paid when compared to physicians who are not EM residency-trained, even if they were trained in another specialty."

A little further up:

"Finally, physicians with EM residency training were compared to physicians with residency training in another specialty and at least 5 years of Emergency Medicine malpractice coverage with COPIC (comparable to what was the American Board of Emergency Medicine practice track criteria for EM board certification). There were 165 closed claims filed against EM residency-trained physicians with indemnity paid in 22 cases (13%, 95% CI 7.7–18.1%) totaling $1,773,524. For those physicians with residency training in another specialty and 5 years experience (practice tract criteria, or PTC-physicians), there were 212 closed claims with indemnity paid in 49 cases (23%, 95% CI 17.3–28.7%) totaling $3,482,206. This difference was statistically different (χ2, p = 0.02)."

There are also a few letters to the editor that rip the article apart for multiple reasons.

I only see two in the July 2001 issue - from Drs. Schorin and Dajer. Neither seems to 'rip' apart the study as you characterize it, and the authors did respond in a meaningful way. Am I missing subsequent letters?

 

[chimichanga]

If you have a legitimately ill patient - this month I've sent a hypotensive new-onset afib with RVR and a crushing chest pain to the ED - who drove themselves to their appt that day (and most of my patients do drive themselves), you can't very well have them drive to the hospital. They're getting there via ambulance, and when you call EMS for one, their protocol dictates the patient goes to the ED. EMTs don't take patients to the floor. I'd prefer direct admits, and so would patients. They're cheaper and easier on the patient and family.

Some FP docs actually do have them drive to the ER...Had one last week...Bradycardia (30's) drove to the office, drove to the ED...at least he called us to give us a head's up

I've never heard of "protocols" dictating all ambo pts must go to the ER...
It's called an ALS ambulance (private company, interfacility transport); call the house sup and the accepting doc, arrange for the ALS transport, and voila, a direct admit...

 

[f_w]

I've never heard of "protocols" dictating all ambo pts must go to the ER...
It's called an ALS ambulance (private company, interfacility transport); call the house sup and the accepting doc, arrange for the ALS transport, and voila, a direct admit...

Some hospitals might do this. On one hand, it allows them to slap an ER charge on the bill, on the other hand it keeps the number of sick patients on the floor down (--> cheaper staffing).

If a hospital doesn't allow direct admits with ambulance transport then this is a local custom/rule/ripoff.



In the world of paid for medicine (in a separte galaxy from the world of academic teaching hospitals), ED docs don't mind those direct admits that get routed through the ED:

- they already have a service willing to take them (placement is everything)
- all they need is some diagnostic tests along the way
- if served up with the proper documentation from the PCPs office (e.g. fax copy of last H+P and medlist), they are easy on the documentation end
- have complicated enough issues to warrant a higher level code
- if they have a PCP, they usually have insurance/medicare

So in the caa-ching/(effortxhasslexliability)= 'ED doc happyness' equation they have a lot going for themselves.

 

[AlternateSome1]

It's easy to dismiss a study on a few lines taken out of context. Here's the full paragraph:

...

Actually, two paragraphs up they make specific comparison between EM-residency trained and other residency trained but with 5 years of EM experience:

...

A little further up:


...


I only see two in the July 2001 issue - from Drs. Schorin and Dajer. Neither seems to 'rip' apart the study as you characterize it, and the authors did respond in a meaningful way. Am I missing subsequent letters?

"There were 165 closed claims filed against EM residency-trained physicians with indemnity paid in 22 cases (13%, 95% CI 7.7–18.1%) totaling $1,773,524. For those physicians with residency training in another specialty and 5 years experience (practice tract criteria, or PTC-physicians), there were 212 closed claims with indemnity paid in 49 cases (23%, 95% CI 17.3–28.7%) totaling $3,482,206."

The confidence intervals for the two indemnity percentages actually overlap.

Sorry, their were a couple of editorial letters which rip apart the article, not a few.

 

[deleted109597]

The largest EM issue right now is not this minor direct admit/eval/whatever nonsense. It is the fact that on average, admitted patients have a long wait in the ED, and take up space that the people in the waiting room can't use.
ACEP tried to get it passed where the hospital isn't paid for patients boarded in the ED, but that didn't pass (and never had a chance) because the hospitals won't stand for that, and they are the biggest lobby out there for healthcare (well, the AARP is close). This is also why residents couldn't have the match stopped, because the hospitals knew their supply of free labor and 100K paychecks per resident might get shut down. So it has a Congressional pass to the Sherman Anti-Trust Act.

For Alternate, while the CI might overlap ever so slightly, look at the total payout to see if you have a difference between the two groups.

 

[Faebinder]

"There were 165 closed claims filed against EM residency-trained physicians with indemnity paid in 22 cases (13%, 95% CI 7.7–18.1%) totaling $1,773,524. For those physicians with residency training in another specialty and 5 years experience (practice tract criteria, or PTC-physicians), there were 212 closed claims with indemnity paid in 49 cases (23%, 95% CI 17.3–28.7%) totaling $3,482,206."

The confidence intervals for the two indemnity percentages actually overlap.

Sorry, their were a couple of editorial letters which rip apart the article, not a few.

Actually on a Fisher's exact test, the p value is 0.01, so there is a significant difference. Still the concept is flawed. Can't use just any physicians... are those physicians full time urgent care or doing this on the side?

 

[Faebinder]

The largest EM issue right now is not this minor direct admit/eval/whatever nonsense. It is the fact that on average, admitted patients have a long wait in the ED, and take up space that the people in the waiting room can't use.
ACEP tried to get it passed where the hospital isn't paid for patients boarded in the ED, but that didn't pass (and never had a chance) because the hospitals won't stand for that, and they are the biggest lobby out there for healthcare (well, the AARP is close). This is also why residents couldn't have the match stopped, because the hospitals knew their supply of free labor and 100K paychecks per resident might get shut down. So it has a Congressional pass to the Sherman Anti-Trust Act.

For Alternate, while the CI might overlap ever so slightly, look at the total payout to see if you have a difference between the two groups.

Indeed, we are quick to learn that the greatest enemy of the physician is the hospital itself.

 

[Winged Scapula]

i must admit, that's a first. pediatricians the biggest PITAs? some of us are gunshy after being burned too many times by otherwise adult oriented folks trying to kill our patients (my most recent experience was a DKA in the ED) but i think the average @sshole quotient for peds is lower than everyone else

--your friendly neighborhood friendly caveman

I agree...that's why it was such a suprise and I chalked it up to my medical school experience. However, in residency many of the pediatric SPECIALISTS (maybe that's the smoking gun) were rude and condescending to the surgical residents...then again, everyone is rude and condescending to residents in the NICU and PICU!

 

[Winged Scapula]

Lots of places have system problems, and lots of places abuse whatever group doesn't have the best representation at the table. Really medicine needs to as a whole stop the "me against the world" idea, and work together before other groups take over because there isn't a unified front.

Prescient words in this particular thread!

 

[f_w]

I agree...that's why it was such a suprise and I chalked it up to my medical school experience. However, in residency many of the pediatric SPECIALISTS (maybe that's the smoking gun) were rude and condescending to the surgical residents...then again, everyone is rude and condescending to residents in the NICU and PICU!

There is a point in peds residency where two groups emerge. The 'cuddly bear costume homeopathy isn't all that bad' crowd that goes straight into primary care and the 'shucks, I ended up in peds and will starve for my latter days unless I get into peds-GI and make bank' crowd. The former are for the most part laid back, enjoy their job and as primary care peds don't have much interaction with the rest of the medical universe. The latter are a PITA, very insecure about anything but a sub-area of their specialty (worlds expert on basophilic gastroenteritis but can't scope if someones life depended on it) and compensate for their insecurity by being rude to:
- their patients parents
- their residents
- their colleagues
- all those consult services that are just out to kill their patients (first and foremost the GS residents who cover the peds-surg service at night when the peds-surg fellow who has to cover 12 hospitals is asleep).

 

[Winged Scapula]

There is a point in peds residency where two groups emerge. The 'cuddly bear costume homeopathy isn't all that bad' crowd that goes straight into primary care and the 'shucks, I ended up in peds and will starve for my latter days unless I get into peds-GI and make bank' crowd. The former are for the most part laid back, enjoy their job and as primary care peds don't have much interaction with the rest of the medical universe. The latter are a PITA, very insecure about anything but a sub-area of their specialty (worlds expert on basophilic gastroenteritis but can't scope if someones life depended on it) and compensate for their insecurity by being rude to:
- their patients parents
- their residents
- their colleagues
- all those consult services that are just out to kill their patients (first and foremost the GS residents who cover the peds-surg service at night when the peds-surg fellow who has to cover 12 hospitals is asleep).

I think you may have hit the nail on the head!

 

[Bitsy3221]

But sometimes, especially when you have a FULL waiting room, disposition is what matters most. So if the patient's going to get admitted b/c they're sick, there are times when the work up isn't finished since it can be finished on the floor.....Where I'm doing my residency, the admission rate is about 20-25%, and our waiting room is more often than not, full. But on days where the volume is constant, we have to "move the meat" since there will be sick people that have been waiting for hours that need to be seen.

So what you're saying is that you're too stupid to perform a direct admit? Can't get studies as an inpatient? Can't send someone to the OR without stopping by to see the ED?

No, it is because they are too ****ing lazy to do the work themselves, so they make the ED do it. The ED is treated like a residency position in that they are always there, so might as well make them do something that you could do yourself. Someone calls your call line complaining of something? Don't ask them questions or call in a med, send them to the ED. Someone in your clinic sick? Don't slow down clinic to work with them, call an ambulance to send them to the ED. I've had people come from surgery clinics to have lacerations sewn. I've had people have to come back to the ED to have sutures removed from their surgery because the clinic couldn't find the time to have a nurse remove them.

So when an FP/pediatrician/IM in clinic sends a sick patient to the ED, they are being "too ****ing lazy to do the work themselves" to not "slow down clinic to work with them", yet it is perfectly acceptable for an EM physician to "move the meat" and not stop and do a work up before paging out a consult when they get busy since they have a full waiting room? Interesting......

 

[Dr. Will]

So when an FP/pediatrician/IM in clinic sends a sick patient to the ED, they are being "too ****ing lazy to do the work themselves" to not "slow down clinic to work with them", yet it is perfectly acceptable for an EM physician to "move the meat" and not stop and do a work up before paging out a consult when they get busy since they have a full waiting room? Interesting......

I love how you combined TWO DIFFERENT posts by TWO DIFFERENT posters to come to some sort of "conclusion." I have yet to weigh in on the "sent into ED from clinic" issue so I would say it's inappropriate to combine my thoughts (on something discussed prior) to a somewhat related, but not entirely, subject someone else had thoughts on.

To respond to that subject...I personally don't mind having someone sent in from clinic, especially if they have something that could potentially be serious/life threatening, or to utilize the ED for it's resources (like getting a CT/stat labs in a very quick manner. What I do find issue with (and yes I've seen this), is "patient sent to ER for rectal exam (yes, I have seen this), or various other complaints that COULD have been taken care of in the office. The other issue I have are patients that are sent in to the ED with absolutely NO INFO regarding what the concern is (including a list of meds, medical history, etc), or heck cuz it's the respectful thing to do, a phone call to communicate what the concern is.

Regarding the consult issue. Myself, and others at my program, NEVER call a consult without a specific question...meaning, the appropriate work up is done for that consultant so that specific question, or definative treatment, can be answered/started. My speil on not having workup finished is in regards to an acutal admission...as in the patient is being admitted for some reason but the final diagnosis may not have been made, but a working diagnosis is in progress. And in all honestly, most people showing up to their doctors office/clinic/pediatrician are not as emergent as those in the waiting room of the ED. And while not everyone in the ED waiting room is sick...there will be more sick people there based on numbers alone. So it's apples and oranges.

As for the data for the EM lawsuits...I thank tkim for posting some data. I'm waiting to get the papers (and see whether it's the same one) by the faculty at my program that brought it up during a recent MandM. I'll post it when I get it.

 

[deleted109597]

So when an FP/pediatrician/IM in clinic sends a sick patient to the ED, they are being "too ****ing lazy to do the work themselves" to not "slow down clinic to work with them", yet it is perfectly acceptable for an EM physician to "move the meat" and not stop and do a work up before paging out a consult when they get busy since they have a full waiting room? Interesting......

How is it you quote two people and then use both of them to form a unified opinion? The only time the consult is called before the workup is complete is if the patient is going to be admitted anyway. Therefore, it doesn't matter if their admission diagnosis is COPD exacerbation or pneumonia, or sepsis, or any number of things. Medical problems that demand admission might differ a little between some nuances, but they still require a bed, so getting that ball started before knowing everything isn't a bad problem.
Calling consults before knowing anything about a patient or even laying eyes on them is pretty chicken-**** and I don't find it acceptable, so you won't find me saying that.

 

[deleted109597]

Also, it isn't often that we don't do a work-up, it is that the work-up isn't complete because the labs/rads/whatever aren't all back before we call. However, the patient is sick/hurt bad/whatever and will be staying overnight or longer, calling the consult early isn't us not doing our work, it is early goal directed therapy.

 

[elwademd]

this thread is interesting in many ways.

suffice it to say, as much as i have some disdain for the er where i work, the er defintely has a purpose, and patients are served/treated going to the er. the er definitely has its role.

How is it you quote two people and then use both of them to form a unified opinion? The only time the consult is called before the workup is complete is if the patient is going to be admitted anyway. Therefore, it doesn't matter if their admission diagnosis is COPD exacerbation or pneumonia, or sepsis, or any number of things. Medical problems that demand admission might differ a little between some nuances, but they still require a bed, so getting that ball started before knowing everything isn't a bad problem.
Calling consults before knowing anything about a patient or even laying eyes on them is pretty chicken-**** and I don't find it acceptable, so you won't find me saying that.

perhaps you should clarify that "it doesn't matter to the er physician if their admission diagnosis is copd exacerbation or pneumonia, or sepsis, or any number of things."

it matters to medicare... it matters to other insurers...
it matters to the patient and the patient's family...
it matters to the hospital in terms of the level of acuity that's needed for the patient, and the medicines that may (or may not be) indicated...
it matters to the admitting physician in terms of his/her liability for taking care of the patient as well as his/her getting paid...
it matters to the hospital in terms of getting paid...

and in many ways it should matter to the er physician since the paperwork and documentation should support what he/she has done... and what he/she is going to bill for...

 

[Dr. Will]

perhaps you should clarify that "it doesn't matter to the er physician if their admission diagnosis is copd exacerbation or pneumonia, or sepsis, or any number of things."

it matters to medicare... it matters to other insurers...
it matters to the patient and the patient's family...
it matters to the hospital in terms of the level of acuity that's needed for the patient, and the medicines that may (or may not be) indicated...
it matters to the admitting physician in terms of his/her liability for taking care of the patient as well as his/her getting paid...
it matters to the hospital in terms of getting paid...

and in many ways it should matter to the er physician since the paperwork and documentation should support what he/she has done... and what he/she is going to bill for...

No...what matters is that the patient is being admitted and that we've ruled out the very serious conditions that can quickly kill you with respect to your symptoms. We are taught to think of the worst things first and work our way down. For example, the neutropenic fever is going to be admitted whether or not we have a source at that moment for a specific diagnosis. The 70 something old female with syncope that has a no etiology discovered in the ED is going to be admitted for further workup. The examples you listed above, "copd exacerbation, pneumonia, sepsis," are ones made in the ED all the time and not the types of situations I describe when workup is not finished, at least where I am and in my experience. I can not speak for any other ED.