Wednesday, September 17, 2008

Slate Takes a Swing

Slate Online has a pretty good take on ER abuse and overcrowding. I don't really have too much to say contrary to their conclusions as they tend to be one's we have made here already (though I know that every town has five or six people who run up millions in medical bills that will never be paid and call the ambulance every other day). This would be an interesting study... find the patients seen more than twenty times in a year in a single ER and compare these twenty patients bills with the rest. Anyone?

Particularly in reference to the availability and ability of primary care physicians to do complete workups in their office the ER has become a "one stop shop" for all, insured and uninsured alike. A prior post on MDOD is worth a look, Whither the Generalist, the thing the Slate authors do NOT talk about is that by punting even the 'maybe sick' to the ER the Family Practitioners, General Internal Medicine docs, and many General Surgeons are losing their critical skills and clinical judgement. On the other hand, as Slate points out, they really have no other option given the malpractice climate and their terribly poor pay. They have to see forty or fifty patients a day to break even, and one complicated patient not only puts them in the red, that patient can not, in most practices, get the immediate results we can get in the ER. And woe be unto them if they 'miss' a diagnosis. I know Bart Durham and his clones are ready to help any patient hit the medical lottery and have, without a doubt, the worst commercials I have ever seen. I mean how could the horribly injured legal lottery winner lounging by her new pool have been that injured?

My only quibble with Slate is to point out that this did not need to happen. When receiving the best medical care in the world was separated from a patient's requirement to pay, if only a small amount, then the floodgates opened. Good job Slate.

many thanks for the heads-up dev!


  1. You're welcome, Doc! Now, how about that awesome bit of medical news for those of us who will be 50 some day: Virtual colonoscopies achieve comparable results with the OTHER kind. Yeah!

  2. Heh, as one who is just north of 50, I read that article in my paper with interest.

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  4. Sorry, I had to temove the above post. I am in a bad mood, maybe I should start my own blog so I can rant too. :-D

  5. devorrah-for real? I have had a colonoscopy and while it wasn't the most awful thing ever, I would be glad to never have to do that again! I need to start reading the paper I think.

  6. amy65c,
    no need to retract that comment. i thought it was good. if i remember it correctly there's two things i would say....

    1. 'proving' someone is faking is incredibly difficult.
    2. 'proving' someone is laying it on thick is impossible.
    3. many ERs have tried to kick out the non emergent patients but there are incredible difficulties here too. first, even though it makes no sense, often, the triage nurse is NOT a good triage nurse. often, the triage nurse is put in triage because she can't do her work IN the ER. it is THE MOST IMPORTANT JOB on the nursing side and if someone with poor clinical judgement is out there then things will be missed and the 'non emergeny' patients often sit out there for hourse while having their heart attack that the triage nurse thought was 'just heartburn'. it happens all the time. on the nursing side the culture is that no one is sick and if they are then they are sick enough for anyone to tell. vital signs are key here and for some reason people with heart rates twice what they should be are ignored because they happen to be 'only thirty years old'.

    they are USUALLY right that a particular patient is not sick BUT we have to bat 1000 or face malpractice litigation. in the end, hospitals have largely given up on turning away the 'not sick' because the possibility of missing a 'really sick' needle in the haystack is more expensive than simply seeing everyone. thems just the facts of life.

    one solution that i have seen employed with great effect is to have a midlevel provider (ie a physician's assistant or nurse practitioner) do the triage. they can then see and treat the 'easy ones' before even bringing them back to a room AND catch the zebras as well.

    i have no quarrel with the legal remedy for malpractice, we SHOULD be held responsible for mistakes, my quarrel is with the 'lottery' culture and the attorney's who foster this mentality. i would love to be almost really hurt bad in such a way that i could retire on someone else's dime, but, like you, i would only take that option if i really was permanently injured and unable to work.

    there are a variety of solutions here, most of which the attorneys don't like because it would mean less money for them, but so what? capping pain and suffering damages is a good idea, as is increasing the penalties for what the judge or jury determine to be 'fishing expedition' suits. texas has the most doctor friendly system and i'm not necessarily advocating for it, but in texas, before a suit can come to trial, a board made up of physicians and legal types must agree that there is merit. this was instituted because, ten years ago, doctors were fleeing texas for fear of losing it all in one suit.

    west virginia had, and may still have, an almost complete lack of OBGYN physicians because of a few successful ridiculous suits against them for harm discovered twelve years after the birth of a child that 'might' have been related to complications at birth. john edwards had a famous case along these lines.


  7. Your comments on this article were interesting. Nice post!

  8. There is one really obvious error in this article---they say the uninsured don't use the ER more than the insured. Medicaiders have something like 89 visits per 100 people on Medicaid, uninsured is about 45 visits and privately insured is 23 visits per 100 people.

    One cool concept going on around here is some of the bigger medical clinics are buying their own CT scanners and/or having ultrasound techs on call (in addition to Xrayeurs) and staying open until 10pm or so.

    When my mom fell and bruised her hip, she asked to go to the ER by her house because she was having trouble walking on her leg, and when I went there, there was an "urgent care"/walk-in clinic-type-thing down the hall and the regular ER. The ER waiting room was crowded and the urgent care had a 15 minute wait and was billed as an office visit.

    Sadly, the staff are not legally able to tell the patients to try the urgent care because that would be illegal, you just have to kind of figure it out on your own despite it being way down the hall and having no flashing signage.

  9. RadGirl: True story! Of course they still have to hose you out if the bot actually finds anything, and certain kinds of polyps are harder to detect.

  10. 911,

    You've pointed out before the problems at the family physician/internist level that make the ED situation worse, just figured I'd add some detail to it.

    I'm expected to be fully booked at the beginning of each day. Keep in mind "fully booked" in today's shi*ty payment world for primary care means overbooked in reality.(also, suits decide what a full schedule is, not me) So I'm struggling to keep my head above water just seeing who's already on my schedule, addressing all the needs of increasingly complicated patients in increasingly shorter appointments. (burnout anyone?).

    When a patient not on the schedule calls in with concerning symptoms that will likely necessitate a thorough and often time intensive evaluation, I simply do not have the time to address it. So "go to the ED" becomes the default.

    Additionally, even if I did have the time due to some miraculous change in the scheduling problems mentioned above, I cannot work up many potentially serious problems in the clinic to the current standard of care. I can't get troponins, bun/cr, electrolytes, d-dimers, MRI, CT scans, at the point of care, they get done at the hospital, results coming back hours later. Don't get me wrong, I'd like to use medical judgment occasionally for chest pain or abdominal pain or shortness of breath or confusion without all that overkill in testing. But the legal enviornment doesn't allow me to do that. So off to the ED for those complaints, even if time isn't an issue.

    So it's a double whammy. I don't have the time, and even if I did, I can't meet the medicolegal standard of care in my office that our irrational system demands.

    I feel sorry for the ED docs, but I don't feel there's much of a choice, at least from my perspective.

  11. the triage nurse is NOT a good triage nurse. often, the triage nurse is put in triage because she can't do her work

    I've seen ineffective teachers moved around rather than be fired because they have tenure. I've seen city workers promoted so they would do less damage in their current position, but INEFFECTIVE TRIAGE NURSES? Good god, my life could depend on them, and I'm powerless.

    Stupid question, but wouldn't firing stupid medical people cut down on the hospital's legal vulnerability?

  12. why yes, lynn, it would. but nurses are hard to fire and until someone dies too bad. also, when they do, the doc hangs, not the nurse. now the nurse may be named, but deep pockets and respondeat superior etc...

  13. As someone who works triage routinely, I can safely say at least in my ER, we rotate people through all the different areas of the ER, including triage, and it's not based on who is good or bad. Not being stuck in one area is good for burnout prevention.

    You need at least 1 year ER experience to go to triage where I am.

  14. "We also should restructure the payment system for primary-care doctors so they won't go belly up if their schedules aren't 100 percent booked, given how little they're paid per patient."

    That's the problem in a nut-shell. At least you guys get paid more than $45 to take a history, do a physical, order an EKG, chest X-ray, troponins, d-dimers, cbc, hcg, Chem 19, UA, gallbladder ultrasound and call a surgeon when a 35 year-old woman comes in with epigastric pain. I have to see three patients an hour just to break even--to pay the rent, insurance, my employees' salaries, office supplies, toilet paper for the bathroom, the transcription service and so on. It's that fourth patient I see that hour that actually buys macaroni and cheese for my family. When I squeeze in a fifth patient, we can afford hamburger helper.

    But there's only so much I can do. I can't possibly squeeze in a sixth patient per hour just to keep him out of "your ER," from where you'll drive home in your BMW to your 5 bedroom mansion after your shift ends while I'm still at work filling out ULTC-100 and FMLA forms.

    Disgruntled Internist.

  15. Disgruntled Internist
    Your comments are spot on, and we in the ER empathize, up until the cheap shot. I drive a 9 yr old Toyota Highlander, no BMW or mansion as you suggest. And as I drive home at the end of my shift, in the back seat I have the ghosts of the two simultaneous cardiac arrests that I lost today while working on the GSW to the chest. My satisfaction scores are down, my CEO has chewed my butt so many times that he is spitting out diverticula, and I came in to a conversation this morning that started "Do you remember the patient you sent home yesterday with..." that never ends well.
    So, I ask you to think of it this way. We all get the same amount of pain and grief in a day. I get it in a bolus, you get it as a drip.

    The slate article does miss the point with the stats provided. Nurse K has the correct stats. The multi-million dollar abuser is most likely insured, but by the government. And the same government, along with the lawyers, prevent us from stopping it. Even a strong primary care network would only help a little, because, by federal law, we still have to see the patients/abusers before triage to primary care.
    We have, thanks to the reinforcement of the lawyers, a culture of "it might be". An example: take the old fashioned baseball collision between the second base and the runner at a little league game. In the old days, the coaches would come out, dry the tears, dust the kids off, and tell them to be more careful. Any bone deformities would be put in the coach's car and taken to the ER. Now, right after the collision, coaches immobilize the kids, call the ambulance, and viola! Two C-Spined patients arriving by ambo in 10 min for curative radiation. Why? "It might be" a head injury. "It might be" internal bleeding. "It might be" a broken bone. No one along the way will stop that train from leaving the station, because no one wants to apply common sense to the "it might be" culture. The lawyers make it too costly, in terms of money and grief, for anybody but us to apply common sense in the 1 in a million event it was a head bleed. And the government stops us from turning it away at triage. (Your comments about nurses and triage notwithstanding).
    So, we ER Docs become the professional responsibility-takers, or the sin-eaters. We have done this to ourselves. You may disagree, but unless we apply some common sense and some form of legal immunity to the triage process, it is only going to get worse.

  16. Speaking of 'Bart Durham' clones; I once found a stack of business cards from an equally slimy lawyer stategically placed around my hospital. That's some nerve. I would have loved to catch the guy in the act...

  17. Well said Igloo, I have you beat though. I have a 2005 Tacoma. My mansion is my 1800 sq foot house on which I am still saving for my property taxes that are coming up.

    Yes, ED Docs are rolling in it. I have so much money my wife still works full time.