Thursday, August 12, 2010

The Specialist Wall

American Medicine will die or be reborn in the next ten years. Correction, it will either continue an accelerated slide into banal mediocrity, or be reborn. The battle is finally joined, and it has been joined by the specialists. Thank you, doctors, for drawing the line in the sand. I hope you win. Honest.

I am cheering against my own college here because they have been so obviously wrong for so long, and our leadership, such as it is, has continued to try and put a hammer-lock on our consultants by passing resolutions and amending hospital bylaws and throwing guilt trips at these most-skilled physicians. All of this instead of making sure the stars are in good shape for the big game. All of this instead of advocating for physicians and fighting against EMTALA.

If you are unfamiliar with EMTALA or our take on it you can read about it here, but to be brief, EMTALA is an unfunded federal mandate passed in 1986, which, de facto, has made it a crime to tell anyone 'no' in the ER. Because of this, the specialists on call have learned to hate the ER. The ER is no longer a place from which one can build a practice, it is, rather, a place that compels you lose sleep, and money. It compels consultants to expose themselves to full malpractice liability EVERY SINGLE TIME they accept a patient from us whether they ever get paid or not.

No doubt there is a strong tradition in western medicine to treat first and seek payment later. This dates to Hippocrates and is part of the original oath. My question is this. How far should this obligation extend, AND, should it be extended by force of law rather than by individual choice? My answer is that the obligation should never be extended de jure. Medical schools, training programs, and hospitals can choose to extend this requirement to their students and physicians and the students and physicians can choose to participate or not, but the government does not have this right. Seems to me we fought a war over a similar issue, for this is analogous to taxation without representation, only this tax is paid in time, liability, AND money (and it never ends).

But let me take the opposite view and say that creating the obligation to deliver care gratis to whomever is sick in the ER during your on-call shift IS a proper government function. The next question is this... How much exactly? How many charity cases are you required to do per year? Is the answer, "as many as the situation demands"? It can't be that because then you have made medicine into a charitable endeavor, and maybe this is what it should be, but it is not what it is, and not what it was, ever, anywhere. This is not to say that there are not physicians who aren't motivated solely by charity, but it is to say that there aren't many of them. If it's not "as many as the situation demands" then what is the answer, and who gets to decide?

So the specialists are fed up, and they have figured out how to fight city hall. For years their battle has been against the system or even the ER doc downstairs. But now (oh the genius!) they have turned the bureaucrats game against them. EMTALA and the bylaws, policies, and rules that it has generated are being followed to the letter.

For instance, almost all hospitals have an on-call policy for specialists that require them, if the ER doc requests it, to come in to the ER and evaluate the patient. Well, they can be forced to do this, but in many cases they CAN NOT be forced to treat the patient. Unheard of twenty years ago and before EMTALA, but specialists are now routinely coming in, evaluating the patient, and finding reasons why this particular case is out of their area of expertise, or not appropriate for their care, or not in need of surgery immediately, and the specialists are going home.

Recently, a child came in to the ER after sustaining a facial laceration. Two different surgeons were called to fix the cosmetically sensitive but clearly non-emergent laceration. Both came in, and both told the ER doc, "No issue, you can do this." And that's exactly what happened- the ER doc sewed it up (I hope he did it well). And that's exactly what EMTALA means, and exactly what Obamacare means, and it ends up hurting people who do not deserve it, and it ends up rewarding those that do not deserve it. And yes, I said "DESERVE", and yes, I mean it. Punishing the doers eventually causes them to slip the yoke.

But how can a surgeon refuse to operate? Well, well... by way of example, consider the lowly gall bladder. When I was in training the gall bladder came out with pain and an abnormal ultrasound. Now it doesn't. It used to be that surgeons would operate at the drop of a hat because they loved surgery. Not anymore. You see, if a patient with acute cholecystitis can be 'cooled down' with fluids and antibiotics, VOILA!, no need to remove it right now. Have the patient follow up with the surgeon as an outpatient. You can't be sued for an operation you didn't do.

Then the patient goes to the surgeon's office a few days later and is no longer under the rubric of EMTALA, therefore, they must pay for their surgery (payment plans are accepted), or have insurance. Still sounds fair right? I mean, who gets surgery for free, right? Well, these folks do NOT follow through with the surgeon because it's not free, they end up right back in the ER, and on the 28th time they are sick enough to go to the ICU. Some of them die, and they ALL chose to walk the streets with the ticking time bomb in their belly because they wouldn't pay a single dime for surgery (but they happily pay ATT for their I-phones).

EMTALA compliant? Absolutely. Fair? Yes. Optimal? No. How to force the surgeons to operate? I don't know... at the point of a gun? Otherwise, there's no one that can do what they do, not even an attorney. Surgeons, in particular, are unique, and they are needed, and so sorry Miss Jones, but Dr. ___ has resigned from the hospital staff to open a botox clinic and no longer does procedures here.

And guess what? That's a royal fucking flush... the bureaucrats are holding a ten-high. No one else can do your jobs, docs... certainly not those who own us right now. Play your hand, specialists, the pot is huge and you can't lose. Bluff up the pot, get EMTALA in there, lay the cards down, and win a victory for yourselves AND patients. Be the wall on which the tide of enforced mediocrity and misery breaks. And let's get that plastic surgeon in to sew up the little girl's face... happily.


  1. My concern is this:

    It will only take a few headline makers such as the type you describe above to push public opinion against the specialists, via the media. You can practically hear the headline news anchoress oozing empathy with some iteration of the "Area family says that this local specialty doctor REFUSED to treat their daughter," cue family interviews, assorted pics of the kid's scar, and of course, shots of Dr. Peter Goezinya exiting his S550. The classic greedy doc archetype can and will be used emphatically, and as EMTALA takes more time to explain than the public has patience the for, the lowest common denominator will win out. What's to stop politicians from selling themselves as our saviors from the evil, and clearly overpaid, specialists? I mean, com'on, look at what they did to that kid! They should pass a law that mandates the specialists treat everyone, because we all have the right to it. Just start paying them a little more than medicare fare, and taper it off over time. Genius!

    Seems to me that this could go either way. If you can write a 3,000 page healthcare necronomicon, you can probably screw the specialists into some ER coverage mandate. For the kids, of course. More like a pair of 2's to that 10 high.

    Heh, Peter Goezinya.

  2. dear RR,
    it's way past that. the public, at least the public i meet in the ER, already hates doctors. and the specialists are now at the point of having to choose between their own happiness/family/ etc... or busting more ass for less money. the rubicon is crossed. i'm telling you, they will quit, are quitting, and there's precious few coming through training. all the sob stories in the world will not mint a single new surgeon, nor will they work anymore to get these guys to swallow another shit sandwich. and props on the peter goezinhya.

  3. My hats are off to all that you Docs do on a daily basis especially in the ER or "low income" joints from having to deal with the "should have seen the PCP" types to the "just want a free dose of medicine" types. That alone is enough to stress you out and now all of NObamas new stuff *sigh* God Bless you all!!

  4. All physicians should immediately donate themselves for fertilizer. That's the only reasonable solution - then everyone will be happy.

  5. Specialists are leaving hospitals in droves, and many ERs are now permanently uncovered for many specialties.
    In my ER we no longer have plastics, ENT, or optho coverage, and ortho coverage is limited to trauma or life and limb. It's a disaster and the solution in my shop has been that the administration wants the ER docs to do more and more complex reductions, hour long ketamine sedations in kids to do facial lacerations (that used to be called a surgery) and keep other patients as admitted ER patients, as in since the specialty doesn't exist in the hospital anymore the ER docs just forever hand the patient on and act in the role of that specialty. The ICUs are so full that ICU patients stay in the ER for days and the ER staff is now being required to learn to decide when to extubate and send these people home, as many never even make it to the ICU.
    It's a shit show. The hospital is almost abandoned except the ER docs, the hospitalists and some critical care folk.

  6. dear dr j,
    ain't it the truth, and what of our ICU consultants these days? i don't know about you, but when a pulmonologist calls me to the ICU to intubate one of her patients twice in one week i'm wondering WTF, but i did it. i think it's the crest of a wave of less-than-stellar docs coming out of programs that had to take anyone that applied as opposed to 20 years ago when you had to be a star to get in. docs are leaving, in droves, as you say.

  7. Dr. J,
    Great move in Game 4 of the NBA finals BTW, too bad the Celtics Slapped y'all worse than Ike slapped Tina...
    Yeah, I know, it was the Lakers, I was just testing to see if your the "Real" Dr. J...
    and you DO know you need a Medical License to practice Medicine, unless your a P.A., N.P. or D.O.
    Just kidding, I know PA's and NP undergo rigorous training/selection/board certification.
    Same with DO's except its "Rigorous"(I'm Rolling my Eyes) "TRAYYYYYY-NEEN"(I'm sayin it like Bill Murray said "Army Training" in "STRIPES" and "Board Certification" hey, I go to a Chiropractor, I mean D.O. myself, when I can't get in to see a REAL Doctor..

    and is it true you could dunk from 1/2 Court but David Stern wouldn't let you???


  8. Did I miss something? When did D.O.s stop being licensensed physicians?

  9. DOs are fine, in my opinion. And the question about EMTALA is: what did all the "self nonpays" do before EMTALA? Factoring out the very large burden of trivial nonsense they visit the ER for, they either paid or did without. Now I'm real sorry everyone on the planet can't get five star medical care, but that's just an unrepealable fact of the human condition.

    And while most of the folks reading this blog pay for and receive pretty good care, the scum Commies in Washington don't like that; they're gonna make everyone's care EQUAL (except their own, of course). They are doing to health care what they did to public schools.

    So there's no such thing as a private hospital anymore, and all of us are going to get the same shitty care as the great unwashed. So when you're struggling for life one day in some stinking, overcrowded ER, being "treated" by a pea-brained nurse practitioner....well, I know I'll feel better about the whole thing - because things will be EQUAL.

  10. 911 is correct, but I will add a couple of comments.

    Before EMTALA became such an expensive bureaucratic nightmare, people didn't have such an EXPECTATION of "free care in the ER". Not to say that we didn't see such, but it was not as great a burden as it is now.

    Sure, some people did without, but even more chose to do with and chose to pay for it at a cheaper venue other than the ER. The culture of "go to the ER for everything and get it for free" wasn't so pervasive or expected.

    Though the Gov't blames medicine...I would point out that Gov't created this monster.

    In addition, the uninformed bleeding hearts push the idea that 100% of our self/no pay patients CAN'T pay. This is wrong. The majority of them COULD pay a clinic fee, they just chose not to. You've seen the posts about the cell phones, name brand clothing, and vehicles nicer than the one I drive which are frequent in many of these patients.

    Like the doc above said, because of EMTALA and the burden on specialists, our hospital has lost Ophthomology, & Maxillofacial coverage, and we have very spotty Neurosurgical GI, & ENT coverage. Unintended consequences of Gov't interference.

    Patient dumping WAS a problem. The law was intended to address that, but as with anything the Congress touches the effects have been far reaching and overall deleterious in many areas that on the whole are are bad rather than good.

    In addition, when I try and transfer a patient to a higher level of care, I have to jump through hoop after hoop, make several calls, waiting for return calls, have administrators talk to administrators, nurses give report to other nurses, etc, etc. A critical, life-threatening condition will (under the BEST of circumstances) take me over an hour to get the patient out of the department, and on average over two.

  11. Frank: You've never seen moves like these. Dunk from half court? Man, I can get an inpatient unit to take a patient upstairs while the nurse is on break, with no 'report' and with some extraneous labs still pending. I can get a neurosurgeon to come into the hospital and check a patients pupils. I can get a drug addict to apologize for spitting at a triage nurse.

    Nah I'm BS'ing you that stuff is impossible, but I can dunk from half court. I've got helium in my afro and butter in my shoes baby...

  12. ERDOC85,
    spot on. i will have to let you educate me on the problem of patient dumping as it was. i believe you practice where one of the 'worst' cases came from. i think before emtala these folks got perfectly adequate care at city and charity hospitals. i may be wrong. now every hospital is a city or charity hospital. and all that has happened is that, as another astute commenter has said, is that excellent care is a rarity for anyone now, and mediocre care a reality for all. i'm sure this makes some people very happy indeed.

    finally, there's one thing we have done which is so stupid, and so ACEP, and that is to work every complaint up 100% in the ER. we have taught everyone to come to the ER and while we joke that it is not McDonald's, that's exactly what it is. whether you need the scan today or not you are going to get it... the local clinics can't do that... hell, they can't even do bloodwork the same day, also because of some gargantuanly stupid federal law.

    dr j, i loved watching you play man.

  13. Here's another point on the "can't pay" phenomenon. I work at a community health clinic, and I hear all kinds of BS from patients which I generally listen to with perfect equanimity. But the one thing that really makes me boil is the claim that someone hasn't been seen for five years or so for diabetes or hypertension or whatever because they "couldn't afford it." Clinic visits are 20$ and meds are 7$ - that's a trip to McD's and few packs of smokes, so unless you live in Bangladesh, that's a pile and sometimes I tell them as much. Some complaints have been filed with admin about me for this - LOL.

  14. the government continues to turn 'needs' into 'rights', and continues to treat its adult citizens like children. many seem to like this.

  15. Anonymous.. wait until the pay based on outcome takes effect. Not only do you get the litany of excuses why the patient hasn't seen you in 2 years with their out of control diabetes/hypertension/insert chronic disease here, you will be penalized because they didn't see you.
    And Dr J... I was already on my way to find your utopia and ask a job until... dammit dood... that was cold. Probably lyin' about the half court too, unless we are talking air balls.

  16. Regarding the plastic surgeon who refuses to treat the daughter, what about the parents who "refused" to pay the surgeon? If the parents let their kid starve to death, that's because the grocery store "refused" to give the kid free food, or if the parents smash the kid's skull in like an eggshell, that's because the baseball bat company "refused" to place a large foam pad covered by a lace doily on the bat just before it clobbered the kid's head.

    Where I'm going with this is, you can't reason with lunatics, so just divide the country in half - 1/2 for "normals," 1/2 for morons. It's the only solution. I'm willing to move for this - I'll bet lots of other people would. Give the cretins their choice of states. We'll even pay them some money just to get them to leave us alone, for God's sake!! I'm begging!

  17. but they know they need us. at least, their masters know this.

  18. Has anyone considered emigrating besides me? Doctors in a number of other countries are doing a lot better than you might think.

  19. "I've got helium in my afro and butter in my shoes baby..."

    Dr.J., Congrats for the best comment in the whole thread.

  20. Where I am the specialists are refusing the patients by saying, "I am not comfortable..." Fill in the blank. I had a cardiologist on call refuse his partner's patient coming in at 3am with an AMI because he wasn't comfortable with diabetes. Not DKA. Diabetes. My favorite was the surgeon refusing a bowel obstruction in a poor person because they had OSA and eczema.

  21. I'm a little confused here. Are you saying that EMTALA exposes specialists to increased malpractice risk because specialists are seeing MORE people in the ER due to EMTALA? Or are you saying that EMTALA exposes specialists to increased malpractice risk because they might be treating people who are indigent and indigent people are more likely to sue for malpractice?

    My sister has some pretty crappy health insurance. So it goes these days. The quality of health insurance deteriorates as steadily as, well, payment to hospitals for emergency treatment since EMTALA went into effect. Never mind she and her husband work their arses off, they work for small companies and small companies can only afford crap insurance. So she at some point develops a hernia. (She's not fat or lazy or any of the other things you lot will assume for a hernia. She has a physical job and overworked her middle aged body.) Her primary care physician tells her that at some point she'll need to have surgery, but it doesn't need to be right away. He warns her however, that if she ever has X, Y, And Z symptoms to get her ass promptly to an emergency room. Of course the day comes when she has x,y, and z symptoms and she goes to an emergency room. While waiting for a surgical eval along comes an accountant. Never mind it's after midnight, they've got beans to count 24 hours a day in hospitals, right? So here comes the bean counter. Bean counter wants to know how she'll be paying her copay tonight. Will that be cash, check or charge, dear? 'Really? Right now, while I'm writhing in pain you want me to pay my co-pay.' Yes. Right now. Never mind she's used this same hospital for 30 years, has never had an outstanding bill -- everything has always been paid and promptly -- right now, we're not sending you a bill for your services tonight. Right now, we're sending collectors into the exam room to collect at the time of service. Wow. That's what EMTALA has done. So finally the surgical consult and the dude says "not an emergency." And tells her that she can go ahead and call his office to schedule the surgery in a month or so. But he'd gone ahead and checked with her insurance and she'd have a $900 copay, and he'd like to have that up front before doing the surgery. So if maybe she needs more than a month to get that together, just give him a call when she's got it.

    Gone are the days when they bill you for the copays apparently.

    Now, she could have saved herself a couple hundred bucks in ER copay and deductible expenses if she'd just had the PCP refer her to the surgeon to begin with. I suppose had she seen the surgeon in his office he would have wanted to proceed ASAP as opposed to ASAYHTC (as soon as you have the cash). Then again, that town's got higher than national unemployment so maybe everyone is hurting a little bit from it.

    You're right though. Unemployed people don't deserve health care. Welfare recipients especially don't. I mean, come on, they're collecting the money we paid out in taxes and they could be scrubbing toilets or flipping burgers and getting by just as well as they do with welfare. Except they'd have no health care coverage. Or food stamps. But they're just lazy asses anyway. Probably have babies to get more welfare. Right? Not like they're people or anything.

  22. Dear CannedAm... You have never been more correct, but after that first sentence... Always rest in the knowledge that you had us at hello, CannedAm... You had us at hello.