Hey, no flames here Paddy and we'll def have to share that drink at ACEP next year if you're going! Sorry that I didn't respond to PM or on here sooner but been out of town on vaca and now finishing a few shifts and day off tomorrow.... so, as I'm sitting here drinking my tequila bloody mary, wishing I had had a perdomo lot 23 cigar.... I'll take a few minutes to respond.
Originally Posted by PaddyMelt
Honestly, I don't have much extra to say, we just have a divergence of opinion on the purview and future obligatory function of Emergency Department services in this country. As I said... current views show a dichotomy of opinions on the subject, but I don't favor opening the floodgates of ED services to treat "perceived" emergencies and broad sweeping definitions of semi-urgent care. I'm not arguing that we are capable of seeing low acuity stuff and easily treating/discharging. Any physician is capable of this. I disagree that our EM training and subjective/objective perspicacious intuition for quickly determining "sick" vs "non-sick" helps us treat low acuity pt's any better than another physician in X specialty. The FP can treat a rash, laceration, skin infection just as easily as you or I can and can determine if the pt is suffering from any concomittant cellulitis, extensive abscess or soft tissue infection, etc.. that would require ED evaluation. The same goes for an otitis media, viral pharyngitis, you name it... Are there some uncommon emergent complications from some of these conditions...certainly, but a PCP and most physicians have a gestalt of their own.... after all, if they didn't, they would never send their pt to the ED, so I disagree that we are better in treating these low acuity pt's. Is it easy work? Sure. Does it pay? Sure. It's easy to take the attitude of "hey I don't mind seeing all of this crap because it's low stress, I'm capable, and I'm getting paid well to do it...." This is a cop out in my opinion. What's the overall purpose of our specialty? We should be "experts" in recognizing, intervening, and managing most emergent or acute presentations of pathology spanning all specialties. We should also be experts in resuscitation and airway management. I'm not an internist, don't know jack about most chronic medical diseases or their management, have the utmost respect for IM guys, but I can recognize DKA,COPD exac,CHF exac, PE, etc.. and manage it with one hand tied behind my back. I'm not an intensivist, but I can manage sepsis just as easily. I'm not a cardiologist, but I can do the same with NSTEMI, STEMI, recognize 3rd deg block and float a transvenous pacer just as well as the cards fellow. I'm not an anesthesiologist, but can fiber optically NT awake intubate a horrible angioedema pt with a bronchoscope with facile, or cric if necessary. HTX, PTX? No problem, chest tubes with ease or even do an ED thoracotomy if I need to on the GSW that just lost pulse. The list goes on along with the specialties. This is what we're trained to be able to handle. Critical care medicine and emergencies in the ED. We're trained to quickly recognize, intervene, stabilize, resuscitate, acutely manage and pass on to the specialist. Now... how facile would an anesthesiologist be with intubations if he only did 1 a week or month for that matter? Cardiologist that only sees a STEMI once every 2 months? If you water down what we see in the ED with an overwhelming low acuity pt population, your skills will suffer along with your confidence. That's why you have guys in rural ED's that forget how to RSI, place chest tubes in the liver or the diaphragm and do other crazy stuff. They probably spend 95% of their time seeing low acuity, clinic type medicine and lose their EM skill set. There's a place for the non-emergent, even semi-urgent, clinic type pt presentations that possibly couldn't wait for a PCP appt, and it's called an urgent care clinic. These pt's simply don't need to be in an "emergency department" with emphasis on "emergency".
No, I don't need to see every vag bleeder with irregular periods and cramping, or vague pelvic complaints requiring expensive tests where all she wanted was a UPT to see if she was pregnant and didn't want to PAY for the test at the local CVS/Walgreens... Nor do I need to see the UTI/BV girl c/o dysuria and vaginal discharge along with the guy with genital warts and hemorrhoids. You're trying to turn my female pt into a r/o ectopic, or IUP/incomplete abortion, etc.. and that's great since our differential is much different than other physicians where we are supposed to r/o the most life threatening differentials first before moving onto the most likely dx, but I simply don't want or need to see that stuff (Even if I'm getting paid well to do it!). You and I both know that many of these pt's, along with the epistaxis, viral URI's, etc.. simply don't need to be there. You're list of emergency differentials doesn't make you any more efficient at treating these people because...guess what? their likelihood of having an emergency was almost nill. They are coming in droves to the ED because it's quick, easier than scheduling an appt with the OB doc or PCP and most of all.... free. Health care is never going to be saved if we encourage this type of blatant misuse of the ED. These are pt's that many times we have never seen or have any medical records on... We essentially are seeing them one time and have one chance to make damn sure they aren't having an emergency. It encourages shotgun workups and over testing, over use of diagnostic studies to basically "save our ***" from litigation. This country needs primary care providers to function as gatekeepers. Pt's going to EDs for anything and everything results in drastically more aggressive workups, regardless of acuity level. Pt's being bounced around among specialists amounts to the same. If pt's learn to just "go to the ED for anything and everything because they'll always see you...." what is to encourage them to see their regular doctor? Nothing. Overcrowding will grow and we aren't pumping out enough EM docs to supply the demand, so you are again... stuck hiring mid-level providers to see the low acuity pt's. You're losing your skill set and doing nothing to earn respect among your specialist colleagues who can go moonlight in a community ED and function just as well as you can because 90% of what they are seeing is basic medical management on low to medium acuity pt's. If they run into trouble, they call a surgeon, anesthesiologist or someone else to handle it. That type of function fits a derogatory term we've all heard before... the EP who is basically a "glorified triage nurse" giving specialists the impression "hey... anybody can do this stuff." It does nothing to earn you credibility and respect among your peers or earn respect for your specialty. We need to make more of an effort to divert pt's to their proper destination and I argue that pt's need to be turned away from the ED more often and referred to PCP's, FQHC clinics, urgent care clinics, you name it. Am I losing some potential business in doing this? Sure... but I'm trying to save the future of our specialty and the future of primary care and decrease overall health care costs without losing a tremendous amount of medical care to empowered nurses who have largely gained independent practice through legislation by politicians, are funding biased outcomes based research studies and have organized an extremely effective and powerful state and federal legislative lobbying force that is directly influencing current and future health policy formation in this nation.
We are losing primary care and the government is leveraging MLP's to "fill the void". This will have dramatically negative impacts on the future of medicine in this country in my humble opinion and further degrade the prestige, respect and autonomy of our role as physicians. I see overuse of the ED as help in facilitating this overall deleterious effect, and again... it is a complete disservice to our colleagues and a twisted distortion of what our specialty was conceived to accomplish. We just got EM as an approved specialty 40 years ago... I don't want to lose that in another 40, regardless of whether I'm old and gray (76?, yikes...) and rich from the profits, already retired, just in time to see the DNP's take over.
The best thing possible for EM is to see more emergencies, less overcrowding, more use of primary care, more referral to proper medical services and decreased bureaucracy that ties my hands behind my back and forces me to manage algorithmically in order to get "paid" i.e. medicare billing (all because the ED bill, and medical care for that matter, costs so damn much to offset the non-payers!). As for ED bills and FICO, they aren't factored into the revolving-credit utilization ratio. Yes, it will affect it if it's sent to a collection agency, but the hospital has to decide whether paying a collection agency for the 20th time to collect on a pt who has never paid the 19 previous times is worth the time, money or effort. Regardless, again.... the pt has the most incentive, initially and potentially indefinitely, to pay on everything OTHER than the medical bill which I think is just ridiculous. Lots of tangents and ranting in there, but.....well, there you have it.
Last edited by Groove; 09-28-2011 at 12:51 AM.
SGU Class of 2009
PGY-4 Emergency Medicine