Are ERs wasteful or the epitome of healthcare efficiency?

I have seen a lot of criticism of ERs lately. The new House Bill for healthcare reform introduces ways to reduce crowding and boarding in the ERs, and better prepare them for disasters like pandemics and Katrina-type travesties. But they also put the focus on reducing ER use, as if overuse of ERs is responsible for the exhorbitant waste and cost of Healthcare.

There is waste in healthcare, and some of the patients who come to ERs are inappropriately abusing the system. But those statistics state that 10% of patients are responsible for 90% of the visits. So the waste in the ERs is largely out of control of those who run them.

This site debunks some of the myths surrounding the ER and healthcare.

I go a step further, and challenge the criticisms that the ERs are unnecessarily over testing patients:

Why do ER docs do a lot of tests?
1) Patients expect and demand it and we are at the whim of Press-Ganey for job security.

2) Consultants demand it. I cannot get a surgeon to even LOOK at my patient without a CT (cat) scan. I would get laughed at-more accurately-yelled at for diagnosing appendicitis without a CT scan at 3am and waking up the surgeon to inform them of this.

Hospitalists and attendings routinely ask for a complete workup before they will admit a patient. That means not just labs, but followups on labs. CT scans to rule out PE (pulmonary embolism) or surgical entities.

I have found that Admitting docs expect more from us than a simple Admit or Discharge. They want a diagnosis and treatment plan. This is partly because Medicare won't pay for certain diagnoses, so hospitals want to make sure that those who come in will be "paying" patients. That requires full workups to prevent admissions that don't need to be in the hospital. In the past you could admit a patient with minimal workup, and let the attendings figure out what was going on. That's not good enough for the government because Medicare will reject payment for patients if they think it is not necessary. Unfortunately, care has already occurred and money has already been spent. No "social" admits for patients who have nowhere else to go and are too sick to be home alone. No observation admits to see if something shows up. Now the patient is worked up in the ER, gets a diagnosis, and the hospital's job is to figure out how to discharge them as soon as humanly possible.

3) Pts in the ER self select as Emergencies. Therefore an Emergency must be ruled out. I can’t always rule stuff out without further testing. Abdominal pain in an office setting and abdominal pain in the ER are not the same animal. You can't just send someone home; you need to rule out deadly reasons for this pain. Nobody comes to the ER because they want to be there (okay, there are a few, but those people aren't typical). If patients thought their problem could wait until they were scheduled to see their doctor, given a bunch of tests that take a few weeks to come back, get the outpatient study they need in a month, and see the specialist when THEY can fit the patient in, then they would have done so. Instead patients who come to ERs want relief of their symptoms. They want answers and often need immediate action.

4) Sometimes patients have ambiguous symptoms that affect areas that require different types of tests. For example, A patient with abdominal pain in RUQ (right upper quadrant) needs an U/S (ultrasound) because that is more effective for picking up GB (gallbladder) disease. However, if I think the problems is in the intestines, a CT is the best choice. CTs do not do well ruling out GB disease, so on occasion you need to do both tests if the first one is negative.

5) Lots of patients without insurance come to the ER. These patients will not get tests unless done in the ER. They will fall through the cracks. If I don’t do the CT scan, nobody will. If they had insurance, sure, they could see their doctor and get an outpatient scan. But in reality, the majority of my patients are uninsured or underinsured and can’t get these tests unless they come to the ER.

For the arrogant doctors who judge the care of the ER docs, don’t throw stones when you live in a glass house. I deal with your complications everyday. I deal with the patients who can’t reach you on the phone and come in with a preventable ER visit. I deal with the undesirables you don’t want to see. And I don’t cast aspersions upon you and question your training.

ER docs now are better trained for emergencies than internists, family practioners and surgeons. We know the emergency aspects of every specialty. We see the overall picture. Do you know how many times I am the first doctor to give them nutrition and prevention advice? Why wasn’t their primary doc doing that? Why didn’t their surgeon explain to them that their surgery will drive up the patient’s blood sugar and they’ll need more insulin?

Perhaps you shouldn’t be asking what should ER docs do to change things. Perhaps you should be looking at why ERs need to be doing what they must to be the safety net that keeps the strands of healthcare from dissolving into complete chaos.

Is our method of training medical students flawed?

The majority of people who go to medical school have an idealistic idea of saving lives and helping sick people get well. Yet patients complain that doctors seem to lack caring, compassion and dedication to the profession. Is something missing from the training of a doctor that prevents them from having the characteristics patients expect? Is it the process of medical training itself that causes this? Or is it that we are simply selecting for medical school the kind of person who will be successful yet incapable of having the kind of attributes that patients want?

I am working on a book that removes the shroud of mystery that surrounds this transformative process. I can and have recounted scores of stories about my medical school training that sound ridiculous and unbelievable, but sadly were true experiences. I would like you to help me in two ways:

1. If you are not an MD, I would like to know what is in your head when you picture what is involved in the training of a physician.
   
   
2. If you are an MD or medical student, I would like to know what is the most cut-throat, horrible experience you've had in pre-med, medical school and/or residency training.

Please write your answer in the comments section. By writing you give consent that your comment could end up somewhere in my book. Whether you use a real name or not, if I use part of your comment, I will give you credit in my acknowledgements. And if I use any part of one of your comments, and you leave an email contact, I will send you a free book when it is published.

Thanks for your help!

I need your help if you are not an MD. What are your preconceptions as to how a doctor is trained? Any myths? Anything you've wondered about?

I am surveying non-doctors to see what they think about how a doctor is trained. Do you have any idea how that happens? What do you think happens? Have you wondered about it? Is it shrouded in mystery? Do you have extra admiration for MDs due to this process? Please make comments to let me know your opinion and you might make it into my next book.

(Disclaimer: If you make a comment, you are giving me permission to use it in a book. If you don't want me to use your comment, don't make one.)

Thanks for your help!

PS

I've already had a few comments that didn't address my question, so I will add this: Everyone knows the kind of qualifications it requires for an MD-college degree with pre-med classes/MCAT, 4 years of med school, and minimum 3 years of residency training.

My question is, when you picture in your mind what a med student has to do to learn what is required to practice medicine, how do you see that happening? This relates to course work, learning how to examine patients, "practicing" on patients, etc...Are there any myths, pre-conceptions (i.e. doctors are all intelligent [not saying that this is true BTW, just an example of what many people assume]), movies that bias you? Have you ever wondered about the rituals that occur to create a med student? It is not straightforward like: you go to class, you learn anatomy, you learn pathology/microbiology/pharmacology, and suddenly you can be someone's doctor. Have you ever wondered what it is really like? Do you think you know what it is like bc you have a friend/relative who is an MD? If so, I want to hear what you think you know.

Thanks!

What I learned at ACEP (American College of Emergency Physicians) conference in Boston

I am in Boston for the ACEP conference. I know, I should be seeing the foliage but who has time? I am eating lots of great seafood. Chowda of course. And I just ate at "No name," a soup nazi type locale with great food and little ambiance. Yum.

But I have learned a lot too, and will chronicle that here:

1. Doctors are nerds who don't care about baseball, bc nobody seems to care that I am a yankee fan wearing my yankee clothes in public.
2. Paul Begala is freaking funny. He gives the best Bill Clinton impersonation. And he managed to calm a skeptical crowd and be informative as well. In his opinion, health care reform will happen bc if it doesn't democrats are done. Put a fork in it done. So if they want future viability something will be passed. But not when obama says so.
3. Only 12% of patients in ERs are non-urgent. ERs area extremely efficient and relatively low cost for the service it provides. Where else can you get seen, examined, tested, diagnosed, treated & admitted or discharged in just a few hours? In the "outside world" a patient goes to Dr. A, who says wait and see. The the patient comes back and is sent for some testing. Two weeks later tests come back with no answer as to what is going on. Outpatient CT scan ordered. A few weeks later test is done. Eventually scan is read by a radiologist. A few weeks later your doctor communicates the results to you. This is beyond their capabilities so you are sent to a specialist. The specialist orders an MRI. That takes a few days. When you suddenly worsen they say go to ER. Where we get you taken care of in just a few hours.
   
   It may cost a lot to go to the ER, but it only costs four times as much to run an ER as to run a medical practice. We are a one-stop shop for good health care. Which is why docs in the community and patients trust us do diagnose and treat ailments that "could" be treated as an outpatient-though much slower.
4. Universal healthcare leads to INCREASED ER visits. An average of 8% in Massachusetts.
5. A little prevention goes a long way: A study shows that if at 15mo of age checkup, parents are educated re: auralgin topic anesthetic for ear pain in children, then when child has pain, parents treat and wait instead of rushing to ER or doctors office. 80% decrease of ER visits for otitis media as a result. And 40% decrease in pediatrician visits as well. WE SHOULD ALL BE DOING THIS
6. Children 3-36months of age do not need blood cultures. 'nuff said.
7. Irritable babies should get urinalysis and culture, as 10% are positive despite no fever symptoms.
   
8. LPs are not needed for febrile seizures if 3-36mo of age
9. No matter how you clip your badge to the loop that goes around your neck, it will always spontaneously flip around to the backside. Unless you want it to be on the backside, in which case it will show your name.
10. KevinMD and Shadowfax are a nice hang, and I learned a lot from their years of blogging experience (see future blog where I will figure out how to add a pic I took of them).
11. When doing a lecture, the audience will only remember 3-4 points. If you try 5 points, they remember nothing.
12. You DON'T need contrast when doing a CT for appendicitis. And you CAN give them opiates for pain without altering their exam findings.
13. And Dr. Hoffman and Dr. Bukata remind me of those muppets in the balcony.
14. www.epmonthly.com is totally classy and I am proud to be associated with them and honored to have my voice heard (and even respected!) amongst the greats in Emergency Medicine.
15. I probably should not have had that second glass of wine...(after the 2 mojitos-yummy made by John at the Birch bar at the westin waterfront). Tylenol works better for hangovers than advil. (that's not a scientific study)
16. My book "How to Survive a Medical Malpractice Lawsuit" has a date for release! April 2010. No cover yet. But I have an ISBN number. Very exciting. And a pretty advert they were handing out that I will scan it in and post that on the website in a few days.