It’s All Excessive Medical Care In Hindsight

An 18th Century Diviner, courtesy Wikimedia Commons

An 18th Century Diviner, courtesy Wikimedia Commons

Buckle your seatbelts, kids, it’s going to be a bumpy ride.

In yet another installment of “emergency physicians don’t know what they’re doing,” KevinMD provides a guest post by gastroenterologist Michael Kirsch, entitled Does the bulk of excessive medical care happen in the ER? At its best, the piece is uninformed; at its worst, it’s insulting and unprofessional.

So let me answer you here, Dr. Kirsch: No, it doesn’t.

Read this beauty from the author (I guarantee he has not practiced in an emergency department (yes, department) since residency):

These unneeded medical tests and treatments are black and white, not gray. It occurs every day in every doctor’s office, including mine. The most dramatic example of it, however, is the care rendered in our emergency rooms. The volume and expense of care given there routinely is absolutely astonishing. It is wasting a fortune of money and exposing patients to the risks and anxieties of extensive testing, even for minor medical conditions. Whenever one of my patients sees me in the office to review a recent ER visit, I try to disguise my amazement, as I look through all the lab results, x-ray reports, CAT scan interpretations and EKG tracings – often performed for some innocent complaint that has already resolved on its own.

The clencher, of course, is my bolded text for emphasis. Remove the retrospectoscope, Dr. Kirsch. It’s daylight out! If you’ve figured out how to divine “minor medical conditions” and “innocent complaints” from badness, boy, you should be writing our textbooks, because we dumb emergency physicians can’t!

Yes, the epigastric pain is just innocent GERD after it gets better and the patient doesn’t deteriorate (hint: sometimes it’s an appy, like I diagnosed just last week!). Unfortunately, according to a Lancet study, 7% of patients with ischemic chest pain actually felt better after a GI cocktail. I’ve seen patients with tender abdomens with no other complaints who have STEMIs. I’ve also seen sharp, right-sided tender chest wall pain with an NSTEMI. We all have.

In the Emergency Department, I lack the benefit of knowing my patients. I often do not have the luxury of knowing their medical problems or medications, as they themselves often do not know them; I often have patients who cannot provide history to me; I often have patients who only have non-specific complaints: “weakness.”

I probably do order more tests than your average internist, but two points: don’t you think there’s a referral bias toward emergencies in a patient presenting to the emergency department? And two, how much of adult medicine is a waste? The vast majority of antibiotics for upper respiratory infections are prescribed by primary care physicians, not emergency ones. And we could certainly find an easy whipping boy in the PSA, which is ordered routinely across the country, yet where’s the data behind it? Apparently there’s no risks or anxieties to ordering cancer screening tests (many of which have a ton of false positives).

ER physicians should practice the same style of medicine that we all were taught to do during our medical training. Take a thorough history, perform an examination and then make appropriate recommendations. As a gastroenterologist, I see patients with chest burning in my office several times a week. The medical history allows me to determine if the chest discomfort is innocent or suspicious.

So you’re a gastroenterologist and you see chest burning. So, yeah, with your gigantic referral bias, most of your patients with chest burning probably do have GERD. I take all comers: the rich, the poor, those with a great primary care doctor and those who haven’t said a word to a physician in 20 years. And it’s now up to me to determine if this chest burning is of a concerning nature. (And by the way, the more we’re (we being emergency physicians) learning about acute coronary syndrome, the more we’re recognizing that the classic “crushing chest pain” is just as atypical as “atypical” symptoms of shortness of breath, abdominal pain, or weakness, especially in women or the elderly.) And what if it’s suspicious? What’s the “appropriate recommendation?” Go see your cardiologist? Go back to your primary care doctor? Get a stress test with a 70-80% sensitivity (thereby missing 20-30% of patients with significant coronary disease)?

The recommendation, of course, is simple. According to Dr. Kirsch’s office (which I just called), here it is: “If this is a life-threatening emergency, hang up and dial 911.” To be taken by an ambulance — likely under the direction of an emergency physician — to be evaluated by … an emergency physician.

If an ER physician, or any doctor, thinks his patient’s abdominal discomfort is from constipation, then treat it accordingly and arrange for proper follow-up in the office.

Uh, trust me, we do. I disimpact with the best of them and give enemas when appropriate. But when it’s an elderly patient with a chief complaint of “constipation,” you better be damn well sure of your diagnosis: abdominal pain in the elderly has a 10% mortality rate. And they’re also classic for having 5-7 days of abdominal pain that turns out to be an appendicitis. Funny how they present like that. (Also: “follow-up in the office?” How about our 45 million uninsured patients who lack an “office” to follow-up in?)

Let’s play a numbers game, too.

  • Emergency care costs less than 3% of the nation’s 2.1 trillion dollar health care expenditures. That’s 63 billion dollars.
  • I don’t know what percentage of care Dr. Kirsch considers excessive, but even if all emergency care is excessive, then that means only 3% of medical care is excessive. (If that’s all, I’d say 97% with a purpose is pretty good!)
  • Using some back of the envelope numbers from the 2002 Journal of Gastroenterology, if today we’re doing 20 million colonoscopies at $1,000 a pop, that’s almost 1% of all health care expenditures, just to put that in some perspective for the GI folks out there. Ahem.
  • I’ll concede one point to Dr. Kirsch: I see a lot of “innocent complaints” in the Emergency Department. It’s our nature, thanks to EMTALA. When EMTALA was passed, we certainly started seeing more patients with non-emergent complaints, but now the two are all mixed together and it’s often difficult to tell them apart. If some other physicians are willing to step in and offload the emergency department of some of our patients with “innocent complaints,” please, go right ahead!

    (I didn’t think so.)

    Until then, we’ll continue having the proud duty of caring for all patients with all complaints all hours of the day.

    It’s really easy for everyone to call bullshit on the Emergency Department (my motto: you’re not getting out of here without a troponin!) when they have the benefit of days, weeks, or even just a few hours of observing the patient. Or some basic labs, or an EKG. But there’s no way in hell I’m going to stop putting the dangerous diagnoses in my differential alongside the more common ones. I’d ask Dr. Kirsch where he’d go if a loved one had, say, a bicycle injury. Would he be satisfied with a history and physical and a quick discharge home with a diagnosis of “contusion?” Of course not. When it’s your loved one, you want the x-ray to rule out the fracture. (As I’ve written before, often the physical exam just isn’t that hot.)

    Until I start critiquing polypectomy skills or demanding an endoscopy outside of normal business hours, it’s probably best that you stick to the GI tract, Dr. Kirsch.

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  1. #1 by drsam - September 29th, 2009 at 00:56


    Nice rant.

    Pretty much spot on accurate too.

  2. #2 by Patrick - September 29th, 2009 at 07:53

    Well, we can all agree that EMTALA is the problem, another piece of well-meaning legislation gone terribly awry. Speaking from the paramedic perspective, we could further reduce ED volumes by giving prehospital providers (under consultation with Medical Control) more latitude in not transporting patients unnecessarily. I realize this is a regional bias, but in Illinois we operate largely under the “you call, we haul” motto.

  3. #3 by Michael Kirsch, M.D - September 29th, 2009 at 13:12

    My blog piece has generated quite a bit of heat, primarily from ER physicians, although your post is the hottest. Yes, you are quite right that I am not an emergency room physician. After reviewing many other physicians’ comments, I realize that I did not sufficiently appreciate the pressures that ER physicians endure. I certainly recognize that ER physicians have a very challenging job with high stakes. In fact, I state in my post that “[ER physicians] perform well under pressure that can rival the tension found in any operating room. They make decisions routinely that determine whether a patient survives or succumbs.” I also point out in my piece and throughout my blog, as you suggested in your posting, that excessive medical care is an issue for our entire profession, including gastroenterologists. This is inarguable and is the basis for comparative effectiveness research, which is one of the few components of Obamacare that I support. The ER is an attractive venue to highlight since every practicing physician interacts with it regularly. It would be more difficult for most physicians to personally relate to many other medical specialties that they do not directly interface with. I suggest that all of us, including ER folks, reexamining our practice styles to assure that we are practicing judiciously and appropriately. If we don’t, then someone else will.

    I understand your points well. I do think, however that there is a legitimate other side to the story. The referring physicians whom you work with may have a different view of ER medicine than you do. If they are candid with you, then you might hear from them some echoes of my piece.

    By the way, it seems that we agree on the PSA test. I don’t think you have to be a urologist to have an opinion on this issue. Do you?

    I intended no insult to you or to your hardworking colleagues. I was hoping for a dialogue and I’m still open to it.

  4. #4 by TheNewGuy - September 29th, 2009 at 13:21

    Yeah, OK Dr. Kirsch…

    You just show up to get that hunk of steak out of the patient’s esophagus when I call you… ‘kay? Otherwise you should stick to what you know… and it clearly ain’t emergency medicine.


  5. #5 by Graham Walker, MD - September 29th, 2009 at 18:15

    Thanks for the follow-up, Dr. Hirsch. I agree that we certainly shouldn’t overtest–I’ve certainly seen the incidentaloma workup go awry with devastating results as well, and think all of us overtest to some degree.

  6. #6 by William Sullivan, DO JD - September 30th, 2009 at 13:32

    “The ER is an attractive venue to highlight since every practicing physician interacts with it regularly. It would be more difficult for most physicians to personally relate to many other medical specialties that they do not directly interface with.”

    If that’s the case, why don’t you highlight the area that you *do* have an interface with – the GI lab.
    Where’s the empiric statement about how many unnecessary colonoscopies are performed? That’s the area of your expertise. Why didn’t you comment on your own specialty?

    Instead, you chose to comment about a specialty in medicine that you have admitted you do not “directly interface with” and you based your assumptions on anecdotal statements made with a “retrospectoscope.”

    A couple of examples:
    Using your example of constipation, do you know “constipation” is one of the most common *misdiagnoses* in patients with serious intra-abdominal processes?
    Do you know that up to 40% of elderly patients presenting with abdominal pain require surgical intervention for their complaint?
    Do you even care?

    You want physicians to practice “judiciously and appropriately”? Perhaps you can lead by example. Give me an example of the “unneeded medical tests and treatments are black and white, not gray” for an elderly patient with abdominal pain from “constipation.” I dare you to try.

    Until you can base your comments on more than your retrospectoscope, perhaps you should stick to your colonoscope.

  7. #7 by Myles Riner, MD - October 9th, 2009 at 08:50

    Ok, everyone take a deep breath. As ED physicians, we should by now be used to having other specialists take a few shots at how we practice. It’s frustrating, but it also comes with practicing in a fish bowl, as we do. There is no doubt that we sometimes over test, and even over treat, even considering the disadvantages of not knowing our patients, or having much assurance that our referrals for followup will be honored by the specialists we direct our discharged patients to. In addition, followup on what happens to our patients after they go home is something that ED physicians often never get, and this lack of feedback no doubt undermines our effectiveness as clinicians (so make those follow-up calls the next day).

    Certainly, we need to correct all the misrepresentations that are directed at our specialty, in particular those that undermine the value proposition of the ED visit. We must acknowledge that the ED is a venue that tends to be a bit more expensive than the clinic or office based practice, even when the service is similar and provided during bankers hours. We also need to recognize that many of these practitioners have been suckered by health plans through capitation into the position of going at risk for the cost of the services we provide to the enrollees assigned to them. ACEP’s recent campaign to disabuse the myths about ‘expensive and unnecessary ED services’ simply reflects the fact that there are many, many people who think the way Dr. Kirsch thinks. Granted, Dr. Kirsch ought to know better (and probably wishes he had been a bit more thoughtful and not so quick to point the fickle finger), but the real problem is the fact that many legislators and business leaders have the same misperceptions about ED care. Rather than rebuff these folks, we need to invite them in, to spend some time with ED physicians so they can better understand the nuances of our practice challenges. I would rather we have the Dr. Kirsch’s of the world as advocates than as detractors, and a ‘put yourself in our shoes’ approach works better than a hockey stick.

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