Virtual PEM is an extensive digital library of presentations from the 2013 Pediatric Emergency Medicine Assembly. With financial support from PEPID, ACEP is offering the entire meeting -17.5 hours of educational content on your own schedule and in the comfort of your home or office or while traveling, anywhere you can get an internet connection. Watch presenters’ slides while listening to fully synchronized audio as if you were actually attending each session. Learn what you need, satisfy your CME requirements, “go to” the sessions you couldn’t see live. Check out Virtual Advanced PEM.
April Audio Summary is posted! Click here (see the left side of the page) to listen to a summary of Aprils’ Annals of EM. Highlights:
-Clinical decision aid derivation for ALTEs: which babies are safe for discharge?
-Head injuries in children with VP shunts
-Access to specialty care through the ED
-Video laryngoscopy, a panoply
-Major problem with the NHAMCS database
-Symptoms as a predictor of emergency visits among cancer patients
-Ultrasound for peripheral IVs: is the data robust?
-Video capsule endoscopy for UGIB in the ED
-Black widow antivenin: a RCT!
-Dabigatran and warfarin bleeding complications in the ED
Email us any time at firstname.lastname@example.org, and tune in every month for more.
Please send your stories to Tracy Napper (email@example.com) today!
When I was working at the Toledo hospital many years ago, we had a patient who came in extremis. She was an elderly female who basically presented as altered mental status. As I began the workup and checked her airway, a person identifying himself as her son admonished me to not do much for mom because she does not wish “to be resuscitated.” Since I didn’t know who he was or what his authority was, I continued with the evaluation and of course checked her blood sugar which was very low. Upon receiving 1 ampule of D50, the patient became awake, alert and in no distress and the son disappeared as soon as possible. I learned later that the son had attempted to terminate his mother by overdosing her on her own insulin. I never heard whether the son who ran away from the emergency department was ever arrested but that certainly left me suspicious of the motives of relatives.
Bruce Janiak, MD
By C.H.E. Sadaphal, MD, FACEP
The Emergency Department (ED) is a fascinating, wonderful thing. It is an area that has dominated the last decade of my life, since I first began my residency training in Philadelphia, to the hospitals in the Northeast where I now practice. Although I have migrated from one department to another, over time I began to realize that despite changes in names and faces, states and principalities, each ED is essentially the same. That is, there exists the same type of patients, personalities, efficiencies, dilemmas, doctors, nurses, techs, waiting rooms, food, drunkards – it is all the same, just dressed up and packaged differently.
This realization came gradually as my exposure to different EDs increased over time. I spent the first few months of my practice getting my feet wet, and acclimating myself towards my particular style of working independently as the attending physician (the top of the doctor pyramid). As a resident and intern (the respective second to last and bottom of the doctor pyramid) you are afforded the luxury of being supervised and working under someone who can guide you with their superior experience, knowledge and clinical know-how. Once your training is complete, there is no longer that crutch to lean on and the buck truly does stop with you. If there’s a problem, you solve it, and if you can’t handle it then too bad—you still have to deal with it. Working through these challenges and hurdles is what develops character, and gives each physician the confidence and experience necessary for the calm and purposeful delivery of appropriate medical care. These same challenges form within each physician the ubiquitous clinical “gestalt”, or “sixth sense” which ultimately serves as the powerful central command of each physician’s clinical decision making.
As time passed and I comfortably settled into my own style of practicing Emergency Medicine (EM), my thought processes evolved from the appropriate means of medically managing patients toward managing the people behind the patients: the psychology, social issues and heightened sense of apprehension that is associated with being acutely ill (or thinking yourself to be ill). It is this evolution in thinking that inspired me to start writing this essay. After all, when it’s 3 a.m. in the middle of a blizzard, you begin to wonder what drives a person to brave the elements in order to seek an evaluation in their local ED. The reader would assume from the title of this essay that an exposé awaits that will unmask the mysteries of the ED. This is true but I also hope that the patients and non-medical personnel reading these pages will have gained some insight into how the mind of the ED operates, and how this relates to the delivery of medical care.
Now the most important lesson I have learned in my EM career is based on perspective and perception. These are two cardinal concepts that permeate any encounter in the ED. Perspective applies to any human being that is involved in emergency medical care—this can be a doctor, a patient, a nurse, or whomever—but can most easily be categorized into two groups: those involved in the provision of care (providers) and those who receive care (patients and their families). Perspective will certainly vary depending on which role you play, but also how much time you spend with the patient. Perspective also varies a few degrees within each group but differs the most between the two groups.
Amongst ED providers, I find that we are generally on the same page, since we all work in the same environment and have similar exposures. After all, a physician will never see a patient by herself, or will a nurse by himself and vice versa. We are familiar with the same acute pathologies and have experience in managing a host of diseases, so it’s almost like following a formula: if Patient X has Y, then we do A, B and C. Sometimes this is very straightforward, and treating patients can generally be boiled down to following an algorithm.
Nurses actually spend the most time with a patient, and often have the best insight into the patient’s condition. On more instances than I can count during my career, there was a nurse who was kind and diligent enough to share information and insights with me that I was unable, or neglected, to procure myself. Being asked the same questions by multiple people is how information is collected in medicine, and this is how the system should work; no one can be right (or at least think they’re right) all of the time, and patients almost always vary the information they give when asked the same question. Providers who have different perspectives can supplement each other’s knowledge to provide the best care possible.
This highlights an interesting point in what I call the “inverse pyramid.” I believe that medicine, unfortunately, is a culture of blame and not one of responsibility. I suppose this is a fact not intrinsic to the field per se, but is a commentary on human nature. When something goes wrong, no one rushes to say “I’m guilty,” but rather they look for someone on whom to place the blame so they can sleep comfortably.
The inverse pyramid comes into play because in medicine, blame tends to move upwards, to the top of the decision-making hierarchy—this is the burden of responsibility. This is “inverse” because in any other arena of life blame always tends to run downhill: the CEO blames the VP, the principal blames the teachers, and the senator blames his aide. It is standard in medicine that a legal arrangement exists where one provider works under another, or a provider practices based upon the consent of a superior. For example, in New York State a physician’s assistant (PA) works under a physician, so legally the PA cannot see and evaluate someone unless under the supervision of a doctor (the supervision need not be direct).
Also, a registered nurse (RN) will care for a patient under the auspices of a doctor, who gives orders that are then fulfilled by the RN. In each case, if something were to go wrong the legal defense for the PA, for example, is that they were working “under the supervision” of the doctor, and thus legal responsibility shifts upwards. It is not a coincidence that PAs and RNs respectively, often hold small policies and are NOT required to have, malpractice insurance, whereas physicians are required to carry policies in the millions of dollars. Now given that setup, if you were a lawyer and wanted to sink your teeth into someone, whom would you go after?
Since the burden of responsibility is vastly different amongst providers from a strictly legal standpoint, doctors have less of an incentive to be more carefree and liberal about patient care. I wouldn’t therefore conclude that other providers have more of an incentive, but they certainly assume less risk, which can influence behavior. I invite the reader to ask any nurse about their experiences with a doctor, and I guarantee that everyone has at least one story to tell about a physician who always “does too much” or “orders things unnecessarily.” Granted, each physician will always have his or her own style and nothing about medicine is absolute, but there are many doctors who will practice in defense of, or in case: a topic for alternate study into the downfalls of the current medical malpractice system, perhaps.
Perception, on the other hand, can also be segregated along the lines of the two groups (providers and patients), and herein lies the greatest discrepancy between the two. Each person’s perception is a lens through which they view the world, and can be tainted by prejudices, expectations, the Internet, their personal physician, past experiences, and comparison: “That’s not what they did the last time” or “That’s not what happened to my brother” or “My wife told me differently” or “That’s what Wikipedia said I have.” More often than not, if there is a conflict or an argument that arises in the ED, it oftentimes involves divergence in perception. When in doubt, I find one simple question can often harmonize any perceptive differences in the start of provider-patient relationship: What are your expectations for your ED stay?
The key point as a practicing EM physician is that I have been trained to view the ED and patients in a certain way: I must seek out and find any acute or life-threatening medical emergencies and then initiate the appropriate treatment. If an acute or life threatening emergency doesn’t exist, then my perception is that my job is done. I may not have found the root cause of a patient’s symptoms, but I can reassure them that they will not keel over and drop dead.
This is the first classic dilemma. Why? Patients, anytime and everywhere, will have a problem and want an answer. It need not be a good answer, but something that gives them clarity. They don’t know what’s wrong, so they go to the hospital with the expectation of seeing an oh-so-smart doctor who has spent countless years learning how to seek out and trample upon those bothersome diseases. If someone spends eight hours in the ED, has blood work done, X-rays, CAT Scans, and whatever else, and after everything is said and done is told, “Everything is fine, you can go home now and follow up with your doctor,” a large sense of dissatisfaction remains.
Sounds annoying, right? Of course it does, because the patient in question came to the ED with the expectation and perception that we would be able to diagnose, provide answers, and clarity. “We couldn’t find anything” is not an acceptable diagnosis to the patient, but at the same time brings relief and satisfaction to the ED physician. This, in reality, is how the system works—oftentimes something can’t be found to the best knowledge and ability of the medical team and the verdict of “ruled out” replaces a definitive answer.
The second classic dilemma involves patients’ expectations: they anticipate one outcome, and receive another. This is certainly my favorite to deal with because it often involves someone googling what they think they have on the Internet, and then coming into the ED expecting that X, Y, and Z will be done. Alternatively, it’s 3AM and the patient calls their doctor who tells them over the phone to “Go to the ER and get an MRI” or “Go to the hospital and have them get Dr. X to come in and see you right away.”
There are many obvious contributing factors to this problem. We live in the information age, when a plethora of data is available at any time to anyone, anywhere. Our world is saturated with social media, where we are always encouraged to give our opinion and “like” or “dislike” something. Our judgments are aggressively sought after. The problem here is that without the appropriate medical background, it is very easy for the layperson to misinterpret common and banal symptoms as signs of life-threatening pathology. If an acute condition does exists then any ED would be more than happy to accommodate that patient, but, when people-en-mass are using the same erroneous logic to self-diagnose, and then demand treatment based on this logic, conflict will arise. Moreover, no provider would be quick to tell a patient, or a potential patient, that they shouldn’t worry, or advise them not to come in for an evaluation, because this puts the hospital and the advice giver at risk.
Don’t get me wrong – one of the most important tools any patient has is to educate themselves. Education is always a good thing, but education and information are distinct entities. The former involves rigorous preparation, proficiency in execution, real-life experience and recurrent exposure; the latter only requires a brief exposure and cursory understanding.
Another issue to keep in mind is that not all hospitals are created equal. Many patients think that if they walk into any ED, that hospital will be equipped to deal with their problem. Of course, the ED will be capable, but the problem may require a specialist that the hospital does not provide. Take, for instance a psychiatric problem (you want to hurt yourself). If the ED in question does not have a psychiatrist on staff, the ED will see and evaluate the patient, but they will eventually need to be transferred out of that hospital where a psychiatrist is available. Alternatively, let us say you bring your child to the ED and it is determined that the youngster needs to be admitted. If the hospital does not have a pediatric service, then the child will need to be transferred to another facility. In an ideal scenario, transfer would be instantaneous, but the reality is far from this. The process is complicated and legalistic, requires multiple steps, and includes securing space at the location to which the patient is going, as well as an accepting doctor at the receiving facility. As one can imagine, if the receiving facility is packed, waiting on a transfer can take several hours or even days before it’s finalized (And yes, that means the patient in question would be waiting in the ED for days).
Medicine is a lot like working on a movie set: often times there’s a lot of waiting around, then the action happens, and then you’re left waiting for what seems like an eternity or longer. In the ED, patients tend to perceive that because nothing is happening now, that nothing has happened or is going to happen, but that’s not the case. In many instances, medicine is very active (like open heart surgery), but it can also be very passive, like keeping your loved one on a heart monitor for 24 hours in order to make sure the heart is beating appropriately. In the latter case, it may seem that the patient is just lying in bed, which they are, but it amounts to more than that. We live in an instantaneous society where the public likes instant results. However, the body sometimes needs several days or weeks to heal.
In any ED, one should not expect rapid and quick results; the medical providers are trying to rule out and treat acute emergencies, and from their end that is executed in the absence of time restriction (this rule applies in most cases, but there are instances where the minutes do count—if you’re having a stroke, for example, there is a window of time for action that opens when your symptoms start and then closes a few hours later). You can also never tell what incidental abnormalities may be found on simple screening. In the mind of the patient, a wait is a wait, and doing it in an ED is unfavorable.
Outside the ED, gauging how long to wait before coming in always boggles the mind. There are some people who will seek evaluation preemptively or at the slightest hint that something is going wrong. There are others, however, who will wait for an inordinate amount of time, and allow what was once a very small, minor issue to turn into a large and complicated one. The bottom line is that there is no golden rule for everyone and everything, but it would be prudent to neither jump the gun nor allow problems to snowball.
If you walk into an ED, all patients are screened through triage, which categorizes those who are very sick and those who are not-so-sick (in fact, within the first 60 seconds of meeting a new patient, all ED physicians answer four basic questions: Sick? Not sick? Stay? Go home?). The sickest patients are seen first. Thus, if an 80-year-old who has had a heart attack in the past is now having chest pain, he takes priority over the 21-year-old who has had a cough for two weeks. This is the only logical method to deliver care in order that the ED can fulfill its role to accommodate emergencies. As a side note, it’s vital to mention that in the life of any ED patient there are three key mental checkpoints: (1) When am I going to be called in? (2) When am I going to see the doctor? (3) When can I go home? Once the last two questions are answered, any angst about the hospital stay is largely resolved. Now some EDs are faster than others, but this is why in many scenarios the waiting times can become exceedingly long, because the newer, sicker patients must be seen before those that have been there longer.
Many patients think that medicine is a predictive science, but instead, at its best, it is a collective art. Doctors can assimilate a history, physical exam, labwork, x-rays, and things of the sort in order to make an informed decision, but despite their best efforts and knowledge, no doctor can predict the future. If I could do that, then I am in the wrong profession. So, patients and families often want to know if they will be OK, and the genuine short answer is: I can’t be 100% percent sure. Despite all the information that I have in front of me now, and regardless of my best judgment and intentions at this moment, the body may change its mind and alter its course in the future. I could also just be plain wrong.
I think possibly the largest separation in perspective is misinformation and trust. In working in both EDs and urgent care centers, the single biggest piece of misinformation I encounter is the thought that any fever or illness automatically warrants antibiotics. I still am unclear where this pervasive misconception was birthed (perhaps the pharmaceutical companies are that good in advertising) but many have assumed that when they are ill, then nothing will help them other than some sort of pill. Yes, in some instances this is true, but people have been getting the common cold (a virus) and the flu (another virus) for thousands of years. Even to this day, medicine has not developed medication that kills viruses; in many cases the cure is time and symptomatic treatment. Alas, try telling that to a concerned mother with a feverish 2-year-old at 4 AM, or to John Doe whose brother “had the same thing” and got a Z-Pack and was instantly better. In both instances, any intellectual argument or medical studies suggesting otherwise fight the larger opponent of the patient’s preconceptions.
There’s also a very large mental satisfaction when something is done to alleviate symptoms. If you walk into a doctor’s office and are told, “It’s a virus, do nothing and go home” or are given “only” reassurance, the patient is left with a void: the medical profession did not provide anything. In the same scenario, if the patient receives antibiotics, or even if they’re given a prescription for Tylenol, they leave with something, and now the void has been filled.
“Phone medicine” can also produce similar strife. If a patient describes symptoms on the phone, sometimes a diagnosis can be made, warranting a referral to the ED. Sometimes, however, describing something on the phone and then examining someone in person can yield two very different diagnoses. If the patient was told to go to the ED for a specific purpose and is then told something completely different on arrival, an uphill battle ensues.
Furthermore, the ED physician typically only sees a patient once—for the most part there is no legacy or relationship. The level of familiarity, and therefore trust, that a patient may have with their family doctor or pediatrician is thus lacking. The patient may figuratively ask the ED physician, Who are you anyway to tell me this? You’re not my doctor!
Another separation in perception involves the entire concept of emergency, defined by The New Oxford American Dictionary as “a serious, unexpected, and often dangerous situation requiring immediate action.” From the providers’ standpoint, we tend to think that if you are coming into an ED you must be acutely ill or on the verge of death. But, in reality the term emergency is relative to the individual or observer; the concept can be interpreted in a number of ways and is altered by personal, ethnic, economic, cultural, familial, and emotional reasons. Providers deal with emergencies all the time, so disease processes and worrisome symptoms become familiar. The general public does not have this exposure, and would therefore have a lower threshold for classification. What may be emergent for patient X is just another weekday for a provider. Hence, the logical conclusion follows that simply because something can be done in the ED doesn’t mean it will be done, given how emergent the problem is.
Once any department begins to reroute resources toward non-emergent tests and procedures, this takes away from its ability to treat other, more acute patients, and the first step on a journey along a downward spiral begins. Many people have also assumed the ED replaces primary care, and unfortunately have abused the widespread availability of EDs to satisfy their own needs instead of establishing a relationship with a primary medical doctor (PMD – also known as General Practitioner, Family Doctor, Internist, or “My Doctor”). Having your own personal physician is always beneficial because they establish continuity, consistency, and act as the primary gatekeeper for all of the patient’s care; just as a mother knows her child best, an established PMD will be best suited to make decisions for the patient and coordinate medical decision-making.
The goal of care in the ED is geared toward acute disease management, not long-term or wellness management; the inevitable discontinuity of care through multiple EDs, or within the same ED with different physicians, only acts against the best interests of the patient. Obviously, many societal and institutional barriers exist that prevent millions from following the ideal prescribed—lack of insurance, the increasing shortage of primary care physicians, and the lack of available office appointments after hours, just to name a few.
In the eyes of the world, the ED is there for any medical problem, whether you’re sick or not; this is the natural consequence of the way in which the system is set up. Hence, a person need not even think they have an emergency, but know that there’s something small that’s bothering them for a while, and—any ED will see them. Of course this is reality, because access to care is guaranteed (the law dictates that anyone who comes seeking care is entitled to a medical screening exam—a good idea), you never need to make an appointment, the doctor is always in, and the ED is always open 24/7/365. The only time an ED does close is after an act of God or some other extreme circumstance. This is a highly necessary and functional system to care for the acutely ill, but it also incentivizes people not to seek care elsewhere. After all, why should John Q. Public wait when he can be seen now in the place where all the resources are anyway?
Having a stroke? Go to the ER. Heart Attack? Go to the ER. Have you just lost feeling in your leg, which is turning blue? Go to the ER. Did you fall and can’t get up? Go to the ER. Is there a bone sticking out of our skin? Go to the ER. Did your water just break? Go to the ER. Have you been constipated for six years? Go to the ER. Don’t want grandma in the house for the holiday weekend? Go to the ER. You have 60 tablets left of narcotic pain medication but they’re just not cutting it and you need something stronger? Go to the ER. Is it cold and would you like a meal? Go to the ER. Is it past 11p.m. and did you just call your own doctor? Go to the ER.
The final perspective separation transcends the staff of the ED and involves the upper management of the hospital itself. It’s what I like to call the “corporatization” of emergency medicine – the same concept can be applied to medicine in general. I previously used the term “providers” to describe ED staff because we are nowadays being viewed as providing a service to a consumer. Hence, the “practice of medicine” is becoming the “business of medicine”. Many physicians have even gone back to school to obtain their MBAs, or enroll in combined MD/MBA programs in order to capitalize on this growing trend. In equating patients to consumers, not only is their medical care being evaluated, but their overall experience as well.
It’s an evaluation that transcends how the patient is doing or how they’re feeling by (for example) inquiring if they were comfortable during their stay, if the staff was courteous, and if the amenities provided to them were adequate. This is taken seriously because reimbursement is partially tied to patient satisfaction, and many other reimbursement models use the individual physician’s satisfaction scores as a determinant of salary. As one can clearly see, anyone involved in hospital administration would have a vested interest in keeping satisfaction as high as possible, which entails beefing up services as well as medical care.
Making someone comfortable is not a bad thing, but patients are not consumers. The goal of a patient is to achieve wellness and health; the goal of a consumer is to obtain goods or services in exchange for monetary compensation. The danger of the consumer model is that when satisfaction and actual medical care are lumped together, the lines blur and the “patient experience” can overpower the delivery of sound medical care. Hospitals may actually start slacking in care, but if the stay is packaged in an attractive, clean, palatable way, the perception that good care was delivered becomes grossly positive. Additionally, in order to maximize happiness, the patients are the ones who will begin to choose and dictate care (because it’s what they want) against the sound medical decisions of the providers. This opens up the door to abuse and grants decision-making power to those who lack medical training. Unfortunately I have witnessed this growing trend first hand, and I regrettably foresee a future where it only gets worse, not better. Many physicians and administrative personnel have been seduced by the lure of money, as opposed to following the maxim “do no harm”. After all, if making the tough decisions was so easy why not grant every person a medical degree?
In addition, a ubiquitous philosophy exists amongst the public that more care equals better care, and more expensive care equals better care. The latter attitude has been validated in a recent study in the journal Health Affairs.[i] In this analysis, researchers utilized patient focus groups and asked the participants to imagine they had a disease, and then imagine they had a host of treatment options available to them—all options varied minimally in effectiveness but varied highly in cost. The researchers found that: the make-believe patients did not want cost to play a role in medical decision making; they acted in their own self-interest and ignored the added burden to the medical system as a whole, doubting their choices would have an impact; they felt entitled to the more expensive treatments; despite comprehensive medical discussions that suggested otherwise, the participants remained firm in the belief that the more expensive treatments were better. The clear danger in this perceptive difference is that it will drastically burden the medical system with excessive spending and waste with little or no resultant health benefits compared to less expensive options.
So you’ve been waiting for three hours for a CT scan? Perspective #1: this is horrible. Everyone is sitting around, doing nothing and I have to waste my day in this uncomfortable chair, in the hallway waiting, waiting, and waiting some more for nothing! I could be at home watching TV or taking a walk in the park. And, to top it all off, my cell phone has no reception. I can’t even text. I haven’t eaten in hours. I’m so hungry, why won’t they feed me. So what if I have abdominal pain. I want some fries and shake!
Perspective #2: I’ve been here for a while, but I’m thankful I’ve walked into the ED with my own two fully functional legs. There’s a man down in the hall, on a ventilator, in a medically induced coma. His family looks pretty upset. I guess I could complain about my circumstances, but then again, the fact that I’m well enough to complain speaks for itself. It could always be worse …
Perspective #3: I’m worried about that young guy in the hallway. He looks OK, but he has a fever and pain in the right lower part of his belly. He wants to eat, which is good sign, but if his appendix is inflamed, he will need emergent surgery and food is not a good idea. We had to move him into the hall and I know he’s peeved about that but we have to keep the elderly man on a heart monitor and give the other elderly woman with the low blood pressure a blood transfusion, something that can’t be done in the hallway. I realize I may have been short with him, but there are plenty more patients to see and I have to keep moving.
Perspective #4: I really don’t understand why that young kid is getting a ct scan. I mean look at him: he’s fiddling with his phone and is more concerned about texting his girlfriend than his so-called pain. I don’t know what they’re thinking, but they’re always ordering all these studies on people, and never find anything. I should be the one treating this guy so I can send him home.
Perspective #5: Where’s the bathroom?
Perspective #6: Can I go out and smoke?
Finally, I believe that medicine has been slow to adopt a team-centered approach to the delivery of care, a concept that is pervasive in mostly all other arenas of life. The business world, for example, focuses on the collaborative efforts of many, where decisions are made through brainstorming, groups, committees and boards. In patient care, medicine normally rests on the executive decision of a solitary physician, unless the patient has a highly complex set of issues requiring multiple collaborative opinions. Medicine also tends to be highly segregated, so the orthopedists only deal with bones, the cardiologists with hearts, the gastroenterologists with the stomach and so on and so on. As a result, everyone keeps their particular focus in mind and leaves other issues to be dealt with by the appropriate specialist.
Accordingly, physicians can often be islands where they are the masters of their domain; it is difficult then, to switch from this method of thinking into a collaborative one. It would be far easier for rival factions within a company to come together for the “good of the corporation,” but that binding force does not have much strength in the medical world. Doctors can be separated along state lines, competing groups in the same area, and be credentialed at different hospitals to name a few examples. Moreover, collaboration need not only be a good thing—I have often said if you ask five different physicians the same question, you will receive twenty different answers. As a patient moves from doctor to doctor, she may receive differing opinions on management. This cannot only be frustrating but deleterious to the overall delivery of care. In the ED, for example, the patient bouncing back three days in a row may receive three separate diagnoses.
In the end, I have realized that the most effective way to manage an ED is not to deal with a patient but to deal with the person who happens to be the patient at the moment. I find people are much more open and understanding when a compassionate, clear and honest explanation is given whenever a discrepancy exists between perspectives and perceptions. When providers openly admit the ED’s inadequacies when things fall short, and tactfully explain when a service falls out of the realm of emergency medical care, everyone can enjoy peace of mind. As always, do no harm.
By C.H.E. Sadaphal, MD, FACEP
As I recently finished another year of working shifts in the Emergency Department, I reflected on the up-coming wide-ranging implementation of the majority of the programs and regulations mandated by the government’s Affordable Care Act (ACA). As a whole for Emergency Physicians, from a financial standpoint the year 2014 will bring us many reasons to cheer: millions who were previously without some form of health insurance will now have coverage and thus the ability to pay. This is a win as any emergency department is required by law to see and treat anyone regardless of their ability to pay; those without means will now have means.
But, if one digs deeper several flaws become apparent. The two most notable is the fact that the ACA maintains the outdated link of health insurance to employment (after all, what does being healthy or sick have to do with being employed? The two are independent of each other) and it shields the healthcare consumer from the real costs of services, leading to over-consumption.
To elaborate on the second point, let’s take a step back. The healthcare industry is the only business in this country where access to basic, routine services requires insurance coverage. If you need on oil change, you don’t call your automotive insurance carrier, but go to the mechanic of your choosing and then pay for the aforementioned services. There is no middleman, just you and the automotive shop. Your insurance only kicks in, let’s say, if you’re in an accident or if a major component of your vehicle breaks down and requires a costly fix. This is a valid, functional model. But, when this model is applied to all encounters, problems arise. Costs will inevitably have to go up, because the scope of services the insurance covers is vastly larger. This inescapably puts the cost of basic care out of reach for an expanding group of people. The fact is, the very existence of health insurance is what’s pushing rates into the stratosphere and causing costs to skyrocket.
How can this be so, you ask? Very simple. In a normal “insurance” circumstance, you, the payee, is given a fixed sum in the event of a catastrophe. So, if your 5-year-old car gets smashed in half by a falling tree, you get a check for a fixed sum. For this benefit, you would be required to pay a fixed annual fee. In the healthcare industry, instead of the insurance company paying a fixed rate for a service, guess who sets the price? You got it, the doctors and hospitals do. Hence, demand (the price of a service) is set by the doctors and hospitals, which is a perversion of normal economic principles. This allows healthcare personnel to increase prices without any limits, causing an exponential increase in healthcare costs.
This is so because the patients are shielded from the real costs, and the third parties (insurance companies) pick up the tab. Moreover, any system that is fee-for-service incentivizes doctors to do the procedures that yield the highest insurance reimbursement (and as often as possible). Therefore, something that should be aimed at making people better has transformed into a business transaction where physicians have become “providers” and the patient’s “consumers.” The ubiquitous use of said language is not accidental.
Let’s say you walk into Jiffy Lube and the clerk tells you an oil change is $10,000. Any sane person would walk out and find a better price at a reasonable shop. But, what if everyone had automotive “insurance” and no matter what you had done at Jiffy Lube, you would only pay a “co-pay” of $10. Now, the shop charges your insurance company $10,000 and perhaps “only” receives $3000, for a “cost-saving” of $7000. And guess what? The poor old schmuck who has no coverage better learn how to change oil for himself or fork over ten grand.
From this example it is clear to see that since you don’t have to pay the full cost of service, you have an incentive to go to this shop as much as possible and have as much done as possible.
Accordingly, I wholeheartedly support physicians in the medical establishment and all the work that they do. After all, it is the diligent and meticulous work of these fine individuals who assist in the care of the nation as a whole. A mobilized legion of doctors, each attempting to “do no harm” forms the backbone of a healthy society, and no one can deny that without physicians and their know-how we would all be living in the dark ages when it comes to health and well being. I specifically have to tip my hat to everyone who provides emergency medical care, for these exceptional individuals serve on the front lines and provide for the acutely ill and those patients who are most in need.
However, that being said I will be blunt: the financial process described above has the potential to corrupt us, the doctors. It’s the natural consequence of a flawed system. We are incentivized not to deal with the patient and their problems but to maximize every encounter from the standpoint of billing for our own economic gain. If an admirable doctor refuses to obey this perversity, he will certainly write his own fate. Most people don’t know this, but every time a patient sees a doctor, the interaction is boiled down to a series of billing codes, referred to as ICD (International Classification of Diseases). So, if John Doe visits Dr. Brown, the office visit results in a series of codes dependent on Mr. Doe’s diagnosis and the procedures performed.
The more codes and the more complex the codes, the higher the billing (The art of billing has now become so integral to the practice of medicine that medical schools offer courses whose sole purpose is to teach how to bill more efficiently and effectively. For instance—did you know physicians are paid more the more body parts are examined?).
In the emergency department for example, all encounters are broken down into levels 1 through 5, and each has a corresponding five-digit code. If you jam your pinky finger, that’s a level 1; if you’re having chest pain and need blood work, an ECG and a chest x-ray—that will be a level five.
People who are terribly ill and require even more attention have even more extravagant codes assigned to them called “critical care”. Now, let’s think about this realistically: if the doctor has a patient’s chart and can dress it up to a higher level of billing, what is he incentivized to do?
Ironically, the government has pushed, and even paid for, the use of Electronic Medical Records (EMRs), and created requirements for documentation (the doctor’s chart) that can only be met by using an EMR. This has forced some physicians to direct energy away from patient care and hire individuals and consultants whose sole purpose is to master the EMR in order to maximize billing.
The government, then, has subsequently turned around and penalized doctors and hospitals when they ask to be compensated for caring for patients! Essentially, the harder you work and the more productive you are, the greater chance of scrutiny and penalty.
There’s another side to this issue. There are millions of family practitioners, general practitioners, pediatricians and internists who perform an invaluable service as the primary gatekeepers in the delivery of medical care to their patients: wellness management. They spend countless hours counseling, obtaining histories, education and many other things of the sort that equip patients with the tools they need to actually get better. But guess what?
All of these wonderful services are not procedures, so these docs are reimbursed peanuts or not at all. Case in point, my wife is a pediatrician who spends countless hours counseling young girls on what to, and what not to do in order to place them on a path towards wellness.
If she spends 60 minutes for each patient going over eating habits, sleep habits, medication counseling, social support networks, contraception management, general education, safety in the home, nutrition, drugs, exercise routines, depression screening – guess what she gets? Next to nothing. Now, if the same young patient were to have an echocardiogram (ultrasound of the heart) or a broken bone fixed, then the dollars start coming in.
Alas, this entire bureaucratic system had mechanized the entire doctor-patient relationship by adding a layer of complexity that consumes time and takes away from the physician’s real purpose, which is to sleuth out a problem and initiate the appropriate treatment. With his energies focused elsewhere, the physician will spend less time actually caring for the patient.
At the end of the day, the ACA should be renamed the pay the healthcare industry act, because now millions of uninsured will have their bills paid by the government, and line the pockets of doctors, hospitals and pharmaceutical companies. Remember, the main goal of the ACA is to provide coverage, which has nothing to do with promoting health. I could also “create jobs” by paying people to dig a hole to nowhere in my backyard, but that does not increase wealth or produce anything of value.
And let us not hide the truth: can any rational person expect a bill that increases the size of the healthcare industry to make people healthier?
Absolutely not. If people aren’t sick, there’s no market for the medical field and no money to be made. Realistically, the medical field is very good at disease management but not wellness management. If you walk into my emergency room, I can do many things to make you better but have little to offer if you ask, “How do I stay well?”
The single greatest factor that determines whether we go to see a doctor is if we have health insurance. A little more than half (57%) of adults 18-64 who don’t have insurance will not go to see a doctor. Compare that with 10% of Medicare recipients and 6.5% of private insurance carriers. One can now see what will happen when millions more people have coverage and the number of physicians remains relatively the same: rationing of care, longer wait times, ER overcrowding, and a redistribution of wealth to the healthcare industry. If anybody thinks healthcare is pricey now, wait until it’s free.
The solution you ask? End the government’s subsidization of the healthcare system, allow patients to be directly responsible to pay the cost of routine care subsequently having the market drive costs down, allow the allocation of pre-tax dollars into Health Savings Accounts (HSAs) for a rainy day fund, and leave “insurance” for what it was meant for—extreme and unexpected circumstances in the untimely illness of yourself or a family member.
In the end, we all live in a so-called free society, but my freedom should never infringe upon anyone else. As such, no one has the right to healthcare, just as no one has the right to a Mercedes or a beach house in the Florida Keys. What we all have is the responsibility to ourselves and families to keep the end in mind and to lead healthy lifestyles; to act wisely by engaging in behavior that promotes longevity, and destroying the self-destructive and immature concept that someone else should take care of us all. That is how we can do no harm.
(This blog is an early release of blogs posted at www.CHESadaphal.com/blogs)
March is here, so is the March audio/podcast from Annals of EM. Highlights include:
-How many procedures do Pediatric EM trainees see? Is this ‘enough’?
-Video vs direct laryngoscopy for simulated ETI in pediatrics?
-Rehydrating pediatric patients: D5 vs NS, a randomized trial
-Cost reduction targets in the ED
-Ambulance diversion: what happens if we’re not allowed?
-Primary care linkage from the ED
-Lactate to predict outcomes with PE
-More more more
Email any time to firstname.lastname@example.org,
Please send your story to Tracy Napper (email@example.com) today!
Emergency medicine is characterized by hours of routine punctuated by moments of terror and then back to routine. We must manage a crush of humanity with routine problems and sort out the critically ill from that chaos, constantly balancing the need for completeness against the need to move on. The critically ill cannot wait for us to do complete comprehensive evaluations on the twenty preceding patients and they are often unable to provide complete information about themselves. Interventions required may be so urgent that even a “hello” is hardly possible. I’m always wondering, when backed up, if the tenth or twelfth patient down the line might be such a person who somehow was mistriaged. When such urgency is needed, we act and react with frighteningly incomplete knowledge of what is happening. Some comfort can be taken in reciting simple mnemonics such as “ABC.” These rote routines help to keep us grounded and organized during moments of panic but I cannot help to admit that the gravity of some of our decisions weighs heavily with me.
Emergency medicine sometimes requires being astonishingly aggressive. For example, before RSI intubation techniques were common in the ED, we were encouraged to have a comparatively low threshold for cricothyroidotomies in trauma patients. It has been years now since I felt the need to perform such a procedure. There is progress! It was and is a procedure which I dread: unpredictably bloody and always feels like murder, cutting someone’s neck. Plus it is a procedure for which little time can be wasted balancing the pros and cons – do it right now or don’t bother because the outcome of a delayed procedure might be worse than death. Weighty decisions. Little time.
Another aggressive procedure which we are performing less and less: open thoracotomies in the ED. It is generally such a futile procedure that in the gallows humor of the ED it is referred to as, “should we do the autopsy now or do it later.” By the time anyone can ever get around to performing the procedure it is already too late. Nevertheless, I felt in my early years that I should have some rudimentary knowledge of how to do this because “you never know what might walk through the door.” I learned the basics of this at the side of a colleague who is now long since deceased. Of course every one of the few patients for whom I saw or performed this procedure died. Arguably they died before the procedure.
Ten to fifteen years ago, while working early morning in a suburban community hospital ED, I had a 13-year-old child stumble through the ambulance entrance on his own feet. An adult was shortly behind and described how the child had popped the clutch on an ATV four wheeler. The four hundred pound machine reared up and landed on the child’s chest. This child collapsed before us and was instantly in extremis upon arrival through our doors. A quiet early morning ED was suddenly a disaster and there wasn’t even an ambulance – they appeared out of nowhere. I was the sole physician in the entire hospital, let alone the ED. Thanks to some very capable nurses assisting, we had the child intubated and large-bore IVs established very quickly with fluids running in. The child was and remained pulseless and unresponsive despite quite normal cardiac electrical activity. I rapidly made what was in retrospect a bizarre decision. Something had to be done quickly. Do it now or do it later? Do something else? Just do something for God’s sake. Everyone knows that opening the chest of a blunt trauma victim in the ED is even more futile than penetrating trauma and frankly they are both pretty futile. But that is what I did. An open thoracotomy in the ED on a blunt trauma victim, a child, without surgical backup.
If I’d ever thought a cricothyroidotomy felt like murder, it was nothing compared to this. A silly spash of betadine, a nonsterile field, and his left chest was ripped open in seconds. As usual for such a procedure, there was no bleeding. The patient was already dead. But this child’s heart was still beating just as his monitor strip would have us believe. I opened his pericardium and delivered the heart through that incision only to be confronted by something I had never experience or expected. Like someone had flipped a light switch, I suddenly had bleeders. The heart, freed from the tamponade, was able to pump and perfuse freely once again. A few well-placed hemostats and…..
Now what? I have no surgeon, let alone thoracic surgeon. I have absolutely no ability or skill beyond this point and one could argue I didn’t have any to even get to this point. What have I done?
We flew the child out by helicopter to the nearest trauma center with chest open and hemostats in place. I kept up with his progress for awhile. He spent three weeks on ECMO (heart lung bypass). An early CT scan of his brain showed “watershed infarcts” which then cleared up on subsequent scans, an indication of how close he had come to very serious irreversible brain damage. If only a minute or two longer down time and who knows what damage would have been done. After 1-2 months in the hospital, he was discharged home, neurologically intact, fully functioning.
Several years later, the child’s aunt visited me in the ED to tell me he was in high school and doing well. I still remember his name and face as clearly as if it were yesterday. Sometimes I try to picture the horrible scar that I must have left across his chest, the lumps where I cut his ribs with trauma scissors. I think back to what an old friend once said to me, “Better a lucky doctor than a smart one.” I honestly don’t know, if confronted again by similar circumstances, if I could do such a thing again. And perhaps that is a good thing. Despite the success, I managed to seriously frighten myself. If I were at all comfortable with what happened, I would be dangerous.
Charles Grassie, MD
By Jesse Pines, M.D.
We at Urgent Matters are very pleased to bring you a brand-new podcast series of exclusive interviews with leaders in the health care field discussing policy issues facing the emergency care community. Each interview lasts about 10-12 minutes and explores a specific topic where the speaker is a topical expert. Here are some of the podcasts we just recently launched:
Transition to Systems Thinking with Dr. Ricardo Martinez
Dr. Ricardo Martinez discusses the need for emergency departments and healthcare systems to transition to systems thinking.
Advocating for Policy with Dr. Nathan Schlicher
Dr. Nathan Schlicher discusses how emergency department stakeholders came together to change Washington State’s 3 visit rule for “non-emergent conditions” that would deny payment and reimbursement to providers and patients.
Geography as Destiny with Dr. Brendan Carr
Dr. Brendan Carr discusses regionalization of hospitals, co-opetition of healthcare and the need to focus on population level health.
UK’s Four Hour Rule with Dr. Suzanne Mason and Dr. Ellen Weber
Dr. Ellen Weber and Dr. Suzanne Mason discuss the United Kingdom’s Four Hour Rule, the effects it had and the implications for the United States.
Narratives in Emergency Care with Dr. Zachary Meisel
Dr. Zachary Meisel talks about the controversial role of narratives in emergency care for patients, providers and policymakers.
CMS Value-Based Purchasing Program featuring Dr. Patrick Conway
Dr. Patrick Conway, Chief Medical Officer for the Centers for Medicare & Medicaid Services (CMS), discusses the Value-Based Purchasing Program focusing specifically on the Hospital Value-Based Purchasing Program and the Physician Quality Reporting System and their impacts on the ED.
After an extensive look at ways to provide cost effective care to emergency department patients, the American College of Emergency Physicians believes there is room to improve the use of specific tests or procedures in emergency medicine to participate in the national “Choosing Wisely” campaign.
“Choosing Wisely” is part of a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite health care resources. The campaign encourages medical specialty organizations to identify five tests or procedures commonly used in their field, the necessity of which should be questioned and discussed by patients and physicians.
ACEP had previously declined participation in the “Choosing Wisely” campaign because of the challenges of this approach with the unique nature of emergency medicine, liability concerns, and a potential harm to physician reimbursement.
The College meanwhile remained steadfast in its commitment to cost-effective care and a high-value health care system, and last year, Immediate Past President Dr. David Seaberg appointed a Cost Effective Care Task Force, chaired by Dr. David Ross. The Task Force was charged with considering tests, processes and procedures with little or no value to emergency care that might represent meaningful cost savings if eliminated.
In a report to the ACEP Board of Directors this month, Task Force member Dr. Jay Schuur said that their Delphi panel and ongoing member surveys have suggested that a number of tests will meet the criteria of the “Choosing Wisely” campaign. They also determined that these tests would not increase the physician’s liability, and would not negatively impact payments for emergency physicians.
After being reviewed by experts, emergency medicine leaders, and the ACEP Board, the report’s data indicates that it would be appropriate for emergency medicine to participate in the campaign. A letter of ACEP’s intention to participate was sent to the ABIM Foundation today.
The list of recommendations should be established by June. ACEP’s Task Force is finalizing the evidence base for these recommendations, in part though the Emergency Medicine Practice Research Network (EMPRN). Attaching estimates of potential real-dollar savings to the recommendations is also being completed. Members of the Task Force and the ACEP Board believe this responsible approach will validate the substance of our recommendations, and provide assurance that there will be a real savings to the health care system while not impacting patient care.
But joining this national campaign is not the only approach ACEP is using its in journey to identify cost savings measures without compromising patient care.
In order for there to be a serious reduction in unnecessary tests and costs of defensive medicine over time, meaningful liability reform and safe harbors are vital. ACEP is encouraging ABIM and its campaign partners to lend their voices to the need for medical liability reform. This remains a top priority in ACEP’s advocacy agenda.
Additionally, the College is working on other significant and impactful efforts, including proposing an elimination of the 3-day-stay rule and better management of transitions of care.
A variety of recommendations that strive to improve patient care and provide meaningful cost savings continue to be initiated, developed, and adopted by ACEP. We are dedicated to ensuring that our specialty can be leaders in health care system efficiency while maintaining a high quality of emergency care and patient safety.
ACEP has arranged for its members to receive a 20% discount on the FH Fee Estimator, a new source of independent charge data from private insurance claims. Participants can access emergency medicine charge data for 491 geographic areas nationwide. This tool gives physicians and management a better understanding of the marketplace and allows instant compare charge data to Medicare fees.
The FH Fee Estimator website, www.feeestimator.org, is easy to use for small data requests. But if you need a more sophisticated data set, contact FAIR Health for custom analytics. To get the ACEP 20% discount, enter the promotion code 20ACEP13 at the checkout screen.
FH Fee Estimator is brought to you by the not-for-profit corporation FAIR Health, whose mission is to bring transparency to healthcare costs through comprehensive data products and consumer resources. Created in 2009 to provide an objective source of data, FAIR Health owns and maintains a database of billions of billed medical and dental services. This database serves as the foundation for benchmark products that reflect the prices charged for healthcare services in specific geographic markets across the country.
This database is a great resource for emergency physicians groups to inform development of fee schedules and other practice decision making, says David McKenzie, CAE, ACEP’s director of physician reimbursement. The data is available based on an aggregation of zip codes and can be tailored for the geographic area you serve. Because it is drawn from actual claims data, it is a wonderful source of information on fees charged in your area, he adds.