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  • #76
    Originally posted by Panscan View Post

    Why should you have to steer patients towards an ED ? I think a lot of people know what is an emergency and what isn’t. The real ones aren’t going to need convincing.

    reality is a ton of ED volume could be handled at by PCP or various specialists in their offices. In the short term it rewarded EM but will go away and long term punish EM due to proliferation of docs and reduced demand. Very similar to how radiologists love increased volume which is a very short sided outlook and inevitably decreases reimbursement per study
    This isn't your fault because we don't have a lot of experience in dealing with other specialties day to day (and typically not more than a month rotation) but many physicians don't know what is an emergency and what isn't...or at least really don't care.

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    • #77
      Originally posted by MaxPower View Post

      About 20% of the EM physicians I interact with shouldn’t be EM physicians. So maybe the herd needs culling.
      Just remember you’re most likely in someone’s 20%.. and if you’re not now you most assuredly will be when some young hot shot out of fellowship thinks you’re a moron.

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      • #78
        Originally posted by Sundance View Post

        Just remember you’re most likely in someone’s 20%.. and if you’re not now you most assuredly will be when some young hot shot out of fellowship thinks you’re a moron.
        Probably not right now, but maybe in the future. I’d say of the ones I think shouldn’t be practicing about 80% of them are just lazy. The other 20% just lack fundamental knowledge that every other ER doc seems to have. If I get to the point where I’m too lazy to do my job properly I would hope someone would call me out on it. At least knowledge can be acquired.

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        • #79
          Originally posted by CordMcNally View Post

          This isn't your fault because we don't have a lot of experience in dealing with other specialties day to day (and typically not more than a month rotation) but many physicians don't know what is an emergency and what isn't...or at least really don't care.
          It’s not always easy to just “see them in clinic”.

          option 1: Your nurse gets a phone call from someone at 2.. nurse doesn’t really know what’s going on but she hears “chest pain”.. nurse tries to relate it to you but she has no answers to your follow up questions. Say you don’t send the patient to the ER and you try and accommodate them in clinic.. they take their time and show at 4. You rush a visit as you’re already full and backed up for the day. Your staff can’t stay late everyday.. You order labs. Who follows up the 8 pm lab results.. you? Lab comes back abnormal.. now you’re trying to call patient. No one answers. You try every 15-30 min. Still no answer. Now what? Finally you get through.. patient now doesn’t want to go In to the ER as they feel fine..

          Option 2: you send them to ER.. triage nurse does standard chest pain labs that are ordered before the doc even sees the patient. eR doc comes in and chats for 5 min. CP is clearly atypical. Trop/ecg negative. Dot phrase a note in 2-3 min. Patient happy with results. Send home

          option 2 sure seems a lot easier for everyone involved.



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          • #80
            Originally posted by Panscan View Post

            Why should you have to steer patients towards an ED ? I think a lot of people know what is an emergency and what isn’t. The real ones aren’t going to need convincing.

            reality is a ton of ED volume could be handled at by PCP or various specialists in their offices. In the short term it rewarded EM but will go away and long term punish EM due to proliferation of docs and reduced demand. Very similar to how radiologists love increased volume which is a very short sided outlook and inevitably decreases reimbursement per study
            The problem is that the EDs are too good at treating acute primary care patients, and getting things done quickly and efficiently. If you could walk into any PCP’s office 24/7/365 be seen in less than 30 minutes and get basic labs, and imaging tests resulted in an hour on Christmas Day, every ED would be out of business.

            Many well-off people would rather come to the ED Friday night at 10pm and do this, than call their PCP, make an appointment for 3 weeks from now, take a day off of work to be seen, then take another day off to get labs or X-rays done, then come back in another week to find out the answer.

            We live in a 24/7 fast-paced, modern world. The current office models for care of simple acute problems is outdated. It’s inefficient and inflexible. That’s what makes the ED so attractive to insured patients. It’s fast, easy and effective when set up correctly.

            Why fight it? You could instead create a system that accommodates this. The current model of Monday-Friday, 9-5, appointment-only, is the problem. It’s an outdated system.

            Comment


            • #81
              Originally posted by Sundance View Post

              Just remember you’re most likely in someone’s 20%.. and if you’re not now you most assuredly will be when some young hot shot out of fellowship thinks you’re a moron.
              I would say the number is more like 40% in some places. Recently got a call from an internist staffing a rural ER who wanted to fly a tension pneumothorax to me. Luckily the flight crew knew how to put in a chest tube because he told me he's not qualified to do so. He had never done a needle chest decompression either. No surgeon available or anyone else that could help him out. Felt sorry for the patient.

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              • #82
                Originally posted by Sundance View Post

                It’s not always easy to just “see them in clinic”.

                option 1: Your nurse gets a phone call from someone at 2.. nurse doesn’t really know what’s going on but she hears “chest pain”.. nurse tries to relate it to you but she has no answers to your follow up questions. Say you don’t send the patient to the ER and you try and accommodate them in clinic.. they take their time and show at 4. You rush a visit as you’re already full and backed up for the day. Your staff can’t stay late everyday.. You order labs. Who follows up the 8 pm lab results.. you? Lab comes back abnormal.. now you’re trying to call patient. No one answers. You try every 15-30 min. Still no answer. Now what? Finally you get through.. patient now doesn’t want to go In to the ER as they feel fine..

                Option 2: you send them to ER.. triage nurse does standard chest pain labs that are ordered before the doc even sees the patient. eR doc comes in and chats for 5 min. CP is clearly atypical. Trop/ecg negative. Dot phrase a note in 2-3 min. Patient happy with results. Send home

                option 2 sure seems a lot easier for everyone involved.


                Minus the thousands of dollars in healthcare resources used. I’m not talking about the chest pains. Chest pains are better served being seen in the ED. I’m talking about the asymptomatic high blood pressures, “abnormal EKGs” that are down for reasons other than chest spin, swollen leg x 1 month, etc. You mentioned that option 2 is easier for everyone involved but many times it isn’t what’s best for the patient from a care standpoint or from a financial standpoint.

                Comment


                • #83
                  Originally posted by southerndoc View Post

                  I would say the number is more like 40% in some places. Recently got a call from an internist staffing a rural ER who wanted to fly a tension pneumothorax to me. Luckily the flight crew knew how to put in a chest tube because he told me he's not qualified to do so. He had never done a needle chest decompression either. No surgeon available or anyone else that could help him out. Felt sorry for the patient.
                  Yeah I covered a rural er for a weekend with home call an hour away. Got a call from them wanting me to come put in a central line for a gib patient because they couldn’t get venous access. So I get in my car drive 45 minutes only for them to call me and say they finally got something and they were transferring the patient out.

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                  • #84
                    Originally posted by Jaqen Haghar MD View Post

                    The problem is that the EDs are too good at treating acute primary care patients, and getting things done quickly and efficiently. If you could walk into any PCP’s office 24/7/365 be seen in less than 30 minutes and get basic labs, and imaging tests resulted in an hour on Christmas Day, every ED would be out of business.

                    Many well-off people would rather come to the ED Friday night at 10pm and do this, than call their PCP, make an appointment for 3 weeks from now, take a day off of work to be seen, then take another day off to get labs or X-rays done, then come back in another week to find out the answer.

                    We live in a 24/7 fast-paced, modern world. The current office models for care of simple acute problems is outdated. It’s inefficient and inflexible. That’s what makes the ED so attractive to insured patients. It’s fast, easy and effective when set up correctly.

                    Why fight it? You could instead create a system that accommodates this. The current model of Monday-Friday, 9-5, appointment-only, is the problem. It’s an outdated system.
                    Sorry but my local ER is not so efficient. I guess it is for chest pain and stroke and anything else that the hospital will get dinged for. The last time I visited as a patient was a horrible time wasting experience. If you are coming in with something that the triage nurse deems non-emergent you sit in the waiting room with others who are non-emergent for hours with no idea when you might actually be seen. You will encounter an extender every so often to give you hope. You will spend 5 minutes with someone who has a MD but the care is rendered by a PA. I was not impressed. If I could of sewn or glued my own chin I would have.

                    Comment


                    • #85
                      Originally posted by Hatton View Post

                      Sorry but my local ER is not so efficient. I guess it is for chest pain and stroke and anything else that the hospital will get dinged for. The last time I visited as a patient was a horrible time wasting experience. If you are coming in with something that the triage nurse deems non-emergent you sit in the waiting room with others who are non-emergent for hours with no idea when you might actually be seen. You will encounter an extender every so often to give you hope. You will spend 5 minutes with someone who has a MD but the care is rendered by a PA. I was not impressed. If I could of sewn or glued my own chin I would have.
                      Now that people are coming back to the ED in droves in addition to the fact there’s a staffing shortage everywhere, many EDs are overwhelmed and have huge waiting times.

                      Comment


                      • #86
                        Originally posted by Hatton View Post

                        Sorry but my local ER is not so efficient. I guess it is for chest pain and stroke and anything else that the hospital will get dinged for. The last time I visited as a patient was a horrible time wasting experience. If you are coming in with something that the triage nurse deems non-emergent you sit in the waiting room with others who are non-emergent for hours with no idea when you might actually be seen. You will encounter an extender every so often to give you hope. You will spend 5 minutes with someone who has a MD but the care is rendered by a PA. I was not impressed. If I could of sewn or glued my own chin I would have.
                        Sadly a lot of places are set up like this. Granted, there are huge unpredictable fluxes that occur in every ED so there will be waits sometimes, but it should really function with very little wait times almost all the time. The entire hospital has to be functional for this to occur though. If you have an ED that often boards and hold inpatients, then you have a failure on the inpatient/hospital side and all bets are off.

                        You see a lot of places where the ED is a mess, but when you look a little deeper the entire hospital system is a mess on every level, and the ED is just a symptom of this. If you have a place where radiology, the lab, and the inpatient units are all dysfunctional, it will be impossible for the ED to function. These will be the places where you hear, “the ER orders too many xxxx” (translation: “I can’t do my job, because I am overwhelmed”), and you have inpatients sitting in the ED for hours or days, causing huge delays in ED care. Because these places are a mess, they often get suboptimal providers, shall we say.

                        When you approach the ED as a place for just “emergencies”, you get healthy patients with tiny chin lacs waiting hours. I bet if you were in and out, door to door in an hour, you’d have been a lot happier with the experience. You won’t see this turn around time at your local University Hospital.



                        Comment


                        • #87
                          Originally posted by Jaqen Haghar MD View Post

                          The problem is that the EDs are too good at treating acute primary care patients, and getting things done quickly and efficiently. If you could walk into any PCP’s office 24/7/365 be seen in less than 30 minutes and get basic labs, and imaging tests resulted in an hour on Christmas Day, every ED would be out of business.

                          Many well-off people would rather come to the ED Friday night at 10pm and do this, than call their PCP, make an appointment for 3 weeks from now, take a day off of work to be seen, then take another day off to get labs or X-rays done, then come back in another week to find out the answer.

                          We live in a 24/7 fast-paced, modern world. The current office models for care of simple acute problems is outdated. It’s inefficient and inflexible. That’s what makes the ED so attractive to insured patients. It’s fast, easy and effective when set up correctly.

                          Why fight it? You could instead create a system that accommodates this. The current model of Monday-Friday, 9-5, appointment-only, is the problem. It’s an outdated system.
                          I think the office models will adapt out of necessity. Systems are going to see how they can save money and if staffing the family practice from 5- midnight saves them money on a few ed visits per office they will pay to do it.

                          My main point is everything trends towards efficiency/cost savings over time and as you have bigger systems involved and more data on the extremely high cost of going to the ED as we move to more and more bundled payment models and less fee for service type of set ups, we will probably see decreased utilization of the ED and increased utilization of office based set ups.

                          Comment


                          • #88
                            “Why fight it? You could instead create a system that accommodates this. The current model of Monday-Friday, 9-5, appointment-only, is the problem. It’s an outdated system. ”

                            Seems to suggest a need for some major changes. Things like shift work, on call, level 1-4 trauma centers having specialties available 24/7 is expensive . Not many specialties are actually needed 24/7.
                            Cafeteria healthcare, no reservations needed. Sometimes I like to choose the restaurant and have a reservation. Level 1 is is 5star, but expensive.

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                            • #89
                              ERs will never go away due to 24/7 availability and also not requiring a co-pay to be seen. Urgent cares should fix some of the issues, but people don't want to pay before being seen. The other issue is that expensive imaging done in the ER is covered under the ER co pay but if done as an outpatient will have to go to the deductible with some insurances. The difference between paying $200 for ER copay vs $2000 for outpatient MRI is an easy choice for a lot of patients.

                              Good physicians (PCPs and otherwise) want to take care of their patients and try not to punt to the ER.

                              United healthcare dropped the possibility of not paying for non-emergent care given in the ER. That likely will never happen for a variety of reasons.

                              Comment


                              • #90
                                let's not conflate the future of EM (an abundance of grads who want primo positions in primo locations, competing with low-cost non-doctors) and the future of the ER (high level care, fast, efficient).

                                as for insurance not paying for ER visits, yeah, this has been tried but I thought it was finally addressed with the federal balance billing legislation? if not, of course I'll support their efforts, but I'll let the consumer groups take the primary fight for one.

                                for primary care, I recently signed on with a concierge model--thought I would give it a try. it is worth it to me to skip the office staff and the frustration of scheduling, deal directly with the doc. it is almost like an ER, except I still have to wait for labs/imaging. for sure, I can take care of most things by myself, but so far the price of admission has been worth it, for the peace of mind, if nothing else.

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