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  • G
    replied
    Originally posted by Jaqen Haghar MD View Post
    I generally agree that there is a significant percentage of terrible physicians. 10-20% seems reasonable. But I don’t think it’s isolated to the ED. I think it’s across all specialties. It’s just easier to bash the ED from the comfort of the dictation room the next day. I don’t post about every complication I see from xx surgeon, or every misdiagnosis by xx medical guy, but we do know who they are.

    I think the ED often makes a convenient villain. I’ve had a trauma surgeon almost in tears, screaming “the ER broke me again!!!” After a particularly bad day with multiple critical traumas. But was it the ER that really broke you again, or was it the universe flipping motorcycles all over the highway and shooting everyone in the chest? Same with the 3am free air, or the 3rd code stroke in 1 hour.

    I always found it interesting that some of the now specialist physicians that I went to med school with, think ED docs are so incompetent, yet their records weren’t competitive enough to even come close to matching in EM back then. I also have other competitive field’s residents rotating through the ED and they struggle with basic diagnosis, procedures, and work ups, and are moderately terrible performers in the ED, while seeing one patient at a time, every 2 hours. This tells me that ED docs aren’t inherently unintelligent or lazy, compared to everyone else. It’s just a different type of job.

    Anyone can sit down and work on one case for an hour or two and get everything perfect. In the ED the question is, can you do 20 cases at the same time, with very limited time, information, and resources and get everything perfect?

    That being said, diluting down the field isn’t going to help, nor is teaching residents they are there only to address “emergencies”, when in actuality there are there to treat “urgencies” also, while providing a service to other physicians.

    EM docs should know their PCPs and consultants well enough to know who wants the Coags for their vaginal bleeders and who doesn’t, who wants a 1am call to their cell vs their home number about every patient, and who wants a text there in the AM instead, letting them know what went down on the guy you sent home. And who wants nothing at all.

    Consultants often have legitimate gripes with the ED, and sometimes ridiculous ones. It’s important for the ED to do what they can to make physician’s lives easier and ensure that the patients get the best care. When we view each other as enemies, things deteriorate, when we work together, things get better for everyone involved.
    And bringing it back around to the original topic...CMG residencies in marginally qualified hospitals plus midlevels with a fraction of the proctored training of doctors, things will be peachy all around!

    Leave a comment:


  • Jaqen Haghar MD
    replied
    I generally agree that there is a significant percentage of terrible physicians. 10-20% seems reasonable. But I don’t think it’s isolated to the ED. I think it’s across all specialties. It’s just easier to bash the ED from the comfort of the dictation room the next day. I don’t post about every complication I see from xx surgeon, or every misdiagnosis by xx medical guy, but we do know who they are.

    I think the ED often makes a convenient villain. I’ve had a trauma surgeon almost in tears, screaming “the ER broke me again!!!” After a particularly bad day with multiple critical traumas. But was it the ER that really broke you again, or was it the universe flipping motorcycles all over the highway and shooting everyone in the chest? Same with the 3am free air, or the 3rd code stroke in 1 hour.

    I always found it interesting that some of the now specialist physicians that I went to med school with, think ED docs are so incompetent, yet their records weren’t competitive enough to even come close to matching in EM back then. I also have other competitive field’s residents rotating through the ED and they struggle with basic diagnosis, procedures, and work ups, and are moderately terrible performers in the ED, while seeing one patient at a time, every 2 hours. This tells me that ED docs aren’t inherently unintelligent or lazy, compared to everyone else. It’s just a different type of job.

    Anyone can sit down and work on one case for an hour or two and get everything perfect. In the ED the question is, can you do 20 cases at the same time, with very limited time, information, and resources, and get everything perfect?

    That being said, diluting down the field isn’t going to help, nor is teaching residents they are there only to address “emergencies”, when in actuality they are there to treat “urgencies” also, while providing a service to other physicians.

    EM docs should know their PCPs and consultants well enough to know who wants the Coags for their vaginal bleeders and who doesn’t, who wants a 1am call to their cell vs their home number about every patient, and who wants a text there in the AM instead, letting them know what went down on the guy you sent home. And who wants nothing at all.

    Consultants often have legitimate gripes with the ED, and sometimes ridiculous ones. It’s important for the ED to do what they can to make physician’s lives easier and ensure that the patients get the best care. When we view each other as enemies, things deteriorate, when we work together, things get better for everyone involved.
    Last edited by Jaqen Haghar MD; 06-23-2021, 08:37 PM.

    Leave a comment:


  • CordMcNally
    replied
    Originally posted by MaxPower View Post

    I’m not really sure how you got that I expect ED docs to be experts at everything from my post.

    I didn't get that. I got the opposite that they're mostly idiots based on your experience.

    Originally posted by MaxPower View Post
    I don’t even mind the phone calls, but when you obviously haven’t even performed an H&P or can’t follow simple directions (get post-reduction xrays), then how much Monday morning quarterbacking do you really think needs to be done? Those are not even intern level mistakes. So what conclusion do you, the ER expert, draw from those situations that can be ascribed to something other than laziness?

    I conclude what I think the same thing you do is that those are just particular situations and aren't generalizable to the entire profession, just as my bad encounters with Ortho aren't generalizable to the entire profession.

    Originally posted by MaxPower View Post
    All I tried to do was support my statement that a not insignificant number is ER docs that I associate with probably shouldn’t be ER docs or physicians in general. Like any bell curve, there’s people at the left tail. I also don’t dispute that there is X percent of other physicians in other specialities who aren’t good their jobs and shouldn’t be doctors. This isn’t a problem unique to the ER, but this post is about the huge forecasted excess of ER docs, in some cases due to what sounds like substandard training environments. I was merely suggesting that a number of ER docs could be run out and replaced with good docs and things would get better and not worse.
    The whole thread is about the future of EM and future issues with substandard training and your comments seem to lean more towards the current. If you want to say that all other specialties have about an equal percentage of bad docs as EM then I could buy that. EM has a very distinct interaction with other specialties in comparison to how many other specialties interact. I understand that many specialties don't interact the same why with others as they do EM but your judgement of EM as a whole seems to reflect this.

    Leave a comment:


  • MaxPower
    replied
    Originally posted by CordMcNally View Post

    If you really want to start posting anecdotes about specialties then I'm sure we could all tell stories about how *insert specialty* is an idiot. There is some truth that EM is looked down upon but that's ok because the ED is a place ripe for Monday morning quarterbacking. It isn't a place for egos or thin skin. When we typically call a patient, we're calling the specialty who is the expert on that particular problem. We don't call Ortho with cardiac issues or GI for skin issues. I'm sure every cardiologists thinks we admit every chest pain we see, GI thinks we admit every stable GI bleed we see, and on and on. This is a small issue on why physicians are idiots when it comes to many things. We can't even respect each other enough to help move physicians, as a whole, forward within the house of medicine.
    I’m not really sure how you got that I expect ED docs to be experts at everything from my post. I don’t even mind the phone calls, but when you obviously haven’t even performed an H&P or can’t follow simple directions (get post-reduction xrays), then how much Monday morning quarterbacking do you really think needs to be done? Those are not even intern level mistakes. So what conclusion do you, the ER expert, draw from those situations that can be ascribed to something other than laziness?

    All I tried to do was support my statement that a not insignificant number is ER docs that I associate with probably shouldn’t be ER docs or physicians in general. Like any bell curve, there’s people at the left tail. I also don’t dispute that there is X percent of other physicians in other specialities who aren’t good their jobs and shouldn’t be doctors. This isn’t a problem unique to the ER, but this post is about the huge forecasted excess of ER docs, in some cases due to what sounds like substandard training environments. I was merely suggesting that a number of ER docs could be run out and replaced with good docs and things would get better and not worse.

    Leave a comment:


  • CordMcNally
    replied
    Originally posted by MaxPower View Post

    Probably some introspection to figure out why someone would be saying that.

    Just in the past week I’ve had different ER docs 1) tell me a lady was a minimal ambulator/bedbound because she was just “old and deconditioned”, when in reality she was 62 years old and a hemiparetic from a CVA 2 years ago, a fact I learned within 2 minutes of performing an H&P, 2) tell me that a terrible triad elbow fracture dislocation was “open” and he didn’t want to reduce it because the radial head had poked through the skin, even though the laceration turned out to be on the ulnar volar forearm, 3) send out a fracture dislocated ankle still 80% subluxated after one closed reduction attempt and not getting post-reduction xrays like I told them to, and 4) refusing to do a great toe nail bed repair and lac closure because who knows why (I was just starting a terrible humeral neck/shaft fracture case and told him I would be probably three hours). That’s one week’s worth of experiences at one ER, just in orthopedics.

    I suppose you could argue that the last one was out of the ER doc’s scope (but how hard is it to put dermabond on a nail bed lac and close 3 cm worth or laceration on either side of the nail bed?), but the other 3 are either extreme laziness or pure incompetence, and I think it would be difficult to justify any other conclusion. And this isn’t a podunk ER in the middle of nowhere. This is a fairly moderately sized metro area.
    If you really want to start posting anecdotes about specialties then I'm sure we could all tell stories about how *insert specialty* is an idiot. There is some truth that EM is looked down upon but that's ok because the ED is a place ripe for Monday morning quarterbacking. It isn't a place for egos or thin skin. When we typically call a patient, we're calling the specialty who is the expert on that particular problem. We don't call Ortho with cardiac issues or GI for skin issues. I'm sure every cardiologists thinks we admit every chest pain we see, GI thinks we admit every stable GI bleed we see, and on and on. This is a small issue on why physicians are idiots when it comes to many things. We can't even respect each other enough to help move physicians, as a whole, forward within the house of medicine.

    Leave a comment:


  • MaxPower
    replied
    Originally posted by MPMD View Post

    out of curiosity, if someone told you today that they thought you were too lazy to do your job properly, how would you respond?
    Probably some introspection to figure out why someone would be saying that.

    Just in the past week I’ve had different ER docs 1) tell me a lady was a minimal ambulator/bedbound because she was just “old and deconditioned”, when in reality she was 62 years old and a hemiparetic from a CVA 2 years ago, a fact I learned within 2 minutes of performing an H&P, 2) tell me that a terrible triad elbow fracture dislocation was “open” and he didn’t want to reduce it because the radial head had poked through the skin, even though the laceration turned out to be on the ulnar volar forearm, 3) send out a fracture dislocated ankle still 80% subluxated after one closed reduction attempt and not getting post-reduction xrays like I told them to, and 4) refusing to do a great toe nail bed repair and lac closure because who knows why (I was just starting a terrible humeral neck/shaft fracture case and told him I would be probably three hours). That’s one week’s worth of experiences at one ER, just in orthopedics.

    I suppose you could argue that the last one was out of the ER doc’s scope (but how hard is it to put dermabond on a nail bed lac and close 3 cm worth or laceration on either side of the nail bed?), but the other 3 are either extreme laziness or pure incompetence, and I think it would be difficult to justify any other conclusion. And this isn’t a podunk ER in the middle of nowhere. This is a fairly moderately sized metro area.

    Leave a comment:


  • MPMD
    replied
    Originally posted by MaxPower View Post

    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.
    out of curiosity, if someone told you today that they thought you were too lazy to do your job properly, how would you respond?

    Leave a comment:


  • Hatton
    replied
    Originally posted by Jaqen Haghar MD View Post

    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.


    Unfortunately for me my injury occurred on the day the hospital switched EMRs to Cerner. I went to the ER rather than urgent care because I thought I might have broken my jaw. The long wait made me realize the jaw was ok before I was called back.
    I had to go to urgent care yesterday. I have my hospitals insurance so I went to one of their owned clinics. It was the first time I ever went to an urgent care. I cut my 2nd finger with a kitchen knife. It was still bleeding >12 hours so I decided to go. The clinic had one NP. He glued the injury. It had stopped bleeding because I silver nitrated it, splinted it, and wrapped it in coban before I left my house. I thought it was interesting that the entire check in was done with my iphone. The front desk person had no idea what my copay would be. The NP had previously been an engineer and actually had a PhD and mainly taught and did research. So even in a medium sized town in Alabama we have urgent cares staffed by NPs. Not sure what would happen if someone was actually sick.

    Leave a comment:


  • G
    replied
    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.

    Leave a comment:


  • Sampter
    replied
    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.

    Leave a comment:


  • Tim
    replied
    “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.

    Leave a comment:


  • Panscan
    replied
    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.

    Leave a comment:


  • Jaqen Haghar MD
    replied
    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.



    Leave a comment:


  • CordMcNally
    replied
    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.

    Leave a comment:


  • Hatton
    replied
    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.

    Leave a comment:

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