Emergency medicine is a 24/7/365 day of the year service. The visits are not scheduled and ED's cannot hang up a sign on Friday afternoon that says, "Closed at 5 p.m. will open on Monday at 9:00 a.m." Our society has grown to understand that it is the only place in the nation where they can get around the clock assistance for "unscheduled and emergency care." And, other physicians, (both primary care and specialists) have found that out too. They also send their patients to the ED when they cannot provide for their patients' care during office hours or after office hours when the office is closed.
That said, ED's have been accused of not being "cost efficient" and "expensive." By the nature of the business, there is a basic operating cost to staff and operate an ED - equipment, personnel, etc. Barring volume, there is a certain amount of fixed costs regardless of whether there are 10 patients seen in a day or 20. Obviously, as volume increases, costs increase for personnel and equipment. So is it fair to say, that it is inefficient? I don't think so, since the ED is now the FRONT door to the hospital. Most hospitals have over 50% of the admission enter through the ED.
In fact, no longer do many hospitals have direct admissions, where patients come sick directly from home or a nursing home. Rather they come to the ED first to have further diagnostics testing and initiation of their treatment prior to being admitted to an inpatient bed. Years ago someone presented to the ED with abdominal pain, they may have had lab studies, x-rays and maybe admitted for observation or consultations and over the course of 2-3 days have a CT scan, further consultations, and other testing. But now, the same patient comes in and can spend 6-8 hours in an ED but the work-up is streamlined and a decision made to either safely send the patient home, send them home for further outpatient management and testing, or admit them to the hospital for further care that they cannot receive as an outpatient. A far cry from what happened years ago. Actually most of us would consider that MORE efficient and cost effective avoiding an even more expensive hospitalization.
Tuesday, July 21, 2009
Monday, July 20, 2009
Optimizing Visits to Blogs
Still trying to figure out how to optimize exposure for blogs, if anyone has any suggestions I would like to hear from you (as long as you are not some sales person selling software or a spammer). I thought perhaps people would want to know what really goes on in ED's but maybe that's just not the case.
People assume that when they need emergency care, ED's will be there for them. Unfortunately, not all ED's are alike. Although many physicians who work in ED's are board certified in the speciality, many are not.
Recent staffing studies suggest that there will be a continued shortage of emergency medicine physicians. Emergency medicine is a relatively new specialty (only 40 years old). The "baby boomers" who started emergency medicine are moving on to other things or are retiring.
Interestingly, the majority of patients go to smaller and midsized ED's that may not be staffed with board certified emergency medicine physicians. That means the physician may still be trained in some other field - surgery, internal medicine, family practice, etc. Where I don't mean to degrade the capabilities of those who have practiced emergency medicine for a far longer time than I, I think the public needs to know this. That said, I have seen less than optimal care provided by physicians who are board certified in many specialities so board certification does not guarantee excellent care but it does imply specialized training in the field.
Many hospitals require physicians to be "board certified" but that does not mean that the person working in the ED be certified in emergency medicine. For the educated consumer, you need to find out what percentage of those physicians in the ED are "board certified or residency trained in emergency medicine." Where you don't have this luxury to shop around when you have an emergency, it helps to know what hospitals near home fall into this category. You may be surprised. And the size of the hospital may not determine the percentage of EM trained physicians!
People assume that when they need emergency care, ED's will be there for them. Unfortunately, not all ED's are alike. Although many physicians who work in ED's are board certified in the speciality, many are not.
Recent staffing studies suggest that there will be a continued shortage of emergency medicine physicians. Emergency medicine is a relatively new specialty (only 40 years old). The "baby boomers" who started emergency medicine are moving on to other things or are retiring.
Interestingly, the majority of patients go to smaller and midsized ED's that may not be staffed with board certified emergency medicine physicians. That means the physician may still be trained in some other field - surgery, internal medicine, family practice, etc. Where I don't mean to degrade the capabilities of those who have practiced emergency medicine for a far longer time than I, I think the public needs to know this. That said, I have seen less than optimal care provided by physicians who are board certified in many specialities so board certification does not guarantee excellent care but it does imply specialized training in the field.
Many hospitals require physicians to be "board certified" but that does not mean that the person working in the ED be certified in emergency medicine. For the educated consumer, you need to find out what percentage of those physicians in the ED are "board certified or residency trained in emergency medicine." Where you don't have this luxury to shop around when you have an emergency, it helps to know what hospitals near home fall into this category. You may be surprised. And the size of the hospital may not determine the percentage of EM trained physicians!
Sunday, July 19, 2009
Undocumented Immigrants & Health Care...
As I spoke of in the past, EMTALA federal legislation applies to all patients presenting to the ED. This includes the care for the estimated 11 million undocumented immigrants who are a part of our population and add to the burden of the uninsured. What is interesting is that no national Health Care Reform plan takes on this issue to date (or maybe it does because of the purposeful exclusion of these patients).
Where I don't want to get into a philosophical diatribe about whether to insure undocumented immigrants, what does the public expect ED's to do when these patients arrive? Probably the same we do now....treat them and expect no payment for services. At least (for the most part) one does not have to worry about malpractice since most attorneys will not touch these cases since there is very little room for economic damages - the guy planting your shrubs or mowing your lawn or the woman cleaning your house or the person behind the counter at McDonald's can't claim millions of dollars in damages if he or she is disabled. Our society really is twisted!
Our elected officials in state and federal government are smart. They can avoid this issue (so they can't be labeled as bigots and worry about loosing votes if they refuse to insure undocumented immigrants). Congress and policy writers know that these people can at least get "free care" in any Emergency Department in the nation off the backs of physicians, hospitals, and other providers, including insurance companies and other patients secondary to cost shifting! Who said Congress was stupid?
Where I don't want to get into a philosophical diatribe about whether to insure undocumented immigrants, what does the public expect ED's to do when these patients arrive? Probably the same we do now....treat them and expect no payment for services. At least (for the most part) one does not have to worry about malpractice since most attorneys will not touch these cases since there is very little room for economic damages - the guy planting your shrubs or mowing your lawn or the woman cleaning your house or the person behind the counter at McDonald's can't claim millions of dollars in damages if he or she is disabled. Our society really is twisted!
Our elected officials in state and federal government are smart. They can avoid this issue (so they can't be labeled as bigots and worry about loosing votes if they refuse to insure undocumented immigrants). Congress and policy writers know that these people can at least get "free care" in any Emergency Department in the nation off the backs of physicians, hospitals, and other providers, including insurance companies and other patients secondary to cost shifting! Who said Congress was stupid?
Saturday, July 18, 2009
Bad Things Happen...
I saw a 50 yo Hispanic gentleman who came into the ED because his blood sugars were running high. He was recently treated for a "bronchitis" and placed on an antibiotic...at that time his sugars were high and he had not been compliant with his diabetes medication. He had no insurance and paid for his medications himself. He started back on the medication but his sugars were still high and wondered what was going on.
He also was complaining of continued shortness of breath with some wheezing. I repeated his chest x-ray which showed a large mass (probably cancer) and a new pneumonia secondary to the tumor. I then performed a CT scan of his chest which confirmed my suspicion. The man had a tumor that had also spread to his lymph nodes in his chest. I was shocked since he was relatively young, a nonsmoker, and no history of any occupational exposure to explain why he had the tumor.
He was subsequently admitted for further treatment. He, of course, has no insurance so I will not be paid and the hospital will receive some money from the state to cover some expenses. All the other physicians who care for him will not receive any payment either. I'm not complaining about the money, I at least made the unfortunate diagnosis and was able to get him help. Perhaps he has a lymphoma that may respond to treatment. My point is...did his lack of insurance lead to a delay in diagnosis and if he had better care would the diagnosis have been made earlier? Who knows...
He also was complaining of continued shortness of breath with some wheezing. I repeated his chest x-ray which showed a large mass (probably cancer) and a new pneumonia secondary to the tumor. I then performed a CT scan of his chest which confirmed my suspicion. The man had a tumor that had also spread to his lymph nodes in his chest. I was shocked since he was relatively young, a nonsmoker, and no history of any occupational exposure to explain why he had the tumor.
He was subsequently admitted for further treatment. He, of course, has no insurance so I will not be paid and the hospital will receive some money from the state to cover some expenses. All the other physicians who care for him will not receive any payment either. I'm not complaining about the money, I at least made the unfortunate diagnosis and was able to get him help. Perhaps he has a lymphoma that may respond to treatment. My point is...did his lack of insurance lead to a delay in diagnosis and if he had better care would the diagnosis have been made earlier? Who knows...
Monday, June 29, 2009
Too Long for Silence
OK, I admit, that it has been well over 6 months since writing anything here...I suspect not because I am not motivated to find anything to write about. On the contrary, I can go on for years about my experience. Rather, the issue is the time. After working in the ED, one is totally exhausted. Often times, you get the feeling that everyone is sucking every vital juice from your body...the staff, the patients, the family members, EMS, your colleagues, everyone...you get sucked dry.
And, despite this, you still need to perform at your best with every patient encounter, never leaving your guard down to make the wrong diagnosis, or somehow not being able to filter through what a patient is telling you...Mrs. Smith complains of a headache, chest pain, insomnia, depression, menopause, diarrhea, weight gain, abdominal pain, tingling....is it all real, or is there one or two things here related to her medical condition. Is she just anxious, or is there really something wrong with her that may kill her if I send her home...that's the way most EM physicians think, because the number one reason for EM malpractice cases is "failure to diagnosis" and even crazy or anxious people get sick and die...
It's almost like Chicken Little, and the "Sky's falling..." except Chicken Little doesn't have a family who can find a personal injury attorney to build a case against your decision making ability when the sky actually does fall down and kill, or worse yet, maim Chicken Little! Somehow, I don't believe that leaders in Washington (the majority who are supported by trial attorneys) will ever come to terms with any meaningful tort reform in this country.
And, despite this, you still need to perform at your best with every patient encounter, never leaving your guard down to make the wrong diagnosis, or somehow not being able to filter through what a patient is telling you...Mrs. Smith complains of a headache, chest pain, insomnia, depression, menopause, diarrhea, weight gain, abdominal pain, tingling....is it all real, or is there one or two things here related to her medical condition. Is she just anxious, or is there really something wrong with her that may kill her if I send her home...that's the way most EM physicians think, because the number one reason for EM malpractice cases is "failure to diagnosis" and even crazy or anxious people get sick and die...
It's almost like Chicken Little, and the "Sky's falling..." except Chicken Little doesn't have a family who can find a personal injury attorney to build a case against your decision making ability when the sky actually does fall down and kill, or worse yet, maim Chicken Little! Somehow, I don't believe that leaders in Washington (the majority who are supported by trial attorneys) will ever come to terms with any meaningful tort reform in this country.
Sunday, December 28, 2008
Why Emergency Medicine Can Add to Health Care Costs....
In America, everyone expects perfection...people want to live forever (or as long as they possibly can). Hence my candid feelings about prolonging the inevitable. Frequently, patients are transferred from Nursing Homes sick...very sick. They arrive with limited information (hopefully a copy of the medical list and a short one page synopsis of their medical history). Unfortunately, many cannot speak secondary to their condition.
Many times treatment decision need to be made rather swiftly, sometimes in seconds, sometimes in minutes and more frequently in an hour or two. The decisions will ultimately add to the costs of medical care and perhaps to their suffering or perceived discomfort. What is frustrating to providers in the ED, is the lack of communication for advanced directives, documents that would help health care professionals determine "how far, and at what costs" patients and next of kin want for care.
All too often in these extreme cases, the patient is too sick or comatose to make such a decision and family members are guilt ridden with making a decision that may ultimately lead to a loved one's death. Unfortunately, families do not always make decisions in the best interest of the patient but rather for the best interest of the psychiatric care of the family - like placing octogenarians on ventilators when there is absolutely no hope of recovery let alone a decent quality of life.
In America, we spend a considerable amount of money near the end of people's life's but, even with health care reform, I can't see the government changing this. Do you really expect Presdient Obama and the rest of Congress to say, "Grandma's lived long enough, time to pull the plug?..." NOT!
Many times treatment decision need to be made rather swiftly, sometimes in seconds, sometimes in minutes and more frequently in an hour or two. The decisions will ultimately add to the costs of medical care and perhaps to their suffering or perceived discomfort. What is frustrating to providers in the ED, is the lack of communication for advanced directives, documents that would help health care professionals determine "how far, and at what costs" patients and next of kin want for care.
All too often in these extreme cases, the patient is too sick or comatose to make such a decision and family members are guilt ridden with making a decision that may ultimately lead to a loved one's death. Unfortunately, families do not always make decisions in the best interest of the patient but rather for the best interest of the psychiatric care of the family - like placing octogenarians on ventilators when there is absolutely no hope of recovery let alone a decent quality of life.
In America, we spend a considerable amount of money near the end of people's life's but, even with health care reform, I can't see the government changing this. Do you really expect Presdient Obama and the rest of Congress to say, "Grandma's lived long enough, time to pull the plug?..." NOT!
Friday, December 26, 2008
The Economy's Impact on ED Visits...
As the year's end approaches, I wonder what the ED will be like. During a recession, people loose jobs and for the most part, their health insurance, which is tied to their employment. Very seldom will people still have the ability to pay their health insurance premiums without employment.
That said, it is a vicious cycle. People loose their jobs, they loose their health insurance and still need health care. But most often, without insurance they do not get routine health care, (except perhaps for their children). Parents tend not to be selfish, and will still provide for their kids at the expense of their own health and needs. People are less likely to take care of themselves and end up looking for episodic care - care when they need it. They forgo elective hernia repairs or perhaps put off having their gallbladder removed because of the loss of insurance.
People also tend to suffer not only financial but also emotional distress. Depression, drug and alcohol dependence, anxiety, etc. increases. The bottom line, society suffers in more than one way. And the impact on the ED - perhaps more visits for sicker and more desperate people who can't afford to pay their bills. They come to an even more expensive health care environment (the ED) to have their needs met.
Whether this will ultimate happen, is yet to be seen. But if the economy continues in a downward spiral with more people loosing their health insurance along with their jobs, the results are inevitable. With the new Obama administration, perhaps more will be insured, but the jury is still out. Financing for health insurance has to come from somewhere, and if that means from public funds either additional taxes, or cuts in other programs will have to pay for a hefty and expensive plan regardless of what the final product looks like...
That said, it is a vicious cycle. People loose their jobs, they loose their health insurance and still need health care. But most often, without insurance they do not get routine health care, (except perhaps for their children). Parents tend not to be selfish, and will still provide for their kids at the expense of their own health and needs. People are less likely to take care of themselves and end up looking for episodic care - care when they need it. They forgo elective hernia repairs or perhaps put off having their gallbladder removed because of the loss of insurance.
People also tend to suffer not only financial but also emotional distress. Depression, drug and alcohol dependence, anxiety, etc. increases. The bottom line, society suffers in more than one way. And the impact on the ED - perhaps more visits for sicker and more desperate people who can't afford to pay their bills. They come to an even more expensive health care environment (the ED) to have their needs met.
Whether this will ultimate happen, is yet to be seen. But if the economy continues in a downward spiral with more people loosing their health insurance along with their jobs, the results are inevitable. With the new Obama administration, perhaps more will be insured, but the jury is still out. Financing for health insurance has to come from somewhere, and if that means from public funds either additional taxes, or cuts in other programs will have to pay for a hefty and expensive plan regardless of what the final product looks like...
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