Sunday, August 2, 2009

Emergency Room Medicine: Model for Excellence or Excess?


The concept of medical excess is very difficult for ordinary patients to grasp. The medical community has worked hard for decades teaching them that more medicine meant better medical care. The public has learned these lessons well. Physicians who sent their patients for various diagnostic tests or specialty consultations were regarded as conscientious and thorough. Patients approved of doctors who prescribed antibiotics regularly for colds and other viruses believing that something beneficial was being done for them.

We can’t expect a patient to know if a CAT scan a physician orders is medically necessary. From a patient’s perspective, a test is medically necessary if the doctor orders it. However, physicians, with professional training and experience, know whether medical testing is urgent or optional. Isn’t that our jobs?

Of course, the practice of medicine often resides in the murky gray area where there is no single correct answer. In these instances, there can be several rational medical options available. Often, different medical studies examining a clinical question reach opposite conclusions. Sometimes, the medical issue at hand hasn’t been scientifically studied so there is no authoritative medical evidence to rely on. In these examples, differing medical recommendations are to be expected.

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

A serious risk of this buckshot-style medicine is that any one of the ultrasounds, CAT scans or other tests will detect an irrelevant and innocent abnormality that drags the patient to a brand new avenue of medical adventure. These new ‘abnormalities’, found by accident, create anxiety, cost money and mean more medical testing. This vicious circle is no merry-go-round carnival ride.

Why do ER physicians practice this way? Are they dumb? Hardly. In general, they are extremely capable and well trained. They perform well under pressure that can rival the tension found in any operating room. They make decisions routinely that determine whether a patient survives or succumbs. They have all of the necessary tools to practice judicious and conservative medicine, but they don’t.

They claim that the ER is a different medical universe, unlike primary doctors’ offices. They argue that they can’t miss serious diagnoses like heart attacks, strokes and blood clots to the lungs, all of which can be fatal. They need to test extensively because they have only one visit with the patient to get it right. Additionally, they point out that some of their patients may not follow up afterward with their primary physicians, even though they are advised to do so. Understandably, these physicians fear lawsuits against them if a patient they saw deteriorates after discharge. This latter reality motivates them to test patients aggressively.

I reject these arguments. In fact, the same ones could be applied to patients I see every day in my office. ER physicians should practice the same style of medicine that we all were taught to do during our medical training. Take a thorough history, perform an examination and then make appropriate recommendations. As a gastroenterologist, I see patients with chest burning in my office several times a week. The medical history allows me to determine if the chest discomfort is innocent or suspicious. In most cases, these patients don’t need a stat cardiac work up. Yet, if this same patient were seen in an ER…

Physicians, being members of the human species, are not perfect. It is not our task to test for every conceivable diagnosis in one visit. If an ER physician, or any doctor, thinks his patient’s abdominal discomfort is from constipation, then treat it accordingly and arrange for proper follow-up in the office. Don’t start a scan attack just because you can’t exclude appendicitis with 100% certainty. When we shoot for perfection, we are target our own profession.

I don’t think that the ER needs a different playbook. It just needs to play differently.

32 comments:

Evinx said...

Of course, you are 100% correct.
In my view, the core of the problem comes from our payment system - rarely is the patient concerned about cost. The third party payment makes it seem "free" to patients or the person making the medical choices for the patient.

I have had drs say to me,"why don't you want the test? Won't your insurance pay?" I have also had a dr (internist) friend casually say, "If a patient takes enough tests, I'll always find something" (this dr had much of the test equipment in his office - ultrasounds, bone density, etc).

If a test is "free" to the patient + the patient wants every assurance that nothing is medically wrong, +the dr has some fear of lawsuits, + if year after year, this has become accepted practice, then the medical culture evolves to accept this as standard procedure. I think this is where we are at now.

In addition, politics has gotten into the act as millions look to the govt to solve life's problems. Years ago, most looked to God but we have become more secular and now we have replaced God with Govt - a very bad tradeoff, imo.
As a secular person myself, the mix of politics (and therefore, special interest groups) with medicine is a horrible mix which has led to, and will lead to further, bad outcomes.

Ashok V. Daftary, MD, FACP. said...

Alleluia

Anonymous said...

Nothing will change with the health care crisis until we deal with the central issue, the AMA restricting the number of doctors that can graduate, to keep their incomes high.
See here:
http://bradhicks.livejournal.com/432458.html

America's doctors, the most overpaid labor union in the world. Naturally, the usual diversion is to talk about malpractice, but the disgusting closed shop is by far the biggest reason for rising medical costs.

Evinx said...

Anonymous
How about selecting a screen name to avoid confusion with other Anons?

The link you provided is not a statistical data link but one bloggers opinion without sourcing - and if you read it, it is a very biased opinion piece.

OTOH, if you go to the OECD 2003 health data, you will see the US is 2nd in the world in dr consultations/person/year at 8.9. For comparison, Canada is 6.3, UK is 4.9, and Sweden is 2.8.

Our system is far more efficient - we have loads of PAs. If there was such an acute shortage as you indicate, how do we end up with more dr visits per person per year than every other country in the world (except Japan)?

And who cares how much people earn? I care about the quality and service I get.

Anonymous said...

Evinx, I notice in your post you dont address the central question, that the AMA holds down the numbers of medical graduates to keep its incomes high.

If taxpayers and patients are paying the bills, then yes, we care about how much the doctors make, because its coming out of our pockets.

Slowly the american people are waking up to the kleptocratic closed shop that is the medical profession. Stop the profession restricting doctor numbers! do it now!!!

Anonymous said...

Itr just amazing the way 'conservatives' tut tut about labor unions, yet slavishly support the right of doctors to run a closed shop and charge what they like. If conservatives were genuine, they would stand up against this disgusting monopoly.

Evinx said...

"If taxpayers and patients are paying the bills, then yes, we care about how much the doctors make, because its coming out of our pockets."

By that logic, you must care about how much pilots earn, how much restaurateurs earn, how much pawn shop owners earn, + so on. Come on, that is plain silly. Each seller should have the right to charge what they want for their services and each buyer has the right to accept or reject. If it a coercion-free tranaction, then what their take home pay should not matter.

And yes, if the AMA is restricting MDs, that is wrong. But remember, we also hae DOs, and who is restricting their numbers? They are not part of the AMA.

BTW, do you also "genuinely" support right-to-work laws so that there can't be union closed shops (in any company)? I would hope you do.

Anonymous said...

Evinx, I would happily support right to work laws, provided at the same time, any control by the AMA over doctor training numbers (including the influence they currently have on the LCME) is totally and utterly removed.

You make a comment that we shouldnt worry what people charge - if its a free market. I agree, but the current market for doctors is not 'free' - it is rigged to keep training numbers down. And this monopoly costs taxpayers and patients a fortune.

Michael Kirsch, M.D. said...

I do not belong to the AMA, so I may not be as informed about the organization as is the anonymous commenter. How exactly are they controlling the number of physicians being trained? Would appreciate some evidence, not just another statement. I also reject the term 'monopoly' with regard to the medical profession, since no doctor who accepts insurance sets prices.

Anonymous said...

The AMA dominates and helps fund the LCME which controls medical school licensing in the US. They have a well known opposition to opening new medical schools.

Evinx said...

Anon
How are they keeping the number of DOs down? How do they keep the number of foreign trained physicians down?

And why is your support for right to work laws conditional on AMA policy? Shouldn't we work to eliminate all such restrictions? Why only the focus on doctors and med schools?

What about zoning requirements? Licensing requirements for barbers + hair cutters? And how about taxis? NYC has been limiting the number of medallions for taxis for decades and then putting restrictions on who can pick up passengers + where. What about rent control laws? Why can't a person who owns an apartment building charge what they want for rent? Nobody is forcing someone to rent there.

In other words, where is the underlying principle behind your position on the AMA?

And how about a screen name just to avoid confusion?

Anonymous said...

Evinx, your constant straw man attacks are wearing thin. I believe in free markets.

Currently the WORST ABUSER of free markets in terms of workforce is the AMA, in terms of the sheer cost imposed by their restricted numbers policy. It therefore makes sense to make this abuse a central priority point, because it is the worst.

So, to ask you a question, if you believe in free markets, do you fully and totally oppose the AMA's outrageous rigged market through the LCME ?

And yes, I support the other causes you mention, ie removing distortions on markets.

One very notable thing with conservatives is how they selectively apply their free market principles. Unions=bad, AMA=good despite them being the same thing.

Michael Kirsch, M.D. said...

To the anonymous commenter: I think you exaggerate the influence of the AMA. I don't belong to it and I don't know any of my colleagues who do. I think that they're weaker now than at any other time in their history, and that they will continue to lose relevance.

Anonymous said...

But you haven't address the central point, that the AMA controls, through the LCME, the numbers of medical schools/possible student accredited.

Evinx said...

Anon - here is what you wrote:

America's doctors, the most overpaid labor union in the world. Naturally, the usual diversion is to talk about malpractice, but the disgusting closed shop is by far the biggest reason for rising medical costs.

You sir are using the AMA as your straw man to blame high costs on drs. That just doesn't add up. Medicare, which sets reimbursement rates accounts for 44% of all healthcare spending. Medicare payments are set by Uncle Sam + they are known to be very low.

The AMA does not control the number of med schools - they do require "massively credentialed" physicians. So they set the quality bar. That came about bcs years ago there were basically many snake oil salesmen doctors. See Flexner report.

Here is a listing of med schools recent or soon to come on stream:

NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT HAVE OFFICIALLY OPENED

MD - University of Hawaii-Kakaako - 2006
DO - Touro/Las Vegas - 2005
DO - PCOM/Atlanta - 2005
MD - University of Miami/FAU joint program - 2004
MD - Cleveland Clinic/Lerner - 2004
DO - LECOM/Bradenton - 2004
MD - Florida State University - 2002
DO - VCOM - 2002

NEW MEDICAL SCHOOLS THAT WILL OPEN SOON

MD - Florida International Univ - 2008
MD - Univ Central Florida - 2008
MD - Touro/NJ - 2008
DO - Touro/Harlem - 2008
DO - Pacific Northwest/Yakima - 2007
MD - Michigan State University/Grand Rapids - 2008
MD - University of Arizona/Phoenix - 2007

NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT ARE IN PLANNING

MD - University of Cal Merced
MD - University of Cal Riverside
MD - University of Texas El Paso
DO - Vista/Colorado
MD - OHSU/Eugene
DO - MSUCOM/Detroit
DO - Barry University/Miami FL

Nearly half are DOs - absolutely no relationship to AMA.

The AMA which represents only about 30% of practicing MDs,
has never lobbied against med schools. Show me hard evidence.

The US uses PAs + NPs to a great extent. That is why we can have 8.9 dr visits per person per year -- higher than every country in the world except Japan.

Dr fees are not the single biggest reason we have high healthcare costs. Why haven't plastic surgeon fees gone up? Are they not in the AMA? How about Lasik which has come down dramatically? Are those ophthalmologists just more altruistic?

Fact is the less govt involvement, fewer mandates, the less govt imposed restrictions on interstate sale of health insurance, + the eiimination of 3rd party payment, and no community ratings will mightly contribute to lower the cost curve. Monopoly + monopsony power will have horrible
consequences. And blaming the AMA solely for the problem is simply the wrong diagnosis.

Chris Johnson said...

Virtually all healthcare experts agree that the usual economic rules of supply and demand do not apply here: in medical care, more supply generates its own demand for more services, thereby raising, not lowering costs. So more physicians would raise, not lower costs. This peculiarity of heathcare economics was first described 50 years ago (http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf).
The Dartmouth studies (http://www.dartmouthatlas.org) are also a useful place to look, if you are interested in actual data on which to base your opinions.

Chris Johnson said...

I should add I'm addressing anony-mouse, not the blog owner.

Anonymous said...

This week's blog article is, as expected by now, very interesting and extremely well written. But it does beg for a clarification, particularly in view of previous articles on excessive testing posted here months ago.

Overtesting in ER apparently occurs for the same reasons that were mentioned in an earlier article on this blog. Is the point here that ER is one of the worst offenders? Or is it just as bad as others? Should reforms start in ER and spread elsewhere? Don't ER physicians have more bad but understandable reasons for excessive testing?

Also I'm curious whether over testing in MDWhistleblower's office is, in his opinion, less than average. One would guess that it remains to protect against possible lawsuits and to please some patients who may be highly pleased and possibly upset otherwise. Are there any other reasons?

Michael Kirsch, M.D. said...

Above comment appreciated. I think that nearly all physicians - including me - are culpable. As suggested in this posting, and in prior postings on this blog, physicians oreder excessive testing and treatments for various reasons. The ER is the best example of this behavior as the excessive care is consistently present, is easily recognized and is disproportionately higher than in other medical venues.

Aaron Osborne, MD, PhD said...

Instead of posting comments and unsubtantiated "facts" pulled from blogs under the name anonymous, why not let your readers know your affiliations and allegiances. Your hiding your identity while bashing the hard working, dedicated, altruistic and often over-worked and under-appreciated Emergency Physicians of America as well as the AMA is shameless.

In addition, Dr Kirsch seems to have spent too much time with his colonoscope up peoples' rear ends. To suggest that he can tell when someone in his office that complains of burning retrosternal pain is simply experiencing heartburn/esophagitis merely by taking a history is ignorant at best. First, his patients are invariably referred to him from a primary care physician or ER physician. These other physicians have already worked up the complaint and determined it not to be emergent or life threatening. Indeed, in Dr. Kirsch's line of work, about the only true life threatening emergency he is likely to see is a massive GI bleed or iatrogenic (doctor caused) esophageal rupture. Even then, as an outpatient colonoscopist the former seems rather unlikely and the latter is caused during his procedures. He is simply in no position to understand, much less criticize, the way in which Emergency Physicians practice medicine. We are tasked with having to sort out, in short order, whether someone's sudden onset of retrosternal pain (for example) is heartburn or rather an immediate threat to life such as a heart attack, pulmonary embolism, ruptured esophagus, pneumothorax, or aortic dissection (just to name a few). No Emergency Physician ever orders all possible tests to exclude these diagnoses. Rather they do indeed use the clinical history, past medical history, and physical examination to narrow the possible diagnoses. However, I and others like to apply a very simple principle to the way we practice Emergency Medicine. That is, do for other as you would have done to your mother. If your mother felt that her chest pain was serious enough to come to her local Emergency Department wouldn't you expect the physician to take her complaint seriously and definitively rule out life threatening causes for her complaints? This simply cannot be done on the basis of historical information alone as you have ignorantly suggested. And, despite what you 'simply reject' Dr. Kirsch, the fact is that Emergency Physicians are routinely sued for missed diagnoses such as 'silent heart attacks' and other bad outcomes. This is an unfortunate fact of practicing medicine today. Most physicians would agree that malpractice suits are not the prime reason for the out-of-control rise in health care costs. However, to summarily reject them as a reason why defensive medicine, and thus excessive testing, is practiced in all fields of medicine is ignorant at best or clearly disingenuous at worst.

Stick to what you know best Dr. Kirsch and anonymous. When the day comes you or your loved ones have to come to an Emergency Department, you'll be thankful the EM physicians went the extra mile to protect what you hold most dear.

Aaron Osborne, MD, PhD
Emergency Medicine Physician

Michael Kirsch, M.D. said...

Aaron, I appreciate your comments. We disagree. My experience, and the views of nearly every medical colleague I work with, agree that the ER is an arena of medical excess. That other specialties, including my own, are flawed doesn't change this reality. I presume that you or your department reviews your cases for quality and outcome. I strongly suspect that if you pulled charts on the last 100 patients for whom CAT scans of the abdomen were performed, that many of them were not essential to the care of the patient, even though they can be 'justified' with the dx of abdominal pain. If the majority of your scans are truly needed, then your ER is truly unique.

Aaron Osborne, MD, PhD said...

Dr. Kirsch...I think we are hanging on the phrase 'truly needed'. Indeed, we do chart reviews and yes, there are times in which studies are ordered in excess. As I mentioned, this is most often attributable to defensive medicine. What is 'truly needed' is a debatable term, however. In Emergency Medicine, unlike any other field of medicine, our job is to not necessarily to determine what is causing your retrosternal pain. Rather, it is to rule out immediate threats to life. In other words, we aim to determine what is most likely to kill you today as opposed to what is most likely the cause of your discomfort. In the process, we are often able to accurately diagnose more trivial causes for discomfort such as GERD. Additionally, viewing the term 'truly needed' through the lenses of hindsight is a luxury Emergency Physicians are not provided.

The question of 'truly needed' is philosophical - for instance, is a 5% miss rate acceptable for STEMI, what about 1%, or 0.1%. As physicians, we would like to never miss a life-threatening diagnosis. Furthermore, I'm sure an individual having a heart attack feels a 0.1% miss rate is too high when they are the one missed. Indeed, society holds us to this standard as well given the amazing number of malpractice suits that are filed solely for 'bad outcomes' rather than negligence on the part of the physician. When confronted with an expectation of perfection, you will undoubtedly pull out all of the stops.

That being said, I do agree that in most areas of medicine today it seems that common sense has become rather uncommon. That is largely for the reasons outlined above. The litigiousness of our society and the fact that many people do not worry who is paying for their excessive testing leads to over-ordering of expensive tests across the board. Emergency Medicine is particular hard hit by this, and I'm sure no area of medicine is immune.

In sum, medical excess is a reality. However, it has to be evaluated in the context of what is being asked of an individual physician in order to determine what is 'truly needed'. Emergency Physicians are expected to accurately diagnose life threatening conditions without the benefit of knowing an individuals past medical history, medications they are taking, and other crucial information. In addition, anything less than perfection has been deemed unacceptable by society. To diagnoses someone with heartburn only to have them die later that evening at home while taking Maalox is a tragedy that has to be avoided. Thus, it is prudent to err on the side of caution in Emergency Medicine.

Until we as a society begin to understand that the Emergency Room is not a free clinic, it is not meant to be the primary care physician for the uninsured, and that EMERGENCY in the title means something, these problems that you and I have outlined will not be resolved.

Good discussion...
Aaron Osborne, MD, PhD
Emergency Medicine Physician

Michael Kirsch, M.D. said...

Thank you Aaron. It's refreshing to respond to someone who will sign his name to his remarks. I understand all of your points, as I am also a practicing physician. I maintain, and have pointed out throughout this blog, that practicing excessive medicine is a global phenomenon. I believe that this practice style is most evident in the ER. From a medical point of view, this should not be more justified in your venue than it is in a private MD's office. Consider your remark: "To diagnoses someone with heartburn only to have them die later that evening at home while taking Maalox is a tragedy that has to be avoided." I presume that this statement is to justify ER imaging studies, EKGs, etc. This same patient is seen in physicians' offices daily in every city in the country, yet most of these physicians would not be ordering STAT pulmonary angios. I think it is arguable that mere presence in the ER justifies an expansive and excessive practice style. If you feel the need to nearly eliminate risk of missing a critical dx at the time of the encounter, then shouldn't every MD in the community do the same during their office visits?

Ms. Merson said...

Mr. Kirsch, I almost hesitate to call you "Dr"! I am not a physician, merely a layperson. However, I am somehwhat horrified to see you compare a patient seen in a physician's office in a daily basis to one that feels that his/her pain is severe enough to warrant an emergency room visit. Unless you are calling all of us who have ever visited an emergency room for a true emergency idiots, I would surely hope you see very few patients, which would give you less opportunity to do harm.

Michael Kirsch, M.D. said...

Ms, Merson, I believe that you have misunderstood my point. I argue that many patients in the ER are receiving diagnostic testing that is not truly essential and would not be ordered if this same patient were seen in a doctor's office. I offer no criticism of patients who come to the ER to have symptoms evaluated. It is also true, however, that many patients seen in ERs could be seen in less acute facilities, such as urgent care centers or preferably in physicians' offices.

Anonymous said...

Thanks Aaron for a wonderful explaination of EMERGENCY care. I find it amazing that Mike feels so abused by ED physicians who must work fast effeciently and correctly in many facets of various medical illnesses. Yet as a physician practicing in both Mike and his wife's local, I have personally seen many of both of their patients, that they quickly referred to our ED for further testing. In fact, many physicians do this daily, because they realize the ED will "get it done", for them. Instead of complaining a simple "thank you" will do. I know I have thanked you Mike for assistance with GI bleeds and other GI ailments. Why not stop throwing insults, join the medical team, and realize we are all in this together, for the betterment of the patients, we care very much for. I also know many primary care physicians, who do complete work ups in their offices and then refer to the ED, when medically appropriate. For these physicians, I say,"Thank You".
Don Spaner MD Name given here as posting required Anonymous.

Michael Kirsch, M.D. said...

I must respond to my colleague Don Spaner,M.D.,who has commented above. Don is a highly capable ER physician who works in a wildly busy ER. There was no offense intended in my posting. I state: [ER physicians]perform well under pressure that can rival the tension found in any operating room. They make decisions routinely that determine whether a patient survives or succumbs." I also indicted myself as a physician who contributes to medical excess: "These unneeded medical tests and treatments are black and white, not gray. It occurs every day in every doctor’s office, including mine." Nevertheless, there is no doubt that ER evaluations are much more comprehensive than would occur in physicians' offices to address the same clinical issue. There are many reasons explaining this discrepancy, as appears in the posting. Don and his colleagues are fine physicians. But, the culture in the ER, as in other medical venues, favors diagnostic excess. I suspect that most primary care physicians would agree with this.

jonson said...
This comment has been removed by a blog administrator.
Anonymous said...

I am alive to give thanks this Thanksgiving weekend because a caring and talented ER physician and his very capable PA recognized that I was in dire straits when I entered the ER 4 days ago. Prior to then, I had been in treatment with a recognized specialist for 5 weeks for what has turned out to be a very, very complicated case. At the ER, it was decided I may have a penicillin-resistant bacterial infection, and that decision saved my life. After my antibiotics were changed, within 48 hours I went from taking a percocet every 4 hours to absolutely nothing for pain. I believe my regular MD was either in denial or disinterested about the complexity of my case. A good ER physician is wired differently. They are alert to the possibility that anything can be wrong. In my experience, all too often specialists reduce patients to a specific body part, to the detriment of the patient.

Michael Kirsch, M.D. said...

To those interested, here's an interesting piece from USA today examining why ER physicians perform excessive diagnostic studies. Enjoy! http://bit.ly/9lpSdc

Barry said...

If you ever need emergency care, I truly hope that your emergency physician hasn't read your terribly offensive comments regarding their medical specialty. I don't imagine there are any emergency physicians out there second guessing your decisions regarding who needs a colonoscopy. But, then again, why would they? You clearly practice only perfect medicine. Your holier than thou attitude is despicable. People in glass houses...

Michael Kirsch, M.D. said...

Barry, please see this link of a Washington Post article reporting on medical study concluding what is self-evident: the majority of physicians including ER physicians practice excessive medicine. While I understand why physicians like me and my ER colleages do this, it indicates the need for effective tort reform. http://bit.ly/deGSoC

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