tag:blogger.com,1999:blog-7323692122514281455.post6888983795566751177..comments2024-03-22T17:05:55.267-04:00Comments on MD Whistleblower: Emergency Room Medicine: Model for Excellence or Excess?Michael Kirsch, M.D.http://www.blogger.com/profile/07555280388086931097noreply@blogger.comBlogger32125tag:blogger.com,1999:blog-7323692122514281455.post-3091711697834006672010-06-29T07:53:02.215-04:002010-06-29T07:53:02.215-04:00Barry, please see this link of a Washington Post a...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/deGSoCMichael Kirsch, M.D.https://www.blogger.com/profile/07555280388086931097noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-76320608296520916672010-06-27T06:17:01.074-04:002010-06-27T06:17:01.074-04:00If you ever need emergency care, I truly hope that...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...Barryhttps://www.blogger.com/profile/12787026908825516359noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-27057005651560405292010-06-21T13:11:26.589-04:002010-06-21T13:11:26.589-04:00To those interested, here's an interesting pie...To those interested, here's an interesting piece from USA today examining why ER physicians perform excessive diagnostic studies. Enjoy! http://bit.ly/9lpSdcMichael Kirsch, M.D.https://www.blogger.com/profile/07555280388086931097noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-37585879817634481782009-11-25T18:45:20.417-05:002009-11-25T18:45:20.417-05:00I am alive to give thanks this Thanksgiving weeken...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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-7888734394686416962009-10-19T01:41:17.489-04:002009-10-19T01:41:17.489-04:00This comment has been removed by a blog administrator.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-75270458724634833132009-09-14T15:28:30.845-04:002009-09-14T15:28:30.845-04:00I must respond to my colleague Don Spaner,M.D.,who...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.Michael Kirsch, M.D.https://www.blogger.com/profile/07555280388086931097noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-4051348069205705392009-09-14T12:30:20.690-04:002009-09-14T12:30:20.690-04:00Thanks Aaron for a wonderful explaination of EMERG...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".<br />Don Spaner MD Name given here as posting required Anonymous.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-65676206520645797652009-08-30T09:47:54.734-04:002009-08-30T09:47:54.734-04:00Ms, Merson, I believe that you have misunderstood ...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.Michael Kirsch, M.D.https://www.blogger.com/profile/07555280388086931097noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-92057264400625194402009-08-29T23:45:03.143-04:002009-08-29T23:45:03.143-04:00Mr. Kirsch, I almost hesitate to call you "Dr...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.Ms. Mersonnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-60207265728043566752009-08-29T15:07:00.848-04:002009-08-29T15:07:00.848-04:00Thank you Aaron. It's refreshing to respond t...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?Michael Kirsch, M.D.https://www.blogger.com/profile/07555280388086931097noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-68024563371219809572009-08-29T13:19:40.427-04:002009-08-29T13:19:40.427-04:00Dr. Kirsch...I think we are hanging on the phrase ...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. <br /><br />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. <br /><br />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. <br /><br />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. <br /><br />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. <br /><br />Good discussion...<br />Aaron Osborne, MD, PhD<br />Emergency Medicine PhysicianAaron Osborne, MD, PhDhttps://www.blogger.com/profile/14693309436695059514noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-63196368654859979462009-08-29T10:14:50.595-04:002009-08-29T10:14:50.595-04:00Aaron, I appreciate your comments. We disagree. M...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.Michael Kirsch, M.D.https://www.blogger.com/profile/07555280388086931097noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-82474141366048061132009-08-28T23:44:02.424-04:002009-08-28T23:44:02.424-04:00Instead of posting comments and unsubtantiated &qu...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. <br /><br />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.<br /><br />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.<br /><br />Aaron Osborne, MD, PhD<br />Emergency Medicine PhysicianAaron Osborne, MD, PhDhttps://www.blogger.com/profile/14693309436695059514noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-10967550492004380142009-08-07T16:14:02.021-04:002009-08-07T16:14:02.021-04:00Above comment appreciated. I think that nearly al...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.Michael Kirsch, M.D.https://www.blogger.com/profile/07555280388086931097noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-90687241983791841262009-08-06T21:49:37.772-04:002009-08-06T21:49:37.772-04:00This week's blog article is, as expected by no...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.<br /><br />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?<br /><br />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?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-15579604268396782542009-08-06T15:37:10.032-04:002009-08-06T15:37:10.032-04:00I should add I'm addressing anony-mouse, not t...I should add I'm addressing anony-mouse, not the blog owner.Chris Johnsonhttp://www.chrisjohnsonmd.comnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-75567728009364665512009-08-06T15:35:33.509-04:002009-08-06T15:35:33.509-04:00Virtually all healthcare experts agree that the us...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).<br />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 Johnsonhttp://www.chrisjohnsonmd.comnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-45722836900235833512009-08-04T23:42:19.404-04:002009-08-04T23:42:19.404-04:00Anon - here is what you wrote:
America's doct...Anon - here is what you wrote:<br /><br />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.<br /><br />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. <br /><br />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.<br /><br />Here is a listing of med schools recent or soon to come on stream:<br /><br />NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT HAVE OFFICIALLY OPENED<br /><br />MD - University of Hawaii-Kakaako - 2006<br />DO - Touro/Las Vegas - 2005<br />DO - PCOM/Atlanta - 2005<br />MD - University of Miami/FAU joint program - 2004<br />MD - Cleveland Clinic/Lerner - 2004<br />DO - LECOM/Bradenton - 2004<br />MD - Florida State University - 2002<br />DO - VCOM - 2002<br /><br />NEW MEDICAL SCHOOLS THAT WILL OPEN SOON<br /><br />MD - Florida International Univ - 2008<br />MD - Univ Central Florida - 2008<br />MD - Touro/NJ - 2008<br />DO - Touro/Harlem - 2008<br />DO - Pacific Northwest/Yakima - 2007<br />MD - Michigan State University/Grand Rapids - 2008<br />MD - University of Arizona/Phoenix - 2007<br /><br />NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT ARE IN PLANNING<br /><br />MD - University of Cal Merced<br />MD - University of Cal Riverside<br />MD - University of Texas El Paso<br />DO - Vista/Colorado<br />MD - OHSU/Eugene<br />DO - MSUCOM/Detroit<br />DO - Barry University/Miami FL<br /><br />Nearly half are DOs - absolutely no relationship to AMA.<br /><br />The AMA which represents only about 30% of practicing MDs, <br />has never lobbied against med schools. Show me hard evidence.<br /><br />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.<br /><br />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?<br /><br />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<br />consequences. And blaming the AMA solely for the problem is simply the wrong diagnosis.Evinxnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-41706602317986873912009-08-04T22:22:52.281-04:002009-08-04T22:22:52.281-04:00But you haven't address the central point, tha...But you haven't address the central point, that the AMA controls, through the LCME, the numbers of medical schools/possible student accredited.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-3609631311788593912009-08-04T21:48:09.197-04:002009-08-04T21:48:09.197-04:00To the anonymous commenter: I think you exaggerate...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.Michael Kirsch, M.D.https://www.blogger.com/profile/07555280388086931097noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-42542544500887421782009-08-04T21:32:13.042-04:002009-08-04T21:32:13.042-04:00Evinx, your constant straw man attacks are wearing...Evinx, your constant straw man attacks are wearing thin. I believe in free markets. <br /><br />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.<br /><br />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 ? <br /><br />And yes, I support the other causes you mention, ie removing distortions on markets.<br /><br />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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-13869866907938933192009-08-04T11:26:05.783-04:002009-08-04T11:26:05.783-04:00Anon
How are they keeping the number of DOs down? ...Anon<br />How are they keeping the number of DOs down? How do they keep the number of foreign trained physicians down? <br /><br />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?<br /><br />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.<br /><br />In other words, where is the underlying principle behind your position on the AMA?<br /><br />And how about a screen name just to avoid confusion?Evinxnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-68385258947378216952009-08-04T10:18:30.183-04:002009-08-04T10:18:30.183-04:00The AMA dominates and helps fund the LCME which co...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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-20729209255581440932009-08-04T09:15:47.971-04:002009-08-04T09:15:47.971-04:00I do not belong to the AMA, so I may not be as inf...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.Michael Kirsch, M.D.https://www.blogger.com/profile/07555280388086931097noreply@blogger.comtag:blogger.com,1999:blog-7323692122514281455.post-64982656608742202332009-08-04T03:22:20.150-04:002009-08-04T03:22:20.150-04:00Evinx, I would happily support right to work laws,...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. <br /><br />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.Anonymousnoreply@blogger.com