Yes, ERs are in crisis. A favorite topic here. A major part of the problem can be traced to poor primary care access and “defensive medicine”. Let me elaborate:
1) Lack of access
Lack of primary care incentives for medical students and providers = dwindling primary care access = patients going to the ER for “routine” or non-emergent care = ER overcrowding = eventual collapse. Simple.
2) “Defensive medicine”
Sending patients to the ER is how office providers practice defensive medicine. Any patient who presents to the office with RLQ abdominal pain or chest pain gets immediately sent to the ER to rule out appendicitis or heart attack. Imagine the outrage if a PCP “missed” an appy or heart attack. As the defensive medicine mentality continues to run rampant, the threshold for sending people defensively to the ER continues to lower.
The same goes for overnight and weekend calls. As the perceived threat of malpractice rises, no doctor would be willing to give any advice over the phone. The liability exposure for telephone medicine is too great. Hence, “go to the ER” will soon be universal telemedicine advice.
Argue about the sense of this if you must, but hey, I just tell it like it is.
The solution? Fix primary care access and reform the malpractice system. These two issues are direct causes of the ER crisis and their resolution will go a long way to healing the broken system.
Update:
Medrants chimes in.
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I am well aware that 100% accuracy in testing isn’t possible, and never claimed otherwise. But that’s not the issue.
What degree of diagnostic certainty do you propose can be reached by a primary care physician in a typical family practice, confronted with a patient with a possible heart attack? If it’s 99.99999999%, a trip to the ER is of questionable value and would be unlikely to be authorized by any managed care provider – but there would be a decent prima facie case against a primary care physician who missed the diagnosis. In such a case, a referral wouldn’t be defensive medicine – it would be CYA for bad doctors. If it’s 10%, then a trip to the ER is obviously necessary in order to provide any degree of medical certainty in the diagnosis. Reality obviously falls somewhere in the middle – I leave it to you to tell me where.
It should also be recalled that lawyers don’t create the standard of practice for medical care – that’s set by doctors. If doctors within the primary care physician’s area of practice define the standard of care as “10% is good enough”, a lawyer can’t make a case based upon the failure to send the patient to the ER. But who would say that?
CJD,
I pay about 30-35k/year in CA in 2006. The national median was 53k (AMA 2003) with many paying over 100k.
Cap is only on “pain and suffering”. If they have a legitimate claim with legitimate liability all there other needs should be taken care of.
“Cap is only on “pain and suffering”. If they have a legitimate claim with legitimate liability all there other needs should be taken care of.”
You’re right. A lifetime of pain and suffering should only be worth what you make in a year. Ask Steven Olsen:
http://www.commondreams.org/cgi-bin/print.cgi?file=/views03/0210-08.htm
What would be a fair number for your child’s sight and brain function? But hey, at least he can pay his physicians, right?
“I pay about 30-35k/year in CA in 2006. The national median was 53k (AMA 2003) with many paying over 100k.”
I call this paragraph “Fun with statistics”. You go from what YOU pay to the “national median”. Lies, damn lies, and such.
CJD
You’re right – I’m hopeless. I’m crazy for pointing out your misleading use of statistics. How outrageous!
But with regard to the alleged problems with the shortage of generalists, the solution is simple. Pay more for it. Doctors are no less immune to financial incentives than any other profession.
CJD
CJD,
“I’m crazy for pointing out your misleading use of statistics”
Gee – and you’re not guilty of that? Oh, please.
“with regard to the alleged problems with the shortage of generalists”
Alleged? ALLEGED? I suppose you think there is no shortage? Where the hell are you living?
CJD,
Grass is purple
Grass is purple
Say it over and over to yourself 100 times so you will believe it. Ignore reality, Ignore facts. Way to go counselor.
“Gee – and you’re not guilty of that? Oh, please.”
Please, point out where I have used misleading statistics. Don’t project your own actions on to others.
“Alleged? ALLEGED? I suppose you think there is no shortage? Where the hell are you living?”
My mistake – should have been more clear. I mean the alleged problems that are CAUSING this shortage. The only real problem is that it is not compensated as well.
“Ignore reality, Ignore facts.”
Says someone who puts his faith insurance companies.
I guess my daughter’s situation was an exception. RLQ pain -> to PMD -> to surgeon’s office -> direct admit to hosptial for appendectomy.
Somewhere along the line I’m sure some testing was done, ie white count and probably CT, but none of it was in an ER.
I remember being pretty impressed at the time.
Good postThe general populus will not, however, see this as a crisis until things get significantly worse. To them, there is no shortage, and the waits in ER are, although long, apparently tolerable.
Appealing to them by pointing out what is likely to happen given current trends will not, I think, be successful. I think people like the idea of MDs making less and struggling, not realizing of course that this means (first) fewer primary care docs, then (second) fewer bright young poeople choosing medicine, or limiting their practices to those which are highly renumerative.
The crisis is, at this point, only felt by MDs and health care observers, not patients as such, at least not to a significant enough degree to form any agreement.
So I agree that all of what you say is true. But things are going to have to get far, far worse before people will complain about it. To them, it’s just bad for MDs, therefore …so what?
My take is:
Removing attorneys from the healthcare equation via tort reform.
Reducing healthcare exec’s pay and corporate downsizing. There’s so much redundancy in hospital administration it’s ridiculous.
Increased tax funds for community health clinics, with special concessions for 4 PAs to every physician ratio at those clinics.
Increased funding for preventative medicine instead of tertiary medicine…ie tax incentives for those with healthy lifestyles, increased spending for public education, increased spending for community health programs.
Re-opening long term mental health institutions for the severely and chronically mentally ill with mental health professionals for counseling/case management and PAs for psych meds.(Yes, this is radical, but how expensive is it to have a psych patient hang out in your ER for 12 hours until a psych bed can be located?)
Reducing illegal aliens’ ER usage by changing EMTALA laws regarding mandatory care. Sorry…but it’s going to have to be this way or we will all go without quality medical care sooner or later.
Sending patients to the ER is how office providers practice defensive medicine. Any patient who presents to the office with RLQ abdominal pain or chest pain gets immediately sent to the ER to rule out appendicitis or heart attack.
This actually is defensive medicine on the PMD’s part. Who will likely be named in a lawsuit when it comes down to the beloved primary MD that tried to save me by sending me to the ER, or the dumb (and overworked ER doctor) that made me wait 2 hours with my appy while it ruptured. Of course, not to mention that the ER doctor was doing the same service for 10 other patients that had been sent from home by their PMD. Sh&* rolls down hill and is usually caught by the safety net that is the ER.
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