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.
Related posts:
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- Studies of the obvious: It’s easier to get a dermatologist for cosmetic procedures
- Chronic pain in the ER
- Does telemedicine reduce malpractice risk?
{ 36 comments }
This is obvious to every doctor in practice. There is no easy fix for this besides not being the guy in the middle of the dodgeball game.
I’d like everyone who reads this post to know that when they go to see their primary care doctor, he/she is underpaid and you are abusing him through your insurance intermediary. Also know that if that person has enough savings and skills, they will not be there for the next 30 years like you expect them to be. They are rational players and are doing their best to extract themselves from an untenable situation.
“Fix primary care access and reform the malpractice system.”
Those aren’t “solutions” those are goals. How would you implement them is the question.
As for the latter, many states already have draconian tort reform. Are California ER’s not in crisis as a result?
Kevin, you’re getting lax in your factual support for your positions.
I left primary care two months ago for a hospitalist position. When I left the office was down to 2.5 PCPs, down from 7 PCPs that we had 8 months ago. I work less for more money and deal with a lot less aggravation. The docs leaving primary care aren’t just a trickle here…it’s a regular waterfall.
Don’t worry, the powers that be are trying to make it more palatable by appealing to what you guys value most:
http://medrants.com/index.php/archives/2832#comments
I think a great way to fix the primary care problem is to sarcastically deride doctors for responding to financial incentives LIKE EVERY OTHER PERSON ON THE PLANET DOES.
As long as people keep ignoring the problem and blame the doctors, access will decline. I’m sure the critics who come to this blog think all doctors are overpaid, arrogant creeps who hate patients. That is so far removed from reality it surprises me people still think that way. However, it is a convenient rationalization for opponents of reform such that they have a political correct scapegoat to blame (rich greedy doctors). When the rich greedy doctors are gone, who will you blame then?
Anon lawyer 6:41, I hope you have found the only independently wealthy physician martyr to be your primary care doctor. That way you can safely ignore the problem while everyone else suffers. What will you do when your selfless martyr feels he has to see 50 people a day instead of 20? You won’t be able to pay him more to see you, because he doesn’t value money, remember?
Anonymouse 7:40, I hope the irony of a physician like yourself (I presume) complaining about others scapegoating based on wealth is not lost on you.
As for Anon 6:41’s comments, they are correct. Kevin offers no solutions, only goals. One of his solutions has been tried in many states, and evidently hasn’t alleviated the ER problem in those states. Do you dispute that?
Malpractice concerns are just ONE element of the ER crisis. Fixing that alone won’t solve it. I’ll concede you that. It may help to bring back specialty back up coverage to ER’s that would benefit patients and lessen transfers.
In addition to Kevin’s reasons for ER crisis there are many other including, but not limited to
-EMATALA – federal unfunded mandate to medically screen all comers.
-ER/hospital closures (discussed in the link)
-illegal aliens
-uninsured
-alcohol
-drug abuse
-human stupidity
-convenience: “why bother with making an appointment when I can go torture the ER doc at 3am with my chronic problem or my hangnail”
-poor mental health services
-the perception that you actually need to see a doctor if you vomited once, have a sniffle, your kid has a fever but looks fine.
I’d like to thank the last commenter for posting, as those are most of the reasons for ER overcrowding……….
“It may help to bring back specialty back up coverage to ER’s that would benefit patients and lessen transfers.”
Has it in California?
Is not medicine both business and art? Just like plumbing, IT, auto mech, etc. If you had a water pipe break in your home in the middle of the night what would you do? Many people smarter than I have asked the same question. They have applied the same logic to health care (e.g. VA Healthcare IT System). How do we as consumers, providers and intermediaries (ins.,legal, MCO etc.) begin to reason what is the most important “business and art” considerations we want answered. ER’s are under enormous pressure to fullfill a “safety net” function because we don’t know what all the “parties” are willing to sacrifice or commit. So the next time your auto doesn’t start in the early morning think about the ER providers practicing a “business and art” because that’s what they are committted and sacrificed to.
Probably not.
A lot of posters here seem to have an illusion that California must be a good place to practice medicine because of tort reforms. Yes there are caps on pain and suffering but that has not lessened the number of litiginous a-holes around, or raised the bar for lawsuits to be filed. You need a very low burden of proof in CA to bring a lawsuit. Caps on damages have not done enough to lower rates to help out the emergency room.
Example: A good ENT friend has practiced 10 years without a lawsuit. He has to pay 50K/year extra in malpractice premium if he is going to provide emergency/trauma call. That is an easy business/lifestyle decision. Pay 50k for the chance to have to come in at 0300 on a sunday morning and treat some cussing drunk. He said “No thank you”
California also has probably the highest numbers of the “other” facters leading to ER crisis, namely: hospital closures, illegal aliens, uninsured wo there is just too many variables in the equation you ask about.
“You need a very low burden of proof in CA to bring a lawsuit. “
What’s the difference in their standard and any other standard?
“Caps on damages have not done enough to lower rates to help out the emergency room.”
Funny, they don’t seem to work ever, do there?
Who would have thought that all the problems in healthcare couldn’t be fixed by caps? Or that they would have little to no effect except on insurer return?
Stunning.
California doesnt have just tort reform, they have strict regulations on med mal insurance carriers that other states dont have.
So if you are going to claim that Cali’s system still isnt working, you have to fault both tort reform AND insurance regulations.
“Funny, they don’t seem to work ever, do there?”
“Who would have thought that all the problems in healthcare couldn’t be fixed by caps? “
Who claimed they were going to cure all problems in healthcare? That is what you think the whole argument is about.
Insurance rates are SIGNIFICANTLY lower in CA than elseswhere. It also limits ambulance chasers from making a killing on contingency fees from a sob story. So in those regards they 9caps) are effective.
Fewer doctors = better health outcomes. I hope more of you leave.
Elliot,
the date you seem so comfortable quoting illustrates the law of diminishing returns. This is evident in any industry. If you put too many workers in a factory, produtivity will actually fall. That is what these studies proved, something that has been known for years.
the flip side of this problem is what is happening in rural america, where women have to drive an hour for prenatal care and deliveries. I suppose you live in an urban area and just dislike doctors in general, as it wouldn’t make much sense for you to wish that your access to care is reduced.
although I wish it was for you.
Eliott:
You do whatever good you intend a disservice.
Being an angry crank, or merely acting the part, with an irrational dislike of doctors really discounts your point of view, just as much as those who mindlessly rail against lawyers.
You paint the picture of a frustrated, angry, lonely person who has directed his energies in ways that probably make you more likely to be isolated and sidelined, and whose opinions are met more with an eyeroll than with any real interest. If true, it has to be limiting. Your presentation alone, and the consistency of that presentation, makes me want to discount what you say. I can’t believe that is what you intend.
If you are an insightful person, you might try a different tack. You might assume something other than the worst of those whose opinions differ from yours. It isn’t all you could do, but it would be a start.
“…the perception that you actually need to see a doctor if you vomited once, have a sniffle, your kid has a fever but looks fine.”
The only problem I have with this (and it’s minor…the perspectives here are very eye-opening) is that clinics and hospitals do — at least in my neck of the woods — promote themselves as being readily available for just this sort of thing.
The only thing that will improve ER presentations (particularly inappropriate presentations) is an adequate primary care system. I don’t mean simply more primary care physicians – I mean a better SYSTEM In the US there is not a systematic, government supported, widespread, integrated primary care system (perhas in rural areas it comes close, but even then its undermined by state and federal policy) More ER’s and specialists overall dont increase population longevity – primary care does. Look at work of Barbara Starfield et al for more info
Lyndal (Australia)
B. STarfield is staff at Johns Hopkins
Here is her bio
http://faculty.jhsph.edu/?F=Barbara&L=Starfield
and a summary of her work
http://medicalreporter.health.org/tmr0699/importance_of_primary_care_to_he.htm
See what you think…
The short version of the California story appears to be that insurance companies profit from caps (to the detriment of malpractice victims and with no meaningful reduction in the cost of insurance), and doctors benefit significantly by the regulation of insurance companies (to the detriment of insurance company profit margins but with no negative impact on patient care).
I am wondering about this:
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.
What does that have to do with “defensive medicine”, as opposed to providing an accurate diagnosis of a potentially life-threatening condition? If a primary care physician can’t rule out a potentially life-threatening heart condition, what would you have the doctor do? Send the patient home?
It’s a rare appendicitis case which would result in a malpractice suit, isn’t it? Here in Michigan, a few years back, I spoke with a lawyer who was trying to find a malpractice attorney who would take an appendicitis case – a missed diagnosis followed by a ruptured appendix, emergency surgery, and brief hospitalization for peritonitis. Every malpractice lawyer he had consulted turned down the case, not because they could not show a violation of the standard of care, but because they couldn’t recover enough in damages under those facts to offset the cost of litigation. So if the goal of malpractice reform is to allow a doctor to avoid consequence for making a bad diagnosis, in that case it earned a gold star.
What does your link about issuing prescriptions by telephone have to do with defensive medicine, as opposed to an overbroad, anti-patient office policy? Can you identify even one lawsuit, anywhere in the world, at any time in recorded history, where a patient successfully sued because he was given an antibiotic prescription by phone for conjunctivitis, with appropriate instruction about follow-up care?
Aaron,
Thanks for your comments.
100% accuracy in medical diagnosis is an impossibility that the public and lawyers fail to understand.
I encourage you to read this post to help you understand the physicians’ perspective:
http://www.kevinmd.com/blog/2005/09/harms-of-overtesting.html
There has to be acceptance of a small amount of misdiagnosis despite appropriate standard of care.
Or else, we’ll be performing laparotomies for every RLQ abdominal pain and heart caths for every chest pain.
I’m sure that you can understand how unfeasible that is.
Thanks,
Kevin
“100% accuracy in medical diagnosis is an impossibility that the public and lawyers fail to understand.”
Kevin, given that lawyers turn down many cases with bad outcomes because there isn’t negligence there, and juries find for physicians 75% of the time at trial, how do you support this statement? Is this a fact based or faith based opinion?
CJD
“Insurance rates are SIGNIFICANTLY lower in CA than elseswhere.”
Really? How much?
“It also limits ambulance chasers from making a killing on contingency fees from a sob story”
And the patients? How do they make out?
CJD
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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