Taken to the heartless extreme.
Related posts:
- Refusing to wash hands on religious grounds
- Are patients refusing doctors who no longer do hospital work?
- What happens if the safety net clinics start refusing to see Medicare or Medicaid patients?
- Refusing flu shots; Ascending cholangitis; Hospitals cherry-picking; Pfizer goes generic; Stroke in a 32-year old; Medicare for all inevitable?
- Being on call
- On-call
- On call
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As usual Kevin, it’s not as clear cut as your National Enquirer-like header would lead one to believe. It’s about a poorly staffed ER trying to dump a case onto a neighboring hospital’s consultant. As usual Dr. Leap is wildly naive about how the real world functions from his little ivory tower of salaried, shift work.
Wow, I didn’t know I was salaried! I need to talk to administration about some back pay.
Well, here’s the thing. Our ER is staffed by nine physicians, all board certified by the American Board of Emergency Medicine. In fact, until recently, we were the only hospital in SC that could make that claim. I don’t consider us poorly-staffed.
Our hospital has struggled with specialty staffing, as many rural facilities do. We only have one ENT now, though we’ve recruited another. That one ENT doesn’t have to be on call every day. In fact, he only has to be on call every third day.
We have arrangements with other facilities, but I assume that since this was a child my partner tried to send him to our pediatric referral center. But even those places where we have arrangements are often hesitant to take transfers. I understand; they’re already overworked. But this wasn’t just any situation.
It wasn’t a dump, anonymous, it was a child who may have lost an airway and died, and who needed surgical involvement. We try to keep everything in house, since transfers are difficult, dangerous and often met with unprofessional, angry attitudes.
I have done this for almost 15 years, and one thing I’m not is naive. The real world is very clear to me, since I bill my patients and have never worked at our hospital for salary. In fact, our uninsured patient population is about 30%, much higher than most places. And if you think a non-profit, private hospital in a rural area is an ivory tower, then maybe you need a class on ivory, or towers, or something.
Sincerely,
Edwin Leap, MD, FACEP
If the crooked lawyers, oops I meant distinguished South Carolina legislature, made ER duty liability free, there would be no shortage of specialists.
ER on-call is an undesirable public service for consultants. Lets recognize this legally.
So it’s OK that your tertiary referral center is too overworked to take the child, but it’s not OK for the overworked private guy in the neighboring hospital to refuse?? It’s OK for your hospital not to have in place a contingency plan for these emegencies, but it’s OK to dump that responsibility on a private consultant who doesn’t attend at your hospital? BTW where was YOUR ENT in all of this? How is it that the child fared alright inspite of not having your needed consultant after all?
Sorry I din’t know your weren’t salaried. But answer the questions please.
Dr. Leap, what’s the status of tort reform in your state? Specifically noneconomic damages. Or…..as I don’t know your referral area, the status of tort rules in a neighboring state if you need to refer across state lines.
Edwin Leap MD, FACEP:
You are glossing over the fact that your hospital is unprepared to deal with after-hours emergency specialist call. Why is there only one ENT? Why haven’t they successfully recruited more? Why didn’t you call the ENT from your hospital, even if he wasn’t on call that night? What could it have hurt? He must be getting your regular referrals, so it would have been reasonable for him to bend a little to take this one. Or does your ER have a practice of sending the good referrals one way and other things another way when your staff specialty docs aren’t on call? If that is the case, then you were dumping, plain and simple. You really have no right to expect staff specialists at other hospitals but not your own to play the patsy for you. And holding up the patient like a hostage is, child or not, the last refuge of a scoundrel.
Most specialists get difficult about accepting out of area transfers out of miserable experience and abuse. Hospitals that treat local specialists who generate surgery billings at the local hospital preferentially but are quick to dump uninsured patients out the door on other ERs and their covering specialists with the argument that they don’t have coverage quickly get known for their practices.
I am a specialist surgeon and I get calls from ERs in other states wanting to send me patients (some who have not even been properly stabilized) because their specialists who are on call just don’t answer their phone. The problem I have with those EDs is that they never send me patients otherwise, it is only when they need to dump someone when their own docs aren’t answering. Sorry, but you can’t play things like that both ways. So I really don’t feel I owe it to them to bail them out when I realize I am only a chump to them.
–A Specialty Surgeon, FAAO, FACS
I posted this at Dr. Leap’s blog; it makes even more sense after the surgeon’s post above:
I can’t think of a likely explanation for the ENT’s response except that he’s a jerk, but unfortunately, he’s allowed to be a jerk. I would not respond as he did, but, understanding that he’s a jerk, his response was rational. Working on sick infants at night is never easy, and for him, the risk/reward ratio was in favor of going back to sleep, watching TV, reading, or whatever he was doing when he was called. Accepting a sick child in most places sets the doc up for ~2 decades of potential liability, probable Medicaid (at best) reimbursement, and potential dealings with toxic parents. When we have HIPAA, EMTALA, hospital administrators, JCAHO, insurance companies, legislatures, and lawyers constantly telling us who we have to take care of, where we can take care of them, how long we have to get there, and what we are allowed to charge, not to mention the possible loss of our livelihood from a bad outcome, the motivation for picking up that extra emergency patient from an out of town hospital wears thin.
Come to think of it, he doesn’t have to be a jerk, just a rational actor. Practicing medicine in the USA in 2008 is not a rational activity.
it seems best if we decide that getting sick at night should be a never event.
i am a 24/7 specialist in a rural area. it sucks covering my own area, let alone someone else’s. it only takes a few calls to really ruin a weeks sleep and make your life miserable. it is not so easy to recruit specialists into rural areas. i would dearly love to have more, but there is no business for it.
i’m not even sure how long i can last here, because i got busier and busier. eventually something is going to have to give.
jb : 1:00 PM:
Your eloquence in the above post is downright scary. You probably just convinced half the specialists who read your post to quit taking call.
My only problem with all this is: who is going to take call when you or I get sick at 4AM? Remind me never to grow old or get ill.
How often do you read the flip answers from non-physicians and a certain lawyer about how we’re poor businessmen, just drop out of the insurance contracts, and in various ways have brought our problems on ourselves?
Well, you’ve just seen what happens when the doctors are good businessmen. The doctors don’t necessarily disappear when malpractice liability is a threat. They just reorder their lives so as to minimize their exposure to risk. The neurosurgeons bring their business to non-trauma hospitals so they don’t have to do emergent intracranial neurosurgery.
The ENT surgeon gets little benefit from a business standpoint from accepting the child. Medicaid or uninsured is more likely. The patient did not necessarily need surgery, so even if insured, little monetary benefit. And a BIG litigation risk if things go wrong.
And goodwill? Sounds like the ER in question is not a significant referral source for the ENT consulted.
There are other businesses, banks, various enterprises that find certain customers are not worth having. Here’s a doctor who feels the same way.
No, I’d treat the kid. But I’m not rational. The ENT surgeon *IS* rational from a business standpoint.
Oh, and in my rural hospital, the ER docs faced with this problem try to force the child onto the FP on-call. I’ve had my share of such problems. Then it’s my problem to find the consultant.
That’s why I stopped taking ER call at my hospital. The problem rolls on.
And no, I don’t want to see tort liability reduced just for ER work. All that does is spread the liability to the primary care doctor. Tort reform for all doctors, or none.
Playing a small part in the education of present day residents is enough to make me pray for good health. If you think the old timers are reluctant to get out of bed to see a patient, check out the 80-hour residents, who are trained that it’s illegal to get up in the middle of the night.
Just for fun, I looked up the reimbursement for the ENT to drain the abscess. These are Medicare numbers in my state. Medicaid is usually lower, sometimes much lower, commercial insurance usually a bit higher. Sometimes you get real lucky and there is no coverage and no money.
42720 $360
42725 $687
To get either sum from Medicare, the ENT would have to get out of bed, get dressed, drive to the hospital, evaluate the patient, look at the CT, and decide that surgery is needed. He has to arrange for a pediatrician to help him do post-op care. He has to call in an OR crew, wait an hour for them to arrive and get the OR set up. Only then does he start the operation. Then he does the post-op paperwork. All this takes 2-3 hours (more for the 42725), in the middle of the night. He then has to go home, and start a regular workday in the morning. For the next 90 days, he has to take care of the kid’s post op care, in the hospital and in the office, 24/7, all for the “global fee,” which he may or may not receive.
Try to get a lawyer or a plumber to work under those conditions.
“Remind me never to grow old or get ill.”
If you do get old or ill, make sure to avoid rural areas.
If I understand the story correctly, it is not even clear the surgeon will get that.
Meaning, the patient may not even need surgery in the first place.
Effectively, take the medicolegal risk for no benefit. The kid gets admitted to pediatricians, leaving the ENT sitting around to no reward if no surgery, but johnny on the spot to take the liability if things go wrong. And, as jb pointed out, the ticking time bomb can be upwards of two decades. South Carolina, it seems to be seven years for a minor. At least that’s what I see from glancing at the state summaries.
And yes, I agree with Dr. Leap in the sense that it is too bad that doctors don’t want to take on this risk, but I understand how it came about.
In a previous era, before Dr. Leap arrived, I was practicing in an outlying hospital in the upstate of South Carolina. I accepted any and all in my specialty for inpatient care–and soon noticed that the biggest hospital provider in the Greenville-Spartanburg area in my field was sending their uninsured patients out to our ER and telling them to ask for me. (This was pre-EMTALA).
That put me about 80% of the way to being cured of taking ER call. In this case it was a referral down the pyramid instead of up–based on who was the biggest sucker.
Good for him. Refusal to work for free less than market value is the only way that reimbursements will change. It is a shame that only the subspecialists put their foot down.
Maybe, the ENT, like Dr. Kranky is just a bitter self centered jerk. Or maybe he has been up with 2am cases for 3-4 nights in a row and just can’t do it any more.
I would like to be able to slam dunk a basketball. No matter how hard I try it is just not possible for me. Maybe it was just impossible to take on another charity case, not monetarily, but physically and mentally.
That said, the very first anonymous has no clue to the real world. Most ER docs are not salaried. And if the ENT doc himself needed an ENT there would not be an ENT (or plastic, neuro, hand, GI, neurosurg) at a large percentage of hospitals across AMerica.
I would imagine Dr. Leap has the telephone number of the local ENT surgeon. The local ENT doctor has set limits to his “professionalism” or whatever word you want to use. So he doesn’t get worked to death. Remember a generation or two ago, such a doc really would have been expected to be available 24/7.
If that local ENT doc had been called, he’d have said “I’m not on-call today”. Even though he could have conceivably done the work. He set limits.
And that’s OK.
This other out-of-town doc. He set limits as well. He was on-call, but not for the whole planet. There’s probably an African with a parotid tumor compromising his airway. Maybe we can send to the doc on-call. It’s not a drunk with a broken jaw, etc.
But no. The doctor has said he’s on call for hospital “A”, “B”, and “C”….and that’s all. He set limits.
And to Dr. Leap, that’s unprofessional. Why?
Yep Anon 8:44, I Dr. Kranky must be a self-centered, bitter jerk because I don’t want to hang on a cross of someone else’s making.
You, like the illustrious Dr. Leap FACEP are trying to crucify me because of an erroneous assumption I made about him being a salaried physician. (Pardon me, since where I practice the majority of the ER docs ARE in fact salaried) I already addressed that, but please continue to harp on it as it allows you and Dr. Leap to continue to avoid the thorny questions posed- which have been answered effectively by all the above detractors.
Oh and if you DO happen to hear of some guy in Botswana with a compressive parotid tumor in desperate need of an ENT, please feel free to call me as I wouldn’t wish to carry the albatross of “heartlessness” any more than I might be permitted.
I used the example of the African with the big parotid tumor compromising the airway because I’ve been there, done that. Well, as a general physician. The general surgeon got the parotid tumor. We barely maintained the airway until it could get operated. Scary.
We would have sent the African to an ENT in South Carolina but the unprofessional airlines did not give us access to a 747 to ship the guy overseas.
Now heck, I can relate to the plight. But Dr. Leap was asking *SOME* ENT doc somewhere to extend himself. The local ENT doc was not asked to extend himself. The University ENT docs were not asked to extend themselves. But a private ENT doc out of town was asked to extend himself, he declined, and he’s singled out as “unprofessional”.
OK guys,
Thanks for all your comments. I think this is an intriguing line of discussion.
I get the point of being overworked. I’m not suggesting we work for free. I realize the reimbursement is miserable, especially at the Medicaid rates. I know because I, too, take care of Medicaid patients.
I don’t even know if the child in question had insurance or not. The thing is, we run into this problem with both the insured and the uninsured.
I believe in capitalism. I really do! I like making money! But the plight of people in communities all over America is like this. They need something, but no specialist is available.
It isn’t as simple as abuse of real doctors by stupid, simplistic ER doctors who just don’t get anything in their arrogance. That’s a nice, simple way to describe it, and it may be somewhat cathartic, but it’s unrealistic. We make dispositions on countless problems without any specialist help.
But what are we going to do for our children? What are you going to do for your children? I understand not wanting to be worked to death. So do we increase the number of specialists we train? In order for them to go to under-served areas?
Do we bring about the nightmare of national health care? We’ll all get paid for everyone, but not very much. Then, specialists will quit, and the same issue remains.
I wish everyone had private insurance. I wish, in fact, that insurance had never existed. Things would be cleaner, simpler and probably cheaper for everyone.
And maybe, the answer is just this. In order to preserve realistic schedules, and realistic reimbursement, we just need to let more people go without specialist coverage. There will be some disasters, but that might get people’s attention in the halls of power. Is that where we need to head?
I’ve asked for honest suggestions. All I have gotten from detractors is 1) angry personal attacks 2) angry comments about an admittedly broken system and 3) angry discussions of how we’re abusing specialists.
Please tell me what we should do? Please tell me what you would do! I’m honestly curious.
We all need to have these discussions. But name-calling isn’t going to cut it.
I’d love to never bother another specialist out of town. But we weren’t contacting a facility we don’t already refer to regularly. My partner didn’t go down a list of who he had and had not dumped on lately. And rest assured, we don’t selectively send paying patients to our own ENT, but indigents out of town. That may happen some places, but not at the hospital where I work.
My partner was just trying to find help for a situation he was unable to fix himself.
Was it unprofessional of the ENT to refuse? Maybe, in light of the comments here, it wasn’t. Maybe I misspoke. I apologize for that. I’m sure he’s oveworked, overtired, and sick of being consulted on people who aren’t his own. I’m sorry we had to call anyone, and I’m sorry that rural hospitals have to bother anyone at all. I’m sorry we don’t have a neurosurgeon, a CT surgeon, pediatric subspecialties and a full slate of ENTs.
I’d love some direction here. How do we repair this system? How do we get treated fairly, ER docs and and specialists alike?
Less anger, please, and more suggestions.
Edwin
“……It makes me see how malpractice litigation could get out of hand…….”
I see it the other way around. Refusal to see a patient like this did not cause malpractice litigation to get out of hand, it is the RESULT of malpractice litigation getting out of hand. As I recall, you had tort reform pass in 2005. Let’s see if it survives challenge.
Tort reform failed in my state. A story like yours gets far less sympathy locally.
Well said Dr. Leap.
I am waiting for the good constructive ideas.
In response to the question about “what do we do”:
I, too, believe in capitalism. The more that health care is “centrally planned”, the worse the outcome. Our current health care system responds to economic realities. To see the effects, I just have to look at what hospitals and physicians are doing, and what they are not doing. They are doing redo CABGs on 90 year-olds. They aren’t as interested in filling cavities in kids. One pays, the other doesn’t (for the most part).
While I did feel a sense of national shame when I watched “Sicko” (I brace for the boos), I think that the better solution is truly market-based, and revolutionary.
1. Get rid of all of the entitlement programs, the federal insurers, and by extension most of the private insurers. Vastly reduce taxes to the minimum needed to run a federal government (probably less than 20% of the current budget, if that), and ensure meaningful oversight: by physicians and interested citizens, at the local level. Overhaul tort law at the national level.
2. Charge cash for everything. Post prices. This means that if you have a lot of money and are seeking care for your cancer, you can shop around at the best places, and get your care where the outcomes are the same, but the price is right. Prices settle to the “right” level, and when the working poor or indigent person is looking for the same care, they will know what it costs. What would that mean in the ER? Maybe it costs $150 for me to look at your ear and treat your pain from otitis. When an indigent person comes for care, the hospital will decide, based on its mission and values, how much care to provide, in partnership with local institutions. That includes how much it will cost to subsidize my time “being there” for that patient.
3. Let individuals, foundations, churches, etc., decide how to care for those who can’t afford care. The boards who run these local organizations have a better idea of the need and worthiness of individuals seeking care. Keep government out. While I give to charity, I also pay a LOT of taxes. Eliminate a lot of the tax, and unburden the organizations who want to provide care from the myriad regulations that make this difficult and attach strings, and I would believe my charitable giving was on target.
4. Get rid of HIPAA, EMTALA, and all of that. Let local hospitals decide the rules of staff membership, and local communities can decide whether the decisions the hospitals make are in keeping with the values of the community. By extension, open up the medical record to “open source” development, so the most useful and pertinent information is there, in the best possible format (depending on your specialty – in the ER, the screen would show allergies, meds, and major medical problems first). Everyone has a medical ID number, and facilities can track patients by this number, to decrease diversion and abuse of narcotics–and get these individuals to appropriate treatment. Voila! Billions in red tape are gone, and the information is better. Can you imagine the medical record for a patient with a URI? “Patient has three days of cough and rhinorrhea. Normal exam. URI. Supportive care, instructions given.”
Stringently criminalize the misuse of medical information. If you log on to someone’s chart who is not your patient, on purpose, it’s a crime. If you log on and you’re not a physician or authorized to access records, it’s a crime.
There would be a shake-up as the market tried to determine what services actually cost, but overall I think it would be a lot less than what we charge right now. I also think that practicing in this environment would be much more rewarding. You can choose to do charitable care, instead of having it pressed upon you. You can work at a tertiary care center because you want to take care of the sick kid with the peritonsilar abscess, and teach your residents how to do the same.
If you want to “semi-retire” and see patient on a limited basis in a rural clinic, you can do it. Right now, malpractice premiums prevent this.
I imagine this post will be regarded as wildly naive as well. But if you don’t imagine the solution, you’ll never get there.
Unrealistic? In the current setting, yes. But compared to the current system, with HillaryCare grafted onto it? You decide.
anon 2:01,
I am all for it. it is freaking scary that the country is running after Hilary, Barack, and other politicians in just exactly the opposite direction.
I’m just a simple country ER Doc but here’s the standard I’d like to use: What would I want done for my family? I think that’s pretty simple. Quit whining and do the right thing. The only thing worse than a specialist laying into me over the phone as if I’d somehow created this sick patient would be the same specialist in my face because I could not get someone to take care of his/her kid in an emergency. You can’t have it both ways (oh, wait yes YOU can because you’d simply call up one of your buddies, bypass the system and get your child the care they need…as it should be). What about the rest of the folks out there?
Edwin:
I think the immediate answer is to do what you did, keep trying until the child gets while they need, but without wasting energy being judgmental about those who wouldn’t help. Without wearing their shoes, you can’t know if they were stretched beyond their resources and saying the right thing in saying “no” or just plain greedy. Since you can’t know, why bother thinking about it.
When I tried to say yes to all, life was unbearable and I broke eventually. People, including a few ER docs, took flagrant advantage of my willingness to help. “Broke” means that I hurt bad enough to reassess my values, shrug off the sense of responsibility for anyone who I didn’t already have a doctor patient relationship, and set up barriers to all of the other unmet needs out there, just opening the valve a little when I had the time and energy to provide good treatment to my standards.
That naturally means I don’t take ER coverage anymore.
But keep in mind, that I didn’t work in 12 or 24 hour shifts, but took call 24 hours a day for weeks at a time. There were no “turn-off” times.
On the other hand, when I got all of my barriers in place to unmanageable demands (perhaps perfectly manageable to someone made of tougher stuff–but I didn’t make myself so why should I feel guilty) I found myself enforcing my rules to not take on a child, who I probably couldn’t have helped but perhaps have given a small measure of comfort. When it was too late, I realized that I didn’t feel comfortable with that and feel guilty about that.
So now I feel free to make the rules that I need to make to have my life livable, and make it a rule to break them when my conscience compells me to do so.
But it is my conscience that must compel me, not your bind, so that doesn’t solve your problem. Perhaps accepting that everyone is trying to survive this profession in their own way (some by unbridled greed) and respecting that, even if it means that they are unavailable to help you with your patients might help you be more at peace with it.
We all accepted certain frustrations when we entered our chosen profession–although judging from the blogs, I don’t see much evidence of the acceptance part. One of the burdens you accepted by going into ER medicine was putting yourself in the peculiar position of always having to find someone to hand patients downstream to and doing this many times a day. This puts you in the position of being especially impacted by service limitations–such as one or no ENT docs who are actually obligated to be available to your patients–especially upon choosing to work in a semi-rural hospital.
Letting yourself resent that is a bit like a family physician resenting always having his skills compared to specialists, or a psychiatrist resenting his patients being nuts, or a physiatrist resenting dealing with chronic pain patients. Surely you knew it would be so?
Oh my God, what comments we have in here. Look, I totally understand where docs don’t want to cover other facilities, but believe me, as an ED doctor, 1) we do our BEST to not transfer patients and 2) there are NOT enough specialists to provide every hospital in America with 24 hours of call in every specialty.
Any time you get called, put yourself in the ED docs shoes–or maybe even the patients–and see what YOU would want. If we are making mulitple phone calls, that is less time we can spend caring for our patients. And in the meantime the “transferee” can be getting sicker.
I agree with Ed, and well said. And while I take care of an ever increasing population that doesn’t pay me, and my pay check keeps dwindling to match, I still CARE for them.
600 dollars + for a patient?–do you know the MOST we get per patient in an ED is usually in the 300 dollar range, and our average is under 100 dollars? That Dr. LEap was paid (if lucky) on medicaid 90 dollars to do the exam, work up the patient, spend time on the phone, etc? So don’t whine about that to us. Show us your write offs, we will show you ours–I will guarantee you we are higher.
Will someone PLEASE explain to me WHY all this moral dudgeon applies:
NOT to the ENT doctor who reasonably chooses to limit the number of days he is available….
NOT to the University ENT doctor who chooses to limit the number of patients he takes on…..
But it DOES apply to a private out-of-area ENT in a non-referral hospital who chooses to limit the number of hospitals he covers?
Correct me if I misunderstand the facts as above. The ENT is in some community setting and has arrangements to cover certain hsopitals, but no other.
You can limit the number of days you’re on, the number of patients you have, but not the geographic area you cover? If someone from New Mexico wanted to send the patient to South Carolina, would it be an EMTALA violation if the South Carolina doc declined the transfer?
For those who think that’s a reductio ad absurdem, I’d say EMTALA is a reductio ad absurdem. It’s reach extends day by day. They’d extend it to my private office if they could, and I’m sure they’re trying.
Anonymous 5:03,
I agree with the earlier post that stated that we should worry about the future, for ourselves and our families, even in cities.
In the past, there wasn’t so much of an issue. You went into a field, and you took care of the patients, no matter the disruption to your lifestyle. It’s just how it was done.
I don’t think that that lifestyle will cut it today. I’m the first to admit that, although I enjoy my busy rural ED practice, I don’t want to be there 24/7, and I want my time off. While I may sometimes (often?) question the standards to which some of my colleagues adhere (last night I talked to my general surgeon about a [well-insured] 50 year old with appendicitis, at 8 pm; the direction was “admit to my partner so he can take it out in 11 hours), I understand there have to be boundaries.
I agree about the Reductio. Money is tight, and money isn’t enough to motivate people to take care of every patient who really needs care, in a hospital’s referral network or not. In order for physicians to be truly happy in our profession, we need the respect and appreciation of the public. We also need the money, but the fact that many of us make a lot of money (and made more a couple of decades ago) didn’t help with this sort of appreciation.
It’s like drug policy: regulate everything, and you have millions in prison for minor violations, at massive expense. The problem is just getting bigger. The medicine version is: pay physicians less, regulate them more, and then complain that some of them might not want to take call.
Eliminate the entitlements and the rules.
Anon 2:01
I wish Ayn Rand were alive today to write “Aesclepius Sneezed”.
To those who have read Atlas Shrugged, this would make sense. To the rest of you, I recommend strongly that you read Atlas Shrugged.
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