Comments on: A borderline admission from the ER, or not

By: jsmith

jsmith — Mon, 17 Aug 2009 03:01:01 +0000

Do the right thing for the patient, not for society or the insurance company. This is a no-brainer. America screws up the medical system and then expects us docs to be the bad guys for them. Screw them.

By: Robert Ricketson

Robert Ricketson — Sat, 15 Aug 2009 03:26:10 +0000

There is no dichotomy. The responsible choice was to exactly what was done. Stay true to the philosophy and not the system. The only question I had was, when she was diagnosed with lung CA. were there any discussions as to her immediate and future needs? Was the dx from an OP bx or inpatient? What may have been done before that could have been done before the ER visit.? The right thing was done given the immediate circumstances. Take a beating in UR. So what? You still have to go home with yourself.

By: Doctor D

Doctor D — Fri, 14 Aug 2009 22:50:05 +0000

Marc, a lot of these situations happen at 2 am or on a Sunday when no one will answer the phone to set up the CT or the appointment with primary care. The ER doc isn’t passing the buck, he/she simply has no ability to set up what the patient needs at the time he is with the patient.

The only way I can think to solve the “logistical problem” would be to staff primary care offices and radiology scheduling offices 24/7 like an ER. That would certainly increase the cost of healthcare.

A little responsibility by the patient might be required. We should treat our patients as adults rather than children.

By: Marc Gorayeb, MD

Marc Gorayeb, MD — Fri, 14 Aug 2009 21:55:56 +0000

Hold on a minute. Why isn’t it the emergency physician’s responsibility to arrange for a definitive next step? E.g., schedule a CT scan and follow-up with an identified primary physician, with whom one has made dirrect contact. Talk about passing the buck. The inpatient wards are not a dumping ground for difficult logistical problems; they are for acutely sick patients requiring treatment now. We should at least attempt to solve the logistical problem. This is the kind of practice behavior that will get us to Obamacare.

By: Michael Rack, MD

Michael Rack, MD — Fri, 14 Aug 2009 15:33:11 +0000

“Dr. DeBakey replied that if the administrator wished the patient discharged, let him come and write the discharge order.”

That was a while ago. Currently, if a doc said something like that, he would likely be labeled a “disruptive physician” and terminated from the medical staff.

By: Doc99

Doc99 — Fri, 14 Aug 2009 13:18:26 +0000

Physicians should make medical recommendations/decisions based on medical considerations, not economic. Ultimately, the patient has the right of first refusal. One day, the late Michael DeBakey received a call from the hospital administrator concerning one of his patients’ length of stay. Dr. DeBakey replied that if the administrator wished the patient discharged, let him come and write the discharge order.

By: dennis

dennis — Fri, 14 Aug 2009 10:51:29 +0000

This is the sad reality that has become our society. Where money is often weighed against that which benefits the good of people.

By: Okulus

Okulus — Fri, 14 Aug 2009 10:50:41 +0000

Well, Dr. Pines admitted her (or pressured the IM service to admit) and he feels good about that, even if he admits himself she was not sick enough for admission, and he got some column space in the paper for his trouble. No matter. The utilization review folks will cast their vote–using the criteria of Medicaid–and will force the patient out of the bed even Dr, pines thinks she really doesn’t need, or does need, or whatever.

By: Doctor D

Doctor D — Fri, 14 Aug 2009 05:33:31 +0000

Ah, the “social admission.” These things are tricky: If the ER doc gave her good instructions on how to seek follow up and how important it is she would likely get the appropriate care.

The problematic word in that last sentence is “likely.” The doc worries what if the “unlikely” happens and she just never follows up, even though the doc told her about the cancer and what to do about it.

Who would be responsible? A jury may decide the physician not the patient is responsible. So the doc adds an extra $10,000 or so to her medical costs in order to ensure she is responsible.

I admit I’ve done it too.

By: Matt

Matt — Fri, 14 Aug 2009 00:16:27 +0000

This illustrates a difficult dichotomy that exists for physicians. What hat do I need to be wearing right now- the one where I’m looking out for what is in the best interests of the patient in front of me, or the utilitarian hat, looking out for what’s best for the system, thus looking out for costs. At this juncture, it is quite difficult to find a happy medium in many situations.