Does the bulk of excessive medical care happen in the ER?

“These unneeded medical tests and treatments are black and white, not gray. It occurs every day in every doctor’s office, including mine. The most dramatic example of it, however, is the care rendered in our emergency rooms. The volume and expense of care given there routinely is absolutely astonishing.”

Plainly wrong. According to the McKinsey Global Institute, the US spends nearly $650 billion more than predicted from national comparisons–OUTPATIENT CARE accounts for 2/3s of this cost.
http://www.mckinsey.com/mgi/publications/US_healthcare/images/interactive.asp

Michael, heal thyself.

fair points, but i can’t help but notice that these points are being made by someone who does not practice (as far as i know) in an emergency department.

ERs can definitely pack more testing into a single visit than most doctor’s offices can manage. Over the lifetime of a given patient — at least a patient with access to normal outpatient medical care — I’m not sure the ER comes out ahead, though.

Yes, he does see patients with “chest burning” in the office after their potential for cardiac disease has already been assessed and their risk stratification performed. Evaluating a setting where all comers are required to be evaluated by law vs a selected patient population is different. Like the cliche says, apples and oranges.

I have seen patients as both an Emergency Physician and an Internist. There is a big difference in what presents to the different settings and what has been done previously for patients. It is a different “universe” in the ED, but it is also the same for a primary care office vs a sub-specialist office.

Why do ER docs do a lot of tests?
1) Patients expect and demand it and we are at the whim of Press-Ganey for job security.

2) Consultants demand it. I cannot get a surgeon to even LOOK at my patient without a CT scan. I would get laughed at-more accurately-yelled at for diagnosing appendicitis without a CT scan at 3am and waking up the surgeon to inform them of this.

Hospitalists and attendings routinely ask for a complete workup before they will admit a patient. That means not just labs, but followups on labs. CT scans to rule out PE or surgical entities.

I have found that Admitting docs expect more from us than a simple Admit or Discharge. They want a diagnosis and treatment plan.

3) As mentioned above, pts in the ER self select as Emergencies. Therefore an Emergency must be ruled out. I can’t always rule stuff out without further testing.

4) Sometimes pts have ambiguous symptoms that affect areas that require different types of tests. For example, A patient with abdominal pain in RUQ needs an U/S bc that is more effective for picking up GB disease. However, if I think the problems is in the intestines, a CT is the best choice. CTs do not do well ruling out GB disease, so on occasion you need to do both tests if the first one is negative.

5) Lots of patients without insurance come to the ER. These patients will not get tests unless done in the ER. They will fall through the cracks. If I don’t do the CT scan, nobody will. If they had insurance, sure, they could see their doctor and get an outpatient scan. But in reality, the majority of my patients are uninsured or underinsured and can’t get these tests unless they come to the ER.

For the arrogant doctors above who judge the care of the ER docs, don’t throw stones when you live in a glass house. I deal with your complications everyday. I deal with the patients who can’t reach you on the phone and come in with a preventable ER visit. I deal with the undesirables you don’t want to see. And I don’t cast aspersions upon you and question your training.

ER docs now are better trained for emergencies than internists, family practioners and surgeons. We know the emergency aspects of every specialty. We see the overall picture. Do you know how many times I am the first doctor to give them nutrition and prevention advice? Why wasn’t their primary doc doing that? Why didn’t their surgeon explain to them that their surgery will drive up the patient’s blood sugar and they’ll need more insulin?

Perhaps you shouldn’t be asking what should ER docs do to change things. Perhaps you should be looking at why we have to always clean up your messes. And it is not a lack of inpatient training that hampers us. It is a lack of understanding about the ER that hampers you.

There’s no question, at least in my mind that seeing patients in the ER environment is tough and certainly different than in the comforts of an office under a more controlled environment. That being said I still think that some practices done by some ER departments need reviewing.

One of them is the ordering of exams prior to actually examining the patient in order to expedite the patient’s care. The following is a true case. ER patient sent for US of gallbladder. Exam is normal. Tech asks patient to point to site of pain. Patient points to right lower quad. Tech scans RLQ and finds inflammed appendix. Can anyone honestly say that a physician spoke to, much less examined this patient? Things like this are not unusual in my hospital.

One other note: There seems to be a misconception that CT does not do well for ruling out gallbladder disease. This is not true. In most patients the gallbladder is seen very well on CT. The common bile duct can often be seen better on CT than on US. Ultrasound is considered the first imaging step for evaluating GB disease because it is cheaper and requires no radiation or contrast. If the patient has already had a CT of the abdomen with contrast and the gallbladder and RUQ are clearly visualized (as in the case I mentioned in a previous post) there is no need to do an US of the GB unless the CT shows an equivocal finding pertaining to the GB. I think that people order US as a knee-jerk, reflex when GB disease is considered without looking at what information is already available.

Every physician in every specialty has made decisions that probably were not the best or most efficient way of dealing with a problem. We’re all human. In the case of ER I suspect that part of the problem is the “system” in which the ER physician must operate within. They have to get patients in and out in such a short time and not miss anything. While that is a reason I don’t think that it’s a good excuse to practice not good medicine.

btw…a clarification. The ED in my hospital discourages (a better word than disallows) an “official” US for cholecystitis in the middle of the night. The ED has their own scanner which the docs use often, though rarely act on the results until an “official” scan is done by radiology. If cholecystitis is suspected, the patient is admitted and the scan done in the morning.

This article smacks of hindsight bias.
I suspect Dr. Kirsch’s is also the type of physician who hides his amazement when ED physicians don’t do what he considers to be sufficient testing and then fail to diagnose a disease on some vague patient complaint. Once the diagnosis was made, his tenor likely changes to “the patient’s condition was obvious all along.”
And how often does Dr. Kirsch phone triage his patients directly to the ED when they call him after hours?
There are risk-adverse ED physicians who order more tests than average in the same way that there are risk-adverse gastroenterologists who scope anything with an orifice. Generalizing about either is simply bush league. Stick to commenting about an aspect of medicine that you are familiar with. What’s next, a bunch of calumny about how many unnecessary surgeries are being performed?
But while we’re at it, maybe we could take a look at how many gastroenterologists engage in “scoping for dollars”. When seeing patients in the emergency department I have to disguise my amazement about how patients with simple hemorrhoids are violated from above and below with those snakey camera things at several thousand dollars per procedure in order to “confirm” some life-threatening need for Preparation H. GI procedure suites are literally set up like an assembly line to see how many patients they can do procedures on in a day.
And don’t you radiologists even get me started on finger pointing in defensive medicine. If I had a buck every time I read a report saying that “x-ray is nonspecific, recommend CT” and then “CT is non specific, recommend MRI,” I could retire by now.

Thanks for posting Dr. Kirsch’s comments about excessive care in the ED. He touched on one distinction that requires elaboration and reaches an erroneous, or at best, currently impossible conclusion.

Patients with epigastric pain are sent to Dr. Kirsch by primary care practices which have already worked up the case to some degree, or patients self refer and he begins the work up process. Patients are sent to labs, radiology offices, have repeat visits, and maybe other referrals out where other organ systems are checked. At the end of all that, the total costs are not less than what I generate for the same complaint in the ED. The pro-fee component totals are higher. The patient’s time away from work, etc. is much greater.

We live under a very different litigation threat risk in the ED, and a different standard of care. That same patient with epigastric pain will have much more difficulty maintaining a suit against the office based gastroenterologist if the problem turns out to be an MI. Of course our investigations are extensive and our admission rates are high.

This is not to say the threat — or the response — is rational. The only factor shown to correlate with plaintiff favorable outcomes in malpractice litigation is severity of outcome, not fact of error, attitude, etc. Plaintiffs’ lawyers know this. We see increasing numbers of billboards that simply say: “Bad Results? Call Attorney X.” But society, through its avatar the court system, does seem to be telling us we can’t miss anything. I hope our office based colleagues continue to have less of a problem than we do with these expectations.

hi dr kirsch,

i’m an er doctor.

your ‘medical universe’ paragraph makes all the right arguments as to why ER doctors do more workup than gastroenterologists. i’d also add, patients who self select for the ER are sicker than patients who are referred as outpatients to GI doctors, and also ER doctors are held to a higher standard of care than GI doctors when it comes to diagnosing heart disease and other emergent conditions. but overall, you seem to understand the arguments we’re making.

then in the next paragraph, you say you reject these arguments. and you back up your assertion by encouraging physicians to do a better H&P. i don’t think a good H&P in and of itself will exclude MIs, appendicitis, or any number of other emergencies we’re required to diagnose. i don’t think a good H&P will change the fact that my patients are sicker than your patients, and my patients are unable to get into see non-ER doctors within a few days for re-evaluation (when was the last time i could arrange outpt GI followup within a day or two? are you kidding me, it’s impossible to get a patient into GI.)

if you have a better reason to reject these arguments than “do a thorough H&P,” i’m happy to hear it, and appreciate that you’re open to dialogue.

thanks for the post.

Dr. Kirsch, one of the things I have observed is that intelligent people generally make rational decisions. When someone is doing something I, as an outsider to the situation, think is wrong, I try to credit them with good sense. Chances are, if I were in their shoes, I might be doing exactly what they are doing. And even if it is not exactly what I would do, I usually find that it is completely rational and reasonable.

The fact that so many ED doctors have come to the same conclusions about how to practice their craft suggests that there are facts and factors the outsider doesn’t appreciate. They can’t all be this stupid.