ER and internal medicine docs, arguing over a patient admission

Dr. Erdoc happened to look up when the internist walked into the emergency department.

“Oh no,” he murmured under his breath. The consulting psychiatrist was sitting next to him, typing a note. She looked at him and raised an eyebrow.

“I hoped it wouldn’t be him. Unlike his colleagues, Dr. Internist seems to have a deep loathing for us emergency docs,” Dr. Erdoc explained as he stood up. Dr. Internist was frowning as he approached.

“Dr. Erdoc,” Dr. Internist opened, “why are you admitting cellulitis to the hospital? Didn’t they teach you how to treat a bacterial skin infection during your residency?”

“Yes, they did,” Dr. Erdoc said. “They also taught us when someone with cellulitis needs a hospital admission.”

“This man has schizophrenia,” Dr. Internist went on. “Why can’t he be admitted to the psychiatry unit? The medicine consult service can see him there.”

The psychiatric consultant glanced at Dr. Internist, though kept typing.

“Because psychiatry has already assessed him—twice—and they don’t think he has any urgent psychiatric issues,” Dr. Erdoc said. “I agree with them.”

“Twice? What do you mean, twice?”

“If I had a chance to tell you the history, you’d already know,” Dr. Erdoc curtly said. “He’s a 43 year-old homeless guy with hepatitis C and schizophrenia. He came here four days ago with a hot, painful left leg and was diagnosed with cellulitis. Psychiatry saw him then. He was sent back to the homeless shelter with oral antibiotics, but he returned today—”

“His schizophrenia must be affecting his ability to take the antibiotics as directed,” Dr. Internist cut in.

Dr. Erdoc cleared his throat. “He was sent back to the shelter with oral antibiotics, but returned today because the cellulitis has gotten worse. He brought in his medications—including the stuff he takes for schizophrenia, which psychiatry looked at when they saw him today—and the expected number of antibiotic pills are gone. To prevent—”

“Did you call the shelter staff to get more information? Like if he actually swallowed the antibiotics?” Dr. Internist interrupted.

Dr. Erdoc looked blankly at him before replying, “No.”

“Why not?” Dr. Internist demanded. “You didn’t get a detailed timeline of events.”

“Because that wouldn’t change my management. To prevent the cellulitis from getting worse, he needs IV antibiotics, which means he needs an admission to the hospital,” Dr. Erdoc said.

Still frowning, Dr. Internist continued, “Did you draw blood to see if his body is mounting an attack against the infection?”

“Yes, but the results aren’t back yet.”

“I’d like to see them before I admit him.”

“Dr. Internist,” Dr. Erdoc said, taking a step towards him, “his cellulitis isn’t getting better. They did teach you in your internal medicine residency that you don’t need to draw blood or do x-rays to diagnose someone with cellulitis, right? It’s a clinical diagnosis.”

Dr. Internist looked darkly at Dr. Erdoc, but said nothing.

“The best thing for the patient is an admission to the hospital so he can receive more aggressive treatment for his cellulitis,” Dr. Erdoc continued. “Your dislike of emergency medicine docs isn’t going to make patients get better. Now, we can continue to stand here, argue about this patient, and waste our time, or you can do the noble thing and admit this man to your service so we can all move on with our lives.”

Dr. Internist glowered at Dr. Erdoc.

“Fine. I’m doing you a favor,” Dr. Internist said before walking away to see the patient.

“No, you’re doing your job,” Dr. Erdoc muttered.

Sighing, Dr. Erdoc walked back to the computer where he was typing his note. The psychiatrist was finishing up her work.

“The contempt he has for us is fascinating,” he said.

The psychiatrist gave a small smile before commenting, “Sure, though the reasons why he dislikes emergency docs may be much more interesting.”

Maria Yang is a psychiatrist who blogs at In White Ink.

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  • Rob Lindeman

    Maybe they taught Erdoc to treat cellulitis as an inpatient, but the published evidence suggests otherwise (see up-to-date, for example).

    Animosity between docs, ED/internist, ED/pediatrician, etc, often arises over issues of over-treatment, or inappropriate level of care.

    • Apurva Bhatt M.D.

      Curious as to your response, I referenced Up-To-Date:

      “Patients with signs of systemic toxicity or erythema that has progressed rapidly should be treated initially with parenteral antibiotics.”

      Yep, worsening refractory cellulitis (especialy in a shizophrenic homless individual with presumably no PCP follow-up options) still requires admission – no different than my residency training 10 years ago. ERDoc did the right thing IMO.

  • Steven Reznick MD

    Taking potshots at general internists and family practitioners seems to be in vogue today even though there is a dangerous shortage of physicians in these areas of medicine and there are fewer and fewer students entering these specialties. There is no question that the primary reason for this patients visit to the ER was a cellulitis and the patient belongs on a medical service not a psychiatric service. If there are no other less costly ways to suprevise care of this infection than it looks like he requires admission.
    Lets look at other examples. An uncomplicated sixty eight year old woman slips on a water spill at a local shopping mall and falls and fractures her hip. She is taken to the ER where she is seen by the ER staff, orthopedics is called, they write a consult saying she needs a surgical procedure and say ” We are consultants , we do not admit patients to the hospital, and the medical doctor on call is summoned to admit the patient.
    A 82 year old gentleman drives his car into a canal. A paramedic on the banks of the canal fishing with his son breaks out the back window panel and pulls the man into the back seat and out through the back panel before the car sinks in ten feet of water. In extracting the patient he breaks two vertebrae in the cervical spine of the patient. The arriving paramedics have a choice of taking the patient to a level 3 trauma center or a community hospital three minutes closer and defer at the patients request to the community hospital. The community hospital has no neurosurgical operating suites and no neurologically trained nurses. They call the medical doctor on call to admit the patient to their service rather than present the case to the trauma unit at the nearby facility.
    An 82 year old male living in a forty story condominium on the ocean in South Florida took the elevator to the first floor to check on his auto as a category four hurricane approached. As he returned to the elevator the power failed and he did not believe he could walk back up 32 flights. The door man was assisting in evacuating the building as per a governmental decree for coastal areas. He complained of lower abdominal pain and was transported to the hospital ER rather than a shelter. The hospital was on lockdown and had a protocal with on site physicians to care for existing patients. He was examined by the ARNP and put on a gurney. The community fell under a area wide curfew . At 11PM a police officer was dispatched to the gentlemans physicians home ( because phones and power were out) to summon him to the ER. Upon arrival at the ER the patient was found to be fecally impacted.
    A 76 year old man with ischemic cardiomyopathy and severe acute dyspnea self refers himself to his cardiologist who finds him in pulmonary edema. His office is adjacent to the hospital. His nurse wheels the patient to the ER where the ER physician confirms the diagnosis with a Chest X Ray and BNP. They call the cardiologist to care for him and admit him. The cardiologist says ” I am a consultant and do not admit patients call his PCP.”
    There are usually reasons why generalists are leery of certain ER staff. The example presented in this story certainly colors the issue in favor of the ER Doc and makes the internist look undedicated and unprofessional. How many times has this internist been traumatized and dumped on before he adopted this attitude?

    • Anon

      As a primary care internist who was on call last night, I agree with the above commentary. The patient with cellulitis needed to be admitted, no doubt, but the battle fatigue caused by “medicine call” can be overwhelming at times. The classic examples of the orthopedist or cardiologist or other specialist who “does not admit” happen frequently, even if the patient has a problem isolated to their area of expertise. The internist often is relegated to doing the history and physical, and discharge planning (i.e paperwork), after the specialist performs his intervention or procedure and signs off. This can be very demoralizing. There are plenty of patients that need to be admitted to internal medicine, but there are plenty that can and should be admitted to specialists, too. The ER docs are often caught in the middle, and I certainly don’t envy their jobs.

    • Dr. J

      Steve, In my opinion as an ER Doc I think this is a triangle type situation. The ‘consultants’ communicate with the ER Doc as do the Internists. All too often these patients definitely need to be in the hospital and neither group feels it is their problem. Instead of fighting it out with each other they both just fight with the emerg doc instead. I know everyone is over worked and tired but seriously, you would think that I personally put the patient into heart failure, or caused their PE by the tone of the phone conversations at times.

      • Steven Reznick MD

        No question the ER doctors get caught in the middle and catch much flak from all involved. It isn’t fair and most of us realize the valuable role our ER staff plays in todays fractured health care system.
        At the end of the ER docs shift he/she gets to go home and leave the evenings stresses behind. The generalist has a post surgical hip patient on their service and spends days communicating with the orthopods PA , even having some of their medical orders challenged by non physician providers while the orthopedist doesnt stray far from the operating room .
        Hospitalists are ashort term solution but eliminate longitudinal care. For complicated multisystem patients the handoffs need to improve.

  • Carolyn Thomas

    From a patient’s perspective, this kind of pissing match is truly frightening…

    • Steven Reznick MD

      Its pretty frightening from a physicians standpoint as well trying to be an advocate for your patient and having to deal with these type of situations.

    • ninguem

      Carolyn, it should be frightening. I’m with Dr. Reznick on this one.

      I spent the 1990′s seeing battle after battle between the FP’s and the hospitals. Family docs lost obstetrics. First C-sections, then all obstetrics. Yet it’s OK when nurses do it, go figure. The operating room, endoscopy, the nursery, circumcisions, EKG interpretation, ICU care, on and on and on, they were driven out of one thing after another.

      For a long time, the primary care docs were angry about it.

      Then they decided they liked it. They just turned around and walked away. Best thing that could have happened to me, I know that.

      Then, after years of actively trying to drive out the primary care docs, I actually found myself on the receiving end of disdain…….by the hospitals, and the specialists…….because there were no more primary care docs in the hospital.

  • Jack

    Have a hospitalist system to admit all patient to hospital. Done….no more turf battles.

    I agree with many of the above regarding being dumped on. But I do also see the opposite. Simple CHF, pancreatitis etc and specialists are “consulted” or ER called for admission to specialist because they think Medicine or FP are too busy as well. It really depends on where you practice.

  • Skeptical Scalpel

    Great post and good for starting a discussion. It’s not personal, it’s business. ED docs shouldn’t take this type of thing personally. The internist simply didn’t want the admission.

    For all you PCPs, it isn’t limited to you. Every patient with gallstones on a CT scan gets a general surgery consult from the PCP or ED MD even if the history doesn’t suggest GB disease at all.

    Agree a hospitalist service tends to mitigate the battles.

  • Ralph

    The bigger problem why family medicine or internists have this attitude is the ” laziness” of many specialists. I see this all l the time here in Delaware. The Hospitalists have definately added to this but I think specialists have an entitled attitude. I can’t think of the last time a patient went on a specialists service with a consult to me.

    • Steven Reznick MD

      It goes both ways. I remember hearing a specialty surgeon comment that generalists and PCPs are the lazy ones. He cited how they rarely go to multiple hospitals because the fee per visit didnt justify the travel involved. He called them lazy.
      The truth is we all work long hours and very few are truly lazy. Each hospital staff develops its own culture and permits practitioners to behave in a manner that may not be acceptable at other institutions.
      Be asked to render an opinion on a problem you may never operate to fix is considerably different from following a patient on your service who has a primary reason for admission that the bylaws of the institution do not permit you to treat.

      • ninguem

        I’m with Dr. Reznick.

        It’s why I stopped all hospital work.

        Best thing I ever did in primary care. Made not one cent difference in my revenue; in fact it went up a little.

        The difference is a tremendous improvement in peace of mind.

        I suppose hospitalist services improve things, but I wonder. Out hospital has gone through three hospitalist firms in as many years. They don’t seem to last. I’ve had several desperate calls to help out. I helped a few times, and I suspect I know why it’s a revolving door.

        I stick to my office.

        • jsmith

          We gave our inpatient work to the hospitalists January of 2010. I sure sleep better without the call nights.
          If you don’t mind me asking, why is it a revolving door at your hospital? Hospitalists seem to come and go at our place as well. I suspect it is lack of social skills on the part of the medical director.

          • ninguem

            It’s a revolving door because you take the most hellish day of your intern year, and make it a typical day for the rest of your life.

            I have no idea why anyone would want to be a hospitalist.

            It’s a revolving door because the hospital expects Marcus Welby and pays them like interns. The group itself is likely exploiting the employed docs. When it all falls apart, the individual hospitalists have noncompetes. To do that is absolutely reprehensible, it’s like forcing noncompetes on the nurses.

            So when it all falls apart, all the docs have to leave, the good ones, the bad ones, the ones who speak English, the ones you don’t have a prayer of understanding, they’re all out the door.

            Maybe it’s just my hospital, we had three groups in three years. When they were desperately short of doctors, I helped a few times. I got my nose rubbed in it. If I had to do that every day the rest of my life, I’d leave medicine. I dunno, somebody likes it. I suspect it’s mostly the owners of the hospitalist groups.

  • MedPeds Doc

    Wow! Where to start?! I have been ruminating on this one all day. As a matter of disclosure, I am a self-employed primary care provider who does inpatient & outpatient work and is required to cover unassigned call at one of the hospitals I attend. A few comments….

    1) This story seems very slanted, obviously, against we internists/primary care providers. Sure, the worn out and contrary Internists exist, but I believe them to be a small minority of Internists/FPs. This poor bloke is obviously unhappy with himself and his career choice, and this comes through in his professional conduct. Obviously, this case was a warranted Medicine admission. No questions. Not necessarily a desirable admission because of the potential for delirium and psychosis while hospitalized, but clearly appropriate to the Medicine service.

    2) I do agree that a robust hospitalist service would remedy most of the issues surrounding the assignment of unassigned patients. To be clear, I and my practice partners happily admit virtually all patients who belong to our clinic. I say virtually because I believe admitting a postoperative patient for the orthopedist or neurosurgeon after elective surgery is asking a bit much of Medicine. In my community, the surgeons and subspecialists are so tickled with hospitalists that they treat every internist and primary care doc as a hospitalist and want all patients admitted to Medicine. Unassigned call is a nightmare. Acute STEMI going to cath lab…admit at midnight to the poor on call Internist schmuck who has 20 patients scheduled the next day JUST so Cardiology doesn’t have to do H&P, deal with social issues, or disposition patient. I have had to visit the hospital two or more times just to admit a patient because he or she was busy in emergent cath or hemodialysis. Internists and FPs, partially because of how hospital medicine has evolved, have become the glorified residents or paperwork jockeys for the surgeons and subspecialists. It is BS but the ER docs in my community facilitate it b/c we are not as callous and uncaring as our subspecialty colleagues and surgeons and thus don’t fight as hard not to get these patients. Newest trend…orthopedists and neurosurgeons admitting their elective post-op patients to the hospitalists. Soon that will be the “standard of care” in our community, and they will expect primary care to afford them the same luxury. Again, total and unadulterated BS!

    3) I do not envy the position of ER docs and would not want their jobs. That being said, they should do a better job assigning the specialists and surgeons to take obviously appropriate patients. Don’t call Medicine to admit the healthy 60 y.o. who fell at the casino and broke her wrist. This is a dump. I also resent getting called to admit the head bleed on coumadin with malignant HTN who is on vent and IV vasodilators and has been seen by Critical Care Medicine and NSG in the ER and all family has been counseled on situation and plan of care has been determined…however, Medicine is called to be admitting as patient rolling up to ICU simply because neither of the appropriate services wants to admit. This is also a dump. Don’t call me to admit the 5 day post-op knee replacement draining pus because Ortho does not feel comfortable prescribing antibiotics…if they cannot deal with postop complications, they should not be operating. As I tell my ER colleagues not infrequently, I completed residency 10 years ago. I hated scut then and I especially hate it now as my colleagues try to force it upon me. What astonishes me is that the ER docs truly don’t believe they are trying to dump inappropriate cases on Medicine. I can do nothing to repair the before mentioned wrist fracture in a healthy lady, but I am the bad guy because I won’t admit that patient for Ortho to fix it. It never ceases to amaze me.

    • jsmith

      You are being abused, in case you don’t already know it. Sounds like my old job in Oregon.

      • MedPeds Doc

        No doubt. Butting getting my specialty colleagues and ER colleagues to realize it and or change their behaviors is a discouraging battle. One of my only recourses, to the detriment of my patients. is to become a clinic only doctor and leave the hospital behind

  • Muddy Waters

    As a specialist, I usually only receive reimbursement for approx 15% of hospital consults. I’ll be damned if I ever admit a patient and I’m sure other specialists fill similarly. Sorry to the ER docs for seeming entitled, but it many cases we are working for FREE, and therefore we ARE doing your hospital and the patient a favor. Last I checked, ER physicians were salaried quite well and do not do any “favors.”

    • MedPeds Doc

      But you are not hurting the ER physicians by refusing to admit appropriate patients to your service…you are hurting the primary care doc who gets reimbursed as poorly and infrequently as you. And I suspect you are able to generate a salary that is quite a bit higher than mine as a PCP. But in the end, it is about doing the right thing for the patient and for your primary care colleague so we don’t feel as if we are getting dumped on. I might be more willing to stand up and take most patients if the hospital would pay me for taking unassigned call. I doubt that will ever happen. Ironically, it is part of medical staff bylaws that I must be available as designated for unassigned ER patients as well as pay handsomely to admit my patients to said hospital so that they can make money off of my patient’s care.

      No one wants to be on call for unassigned patients because of the time involved and lack of reimbursement for time spent…it is human nature and I laugh inside if lay people are upset by this attitude. I know of no other profession that is so blatantly forced to work without reimbursement but with complete liability. It is different when we decide on our own volition to volunteer our time at free clinics or shelters or health fairs.

  • Steven Reznick MD

    When I began my career in private practice, ER call was a responsibility on a rotating basis for all staff members. If you did not live up to your responsibility to the ER you were fined, suspended or thrown off the staff. As private insurers and business interests created panels of patients and panels of doctors caring for those patients at a reduced fee for service, physicians began refusing to come in to see those patients. It became especially complicated when insurers set up their own on call panels and would not pay a non contracted physician to see a patient in the emergency department. Not getting paid to see ER patients was always part of call. The first time the hospital executive committee let this behavior slide was the last time there was any orderly call in the ER.
    As reimbursements were discounted more, specialty surgeons started doing much of their work at surgi-centers they invested in building. They took their work from the hospital with good reason and dropped off ER call. This created coverage problems especially in high demand specialties which got called frequently to the ER for cases such as hand surgery, neurosurgery, plastics. Our states medical malpractice laws prevented hospital recruiting and search firms from finding specialty physicians to fill the holes. Family medicine and general internal medicine became the hole stoppers. I remember being called to the ER of our western hospital because a patient of mine was hit by a car in a parking lot and dragged for several yards. This near eighty year old actually had sliced off most of the skin and muscle on her right thigh as if a sharp object had peeled it off. Instead of presenting her to the trauma unit at a hospital ten minutes away, the ER staff and administration wanted her on a general medical service in a facility that had no consulting plastic surgeons or trauma surgeons. We had general surgeons who professionally helped debride the wound initially but the local trauma service was more than happy to accept her in transfer. They had a full complement of surgeons and doctors to handle her injuries and rehab and I could follow along medically if needed.
    In many cases it is about ” Get Out of My Emergency Room” with a twist. Everyone is timing length of stay in the ED with some firms posting waiting times digitally on road side billboards and the ER docs are under great pressure to ” make a disposition” even if that disposition isnt the best for the patient.

  • b

    1. Some ER physicians are paid on collections which means that a certain portion of the patients they see they do for free (that mix depends on where the hospital is located
    2. Although there are productivity bonuses built into most hospitalists contracts, the majority of pay is salary. People paid on salary want to do the least amount of work. People paid per piece want to do more work. Must re-align incentives
    3. Neurosurgeons and plastic surgeons 10 years out of training don’t know shit about antibiotics, diabetes, the treatment of hypertension or delirium. When you ask them to care for these patients, you are committing the patient to substandard care.
    4. The ratio of uninsured and underinsured (read medicaid) to reasonable reimubursed patients are rising. This will create increased friction between the group of doctors who are supposed to be “responsible” and the group of doctors who “are willing to donate their time”, i.e. internists vs specialists. If the hospital allows the ER to dump on the primary care guys, they must also institute mandatory call for the specialists so that everyone’s skin is in the game.

    • MedPeds Doc

      It should be embarassing to our profession as a whole and certain surgical specialists specifically that we have allowed surgical specialists to become so focused on their area of expertise that they forget about general medicine basics. To be an MD and not be able to treat the basics of infection or diabetes is not forgiveable but obviously that is what our specialty surgical colleagues are saying to the ER to get out of admissions. I am now seeing surgeons dumping on their own brethren by saying that they cannot take out the diseased GB or drain an abscess in the unassigned patients when they are on call because they only do bariatric work or breast work. It is hard to fight the malpractice attorneys when we are fighting this much among ourselves at the potential expense of patients.

  • Michael Kirsch, M.D.

    We’ve all been there. Of course, when the ER patient is admitted, it relieves the ER physicians of responsibility. The care has now been seamlessly transferred to another physician. How often have I heard from the ER, ‘let’s just watch him overnight’. At times the ER has already communicated to the patient or famlily that a hospitalization is necessary – which it may be – but this leaves no room for discussion about the patient’s disposition. I see hospital consults often for patients admitted with rectal bleeding, that should have been referred to my office for out-patient evaluation. It’s not always the ER. Sometimes the primary physicians admit these patients. We need more quality control here.

  • ninguem

    The rules have changed.

    If the hospital allows the ER to dump on the primary care guys……the primary care guys just leave.

    I know I did. And I was one of the last to do it.

  • Guest

    I too left. I’m an ER Doc and I left American Medicine because of BS like this. I have a special perspective: I spent years as a paramedic and a waiter before I went to med school. Being and ER doc is no different. When you are a paramedic, the ER nurses and docs are pissed at you because you are bringing them work. When you’re a waiter, the cooks are always pissed at you because you are bringing them work.
    Docs on the receiving end are no different. When I call you, I’m offloading work on you. Most of the time you are not rewarded extra for what I am “off-loading” upon you.So you are angry at me.
    If there’s one thing I’ve learned in my 30 years of working, it’s this: It sucks to be on the receiving end. Doesn’t matter if you’re a waiter, an internist or a line cook.

    • Carolyn Thomas

      Brilliant analogy…. :-)

  • emdoc121

    This discussion brings up so many problems with hospital based medicine today. ERs are overwhelmed with patients who have extraordinary expectations of the services they are to be provided. The urban ER is a combination of homeless shelter, drunk tank, old age home, primary care office, ICU, surgical suite and psychiatrist’s office. Unfortunately the guys and girls who have to juggle these roles have to call upon others to care for many of these “clients.”
    The development of the specialty of Emergency Medicine has allowed many specialists to forget the days where an intern running the ER would have to call upon a specialist to present to the ER to evaluate a patient early on. It was expected that if an RLQ abdominal pain presented to the ER a general surgeon would be required to evaluate that patient. That is no longer the case. Specialists know that a patient will be cared for to the point that either they are diagnosed with a condition that requires a higher level of care (take them to the OR) or require admission. Most surgeons today do not meet the patient until they are ready to roll down the hall to the OR.
    The same is true of hospitalists. The expectation is that they can handle everything. Hip fractures being admitted to Medicine has become almost the norm at several hospitals I work at. I was told by one of my general surgery colleagues to admit a hot gallbladder to the hospitalists and he would take the patient to the OR from the floor. I am constantly amazed that the hospitalists stand by and take it, although I believe their corporate groups do not want to put any contracts in jeopardy.
    As primary care MDs are no longer at the hospitals the clout of Internists and Family Practice docs seem to be waning. They are out voted at medical staff meetings by the all powerful specialists.
    I can understand why a given internist can be pissed by having to admit all patients. Just don’t blame the ER guys who are trying their best to get the patient into the system.

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