Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

To admit or not to admit

David M. Mitchell, MD, PhD
Physician
June 25, 2022
Share
Tweet
Share

Imagine that you hired a teenager to sell hotdogs at the local fair, but the teenager started telling customers that hotdogs were really not very healthy, that the price was ridiculously high, and that they could find healthier, cheaper options just around the corner. Is he wrong? From a business perspective, he’s a nightmare, but from a human perspective, he’s absolutely correct.

Where does your current work setting fall on this issue? Of course, physicians should be the primary advocates for the patient, yet we are also undeniably part of the business of health care. It can be a difficult balance with non-physician (and physician) managers looking over us.

I was reminded of this tension last month when I was asked, on short notice, to attend a conference call with my hospitalist administrators. The unstated purpose of the meeting turned out to be about patterns of admissions among hospitalists. Concerns had been raised (not the first time) that I declined admissions from the ED more frequently than other hospitalists and that this pattern was adversely affecting the hospital census (in a small, struggling rural hospital).

Strangely, my leaders did not have a single case to present to me, let alone a case that had been peer-reviewed and found deficient or dangerous. The discussion was based solely on “some” unnamed ED physicians who had complained.

Perhaps I am unusual (i.e., strange), but when I am called from the ED for an admission, I promptly print the patient’s most recent medication list from the EMR, briefly review their medical history and current diagnostic results, then go down to the ED, obtain my history (sometimes calling family members or nursing home staff to gather more information), examine the patient, and make a decision. Most of the time, the admission is a “slam-dunk” — the patient needs to come in, and I tell the ED physician directly as soon as that is clear (often before I even see the patient); but if I think the patient can safely go home (maybe 5 to 10 percent of the time, depending on the specific ED physician), I offer discharge. That said, I still always offer them the option to stay for observation (when justifiable) if they don’t feel safe going home. I’m sure everyone would agree that there is a gray zone when it comes to observation status. Not surprisingly, when offered a choice, most patients prefer outpatient follow-up if it is considered safe. Wouldn’t you?

Unfortunately and understandably, the fast-paced ED sometimes bristles at my “process” (thus generating complaints), as it adversely affects the ED length of stay and, ultimately revenue; and it raises medicolegal issues for the ED staff that would be erased if the patient stayed. It is also sometimes perceived as an offensive mistrust of the ED physician’s clinical judgment. Despite all of that, I have decided that my face-to-face assessment is necessary to make the best decision for each patient. I could give many relevant examples if space would allow.

What’s incredibly ironic is that once these patients reach the medical floor, the hospital wants them discharged as fast as possible, almost proving that they really didn’t need to be there in the first place. Basically, they’re saying: “Buy a hotdog and then move along.” Unfortunately for the observation patient, the average cost of a “hotdog” is around $10,000, and health insurance doesn’t always pay for observation services. Last week, a patient told my PA that he was still paying off an $11,000 bill from an observation stay a few months ago.

Sometimes I feel like we should be asking patients if they would rather buy a new car, take a week-long vacation, or stay in the hospital overnight. I am particularly sensitive to this issue since I work in an impoverished area of the country, with a median annual household income of about $25,000. Can you imagine how it would feel to get a hospital bill with that kind of income or less? On top of that, lawsuits against patients for unpaid medical bills are also very common in this area (and recently in the news)1. Considering that some of these unpaid medical bills are likely for wasteful medical services (in my opinion), it looks even worse; and when a defensive ED physician uses a threatening “against medical advice” form to persuade a patient to stay (and ultimately to pay), the combination of actions could be perceived by some as mild extortion.

Unfortunately, in my personal experience, young hospitalists these days are molded into the business of medicine much more strongly than they are molded into the humanity of medicine — through no fault of their own. The “good hospitalist” just accepts whomever the ED wants to admit (thus gaining praise from the ED), sees the patient only when they reach the medical floor (opening up ED beds quickly), diligently documents “complex” medical decision making, high severity of illness, and multiple life-threatening risks to the patient that they know are overblown (thus gaining praise from documentation specialists). If anything, they mutter, under their breath, or complain to their peers that the admission was unnecessary.

There is no doubt that hospital medicine as a specialty has prospered by providing fast, efficient care in a DRG-based revenue landscape; early “subsidies” to hospitalist groups from hospitals were based on projected financial benefits to the hospital. It reminds me of an unusual opening speech at an early national SHM conference I attended about 15 years ago, given by one of the founders, which focused entirely on how the rising salaries of hospitalists were evidence of our value to hospitals. The dangerous concept that “whatever makes money for the hospital makes money for me” threatens to turn a profession (with self-imposed principles and ethics) into “just a job” (in which we simply learn to check the boxes that are required to maximize profit).

It is much easier to float down a river than to walk up that river. We all like praise more than criticism. For those with debts to repay, families to raise, financial goals, and administrative aspirations, it makes a lot more sense to shut up, get in line, and do whatever it takes to make the hospital financially successful.

We sell hotdogs. Any questions?

David M. Mitchell is a hospitalist.

Image credit: Shutterstock.com

Prev

Medicaid expansion for postpartum support

June 25, 2022 Kevin 0
…
Next

America trains enough doctors: Redefining medical supply and demand

June 25, 2022 Kevin 1
…

Tagged as: Hospital-Based Medicine

Post navigation

< Previous Post
Medicaid expansion for postpartum support
Next Post >
America trains enough doctors: Redefining medical supply and demand

More by David M. Mitchell, MD, PhD

  • How patient education can save lives

    David M. Mitchell, MD, PhD
  • Did the unvaccinated just save my rural hospital?

    David M. Mitchell, MD, PhD
  • Parallels between Alec Baldwin’s Rust movie set and the unvaccinated

    David M. Mitchell, MD, PhD

Related Posts

  • A physician’s addiction to social media

    Amanda Xi, MD
  • Don’t judge when trainees use dating apps in the hospital

    Austin Perlmutter, MD
  • When physician pay packages become hospital kickbacks

    Jordan Rau
  • Is physician shadowing immoral?

    David Penner
  • How a physician keynote can highlight your conference

    Kevin Pho, MD
  • Chasing numbers contributes to physician burnout

    DrizzleMD

More in Physician

  • Dr. Glaucomflecken for president!

    Aaron Morgenstein, MD & Amy Bissada, DO & Corinne Sundar Rao, MD
  • What is driving physicians to the edge of despair?

    Edward T. Creagan, MD
  • Do residents deserve the title of physician?

    Anonymous
  • When an MBA degree meets medicine: an eye-opening experience

    Arthur Lazarus, MD, MBA
  • The hidden gems of health care: Unlocking the potential of narrative medicine

    Dr. Najat Fadlallah
  • The dark side of immortality: What if we could live forever?

    Ketan Desai, MD, PhD
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • Breaking the stigma: Addressing the struggles of physicians

      Jean Antonucci, MD | Physician
    • Beyond the disease: the power of empathy in health care

      Nana Dadzie Ghansah, MD | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Breaking free from gaslighting [PODCAST]

      The Podcast by KevinMD | Podcast
    • The pros and cons of using ChatGPT for your health care needs

      Liudmila Schafer, MD | Tech
    • Dr. Glaucomflecken for president!

      Aaron Morgenstein, MD & Amy Bissada, DO & Corinne Sundar Rao, MD | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • Do residents deserve the title of physician?

      Anonymous | Physician
    • A new era of collaboration between AI and health care professionals

      Harvey Castro, MD, MBA | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • How Did Pulse Oximeters Perform in Black Kids?
  • Coffee and Heart Function; Ionizing Radiation and CVD
  • Health Inequity Should Be Labeled as a 'Never Event'
  • Healing the Damaged Nurse-Physician Dynamic
  • Doc Moms, Mind the Gap -- $3M Earning Difference by Sex

Meeting Coverage

  • Switch to IL-23 Blocker Yields Deep Responses in Recalcitrant Plaque Psoriasis
  • Biomarkers of Response With Enfortumab Vedotin in Advanced Urothelial Cancer
  • At-Home Topical Therapy for Molluscum Contagiosum Gets High Marks
  • Outlook for Itchy Prurigo Nodularis Continues to Improve With IL-31 Antagonist
  • AAAAI President Shares Highlights From the 2023 Meeting
  • Most Popular

  • Past Week

    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Healing the damaged nurse-physician dynamic

      Angel J. Mena, MD and Ali Morin, MSN, RN | Policy
    • The struggle to fill emergency medicine residency spots: Exploring the factors behind the unfilled match

      Katrina Gipson, MD, MPH | Physician
    • Breaking the stigma: Addressing the struggles of physicians

      Jean Antonucci, MD | Physician
    • Beyond the disease: the power of empathy in health care

      Nana Dadzie Ghansah, MD | Physician
    • Deaths of despair: an urgent call for a collective response to the crisis in U.S. life expectancy

      Mohammed Umer Waris, MD | Policy
  • Past 6 Months

    • The hidden dangers of the Nebraska Heartbeat Act

      Meghan Sheehan, MD | Policy
    • The real cause of America’s opioid crisis: Doctors are not to blame

      Richard A. Lawhern, PhD | Meds
    • Nobody wants this job. Should physicians stick around?

      Katie Klingberg, MD | Physician
    • The fight for reproductive health: Why medication abortion matters

      Catherine Hennessey, MD | Physician
    • The vital importance of climate change education in medical schools

      Helen Kim, MD | Policy
    • Resetting the doctor-patient relationship: Navigating the challenges of modern primary care

      Jeffrey H. Millstein, MD | Physician
  • Recent Posts

    • Breaking free from gaslighting [PODCAST]

      The Podcast by KevinMD | Podcast
    • The pros and cons of using ChatGPT for your health care needs

      Liudmila Schafer, MD | Tech
    • Dr. Glaucomflecken for president!

      Aaron Morgenstein, MD & Amy Bissada, DO & Corinne Sundar Rao, MD | Physician
    • What is driving physicians to the edge of despair?

      Edward T. Creagan, MD | Physician
    • Do residents deserve the title of physician?

      Anonymous | Physician
    • A new era of collaboration between AI and health care professionals

      Harvey Castro, MD, MBA | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today iMedicalApps
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...