'Bogus' ER visits ail hospitals

Asking a radiologist to comment on a story about the motives emergency physicians have for admitting patients is irresponsible journalism. What basis does the radiologist have for his assertions other than a floor rotation during his internship many years ago? You know - that time just after he graduated from medical school and has little or no exposure to clinical medicine. It is well documented that 2% of patients with acute coronary syndromes are sent home from the emergency department and that missed MIs account for nearly 50% of all malpractice dollars paid. The MI patients that are "missed" are typically the ones with atypical symptoms such as those described in this article. Perhaps the esteemed Dr. Durand could come up with a prospective model to admit only patients with symptomatic cardiac pain while excluding every patient that has no cardiac disease. Then again, he'll probably be featured in another article next year about how the ED physicians inappropriately sent home some patient with chest pain that later died. If you would like to interview me, an emergency physician, about the inappropriateness of nonspecfic radiology readings that request more and more radiologic testing to be done as a form of self-referrals, stop by my blog at whitecoatrants.wordpress.com

The studies cited in this article are part of a small body of literature from the late 80s and early 90s that has long since been debunked due to the fact that they were mainly retrospective reviews of ED charts by non-EM trained clinicians with the advantage of hindsight and a complete data set. This, coupled with the opinion of a second year radiology resident who must still be recovering from having been an internal medicine intern 2 months ago, and who has little or no experience making independent clinical decisions, seems an odd choice for this "journalist" to use for an authoritative position. Articles like this in the lay press undermine the vital role that emergency medicine plays in our society, especially at a time when emergency medicine needs more support, not more detractors. "potentially avoidable admissions", a term more recently used in the literature more accurately describes the situation. Our admissions from the ED are almost NEVER "unnecessary" or "erroneous" at the time the decision is made. This is something that those who work outside of the ED rarely understand. We are making the best decision possible with the information available at the time and the safety of our patients foremost in our minds, including those who are still languishing in the waiting room waiting to be seen due to a shortage of space and hospital beds. Chest pain patients, although the example given by this radiology resident suggests it, are not at all straight forward. The availability of additional information through electronic health information exchanges and a developing nationwide health information network that brings clinical data from disparate sources to the ED doc at the point of care make help avoid some of these admissions. They are NOT currently "unnecessary".

Would I be correct to assume that this article was written by a junior journalist looking for a story who is friends with a disgruntled radiology resident? Whether or not this is the case, you should be ashamed of this truly shoddy journalism. Experienced physicians, myself included, would not trust a radiology intern's physical examination of a patient, never mind his assessment of whether someone is having a heart attack. Heart attacks often present subtly, and initial EKGs (electrocardiograms) are only diagnostic in about 25% of cases. How to determine cost-effectively and safely who is having a heart attack is an ongoing problem for physicians and the subject of large bodies of medical literature. With our best tools at present, it takes hours of serial testing. To save the lives of many with heart attacks, yes it is true, we need to test many who will ultimately be found to not have them. However, many deaths would be caused if every patient whose symptoms sounded like heartburn were sent home by radiology interns. (Don't worry- we don't give them the authority to do so.) Our medical system is overburdened and breaking at the seams in many ways. Emergency Departments pick up the slack by evaluating and treating millions of patients who cannot find care elsewhere. It is irresponsible of your paper, at a time when so many real problems need to be addressed, to print stories that will misdirect the attention of lay people concerned about the healthcare system. I highly recommend that you teach your junior reporters to reconsider their hypothesis if the most recent study they can find to back up what they want to say about a very dynamic system is 20 years old.

The article is absolutely true. In my 7 years of residency and fellowship (interventional cardiology) I saw a ton of "bogus" admits. In 5+ years of practice I see these admits almost on a daily basis. Do not blame the ED docs blame the medical malpractice climate. Why would a doctor send anyone out of the ED (there is NO incentive and a ton of liability). Don't expect any changes even if insurance denies admission. The only fix is a reasonable malpractice climate. So the next time you (or a family member) are waiting for hours to be seen in the ED thank your politicians and lawyers for wasting your time and your money. Don't give the ED a hard time it's their "job" to order a bunch of "bogus" tests (and my job to do "bogus" admits).

I agree with cards doc and the general sentiments of the article. In addition, I find the comments of the self-identified emergency medicine physicians below (Physician, WhiteCoat and ED Doc) to be misdirected. The great thing about this article is that it does not really criticize ED physicians - it shows that they are operating within a system that encourages unnecessary admissions. With the outrageous malpractice penalties acting as a "stick" to physicians and the reimbursement structure acting as a "carrot" to hospital administrators, the system seems designed to encourage "defensive medicine." Perhaps "physician," "ED Doc" and "White coat" should read the article for content instead of being so foolishly defensive, because the only really negative impression I get about ED docs when I read this page comes from their unnecessarily nasty and profoundly unprofessional comments. "The lady doth protest to much, methinks..." - something tells me all three of these guys have admitted their fair share of heartburn.