Editor’s Note: We received many responses to January’s A New Spin article, “What’s on My Mind: Should we focus on the diagnosis or the decision-making process?” by Kevin Klauer, DO, EJD, FACEP. Here are a few of the comments from the emergency medicine community.
Explore This IssueACEP Now: Vol 35 – No 04 – April 2016
I have several thoughts relating to Dr. Klauer’s excellent opinion piece in January’s edition about the Institute of Medicine’s report, “Improving Diagnosis in Healthcare.” I share all of Kevin’s concerns about the way in which the report alludes to emergency medicine and emergency physicians, but I think there are several additional issues deserving of mention.
Having entered the full-time practice of emergency medicine in 1973, my perspective has a long horizon. In the early days of our specialty, the expectation of the rest of the hospital’s medical staff was for us to make an accurate “in” or “out” decision. Having the definitive final diagnosis was deemed nice but not mandatory. Assigning a weak tentative diagnosis was considered bad medical practice. Everyone accepted that there was a subset of emergency patients who clearly needed to be in the hospital because they were, in the emergency physician’s judgment, sick enough to require the additional time and diagnostic resources afforded by inpatient status in order to reach a final diagnosis. Today, thanks to our irrational government health care programs, you can’t admit someone with a diagnosis of “sick enough.” In addition, since RBRVS [resource-based relative value scale] systematically short-changes the thinking doctors (as opposed to the proceduralists), the medical staff has come to expect that every patient arriving on the floor will have a completed comprehensive work-up and, insofar as possible, a definitive final diagnosis. One has to wonder what their true purpose, if any, has become. I thought this situation might change for the better with the advent of hospitalists, but I actually think they’ve made it worse in many cases by forcing the emergency physician to “sell” them on the admission, which, again, typically entails having a completed work-up and final diagnosis. The amiable internist who would admit whatever you asked him or her to do has faded into extinction.
The ED never was and never will be the appropriate setting in which to contemplate and confirm difficult-to-make diagnoses. Forcing it to function as such inevitably detracts from its primary purposes of being the entry point into the healthcare system for many and a provider of safety net and critical care. As Dr. Klauer notes, EMTALA assures a steady flow of high volume, uncompensated safety net care demand that the ED cannot off-load. In addition, many EDs already operate with only a fraction of their beds, the majority being tied up with extensive work-ups and borders. EMR’s have deprived the emergency physician of relevant nursing history and physical findings to factor into the diagnostic thought process. Doing comprehensive work-ups in the ED also raises costs by making all ancillary testing “stat” and it must, of necessity, encourage over-ordering. Is it any wonder that emergency physicians are flocking to freestanding facilities and the more rational practice environments they afford?