While some physicians have contracts with hospitals, most emergency physician groups bill on their own for the services they perform. Doesn’t mean that the bills are paid (see, e.g., California State), but in most cases, emergency physicians aren’t paid by the hospitals.

How many ED physicians haven’t been paid according to their contract? Many. Research PhyAmerica bankruptcy for one. I’m through doing your homework for you.

You’re right about criminal law. My mistake. Heck, hardly anyone is charged with crimes any more and once Johnnie Cochran died, the only criminal lawyer left in this country is Mark Geragos.

The few articles I posted are better than the “zero” articles and the baseless claims that you repeatedly post. I was merely posting a few articles to counter the claims that each public defender in this country should be considered for sainthood.

Your lack of knowledge also goes to ED scheduling. Emergency medicine is a 24/7 job, meaning that I work odd hours (or overnights) on some days, but then on on days I have the traditional public defender’s hours off. What’s *your* excuse?

You don’t have a contract? How many ED physicians have had a hospital go under on them and not been paid according to their contract? And don’t those hospitals receive revenue from the taxpayers courtesy of Medicare/Medicaid?

” For most public defenders, their job is a springboard to the big criminal defense work, and you know it.”

Once again you’re opining on things you know little of. The percentage of criminals who can actually afford to the “big criminal defense lawyers” is exceedingly small compared to the number of public defenders out there. Most go into other areas of law, or just do a little criminal defense as part of a broader practice.

Are you really using a few articles you read about a small percentage of the public defenders nationwide to impugn the whole group? Do you really believe there are no articles out there about crappy ED physicians? Would it be right to paint you with their brush?

And can’t your overworked complaint be applied to you as well? Or are you a full time “journalist” these days?

Glass houses and all.

I consider the public defender’s office like an internship and residency for physicians. Physicians work 80-120 hours per week and get paid less than minimum wage while in their residency training. For most public defenders, their job is a springboard to the big criminal defense work, and you know it. Here’s one article from Kentucky stating that more than half of Kentucky’s public defenders have been with the state system less than three years (less than most medical residency programs).

Give me some other examples about how bad you have it.

Oh, yeah. I forgot.

Public defenders take every single client with a legal problem and work their cases up to the hilt for free. What was I thinking?
If emergency physicians acted like public defenders, they would only treat heart attacks, strokes, and major traumas, telling everyone else “Sorry, you’ll have to go ‘retain’ someone to represent take care of you.

It also appears that there is some disagreement about the level of “competancy” [sic] with which public defenders perform their work:

Court appointed attorneys are doom for poor defendants. They are so notorious for slacking that they are usually and rightfully called “Public Pretenders”. I’ve watched them come into the courtrooms staggering under piles of files they haven’t read until they can quickly peruse them while standing at the bar with a defendant they have barely spoken to and whom they are most likely urging to take a guilty plea just to get the case off the books.

Pride seems to be out the window, too:

The bad news started last year, when a group of private lawyers who contract with Cowlitz County to represent low-income defendants announced that they were ready to quit.
“It’s a lot of work. It’s a lot of stress. And it doesn’t pay enough,” one of them told Stephen Warning, a Cowlitz County Superior Court judge. “Come Jan. 1, I’m the heck out the door.”
Warning said he “begged and pleaded for them to stick around a little longer,” but it didn’t work.
Of the 12 contract public defenders, five quit their contracts last year.

I also read about how Texas Florida can’t find enough public defenders to represent all the indigent capital murder defendants. Lot of “pride” flowing around Florida courtrooms for sure.

You personally seem quite overworked – so bad that you’re checking blogs on the internet during time when you should be representing your clients – or do you have Thursdays off?

Oh, and you forgot to mention professionalism. You use a potty mouth in court and call the district attorneys names, too?

There are three claims under EMTALA: screening, stabilizing and transfer.

You quoted Roberts. Roberts is a transfer case; the patient had been in the hospital for several weeks in an unstable state when they transferred her anyway. During and immediately after the transfer her health declined dramatically. The claim was that the hospital did not appropriately evaluate the merits/risks of a transfer.

Roberts itself references Cleland, a 6th circuit case establishing the “improper motive” requirement for screening cases. Roberts didn’t comment on or overrule Cleland. (Look at paragraphs 19 and 20 of the link you provided to Roberts.) That’s why a number of courts still follow the “improper motive” requirement for screening cases, cases where a hospital completely fails to evaluate a patient at all.

I did define “appropriate” — the hospital just needs to follow its own ER protocols for everyone, regardless of non-medical issues like insurance status. Case law in many places defines “appropriate” downward even further, saying a screening was “appropriate” so long as not colored by an “improper motive.”

None of the above has anything to do with meeting or breaching the standard of care. EMTALA’s requirements are very, very basic and very, very minimal. If you open up an ER and take Medicare funds, you have to ’screen’ everyone there the same, and ’stabilize’ them if they have an emergent condition. If you want to transfer them before they are stabilized, you have to evaluate the benefits/drawbacks of such transfer.

What happens if you ’screen’ someone, completely miss their emergent condition, send them home, and they die? No EMTALA claim.

What happens if you see an emergent condition, admit them, think you stabilized it, discharge them, and they die? No EMTALA claim.

What’s wrong with those requirements? Do you think ERs should be able to pick and choose patients or to refuse them without insurance coverage?

And what’s really the drawback? Who here, at EPMonthly, has ever faced down an EMTALA claim? What did the plaintiff allege? Did they survive summary judgment?

My defensive medicine / differential diagnosis related to the standard of care, a standard established wholly by physicians themselves. The “1 in 10,000″ number is meaningless, it’s like saying that, because planes usually don’t crash, they never crash. Physicians are liable when they cause harm by breaching the standard of care (the one they set), like this bozo ( http://is.gd/jd8A ), who prompted 124 malpractice claims, settled for $100 million.

But it comes back to a point I raised in your defense medicine post: what should be expected of ER doctors? As far as I can tell you’re annoyed that you have to evaluate and treat the patients that come to an ER.

You chose to enter a frontline, emergency setting, one that receives substantial taxpayer support. One that others have proposed making into a quasi-public utility with clear lines of funding, a proposal vehemently opposed by the insurance companies, hospitals and doctors.

How much should an ER get? How much should an ER doctor make? These are questions I’m unqualified to answer — but like I said before, it’s really hard to sympathize with an industry that fights bitterly to preserve the status quo. Can’t be that bad if you’re not up for any major changes.

All I hear is, “don’t change anything except to give us more money and relieve us from the responsibility to treat people fairly and appropriately.”

What would you change?

The “screening” provision doesn’t require an ER doctor do anything even remotely close to the standard of care.” … It simply requires the ER “appropriately screen” all patients roughly the same

Convenient that you don’t define what an “appropriate screen” is. The courts don’t either. That’s why defensive medicine is so prevalent.

Indeed, a number of courts to this day still require a plaintiff show an “improper motive” behind the ER’s decision not to screen or to screen improperly.

Maybe you should review the 1999 US Supreme Court decision in Roberts v. Galen of Virginia, Inc., 119 S. Ct. 685. Here’s the link.

So try Mr. Chest Pain again. The moment you put him into triage, he probably lost his “screening” claim, long before any admission, CT, and whatnot.

I’m not trying to be disrespectful or attack you personally when I say this, but you’re way wrong. The intent behind the law is to determine whether an emergency medical condition exists. You’re saying that we can just eyeball someone in triage with crushing chest pain to fulfill the EMTALA requirements, then do a wallet biopsy and “kick out” those who don’t “look sick”? Even if we do an EKG, up to 50% of EKGs are nondiagnostic in acute MIs. An EKG isn’t sufficient to identify just one emergency medical condition – an MI. What about all the other potential emergency conditions that, according to your previous comments in the defensive medicine post, must be “ruled out”? After all, physicians have to “eliminat[e] the most serious and unlikely diagnoses first … before continuing their basic evaluation, right?”
I would enjoy watching you try to argue your version of a MSE in federal court.

As for charity care … do you really want to enter that debate with a contingent-fee plaintiffs’ lawyer? By the time we get to a medmal trial, you can be assured we’ve put down over $30,000 in costs in the most basic case, plus well over $50,000 in hourly fees.

Hmmm …
Lawyers spend $30,000 on a cherry-picked case with a 1 in 3 chance of turning a several hundred thousand to multi-million dollar profit. They routinely “kick out” legitimate cases where patients have been harmed by a physician’s negligence because there isn’t enough profit potential and have no further duty to the clients whatsoever – “justice” be damned. Then they preach how doctors don’t do enough to protect the 98,000 deaths out of more than 1 billion patient interactions every year in the US (amounting a death in less than one in 10,000 patient interactions) that are allegedly due to medical negligence. Wouldn’t it be interesting if lawyers were chided for losing 1 in 10,000 cases?
On the other hand, emergency physicians and hospitals are mandated by federal law to evaluate *every* patient seeking care and to provide stabilizing treatment to *every* patient with an emergency medical condition. If we even mention that we need money to stay afloat and to keep providing those services, certain groups brand us as greedy. So hospitals close down, services are curtailed, and more bad outcomes occur. But contingent-fee plaintiffs’ lawyers don’t push to change the system *too* much, because without those bad outcomes contingent-fee plaintiffs’ lawyers would be out of business (i.e. read about Texas contingent-fee plaintiffs’ lawyers and tort reform)

Yeah. I’ll take that argument any day.

Actually, the congressmen should pay for clothing out of their personal funds. If they pass legislation, they should fund it using personal funds.

Interesting that you left a gaping hole there. You mention nothing about “competent” legal representation.

The “screening” provision doesn’t require an ER doctor do anything even remotely close to the standard of care. It simply requires the ER “appropriately screen” all patients roughly the same, regardless of personal characteristics, like race, sex or insurance status. If the hospital has come anywhere near its normal ’screening’ procedures — often something as simple as entering the patient into triage — then there’s no liability as a matter of law.

Indeed, a number of courts to this day still require a plaintiff show an “improper motive” behind the ER’s decision not to screen or to screen improperly, which means you basically need a doctor writing “no insurance — kick out!” on the chart. As such, screening claims are incredibly rare, save for extreme circumstances where a patient is refused care entirely for some wrongful reason, like a racial stereotype.

So try Mr. Chest Pain again. The moment you put him into triage, he probably lost his “screening” claim, long before any admission, CT, and whatnot.

You also wrote, “The reason that so few EMTALA claims are paid out upon is because the stakes are so high.” I think you misunderstood what I wrote. I include both verdicts and settlements in “paid out.” There aren’t many. I’d be surprised if there were more than 100 successful EMTALA claims nationwide in a given year.

EMTALA just isn’t the boogeyman it’s made out to be; if a hospital goes so far as create and follow basic checklists for screening, transfer and discharge, it’ll avoid liability.

As for charity care… do you really want to enter that debate with a contingent-fee plaintiffs’ lawyer? By the time we get to a medmal trial, you can be assured we’ve put down over $30,000 in costs in the most basic case, plus well over $50,000 in hourly fees. Adding any complexity to the case easily doubles those numbers, and plenty of medmal cases have over $250,000 in costs alone before ever going to trial.

And that’s for each case, with no guarantee of recovery, and 2 in 3 odds of the jury rejecting the claim, not including odds of the court rejecting the claim. We’re also not including costs like the in-house nurses and outside experts I have to pay to ’screen’ every case before I even decide to take it.