Gastroenterologist Michael Kirsch put up a post on his blog that was then reposted over at ACP Hospitalist asking where the threshold for admitting a patient to the hospital should be.

He asserts that there should be more collaboration between medical colleagues to determine whether or not a patient needs to be hospitalized.
He also talks about outside influences on an emergency physician’s decision to admit patients and gives his readers a list:
–pressure from hospitals to fill beds
–pressure from admitting physicians who seek to increase their in-patient volumes
–belief that hospitalization markedly reduces medical malpractice risk of ER physicians
–desire to eliminate uncertainty that a benign complaint is masquerading as a serious condition. “It’s probably your heartburn, but let’s observe you overnight just to be sure.”
–pressure from patients and families to be hospitalized
–uncertainly that a patient will follow-up with a physician after ER discharge
–ER physicians are making the proper judgment to admit the patient, while we specialists and primary care physicians cavalierly advise discharge.

OK. I agree that there are outside influences on a physician’s decision to admit patients, that docs should collaborate, and that we could all use a little more introspection as to our motives for admitting patients.

Then comes this quote: “I have found that many ER docs pull the hospitalization trigger a little faster than I do.”

To me, that became the thesis of his post: You guys admit patients that I don’t think need to be admitted and we need to talk about it.

OK. Let’s talk.

Interesting. I have found that some doctors who haven’t even examined the patients like to make snap judgements over the phone and risk my license by telling me to sign my name to discharge orders when I think patients do need to be admitted.

If I call a doc and think a patient needs to be admitted and the admitting doc or consultant doesn’t think so. I respect that physician’s opinion. Then I ask the doc to come to the emergency department, examine the patient, and write the discharge orders themselves.
If that happens, I often get the nose-breathing in the phone and the exasperated “fffffiiiine,” sometimes followed by attempted put downs such as “just admit the patient and I’ll discharge him later today.” As if that somehow diminishes my worth as a physician or something.

After a while, the docs begin to trust my opinion. Either that or they learn that they are either going to have to admit the patient or come in to discharge the patient and that they won’t win an argument with me.
Odd thing is that of all the docs who actually omit the nose breathing routine and show up in the ED, I can only remember one time in the past 10 years when a doc has come to the emergency department and discharged someone I thought needed to be admitted. That was on a patient with end-stage cardiomyopathy who the cardiologist said “was already on maximal therapy” and was going to “die at home regardless of what we did.” The cardiologist discharged the patient and the patient did die at home. Not too many people were happy with the cardiologist after the patient’s death.
I can also recall many times where docs have discharged patients that were admitted for only a few hours and then the patients either got worse or died.
It is an odd, but also memorable event to have a patient that you admitted earlier in the day come back and see you via ambulance during your same shift.
“Whaaa? Didn’t I just admit you earlier today?”
“Yeah, but Dr. Doroshow just came in and wrote discharge orders.”
Then there was the seven-figure verdict against one doc who discharged a patient from the ICU six hours after admission from the ED. The patient was found dead 12 hours later.

Granted that occurrences with bad outcomes are much less common than the eye-rolling comments to patients about “I don’t know why on Earth they ever admitted you for this,” but you only need a couple of the former to have a significant impact on your professional life. Defensive medicine? Maybe. Or is it “good care” to be thorough with patient complaints?

If you disagree with a decision to admit a patient, first realize that each doc has different practice patterns and you are not the yardstick by which the practice of medicine is measured. Discuss the case with the department chair. Better yet, if you want docs to engage in better decisionmaking when admitting GI patients, then give a grand rounds talk at your hospital about criteria for admission and discharge of common GI complaints in the ED. Create a list for all us ER docs and give the department chair copies of your handout to distribute to those docs that didn’t make it to your lecture. While you’re at it, read a little bit about EMTALA.

If you want to have a discussion about whether a patient needs to be admitted, I’m all for it. But the conversation is going to be in person. And you can write the discharge order when we’re done.

Now … let’s talk about all those unnecessary colonoscopies that are being done every day in hospitals across the nation.
Personally, I have found that many gastroenterologists like to perform EGDs and colonoscopies much more often than I think is necessary. What’s my explanation for this? Here are some possibilities.

– Pressures from hospitals to do procedures
– Pressure from primary care physicians to get the procedures done
– Belief that endoscopies markedly reduce malpractice risk of gastroenterologists
– Desire to eliminate uncertainty that a benign complaint is masquerading as a serious condition. “It’s probably your hemorrhoids, but let’s scope you just to be sure.”
– Pressure from patients to have the procedure done
– Gastroenterologists are making the proper judgment to scope the patient, but other physicians cavalierly advise conservative and much less expensive care.
– Oh, and let’s not forget greed (a.k.a. “scoping for dollars”).

Kind of different when the retrospectoscope is pointed in the other direction, isn’t it?