WhiteCoat

To Admit or Not to Admit? That is the Question.

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?

28 Responses to “To Admit or Not to Admit? That is the Question.”

  1. [...] via To Admit or Not to Admit? That is the Question. | WhiteCoat’s Call Room. [...]

  2. joebob says:

    Michael Kirsch is a shmuck.

  3. MK says:

    Damn fine post. Agree with everything you said, and see it all the time (esp. the nose-breathing). When it comes time to put up or shut up, they always do the same thing. And his second reason is humorous. I’ve met very few admitting docs who really push to increase their inpatient volume – and a whole lot who push the other way (or cut it entirely and just use hospitalist services.)

  4. throckmorton says:

    I think one of the big problems with admitting patients is just the fact that often there is more than one thing that is going on. The best example I have is the patient with the a bleeding ulcer. He also has anemia, stents, cad, crf and slew of other issues. The specialist can take care of the ulcer but then the patient is still in the hospotal while all the other things are being sorted out. At our facilities, we are fortunate that the patients are often admitted through the hospitalists who manage the overall care while the specialists take care of what they are “specialists” in. This has solved a lot of the “Im not going to admit him” fights.

  5. Tarl says:

    So, what did the picture have to do with the question on whether or not to admit? To my uneducated eye, it looks a little late to ask the question about that patient.

    • WhiteCoat says:

      I looked for a picture of an eye looking through a scope. Couldn’t find one. Then I searched for “looking through endoscope”. Found this picture of one person literally examining another person’s head … with an endoscope.
      Not the best example, but I thought it kind of fit.

  6. Doc4now says:

    In general, if you’re not an ER doc, then you don’t particularly care much for ER docs. In the past, it was different – hospital and ER consults were a great way to build a practice. Nowadays, however, there is a very strong likelihood that an ER call is going to be an unfunded, non-compliant, ungrateful patient. So, to all ER docs, please stop whining when we don’t sound happy when you page. You do shift work, and don’t take call. If the shoe were on the other foot, I’m sure you would tire over coming to the hospital during family dinner as well.

    • Dr. Greenbbs says:

      Ouch. So your biggest issue is that we don’t take call and that we do shift work? When the hell was the last time you spent any appreciable time in the emergency department? Come live my life. I work in a department that sees 115k patients a year. Day in and day out I bust my ass without as much as a meal or toilet break, seeing whatever comes through. I see septic patients next to my ankle sprains, I have to keep track of sometimes up to 20 patients at a single moment, knowing where each and every one is in their workup stages. Until you try doing that on a consistent basis, then you can stop your whining about being paged.

      Oftentimes, we’re the only physicians in the hospital. The ED is staffed 24/7. We don’t close. We work weekends, nights, holidays, during important family and life events. There are days where I don’t see my wife and kids. Oftentimes, I go a few days between seeing my wife for any other time besides bedtime. I missed seeing my only daughter at the time open her holiday presents this year. I worked on my own birthday.

      If you’re so bitter about the patients that you get from the ED, then stop taking ED call and use the hospitalists. We don’t get to choose who we treat. We take all comers through the door, from the rich and famous to the homeless guy who lives under the bridge. Part of being a doctor is the duty to society that comes with the responsibility. That includes taking care of our neediest patients, whether they can pay or not. It’s what’s right.

      Personally, I don’t care whether my patients can pay or not (granted, I’m a hospital employee, but it also takes the greed out of my job….I get paid whether I see people or not). That’s not why I do my job. I do my job because I care about what I do. I work the hours that I do because I feel that I actually do make a difference each and every shift. It’s malignant sons of bitches like yourself that find the need to perpetuate the old-school stereotypes of medicine.

      Spend a day in our shoes. Then eat your crow.

      • JustADoc says:

        Just going along your list: I also see septic patients and ankle sprains. On my weekends on call I am also responsible for 15-20 people at a time(in addition to the 7500 people I am responisble for via the phone) except they are all sick enough to be admitted. I also work weekends/nights/holidays/during important family and life events. And since I work M-F and 1 in 5 weekends it means that I work, on average, 76% of my birthdays(as well as anniversaries, kids’ birthdays, etc). I have worked some part of Thanksgiving weekend(Thursday-Sunday) for 8 out of the last 10 years and worked Christmas Eve or Christmas Day or both 3 out of 4 years.

        I also see patients who are rich and others who are homeless. However when I see the homeless guy I don’t get paid.

        Now I don’t say this to rub your face in it. We all work hard. We all miss important family events. We all practice defensive medicine(Show me a doctor who says he doesn’t and I will show you a doctor who doesn’t actually see patients- or even slides of patients).

        I do admit almost every single patient I am called on(cannot think of a turned down admission in the last 2 years). I do sometimes think the admission is weak. I do sometimes discharge them a few hours later. I do sometimes find that the ER working diagnosis was wrong.

        However, the ER doctor is there and I am not. I’d have to have extremely strong reasons to turn it down over the phone(ie I’ve seen the patient in clinic 20 times for this complaint and just finished the latest completely negative workup of it this week and the ER doc was unaware of that or some such).

      • Kathie R says:

        Good for you Dr Greenbbs. I applaud you for your reply. My husband is also an ER physician. He works long hours and is the only doc in the ED during any given shift. Sometimes he has to practically beg a ‘specialist’ to come in to see a patient, and never calls anyone needlessly. He has a good reputation for not ‘bothering’ anyone with small stuff, but there is one particular specialist who is argumentative and will do anything he can, not to have to come in. ER docs get a bad rap, sometimes, but they are the first physicians to see the patient and there are plenty of very good clinicians who are successful in saving a client’s life in the ED, before anyone else sees him/her. They are highly trained in their own field, and deserve the respect of other hospital personnel. Thanks again for your post!!

    • MK says:

      Uh, you realize that if all those uninsured, unfunded patients had money to pay their bills, we (the ED docs) would make more too. Our paychecks don’t just magically appear. We are seeing them for free as well. The difference is, we aren’t whining about it…

  7. I find the same thing. When one schleps in to see the patient, they invariably admit them anyway.

  8. Zen says:

    Best day of my professional life was when I “gave up” taking ER calls. I feel sorry for guys like Kirsch and D4n who still have to talk to you guys.

  9. [...] “…Whether ’tis nobler in the mind to suffer the slings and arrows of outrageous fortune Or to take arms against a sea of troubles, and by opposing end them? To die: to sleep; No more; and by a sleep to say we end.” Willy Shaky This is an extraction, with paraphrasing of a great segement on “White Coat’s Call Room” about the age old battle of ED vs. speciality teams in the biggest point of contention in our interactions. The full story can be read here, and is well worth a look. [...]

  10. pm says:

    wow.. as a cardiologist i can count the number of times on one hand that the er docs actually examined the pt… or even took a basic history re. chest pain… or knew basic physiology that a pt with “the same chest pain as before” a stent put in 2 days ago with nl ekg nl enzymes is as likely to have restenosis as getting hit by lightning inside your er and doesnt need to be admitted “just to be sure”

    • WhiteCoat says:

      So I’m just curious.

      Using your chest pain example, what would you tell the doc who calls you about such pain?

      Assuming the stent were appropriately placed and the patient has good TIMI flow, what would you posit is causing the continuing “same chest pain as before”?

      Do you agree or disagree with data showing that half of all ACS cases have normal EKGs during admission?

      Would you expect troponin to be “nl” if the patient experienced an acute cardiac event shortly before having a stent placed?

      Would you be willing to give verbal discharge orders over the telephone to a nurse to have a patient presenting with “the same chest pain as before” sent home from the ED?

      And if a patient with such symptoms called you from home two days after a cath, would you tell them it’s nothing to worry about?

      • Bob says:

        note that they didn’t cath those people in that study. I suspect that if they did, you’d realize that it was just demand ischemia from HF, tachyarrhythmia and the like. Just because the troponin is positive doesn’t mean they have real ACS. Type II NSTEMI is a marker of poor substrate rather than plaque rupture.

    • WhiteCoat says:

      Either pm is a troll or he is not a very good cardiologist since he can’t/won’t respond to basic questions regarding a cardiology scenario that he created himself.
      I’m betting that if a patient called pm with chest pain two days out from a stent, he’d be the first one to tell the patient to go right to the emergency department and then would complain to anyone who listened how the dumb “ER doc” called him and wanted to admit the patient.
      People like this are one reason why I always ask patients whether they contacted their physician before coming to the emergency department and always document that their physician told them to come to the emergency department.

  11. [...] is an interesting post about ED doctors coordinating with specialists over ED admissions. The most amusing part is the comments section…there is a bit of spitting [...]

  12. Ben S says:

    Speaking as a 32-year-old Crohn’s sufferer, colonoscopies for all!

    Ps- Firefox wants to correct colonoscopies to colostomies; even I’m not that mean.

  13. Hueydoc says:

    I really love it when the specialist tells their patient on the phone to ” go to the nearest ER” even for a chronic complaint- basically, they are telling them ” Don’t come to my hospital – I might have to work !”

  14. pm says:

    not a troll but have better things to do than check back blogs unless its part of a new email /….or run them… 60% of stents are put in for stable angina and not indicated. chest pain as before likely wasnt angina/ischemia /cardiac to begin with. why would they be still having sx if stents supposed to “fix the problem” what about the er doc that sends pts home w/ dx of gi .. but “well give you sl nitro just in case” or says this is unstable angina.. but doesnt anticoagulate the pt for the entire time theyre in er.. or hears a new 2/6 murmur in pt with fever in noisy er..or and im sure youll have experience w/ this one…”i just dont feel comfortable sending him home” diagnosis. i usually get more info from the pa or np when they call than from any er doc

    • WhiteCoat says:

      “60% of stents not indicated”
      And how do the neanderthal emergency physicians tell which patients need them and which don’t? In fact, how can *you* tell without doing an angio?

      “why would they be still having sx if stents supposed to “fix the problem””
      Notice how you still failed to answer the question.

      Also notice how you failed to answer any of the questions in my previous comment.

      The remainder of your examples don’t make much sense without more information.

      “sends pts home w/ dx of gi .. but “well give you sl nitro just in case”
      A patient can’t have angina and GI pain together?

      “Hears a new 2/6 murmur in pt with fever in noisy er”
      So what? It’s bad to hear a new murmur?

      ”I just dont feel comfortable sending him home” diagnosis.” If you’re so adept at prospectively separating real from imagined cardiac disease, then you should have no problem discharging the patients over the telephone. Do you have any idea what percentage of patients with acute cardiac ischemic events are sent home from the ED?

      If you’re going to try to badmouth docs in the ED, at least give some good examples. Maybe you don’t have top notch emergency physicians in your hospital. So far, all your examples show are that you are a backstabbing Monday morning quarterback.

      Wanna try answering the questions I asked you and engaging in a rational discussion? Or are you just going to post more vitriol?

  15. Dr. Amy says:

    I’m a hospitalist, and the ER where I work is a bit conservative (ie, their threshold for admission is frequently quite a bit lower than mine).

    One factor in the resistance for soft-call admissions is frankly the paperwork. If the patient gets admitted to me, I have to do a full admit note before I can discharge them. If they already have 2 negative troponins and an outside cardiologist, I still don’t understand why they can’t just get the 3rd trop in the ED and be discharged by the ED. That saves me the effort of doing a whole H&P on a patient, doing an admit note, and then discharging them.

    I’m perfectly capable of admitting a patient, writing an admit note, and then discharging them. It just feels like a lot of wasted effort. If I’m planning to discharge them right away, especially if my residents haven’t done their write-ups yet, I’ll try to talk the ED doc into discharging them for me.

    My other pet-peeve is the partial work-up. An elderly person set in from her NH with agitation, but a normal exam and normal labs (no leukocytosis), but no UA. Geez. No, you can’t admit her to medicine for “there may be an underlying infection.” Get me a UA, show me the dirty urine, and I’ll stop fussing and take her.

  16. Cindy says:

    I am trying to find out why in the Hell an ER doc admitted my septic 83 year old mother (Parkinson’s pt) who had pancreatitis & pylonephritis & parked her on the general med floor?? After wasting 24 plus hours on that floor, she was finally moved (after my constant nagging) to a progressive unit. She died w/in 7 days.

  17. Justin says:

    I agree with the above poster who said that most physicians consider themselves the definitive “yardstick” that determines the threshold for admissions. It is the same with the old saying about driving: “Everyone thinks that anyone going slower than them is an idiot and anyone going faster is a maniac”. Obviously, there is no single yardstick. All the anecdotals and trolling above simply entrench both sides into that useless time-suck called “point the finger”. We’re all pawns in the same game. None of us are rooks or queens. We’re all pawns. If you think you’re more than a pawn, everyone in the hospital hates. you.

  18. Mary says:

    These GI docs make $3000 for a scope that takes 7 minutes tops. They are all millionaires. Lets talk fee for service about that. And none of them have admitted a patient in years, it is just “call the resident, I’ll see the patient in the morning”.

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