For the past 30 minutes, my cell phone has buzzed repeatedly, urging me not to climb out of this rabbit hole. “Come back,” it beckons, “we’re not finished yet.”
When KevinMD deleted my first comment about Dr. Kirsch, I decided to keep further comments on my own blogs so they don’t mysteriously disappear again. Now I’ve learned that I’ve been demoted: Instead of my comments on KevinMD posting immediately, I must receive prior approval before my comments can be viewed by anyone else on Kevin’s blog. All because I pull aside the curtain so people could see the real “insider.”
Next will be the stocks. Then an outright ban on my creative postings.
So, as with the previous post, I’ve copied Dr. Kirsch’s comments here and will comment below.
[phone buzzes yet again] OK, I’m typing as fast as I can …
Dr. Kirsch writes:
I have read the comments to my post on this blog and elsewhere. Regrettably, some have resorted to vituperative language and demonization, rather than to engage in civil discourse and debate. If I have made factual errors regarding the reimbursement of ED physicians, then I am prepared to stand down from these comments. The fact that one commenter above who was particularly critical of me wrote, “the hospital loves it when I order tests”, suggests that there do exist economic incentives. I am not prepared to retreat, however, from my belief that over-diagnosis and over-treatment are embedded in American medical culture. This is an undeniable fact. If some commenters wish to opine that their specialty is somehow not part of this reality, then they are free to do so. I think they have a tough case, but they are free to make it. Regarding my own specialty, I have written more than once under my own name, and expressed elsewhere, that my specialty and me personally are part of the problem. A fair minded reader of my own blog would already know this.
To write and circulate throughout the internet that I am an ‘ER basher’ may have some red meat appeal, but it is false and defamatory. I write in my post that “If I were an ER physician I would behave similarly facing the same pressures that they do”. I continue for several sentences offering a sympathetic view of emergency medicine physicians. Not quite my definition of a ‘basher’.
Regarding my NY colleague’s assertion that gastroenterologists are not qualified to evaluate acute abdominal pain, I believe that the other physician readers will agree that this claim has no basis. In my experience, we are the specialists who are first responders to acute abdominal pain.
Responding to the claim that emergency room physicians do not admit patients, this needs some context. While ED doctors may not sign the admission order, they have often advised patients and later the admitting doctors that the patient needs admission. How many times have emergency physicians called primary care physicians or consultants telling us, “this guy needs to come in”? This is a proper exercise of their role, in my view. It is somewhat disingenuous to claim that “Emergency physicians don’t admit patients”, which may be only technically true.
Finally, personal attacks only demean the attacker and provide little opportunity for a dialogue that could offer all participants the chance for a civil airing of divergent views. We can do better than this and we should.
Dr. Whitecoat responds:
My father was a lawyer. One of the points he always used to make about his opponents is that when they complained that he was being mean, or uncivil, or offensive, or otherwise just plain hurt the opponent’s feelings, it really meant that the opponent had no counterargument to his position and was simply trying to gain sympathy with the judge or jury. He never used the word “vituperative,” though. That may have been because I was in third grade when he told me these things, but that’s another story.
So Dr. Kirsch has labeled people responding to his initial post (and I’m sure I fall in that subset of people) as being vituperative, demonizing, uncivil, and engaging in personal attacks. Yes, I was being vituperative in one sense of the definition. According to Merriam-Webster’s dictionary, vituperative means “uttering or given to censure : containing or characterized by verbal abuse.” If you don’t want to be censured, then don’t make vituperative-worthy statements. And if you’re “offended” or consider it “abusive” that I repeatedly mention that you’re an “insider” with “insider’s knowledge” as I eviscerate all of your misstatements, then, after drying the tears from your eyes with the Kleenex for extra sensitive skin, perhaps in the future you’ll consider researching and providing evidence for your assertions rather than making inaccurate statements of fact to policymakers – many of whom lack the knowledge and insight to see through your self-aggrandizement.
[my phone buzzes yet again] I’m WORKING here. Have patience.
I also get accused of the tort of defamation for calling Dr. Kirsch an “ER basher”. First of all, it is an emergency DEPARTMENT.
[another buzz from the phone]
As I was saying, it is an emergency DEPARTMENT, not an “ER.” Since you seem to be stuck on the title of the cancelled TV show from last decade, let me explain. Back in the early days, there was a “room” in the hospital where all the consultants used to take their patients when they had emergencies. The emergency “room”. These days, hospitals have whole departments with lots of separate “rooms” where lots of emergency physicians treat really sick patients. See the difference? It would be like me calling an endoscopy suite an endoscopy closet.
Back on point. Let’s look up the definition of “bash” at Merriam-Webster’s site. To be a “basher”, one must either “strike with a crushing or smashing blow” or “hurl harsh verbal abuse at.” Now asserting
[phone buzzes again. I am now putting it on "airplane mode"]
Asserting that emergency physicians perform “unnecessary” medical care, while as an “insider” knowing that billing for unnecessary medical care is by definition health care FRAUD seems pretty harsh to me. Asserting that we are somehow incompetent in our trade because “there is a significant percentage of ER patients who should be sent home and are sent upstairs instead” seems pretty harsh to me. And to assert that our morals are so low that we would conspire with hospitals that “encourage” us to inappropriately admit patients to make more money sounds more defamatory than your hurt feelings after I labeled you as an “emergency department basher.”
Remember this little post over at ACP Hospitalist and how I called you out on it back then, too? Same tune, different day. You try to make yourself appear as a better clinician, a smarter physician, and as a more cost-efficient steward of resources by second guessing the emergency physicians after you have completed your negative workup. What you either think no one will pick up on or what you’re too dense to realize, though, is that by the time you have come to your conclusion that the patient never should have been admitted, you also have much more information upon which to base your “insider” opinion. Hindsight is always 20/20.
So to end the comments about butt hurt and defamation, recall that truth is an absolute bar to defamation. You don’t like the label, then stop acting the part. And for Pete’s sake stop whining about it. You’re a grown man.
So let’s get to some of your other comments.
“I am not prepared to retreat, however, from my belief that over-diagnosis and over-treatment are embedded in American medical culture. This is an undeniable fact.”
First, this isn’t what you said in your post. You bash the emergency department because “They are in a culture of overtreatment and overtesting.” Now you’re trying to walk it back to say you really meant that “all of us are to blame.” Oh, and for the added emphasis, your statement is “undeniable,” too. I asked you before and you didn’t respond. Give me a list of testing that should never be performed and of some treatments that should never be offered. You’re the “insider,” share some of that information with us “outsiders.” You know why you won’t do it? Because your statement isn’t “undeniable.” In fact, when you try to prospectively examine emergency department evaluation and treatment, it’s highly deniable. There are low yield tests and high yield tests. Whether those tests are ordered depends on a physician’s medical judgment. And you certainly aren’t the yardstick by which an emergency physician’s judgment should be measured.
“I continue for several sentences offering a sympathetic view of emergency medicine physicians.”
Is that kind of like a husband who beats his wife telling her that he really loves her before he winds up for another punch? Just because you feign sympathy doesn’t mean that you get a free pass to backstab emergency medicine throughout the rest of your post. Nice try, though.
“In my experience, [gastroenterologists] are the specialists who are first responders to acute abdominal pain.”
This statement exemplifies what is wrong with you, your insights, and your “inside information.”
YOU HAVE NO EMERGENCY DEPARTMENT “EXPERIENCE.” You’re making yourself the laughing stock of the medical community when you make statements like this. Many emergency physicians have already responded that they rarely if ever call a gastroenterologist for evaluation of abdominal pain. I can add my own experiences to that list. I can’t remember ever calling a gastroenterologist to evaluate a patient with undifferentiated abdominal pain. I’m betting that if someone interviewed the emergency physicians in your hospital’s “ER,” they would say the same thing. But you babble on in your blissful ignorance holding your asserted truths to be self-evident, “inarguable,” and “undeniable.” Enough already.
Finally, your whole argument about whether or not emergency physicians truly “admit” patients is a non-argument. You agree that it is “technically true,” but then you seem to state that it really isn’t true because we advise another doctor that “this guy needs to come in”? What is your point? Another physician is still admitting the patient. Are you going to change your criticisms to attack the true admitting physicians who “unnecessarily” waste all of our precious health care dollars?
I’ll end this response with a Twitter picture that just happened to pop up on my Twitter feed a day or two ago. With hat-tips to @CardioNP for re-tweeting it and to @pkedrosky for initially tweeting it.
I’ve spent a couple of hours responding to something that shouldn’t have even needed a response. Hopefully this ends both this debate and any of Dr. Kirsch’s future uninformed posts about “emergency rooms”.