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.

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?

—Ronald A. (“Ron”) Hellstern, MD,
FACEP(E), Colleyville, Texas

Emergency Medicine has its own language and culture. People who don’t practice emergency medicine think it’s just internal medicine in the ER. They picture us having the same leisures they have in how they manage patients, ie, linearly managing patients with known diagnoses. They will never learn our culture or language because they don’t necessarily even recognize that there is a difference. Like most people, they don’t go looking for things they don’t know are in existence. As such, we will always be misunderstood, I fear.

I have seen positive changes in the way we are perceived over my 20 years of practice, but there is still a way to go. I explain it as thus: Our job is to manage a community resource, the emergency department. Manage is the key word. Everybody else in medicine has the job of managing the patient’s illness. We do that to the extent possible in the background of managing a community resource, but we are never relieved of our duty to first manage a community resource. We co-manage several patients at a time, providing safety for the downstream docs to do their work with major and unexpected medical conditions identified, treated, or ruled out…and, like, 5 minutes ago.

We speak a language that nobody else in medicine speaks. Like anybody in that situation, we often can only shake our heads “yes” and move on.

—William Franklin, DO, FACEP
Bakersfield, California

While I do agree with Dr. Klauer that it appears emergency medicine was unjustifiably singled out in this study, I would like to add a few observations from over 35 years of practicing emergency medicine.

It is an ideal situation if the ED physician is able to arrive at a diagnosis in an efficient and timely manner. Unfortunately, the human machine is not always willing to cooperate and in many cases a definitive diagnosis simply cannot be achieved in the ED within a reasonable timeframe. The next issue for the ED physician becomes “Do I admit or do I refer?” A physician who has listened to the patient’s story—and I don’t mean asked six or seven preconceived “Yes/No” history template questions that “best fit” (but don’t EXACTLY fit) the patient’s chief complaint—has done a focused physical examination—not just the now-ubiquitous “stethoscope tap” chest exam or “momentary palm touch” abdominal exam—formulated a differential diagnosis that is followed, has ordered appropriate lab and imaging tests based on his/her assessment of the patient, reviewed all tests results, and addressed any unexpected results is going to be much more secure in deciding whether a patient with an undiagnosed condition needs emergency admission or simply follow-up with their own physician or a referral to a specialist.

However, in the last 15 to 20 years I have noted a serious and progressive decline in the ability of the average emergency physician to perform a competent history and physical exam. In this day of the EHR, many patients have physical exams recorded that never took place. I recall (I’m semi-retired now) medical students and residents arriving for their emergency department rotations without even a stethoscope. I can’t speak as to whether these same deficiencies apply to other specialties, though I suspect they do. We need to take a closer look at how medical students are being taught and instill in all new physicians and physicians-in-the-making that there is more to medicine than ordering a bunch of tests and then trying to explain away, or in some unfortunate cases, simply ignore the unexpected, for no other reason than it doesn’t fit our preconceived notion of diagnosis and/or disposition.

—Jerry W. Jones, MD, FACEP, FAAEM
Houston, Texas

I believe your comments are right on point with what we as a specialty need to be more outspoken of. The video that IOM created for laypeople (https://m.youtube.com/watch?v=fStBWT6fa3E) is a mockery to physician insight and perception that we would only favor one diagnosis and do not communicate with our patients throughout their hospitalization. The woman with left upper extremity pain that was apparently anginal in nature states that her long-term morbidity is associated to the delay in her diagnosis. However, they fail to mention if she may have reported any other symptoms to the emergency physician evaluating her on that given day that may have led him/her to believe that this could be acid reflux. Further, did her symptoms evolve over those two weeks and manifest into more obvious anginal symptoms? If we admitted every chest pain that would be considered clinically low risk, what are the long-term implications to our health care system? If we admitted every patient that stated they have a “high pain tolerance” and know that something is wrong, what do we further due to our growing narcotic epidemic? Yet, we find more ways to burden our specialty in reflecting on delays in diagnosis and pointing fingers for the growing narcotic epidemic.

We have all recently been asked to meet the CMS standards for severe sepsis in all of our patients. However, what about the patients in our respective institution that ultimately do not have sepsis? It may appear they could have an infection, but for fear of not meeting regulatory standards, still received the 30 ML per kilo bolus and broad-spectrum antibiotics. Maybe the patient even had a lactic acidosis and an interstitial infiltrate that could reflect pneumonia. What are the implications and long-term morbidity and mortality associated with these patients, that we now have been asked to ensure we hit all quality metrics within a three-hour window (just click the sepsis bundle and everything will be taken care of—but the patient)? Did we not learn from the pneumonia initiative, requiring initiatives such as these have negative implications? However, when a patient is negatively impacted because a physician attempted to use his critical decision-making and determine appropriate line of action, he immediately will be referred back to the CMS standards and the IOM initiative and be asked why.

I thought the best statement I heard made at SMACC was protocolized therapy makes stupid people stupider and smart people stupid. Yes, cognitive errors occur in every specialty and each specialty needs to be accountable. Better communication between physicians and physician subspecialties needs to occur, enhancement of our medical school education, etc. We need to stop focusing on certain hospital metrics. We need to allow an illness to manifest and focus on patient care!

—Hijinio Carreon, DO, FACEP
Des Moines, Iowa