The Great ER Caper

Jack Coulehan is a physician and senior fellow at the Center for Medical Humanities, Compassionate Care, and Bioethics at Stony Brook University in Stony Brook, NY. He describes himself as “not only an experienced physician, but also an advocate—in fact, a teacher—of standard-of-care practice.”

But he was no match for the vagaries of the hospital emergency room.

In the most recent issue of Health Affairs, Coulehan writes about hearing tales from friends about being “caught in a web of excessive and unnecessary medical testing” when they went to their doctors for seemingly routine problems. Although sympathetic, he couldn't really relate.

He goes on to say, “Many of the tales also included delays in receiving their test results, frequent referrals to specialists, and poor coordination among health professionals. Naturally, I’d express sympathy or outrage, whichever the speaker seemed to expect, but internally I’d pat myself on the back. I felt fortunate that there was absolutely no way I’d ever be stuck in such a scenario.”

Well, it turns out that Coulehan was wrong. A bout with self-diagnosed shingles on Easter Sunday sent him to the emergency room “to confirm the diagnosis and get my prescriptions.” Instead, Coulehan ended up spending all day in the ER, seeing an ophthalmologist and neurologist, having two MRIs and a CT scan and racking up $9,000 in medical charges.

The tale he tells of “the Great ER Caper,” provides a clear example of the  “unnecessary testing, inappropriate consultation, and uncoordinated care” that are rampant in hospital ERs and throughout the health care system. Chastened by this experience of winding up as “a poster boy for excessive medicine,” Coulehan asks;

“How can we make stories like mine less common? The only way is an approach to health care reform that encourages well-coordinated, standard-of-care practice and one that simultaneously discourages the irrational shotgun approach to medicine.”

44 thoughts on “The Great ER Caper

  1. thanks for passing along a fascinating and depressing piece. more depressing yet is the passive response from both of you. us pitchfork-waving populists want news we can use now — or policies that can protect us. at minimum a Parade magazine style list of “things you can do to avoid excessive ER care.” Instead, you both conclude that reform of the system, something decades away at best, might may things better for the next generation.

  2. As part of my job, I see excessive testing in the ER every day. But I have been chastized by the powers that be here on Health Beat for proposing what I think is the basis for most of this excessive testing.
    Although, I sympathize with Dr. Coulehan, if he is truly a “experienced physician, … in fact, a teacher—of standard-of-care practice” he could have declined all these extra tests and consultations – that is unless he was either not confident of his “teacher – of standard-of-care” experience or he was tied down and forced to undergo them.

  3. Jim,
    Sorry to depress you, but the practices Coulehan outlines are so ingrained that it will take a fundamental change in thinking–both from medical consumers (i.e. patients) and practitioners before we can avoid excessive care. As for a “seven things you can do to avoid excessive care” or some such prescription, when people are sick, in pain and probably, scared, they aren’t usually in a position to stand up to their doctors. I don’t know if doctors get carried away by this power shift, but it would seem like they should be the ones to use constraint and reassure patients that no, another test or another specialist is not needed.
    It’s akin to the experience many of us (OK, me) have when we bring our car to a mechanic. We might want to tell him not to replace gaskets or brake pads because they seem just fine, but really, doesn’t the mechanic know a lot more about cars than we do?
    We trust doctors (and mechanics) to direct our care; we need rational, evidence-based practice guidelines and we need to provide incentives to get docs to stick to them to make sure that trust is not betrayed.
    Legacy Flyer,
    What’s interesting about this piece is that once Dr. Coulehan found himself in terrible pain, drugged up with morphine and in the completely alien position of being an essentially helpless patient, he lost his ability to decline extra tests and consultations. He wasn’t “tied down or forced to undergo them,” but merely experiencing the disorientation and powerlessness most of us feel in serious medical situations. That’s why this is an important story–it shows that even the most savvy medical consumers can be sucked into the excessive medicine juggernaut.

  4. This behavior should surprise no one.
    Over the years, we have begun to test for more and more rare diseases, as “missing” freak occurences has become less and less defensible. Now, we test for conditions that effectively don’t even happen.
    Not only is it expensive, minimally dangerous, but it denys patients a wonderful experience — being told that he has nothing to worry about. No doctor can afford to tell you that now.

  5. since the ER docs aren’t the ones who substantially benefit financially from ordering all these tests, what do the faithful HealthBeat readers think could be influencing such behavior?

  6. Naomi,
    When I first posted, I had not read Dr. Coulehan’s article and did not know that he had received morphine. My premature response was a reaction to (my perception of) a lack of humility in his self description – “I’m not only an experienced physician, but also an advocate – in fact, a teacher – of standard-of-care practice”.
    To me, the most striking aspect of his story is how little of what happened can be attributed to “money driven” medicine and how much can be understood as “fear driven” medicine.
    The first doc who saw him was a younger colleague who agreed with his diagnosis of shingles but “just for completeness’ sake” ordered a Neurology and Opthalmology consult. What was her motive for ordering these extra, probably unnecessary (in retrospect definitely unnecessary) tests? Was it money? No, since she was not going to get a commission (fee splitting) from the Neurologist or Opthalmologist. Her motive for ordering the extra consultations was fear – fear of missing a rare diagnosis – particularly in a VIP (very important patient) colleague.
    Similarly what motivated the Neurologists? (Having the Neurology Resident evaluate the VIP was not good enough so the attending was called in.) Did the attending Neurologist come in from home on a Sunday for the money? – I doubt it. Did the Neurologist order the MRI for money? – I doubt it. In my experience fee splitting for diagnostic testing in a hospital does not occur. The neurologist ordered the MRI “just to make sure”. Again, his motive for ordering the extra test was fear of missing a rare diagnosis in a VIP colleague.
    Finally, the Radiologist acted similarly, invoking “the Radiologist’s National Tree” – the hedge. He saw a “questionable finding” and “couldn’t rule out” a cavernous sinus thrombosis. His motivation – fear of missing a rare diagnosis in a VIP colleague.
    And so went this little drama, which unfortunately (in my personal experience) is played out many times a day in many ERs across the country. Were any of the physicians involved stupid, incompetent or poorly trained? Doubtful – most likely they were all intelligent, competent and well trained. What lead to this monumentally wasteful medical encounter?
    One factor which probably played a role here is the VIP patient – a patient in which no effort is spared or stone left unturned. But similar, but perhaps less dramatic encounters occur every day with patients who are not VIPs.
    Did money play a role? Doubtful in the sense that any of the actors personally profited by ordering extra consultations or tests – I don’t believe any fee splitting or kickbacks occurred occurred. Likely neither the Neurologist nor the Opthalmologist wanted to come to the ER on Easter Sunday to see a single patient. It could be argued that the Radiologist “waffled” in his report in order to generate more business, but I think this is unlikely. More likely he just didn’t want to miss something.
    So what was the cause – fear; fear of being wrong, fear of screwing up the diagnosis and treatment of a VIP, and fear of other unmentionable things.
    Christopher George: please email me at: douglasbrunner@earthlink.net

  7. Nothing like a personal experience like this for an expert to change a mind.
    One would think that the lunatic right(including Congresspersons or at least their families) would have these awfull experiences also since thay are pervasive.
    One wonders why they haven’t seen the mess and translated that into demand for change?
    Dr. Rick Lippin
    Southampton,PA

  8. The inefficiencies and lack of care coordination that run through our current system are costing us countless dollars every day. We need to keep speaking about and enacting models of care that reward the coordination and collaboration of care across specialties and across peoples’ multiple healthcare conditions and issues. This means a variety of things, from borderless care within the United States to reforming our payment/reimbursement model so that clinicians are incentivized to work together and seamlessly share information about patients. http://blogs.intel.com/healthcare

  9. The behavior is rewarded financially, by the “health” of the “health system” employer. The “health system” has the power and control and they want systematic overtreatment to hit their ever increasing numbers goals of admissions, procedures, visits, etc.

  10. pcb —
    “what do the faithful HealthBeat readers think could be influencing such behavior?”
    This is a classic example of one of the biggest problems in US health care, made even worse in this case by the impact of the patient being a doctor from the institution he was being managed in.
    The main reason is not cash. There are some cash factors in this type of behavior on the part of manufacturers eager to sell drugs and equipment, but they succeed mainly because there is a huge demand for what they are selling. I have also seen physicians become invested in promoting services they benefit from, and promote them both formally and informally.
    Careerism on the part of academic physicians also contributes, since they advance based on the “innovations” that they produce.
    Fear of making a mistake or seeming to be a fool is important as well, and as Legacy Flyer says was undoubtedly a major factor in this particular case.
    In the end, the main cause is medical culture — the perception that this is the way things should be done that is passed from teachers to students during medical training and from peer to peer in practice.
    The institutions and practices that are able to break out of this cycle at least partially — the usual Dartmouth All-Stars — can do it because they create an internal culture that trumps the larger culture. You do not have to spend much time at the Mayo Clinic before you hear the phrase “the Mayo Way.” Kaiser and Group Health have explicit practice guidelines directed at breaking the cycle. These institutions have, among other things, a sense of their own correctness, based both on research and on confidence as an institution, that trumps the conformity and fear that drives so much of this.
    This ability to turn away from national trends of waste, overuse, and ineffectiveness also sometimes spills out of the institutions to surrounding areas. Trainees spread the pattern as they disperse. The example of the “flagship” institutions, spread by educational outreach, word of mouth, and by reports from patients who return from the large institutions, creates the kind of “shadow” that the Dartmouth studies found in the Upper Midwest in areas near Mayo, Marshfield, and other similar institutions.
    As far as breaking the pattern nationally, I can see only one hope. We need to have an institution similar to NICE, and that institution needs to have the power to issue guidelines and enforce those guidelines. The IMAC proposal is a step in that direction. It would work even better if following IMAC standards was required not only of government programs but also of private insurers who benefitted from the subsidies for low income people being proposed, and also if it were a requirement for listing on the insurance exchange. However, even without that, I think that private insurers would start to adopt reasonable standards once Medicare and other public insurers did, simply because it would be good business practice and the Medicare adoption would give them cover from complaints. Once some insurers adopted the standards, almost all would have to adopt them soon because of competitive pressure.
    I personally believe that this cycle can be broken if there is leadership willing to take the risk to do it. Obama seems to be willing to take that risk, although his opponents, including many in his own party, are more than willing to resort to lies and rhetoric that would be laughable if they weren’t so tragic in order to stop him. There are a huge number of people and institutions in this country that are invested in protecting the system of overuse. One person’s overuse is another person’s new beach house, and one person’s ineffective procedure is another person’s promotion to full professor. Fighting that fight is one of most important priorities in health care reform, because if we don’t win, before long there will not be enough money to support the cost of health care for almost anyone, regardless of whether they get their care through private insurance, employers, Medicare, or any other program.

  11. The ER is the most profligate spender of resources within our vaunted medical system. But the fault can be spread around.
    First is the reward for doing more system of financing that gives no down side to ordering more tests, despite the fact this behaivor may actually prove harmful to patient care when false positives emerge in the course of diagnosis.
    Secondly is the cadre of lawyers who make their living off this system, thus assuring that ANY mistake can turn into a bonanza for the individual affected or their relatives. Everyone who now has chest pain gets a CT scan of the chest due to the fact that lawyers have feasted on people with a missed diagnosis of pulmonary embolism in the ER. The anticipated response of the medical profession when threatened by these lawsuits should not be unexpected.
    Thirdly, hospitals that encourage such expenditures in their ER, again to avoid litigation, but also to line their pockets from this treasure trove of endless profit.
    And finally insurers who seem unwilling to do anything to limit the use of the emergency room. This behavior I have never understood, but I can only assume insurers gave up trying to contain costs under the barrage of criticism during the managed care era and also out of fear of litigation.

  12. Many ED physician services are subcontracted and are “encouraged” to admit patients. This builds a culture that makes every soul who walks or is wheeled in a potential revenue source for the hospital. So if the patient is more compliant than ill they will test until they find something to admit for (or just make up stuff). Believe me, if you saw the sloppy documentation generated in many ED’s you would see how they are much more focused on finding a reason for admission than avoiding liability.

  13. d’cm,
    What is the basis for your statements?
    I am not sure what you mean by ER docs being “subcontracted” – in my experience, most hospitals contract with ER groups to provide coverage. The ER groups in tern hire physicians to cover their staffing needs. Is this what you mean by being “subcontracted”.
    Secondly, how does the hospital “encourage” ER docs to admit? Again, in my experience ER docs are under a lot of pressure to
    “treat ’em and street ’em”, but I am unaware of any pressure to admit a certain percentage of patients. Are there specific parameters in the contracts that require a certain number of admissions? If a group does not provide the hospital with a certain number of admissions is this a reason for contract cancellation? I would be very surprised if the Feds would tolerate such arrangements.
    Finally, with respect to sloppy documentation – I am sure you are right – I see that too. But does sloppy documentation produce more admissions? Or is it merely the result of being busy?

  14. I agree totally with Legacy.
    d’cd, I don’t know what ER you’ve ever been in, but I’ve worked in 35 in my career and I’ve never seen an ER doc “admit” a patient. They can’t and they don’t. They are required to call and get another physician to do it. They are not an admitting physician in any hospital I’ve worked at. They must call an admitting physician to accept a patient. More often than not they get alot of pushback from those physicians for anything considered a “soft” admit, because it is more work for the physician and more time away from the office. An ER doc more often than not has to cajole another physician to admit a patient. It doesn’t happen nearly as easily as you think it does.

  15. Legacy Flyer,
    “As part of my job, I see excessive testing in the ER every day. But I have been chastized by the powers that be here on Health Beat for proposing what I think is the basis for most of this excessive testing.”
    I know I have had words with you, but I am hardly a power that be. Aren’t you a hospital CEO?!? Are you telling us you see a problem in your own hospital that you can’t fix? Really!? I don’t believe that, and NO I don’t believe “defensive medicine” is the problem. As one of the facilities leaders isn’t it up to you to change the culture?!?!
    And again, I think you’re wrong about Dr. Coulehan, experienced physician or not, IT DOESN’T MATTER WHO YOU ARE we (as patients) seem to be completely powerless to do anything other than enter this broken system for care, and we’ll get whatever they decide to give us, period the end. It’s not that easy to get something done, or not done, in a hospital, it’s not the patient’s choices or decisions, I think you’re an executive at a hospital, are you not? It’s your choices that the experienced Dr. Coulehan had to live with when he went to the ER.

  16. I have seen it too legacy flyer, ER seen as a path to admissions. Such stats are tracked by executives and “mentioned” to the department heads they control during weekly monthly and yearly beatings/threatening sessions.
    I think that there is a large variability in how profiteering oriented management can be by locale.
    You may not consider it possible, yet I see it as commonplace. Things which I see as commonplace I might accuse your institution as doing (unjustly).
    But yes, I have seen exactly what d’cm says and it goes along with a whole host of incredible practices covered by PR and political lobbying.

  17. In my judgment, at least some of the excesses Dr. Coulehan were exposed to were not only obviously unnecessary but in some cases slightly hazardous in terms of excess radiation exposure. This was not a case of excess caution, but simply bad decision making.
    One of the most informative diagnostic tests in all of medicine is time. When Dr. Coulehan went to the ER with a presumptive diagnosis of shingles (Zoster), the characteristic rash had not yet appeared, and so the remote possibility of an alternative diagnosis remained. By the time he left, the rash was emerging, and no doubts remained. Most of the alternative diagnoses considered could have safely waited a few hours – a brain tumor wasn’t about to kill him between morning and evening, and in any case, he was under observation that would have determined which way his condition was headed.
    In my view, future guidelines must be developed to bolster physicians against the insecurity of fearing they might be missing something. These should not only include evidence-based standards indicating which tests are essential and which are not, but also standards for answering questions about “when” something may become necessary, so that it is not imposed unless and until a patient’s condition indicates that further waiting is unwise.
    That would save money, reduce exposure hazards, and spare patients anxieties that are themselves something healthcare should seek to ameliorate.

  18. Fred–
    You wrote:
    “One of the most informative diagnostic tests in all of medicine is time.
    “When Dr. Coulehan went to the ER with a presumptive diagnosis of shingles (Zoster), the characteristic rash had not yet appeared, and so the remote possibility of an alternative diagnosis remained. By the time he left, the rash was emerging, and no doubts remained. Most of the alternative diagnoses considered could have safely waited a few hours – a brain tumor wasn’t about to kill him between morning and evening, and in any case, he was under observation that would have determined which way his condition was headed”
    Yes– very well-put.

  19. I should have mentioned also that there’s a shingles vaccine available. It’s not cheap – I think maybe a couple of hundred dollars – but still a bargain compared with the $9000 his ER visit cost.
    I also noticed that Dr. Coulehan is a Professor Emeritus of Preventive Medicine. Preventive medicine? Hmm.

  20. Lisa,
    “Aren’t you a hospital CEO?!?”
    Hardly – I was formerly Chief of a Hospital Department (Radiology) for 6 years. I was not employed or paid by the Hospital (I didn’t receive any extra compensation from my group either). After years of extra work for no extra pay and dealing with dishonest hospital administrators I quit.
    “Are you telling us you see a problem in your own hospital that you can’t fix? Really!? I don’t believe that, and NO I don’t believe “defensive medicine” is the problem. As one of the facilities leaders isn’t it up to you to change the culture?!?!”
    I see lots of problems in hospitals that I can’t fix. Furthermore, I don’t believe that hospital CEOs have as much power to “change the culture” as you seem to think they do. Expecting a hospital CEO to “change the culture” is a little bit like expecting a Mayor to cut the crime rate in half, fix unemployment and stop drug abuse. True, a good Mayor can influence these issues but not “change the culture” of a city.

  21. Joe Says,
    Well (thankfully) I have not been “in the loop” of conversations between CEOs and ER groups about how many admissions they generate.
    I would think that such a conversation would be risky given the various whistle blower statutes and the powers of the Fed to shut down a hospital.

  22. Fred and Maggie,
    “…a brain tumor wasn’t about to kill him between morning and evening, and in any case, he was under observation that would have determined which way his condition was headed
    Yes– very well-put.”
    I would invite you to have the following conversation with a patient:
    “Mr and/or Mrs. Jones – you might have a brain tumor, but it won’t kill you during the next 24 hours so we are going to wait to do any tests.”
    You are absolutely right from a factual perspective, but the message you have to deliver is not a “crowd pleaser”.
    I say this based upon years of personal experience trying to dissuade ER docs from ordering tests that they will do nothing about that night. And in the old days these were tests that I had to drive in to the hospital for so I am not just being a “goody two shoes”.

  23. There is obviously a lot of pertinent historical and physical exam information that is missing from this piece. If it were all there, and the ER doc could explain his thinking, it would probably seem less fantastic.
    Zoster ophthalmicus is a potentially vision-threatening problem. If this was a classic case, most ER physicians would not have had trouble making the diagnosis after about a 5 second exam, but pain and other symptoms may precede the typical rash by as long as a week, making the diagnosis not so certain in atypical cases. Rarely, the rash does not occur at all.Palsies of the 3rd, 4th, and 6th cranial nerves can also occur. I suspect the MRI was ordered on the advice of the neurologist, and after the rash became apparent, the ophthalmologist was consulted appropriately.
    If Dr Coulehan wants to publicize his case as an example of gross waste and abuse, he should provide more details. I suspect that he should be happy to have had a thorough clinician who didn’t want to miss anything worse in a colleague. If he was concerned about an excessive work-up, as a physician he could have been a bit more proactively involved in his treatment. (Ever mindful of the truism that “A doctor who treats himself has a fool for a patient”)Criticizing emergency physicians who are under incredible time pressures is lame. This is not a good example of waste. More likely, it is an example of good care, or the somewhat misguided efforts of inexperienced (resident) clinicians.

  24. Fred, respectlfully, on what planet do you spend most of your time? It is apparently not on one where you spend a lot of time observing clinicians in EDs or patients in waiting rooms. Sitting around for hours to see what happens is not a reasonable thing to do while patients pile up, wait for hours, and then leave the ED without being seen. Another visit would not have been free and if treatment was delayed, resulting in progression of his illness with loss of vision, you are looking potentially at a very expensive suit. Until the burden on ERs is lifted, and until more better trained, better compensated primary care doctors are available, there will continue to be a crush of patients to be seen in Emergency Departments. Another component which drives up costs in Emergency Departments is the inability to obtain decent histories on patients who, for a multitude of reasons, are unable to describe their symptoms in a way that makes sense. This causes more tests, as does the fact that there are a lot of unreliable “customers” in emergency departments who are not going to follow up as instructed, and for whom you are only going to get one opportunity to make a diagnosis.
    Certainly we can save money throughout medicine, including ememrgency medicine, but thinly supported anecdotes about unusual cases, which sound fantastic, are often not, given the realities of emergency medicine these day. Be careful what you use as an example. And, just for comparisn, at some hospitals where I work, a diagnosis of a sprained ankle can cost $1,000. That puts a case of potential loss of vision in an little different light.

  25. Anyone who follows the blog by and for hospital administrators, Hospital Impact, would understand part of what is “influencing such behavior”, such as the advice they give to each other and their staffs to “push the high-margin procedures,” especially when times are tough. There is an argument to be made that this position contravenes the ACHE standard of ethical conduct, but that’s another discussion (Legacy Flyer’s naive trust in the federal government’s readiness to “shut down a hospital” is touching but misplaced). This position clearly leads to overtreatment, overuse of resources, high costs, and exposing patients unnecessarily to potentially harmful procedures and tests.
    There is also ample evidence that doctors are not being well and consistently trained in basic diagnostic thinking and analysis. Since most med students go into procedural specialties, the educational emphasis is on applying technology to signs and symptoms and presenting conditions. The increasing trends in maternal and infant mortality and morbidity in the US is one example of the fallout of this medical training and culture.
    Finally, the “defensive medicine” argument, if true, is more neurotic than rational, as one analyst has written. First, malpractice insurance and claims contribute only 1%-2% to the cost of healthcare in the US. Second, nobody knows how much “defensive medicine” is being practiced, nor how much it costs, because it hasn’t been researched. The “evidence” for this argument is anecdotal and more along the lines of an “urban legend” than knowledge. Who knows how many times “defensive medicine” is used as the “explanation” for overtreatment and overuse of resources, when the truth is more along the lines of additional income? Third, if more doctors practiced using evidence-based scientific information more consistently, improved their diagnostic skills, and practiced less speculative medicine, the “defensive medicine” argument would be less necessary. IMHO, doctors’ fear of practicing “cookbook medicine” is more dangerous to patient safety and health outcomes than their fear of “missing a diagnosis.”

  26. I appreciate the thoughtful comments of some who have addressed my point about Dr. Coulehan’s ER experience. Based on the stated information, it appears that too many tests were done, when watchful waiting would have obviated some of them, although I agree that additional details would have been helpful in judging . I don’t subscribe to the notion that it is a better utilization of ER time and resources to spend 12 hours doing tests that might have proved unnecessary than to spend 12 hours with occasional monitoring in the ER or even at home via telephone. The fact that watchful waiting over a period of hours might NOT have proved some of the testing unnecessary (e.g., if the rash had not appeared) does not, in my view, invalidate the role of waiting, since until we wait, we don’t know what will remain necessary and what can be avoided. Finally, regarding a brain tumor, that remote possibility in the mind of the ER physician need not have been discussed with the patient, since it quickly turned out to be a false concern.

  27. ACarroll,
    “Legacy Flyer’s naive trust in the federal government’s readiness to “shut down a hospital” is touching but misplaced”
    A hospital that I have worked at since 1984 recently entered into a “consent decree” with the Feds, it fired its CEO, CFO and COO, and reorganized due to the threat of decertification by Medicare. I do not know all the specifics of the case, but it involved salaries paid to Cardiologists by the hospital.
    (An interesting sideline issue is that the arrangement, knowing how this hospital works, had to have been vetted by the hospitals lawyers.)
    The Fed does indeed have the power to shut down a hospital and uses its power to force changes.

  28. Fred,
    There is no doubt that this particular case (as presented)is a dramatic example of excessive consultation and diagnostic testing in the ER. The important question is: Why?
    If in fact the motives of the ER doc, the Neurologist and the Opthalmologist were to overtreat for money, then this is a case of “Money Driven Medicine”. If their motives were not monetary then something else is going on.
    “Joe Says” and other posters have suggested that Hospital Executives track usage, tests, admissions, etc. and “encourage” ER docs to increase the above to bring more money to the hospital. If hospital execs “encourage” ER docs to order more tests, etc., I am not aware of it (not that I necessarily would be). I would be interested to hear from ER docs who have an insiders view of the situation.
    In principle you are correct, watchful waiting would make many of the tests ordered in ERs unnecessary. However from a practical perspective Tom Leigh is correct, it is simply not practical in most ERs. “Treat ’em and Street ’em” is the rule. I know from personal experience that ER waiting times are monitored carefully by hospital execs. (One hospital I worked at had the biggest wide screen monitors I had ever seen and waiting times for all patients were displayed there) Filling all your examining rooms with patients who you are watching does bad things to your turnaround time and really pisses off the nurses.

  29. Well, by golly, if our healthcare leadership can’t change the culture, and consumers can’t change the culture, then I guess we’re all destined to spend the rest of our lives on Maggie’s blog bickering with each other.

  30. “I should have mentioned also that there’s a shingles vaccine available. It’s not cheap – I think maybe a couple of hundred dollars – but still a bargain compared with the $9000 his ER visit cost.”
    It’s an aside, but a quick point on the efficacy of the shingles vaccine.
    1.6% chance of shingles over 3 year period when getting the vaccine. 3.3% chance without. 1.7% difference. Hardly a convincing argument for “preventing” shingles, despite how Merck spins it.
    (data based on the study that led to approval of the vaccine)

  31. PCB:
    According to the figures you provide, your interpretation of the research is bass-ackwards. In terms of risk, you are more than HALVING the risk of developing shingles if you get the vaccine. In other words, you have TWICE the chance of developing shingles WITHOUT the vaccine than if you get the vaccine. Few new interventions can claim that degree of success. You may be a steel-nerved gambler, but I would take those odds any day.

  32. ACarroll:
    “According to the figures you provide, your interpretation of the research is bass-ackwards. In terms of risk, you are more than HALVING the risk of developing shingles if you get the vaccine. In other words, you have TWICE the chance of developing shingles WITHOUT the vaccine than if you get the vaccine. Few new interventions can claim that degree of success. You may be a steel-nerved gambler, but I would take those odds any day.”
    ah, the old relative risk trick. Give me absolute risk reduction (and subsequent Number Needed to Treat) any day over the misleading (and often used by those trying to spin results) relative risk reduction.
    If the risk of something goes from 2 out of 100,000 to 1 out of 100,000, yes, you have cut your risk in half. But you’re pretty much in the same position regarding chances of getting the disease.
    Advertising the difference as “cutting the risk in half” is technically true, but highly misleading.
    But whatever. I’m OK as long as the real numbers, absolute risk reduction, and NNT are presented along side the relative risk. Whatever floats your boat.

  33. To PCB – You raise relevant questions regarding the value of vaccine prevention for shingles, which I interpret as having great value.
    First, shingles can be extremely painful and incapacitating, and residual symptoms can persist for years. Succesful prevention spares patients that risk.
    Second, the calculated 1.7% reduced incidence is for three years, but in older individuals (the most likely vaccinees), incidence rates are not likely to diminish with time, and in fact probably increase, at least at some ages. For a $200 vaccine to be cost neutral in averting $9000 ER costs would require only about a 2.2% risk reduction, and that should be achievable within 4-5 years, with a substantial net cost savings over the entire lifetime of the vaccinee.
    However, these are savings only in patient health and in medical expenses. The larger savings from most preventive interventions involve savings outside of the health system, but rather in worker productivity. Lost worker productivity due to illness subtracts hundreds of billions of dollars from GDP annually, and even a modest reduction in those losses could save the economy tens of billions.
    Not all preventive interventions are cost effective in economic terms, but most vaccines are a good bargain.

  34. pcb:
    Since you are so adamant about interpreting epidemiological analysis, then you must know something about the importance of research design. But, you provided the data without accompanying information about the research itself.
    If the research doesn’t have enough power (yes, including your “number needed to treat”) to find a real difference between 1 and 2, then your argument about “doubling” is moot. But we don’t know that in the research you dispute, do we?
    In addition, this vaccine probably only halves the risk in patients who have had chickenpox in the past or been exposed to it. For at least one generation, there has been a chickenpox vaccine that may or may not further affect the risk of “getting the disease” in younger people.
    There is no such thing as “absolute risk reduction,” or if there is, it’s impossible to know, because all precursor conditions and variables are not known. And it’s impossible to test the entire population and their varying experience/exposure. So, your “solution” to furthering medical knowledge and applying it to real world practice must be “don’t do anything until we can make decisions based on ‘absolute risk’. There is enough illogic in the US healthcare system without adding another layer.

  35. Apropos of the discussion of what motivates ER docs to “over-order” consults and tests, I sent a series of questions to a friend of mine – Dan – a retired ER doc. He practiced for many years at an academic medical center in Boston (high cost state). What follows is our email conversation.
    Question: I know that you told me that when you were practicing ER medicine you were the “cheapest guy in town” – you ordered the fewest tests and other procedures in your group. Did this affect your income? Were you paid less than other docs who ordered more tests, etc.?
    Dan: “No, I was salaried and although we did get a bonus, little if any was based on billing numbers. I never knew the formula for the bonus – the boss kept it a secret, but my sense was I got a mid to high bonus because of other work I did for the department.”
    Question: Was pressure ever applied to you to order more tests or consults?
    Dan: “I never had any pressure to order more tests or consultants. Since that always backs up a department, I think most of the docs appreciated that I handed over a department that was usually under control and everyone had a plan. My boss was interested in why I had low numbers – thought maybe it was my documentation etc., but when we figured it out, I never heard ‘you need to order more’.”
    Question: Was pressure ever applied to you to admit more patients?
    Dan: “Since it was a teaching hospital, most of the departments didn’t want to be bothered to come to the ED. In a community setting one might get more pressure from the privates since they get paid more if they see someone in the ED. The pressure was always to send people out, never admit – no beds, too many patients.”
    Now you could say that he is lying, but he is retired and has “no dog in the fight”. You could also say that his experiences are not typical and that may be true, but his experiences parallel mine in another state. In addition Dan worked for a number of years in Oregon (low cost state) before retiring.
    So for those of you who believe that over-ordering tests and consults is “money driven”, I would like to hear the basis for your belief.

  36. Legacy Flyer,
    I realize your question probably wasn’t directed at me, but you caught my attention again so I’ll comment.
    You can interview one retired physician via email who agrees with you and offer that as proof you’re right, but maybe the answer to your question is “Because there’s just no leadership.” If it’s not to generate revenue, then what is it? I can only offer, again, in our experience, there was no answer (other than generating revenue), our experience wasn’t an expensive (1.7 million was the last estimate I heard), haphazard cluster-you-know-what because they were afraid of being sued. If they feared a lawsuit they would have gotten their act together, they function with immunity and they know it. They had the lawsuit problem solved because:
    Tort reforms (caps on economic damages) were already passed in Texas
    and
    Whatever-they-say-happened-is-what-happened, period, the end, they had their asses covered 6 ways from Sunday with regard to avoiding responsibility or liability due to any and all negligence on their part. And just kept right on being negligent, slamming charges to my husband’s hospital room to the point of being egregious. Our sleepy little bedroom community has blossomed into a mini-medical center almost overnight, and the building and construction continues…I’d venture to say it’s not much different than what’s happening coast to coast, these fancy new imaging centers and pain managment clinics and sleep study institutes etc etc etc aren’t erupting out of the ground because healthcare is broke, it’s because it’s good business. It’s a license to print money and it’s profitable.

  37. Legacy is exactly right. We have both actually worked in an ER. The push if any is to discharge patients not admit. Those that state ER docs are admitting patients for profit, prove instantaneously their dismal medical IQ. ER DOCS DON’T ADMIT PATIENTS. Period. There are no direct incentives in the majority of hospitals to test or order consults on inpatients. DRG based payments encourage less testing, hence one of the many reasons for the explosion of hospitalists. Bottomline, the more normal tests and studies done during a stay the less the hospital makes.

  38. Earlier, I suggested that the passage of time is a valuable, inexpensive, and underutilized diagnostic tool. In the case of Dr. Coulehan’s ER stay, a number of tests that were not urgent would have proved unnecessary when the diagnosis of shingles confirmed itelf with the appearance of the characteristic rash.
    Others responded that occupying an ER bed simply for observation is unrealistic, and would incur the ire of nurses and hospital officials under pressure to ensure rapid turnover. The implication was that Dr. Coulehan’s prolonged ER stay was acceptable because it was punctuated by unnecessary tests, but if the tests had been withheld pending proof of need, the same number of hours would have been unacceptable.
    My responses to this claim are twofold. First, I believe it. Second, it’s too bad. It seems to me that a bit of imagination could envision a remedy for circumstances where observant monitoring and multiple testing are alternative uses of ER time, but only the latter is currently seen to justify it in practice. The remedy would entail the setting aside of a small fraction of total bed space (or even perhaps a “holding room” space) for patients who would be served by observation without urgent intervention. This would presumably involve asking a patient in the main ER to move to the separate area, but that should not be a problem. Of course, in other cases, waiting could be accomplished by a temporary “go home” arrangement, without a need to consider a return a separate admission.
    I’m willing to guess that somewhere, some enterprising institution actually does something like this, and that it protects patients from unnecessary interventions while preserving their need for adequate attention.
    I’d be grateful for any input from others as to the existence and nature of arrangements such as these.

  39. Lisa,
    I respect what you have to say and think that you are honestly looking for solutions.
    Let me suggest that you do the following – talk to some ER docs at your local hospital. Talk to some ER nurses as well. I am not sure exactly how you should approach them, but I think you can find a way. I believe that some of them might be more than happy to talk to you.
    Tell them about your experience and how that has made you interested in Health Care Reform. Ask them what they think the problems are that they face and what should be done.
    After you have had a chance to talk to some of the people “on the front lines”, let me know what they told you and what you think. (If you want to take this off list Maggie has my email address.)
    I think you will find that, for the most part, ER docs and nurses are honestly interested in doing the best they can, but are working in difficult circumstances. I think you will find that, for the most part, they are not “money grubbers” trying to order unnecessary tests and consults to make more money. I think you will also find that they operate in fear of missing something and being sued.
    Good luck!

  40. If one of the most important diagnostic tools is time why go to the ER? Just stay at home until something changes for the worse. ER’s ae busy as it is with other problems. There are not enough beds or staff in any ER to babysit patients for hours, this cant work in reality. Besides to send a patient home without reliable follow up is not good practcie. And, to say all this testing was unnecessary is a joke. To make that statement the whole history should have been provided. Different locations of the zoster rash have different implications. Also, I agree that being a physician, if these tests were truly useless he should have said something or asked the reason for these tests instead of going along for the ride, he could have saved 9000$!

  41. Legacy Flyer,
    I have spoken to health care providers for many years, especially nurses. I have never ever said that doctors and nurses were money grubbers. Nor, to the best of my knowledge and belief have I ever disparaged either profession. It’s a broken SYSTEM, Legacy Flyer, and I for sure do not place blame with the front line workers, I never have. (There’s example after example of doctors and nurses speaking out and tried to improve their conditions or conditions for their patients and they have their lives and careers ruined as a result, I still hear lots of outrageous horror stories in confidence, front line workers are stuck like chuck) It’s the complacency of the L E A D E R S H I P of our health care industry who is to blame. The CORPORATE MAFIA that runs health care, big pharma, yes hospital CEO’s even the dim-witted one’s, hospital boards, insurance executives, device mfr’s these are the people who run health care and guide the behavior and practices and choices of the front line workers.

  42. Oh and how could I forget lawyers. Lawyers run healthcare, not plaintiff’s lawyers but insurance defense lawyers they just want to protect the goose that laid the golden egg. LF it might interest you to know there was no malpracice lawsuit as a result of my husband’s hospitalization, not even a hint of one, but there was a lawsuit… my husband was sued by an army of insurance defense lawyers. He got burned, was damn near killed (on multiple occasions) by the hospital, and then he got sued.

  43. Lisa,
    You and I are on a different page. To some degree, all of us who post on Health Beat are like one of the blind men in “The Blind Men and The Elephant” (http://en.wikipedia.org/wiki/Blind_men_and_an_elephant). You and I have felt different parts of the elephant.
    Like you, I am no fan of lawyers and think our country would be better off with far fewer of them – maybe after we finish reforming Health Care to look more like a European country, we could reform our Legal System so that the number of lawyers per capita is more like Europe as well.
    Take care

  44. I have been a family doc for 20 yrs. If this pt had shown up in my clinic, he would have gotten prednisone, Valtrex, and an optometry consult. We don’t have ophthalmologists in my area of eastern Washington state. Fortunately I’m so dumb I would have missed the lid problem and so would not have imaged the pt.