Crash Cart: Nurse Legislator Says ERs Should Be Able to Refuse People; How ERs Saved Hospitals; Most Docs Have Encountered Abusive Remarks

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This week: GOP lawmaker Diane Black wants EMTALA changed to allow ERs to turn people away to cut costs; People avoided hospitals until ERs revolutionized them; New survey says 59 percent of docs have quietly suffered offensive remarks about their physical characteristics. Join in as our editors discuss the week’s headlines.

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Rep. Diane Black (R-Tenn.), an emergency room nurse, told MSNBC host Chuck Todd she’d like to see ERs be able turn away patients according to their discretion to help keep health care costs down.

She takes issue with Emergency Medical Treatment and Active Labor Act (EMTALA), a congressional response to stories of “patient dumping” (denying treatment to patients or send them elsewhere usually because the individuals didn’t have insurance) signed into law by President Reagan in 1986. Various organizations, including the Institute of Medicine, have long called for amending the law to ease emergency room overcrowding, though outright appeal is unlikely—and talk about it is not common in health care debates. Original Article by Huffington Post.

Ryan McKennon, DO: Half of the problem with EMTALA is that most people don’t understand EMTALA. The congresswomen states, “I would get rid of a law that says that you ― you are not allowed, as a health care professional, to make that decision about whether someone can be appropriately treated the next day, or at a walk-in clinic, or at their doctor.” That is not precisely what EMTALA says. A physician can absolutely tell someone they can be appropriately treated the next day or at a walk-in clinic, after a medical screening exam (MSE) has been performed and there is no emergent condition. EMTALA has no problem with this. Some hospitals, I have heard, are doing this. A MSE is performed and if you want to be treated for a non-emergent condition, co-pay or cash is due up-front. Most do not because by the time a MSE is performed and documented, and required tests and treatment are performed to rule out or treat an emergent condition, all the work is pretty much done. If a congresswoman, who is also an ER nurse, doesn’t understand this, I’d be willing to bed the rest of the House and Senate doesn’t either. My two big issues with EMTALA are that is it an unfunded mandate and vague on its implementation. The federal government mandated all this care without subsidizing it which should change. CMS has also been very vague and fluid with what is considers an emergent condition. Although the courts have generally given great deference to the physician’s determination of whether an emergent condition existed, CMS is not so forgiving, especially recently regarding psychiatric conditions.

E. Paul DeKoning, MD, MS: Ryan nailed it. Unfortunately, she doesn’t know what she is talking about. The lay press won’t either and likely won’t seek to figure it out but rather capitalize on the story to further some agenda.

Seth Trueger, MD, MPH: The big thing that get missed with EMTALA: for the real low acuity stuff, the MSE is the whole visit.

William Sullivan, DO, JD: Most people don’t understand EMTALA, but at the same time that lack of understanding may allow Representative Diane Black, a former emergency room nurse, to make inaccurate arguments with a wider appeal to the public. For example, it creates a lot stronger argument to modify EMTALA by incorrectly stating “we’re required to treat everyone – even the person who has had a sore throat for a week” rather than saying “we’re required to screen everyone and treat those people having emergencies.” The first argument allows her to continue the argument that unfunded government mandates prevent emergency departments from saying “No, an emergency room is not the proper place” for minor complaints. That creates a public furor and gives her more political power. The second more accurate argument does not. I’m not so sure whether Rep. Black is ignorant or whether she’s a well-rehearsed politician. Or maybe both. I suppose the two aren’t mutually exclusive. And Seth is right – often the MSE is the whole visit. But if we want to battle the inertia and begin to change the mindset of people who use the emergency departments to get prescriptions for ibuprofen, who repeatedly demand doctor’s notes after missing work, or who are on their seventeenth visit for the same toothache and have allergies to everything except hydrocodone, something has to change.

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It’s hard to imagine, but hospitals did not always equal health. Prior to the 1870s hospitals were avoided by the vast majority, but sterilization followed by major innovations like antibiotics, diagnostic imaging, dialysis, and corticosteroids ushered in emergency wards with staff employing techniques learned from WWII.

Soon hospitals became “the first line of defense instead of the last resort,” a phrase repeated by many journalists, and demand for for hospitals was met with the 1946 Hill-Burton Act, which funded the construction of over 6,800 facilities nationwide. Original Article by History.

Ryan McKennon, DO: Interesting article. The growth of ER really comes down to the fact that we are so good at what we do. We can take care of any illness and any time of the day or night, and with unprecedented speed.

E. Paul DeKoning, MD, MS: While I’m somewhat partial, I agree with Ryan that we are good at what we do. Both by choice and out of necessity. As I was talking with one of my residents the other day about how we didn’t choose to be cardiologists, we in fact did choose to become cardiologists. And traumatologists, gynecologists, infectious disease experts, and toxicology whiz kids. Dermatologists, pediatricians, gastroenterologists. Social worker, therapist, confidant, and sometimes even friend and chaplain. What an amazing career we are blessed to do each and every day!

William Sullivan, DO, JD: We’re great at what we do, but in a way, we’re becoming victims of our own success. See above. Reminds me of that old Yogi Berra quote – “No one goes there nowadays – it’s too crowded.”

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A joint WebMD/Medscape/STAT survey of more than 800 U.S. physicians showed that 59% have heard offensive comments in the last five years about their physical characteristics—namely youthfulness, gender, race, or ethnicity.

As a result, 47% have had accordingly had requests for other personnel. While African- and Asian- Americans received the most attacks, patients found plenty of other populations to demean. Quoting docs who say the situation isn’t generally talked about, STAT shares numerous personal stories in addition to reporting on the study. Original Article by STAT.

Ryan McKennon, DO: It’s nice to see Penn State Health taking a stand and changing its patients’ rights and responsibilities to cover discriminatory behavior. As policy, they will not honor a request for a new physician based on patient’s prejudices. The comments after the article, however, are severely disheartening; I am surprised how many people are totally fine with physicians being the targets of verbal abuse.

E. Paul DeKoning, MD, MS: Go Penn State (and that’s from an MSU Spartan).

William Sullivan, DO, JD: Difficult topic. On one hand, I think that prejudice against health care workers is under-reported and we do need to talk more about it. We’re just seeing the tip of the iceberg. On the other hand, we also need to be careful not to let our concern for this topic spin out of control. There is a gray area in which patients may make inappropriate remarks with no ill intent. For example, not long ago an elderly patient was having back pain and asked me to stand up by the bedside so she could show me on my back where she was having pain in her back. When doing so, she said “Oh, you have a cute little butt.” I suppose I could have been offended, but laughed it off – along with the rest of her family who was in the room – because I knew she was trying to be funny in what I realized was a stressful time for her. Then I diagnosed her with metastatic disease to her lumbar spine and sacrum. I’ve had patients insult me about my hair loss and the scar on my nose from skin cancer. Do I get offended? Maybe a little. Then I walk out of the room, maybe give them half a peace sign, move on to the next patient, and have a good story to tell during the next dinner party. Some people are just jerks and bringing their jerkdom to their attention probably won’t change them. Another point to consider: We all have biases. We’re human. Is it in the best interests of patients or physicians for Penn State to enforce a policy requiring patients to accept care from physicians against whom they may have a bias? Will patients listen to advice as well? Will patients look for some bad outcome so that they can confirm their unfavorable bias about the physician? Should it matter? Don’t know the right answer, but definitely is a topic that deserves more discussion. And if you want to see how some members of the public are already perceiving this as a bunch of whining by highly paid professionals, read the comments to the article.

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  1. Doctors are just trying to protect themselves from verbal abuse the moment the patients family or the patient itself are not satisfied to the doctor’s services. Though they have no intention of harming they are sometimes blamed for nothing.

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