Crash Cart: Putting emergency back in ERs; mystic hospitals; call women doctor, too!; medical drones

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This week: ERs can return to true emergency care; Top hospitals employ unproven treatments; Female docs often get introduced by their first names, look! up in sky! It’s a defibrillator! Join in as our editors discuss the week’s headlines.

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In recent decades, trips to the ER have risen, with care for non-emergent and less urgent needs being in the spotlight because of the associated higher costs and wasted resources.

In terms of business, solutions have attacked the problem from the wrong side —the demand side—forcing patients to dangerously self-diagnose. Reducing ER use will be more effective if solutions come from the supply side, such as longer primary care hours and telemedicine. Original Article by The Wall Street Journal.

E. Paul DeKoning, MD, MS: While it can sometimes be frustrating on a crazy busy shift to manage hangnails and “STD checks”, the nature of our practice is determining sick vs not sick. It’s what we do. And, as the article mentions, it isn’t always clear. Giving an insurance company or a “coding specialist” the authority to retrospectively determine what was and wasn’t an “emergency” is fraught with danger. It’s in the moment of uncertainty (both for the patient and the provider), with a paucity of time and data, that we need to make decisions. That’s what we do, and to a large extent we need to be comfortable with sifting through the “non-emergencies” try find the one who is trying to die.

Nicholas Genes, MD, PhD: Of course, an ED physician (and not an insurance agent) is necessary to determine who’s sick and who’s not sick. But just as obviously, there is inappropriate ED use that, at some point, should be financially dis-incentivized. I don’t know if it should be after the 10th visit in a calendar year or the 20th, or whether there should be some kind of exception code for cases of transplants or other high-risk conditions. I know Seth will have data that ED super-users aren’t that common and aren’t that expensive compared to other waste in the system. I’m sure it’s true but I’m also sure that, so long as our specialty continues to ignore this are refuses to come up with solutions, we will remain an easy target.

William Sullivan, DO, JD: Basically, this article argues that in order to curtail emergency department overuse, there are only two options: decrease demand or increase supply. Since decreasing demand allegedly hasn’t worked in the past, the author argues that we must increase supply. I’m not convinced. Sure, telemedicine and integrated care provide a short-term decrease in emergency department overcrowding, but when any desirable product or service is provided at little or no cost to the consumer, there will be an unlimited demand. Remember the movie Field of Dreams … “if you build it, they will come”. True that we can’t expect people to know what is an emergency and what isn’t. But we can pick the low-hanging fruit. Every medical malady doesn’t need to be treated as an emergency until proven otherwise. When the common sense of society has withered to the point that people legitimately believe that they need professional medical attention for nasal congestion, bug bites, sun burns, and bruises, our problems run far deeper than cutting emergency department visits. Decreasing emergency department overuse requires a combination of both incentives and disincentives that apply to both patients and providers. The answer to people taking too much free candy out of the bowl is not simply getting a bigger bowl and adding more candy.

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Alternative medicine has been building for years, but it’s surprisingly prominent at 15 academic research centers across the country.

For example, Duke Health charges patients $1,800 a year for basic membership to its integrative medicine center (acupuncture and other treatments sold separately) and repeatedly decline to be interviewed. While some see a place for alternatives when traditional medicine fails patients, open accusations of peddling snake oil are becoming common. Original Article by STAT.

E. Paul DeKoning, MD, MS: I wonder if a big motivator for these trends is the frustration of the lay public with the medical and pharmaceutical communities for promoting medications and treatments that have similarly promised a certain effect only to find out the treatment has horrifying adverse reactions that are worse than the condition they “treat”. There are many who simply don’t trust the medical industrial complex. All one needs to do is watch an add for a new drug on TV then wait for the list of possible (or likely) side effects–“just so you know, your rash may go away or your A1C will be something like 2.5, but your arm may fall off or you may become suicidal. Up to you.” How often is it that we as clinicians find out that a treatment or management we have preached (and had to preached to us) for decades turns out to not be all that great? I can’t remember are eggs good or bad?

Nicholas Genes, MD, PhD: This is bad: it lends legitimacy to really questionable practices, just to make a buck or gain some Press Ganey points. The alternative, however, is harder: 1) forego easy money and 2) convince the patient that you’re the one who’s on their side, with your evidence based medicine, and the Homeopaths and other mystics are the scammers. The whole reason alternative medicine (and now anti-vaxx culture) has flourished is that too many patients felt neglected by, or let down by, evidence-based medicine (and conversely, scammers were better able to make the patients feel heard and appreciated). That’s lamentable, but it’s partly our fault – and bringing reiki to Johns Hopkins isn’t the solution.

William Sullivan, DO, JD: The article can be summarized by one money quote (pun intended): “STAT’s examination found a booming market for such therapies.” When doctors at the Cleveland Clinic are quoted as saying “If it doesn’t work, I don’t know that you’ve lost anything,” the whole specialty of medicine is harmed. Patients lose several things with these unproven therapies: their trust in evidence based medicine, their chance at improvement by using more effective therapies, oh, and this little thing called THEIR MONEY. Legitimizing snake oil … one research center at a time.

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A couple of female physicians at Mayo Clinic noticed that their male colleagues were being introduced with the title “doctor” but they were introduced by their first names.

So they launched a study – looking at 321 introductions from grand rounds, they found women were introduced by title only 49% of the time on first reference compared to 72% for men. Also, women “did it right” 96% of the time compared to 66% for men. Original Article by The Washington Post.

E. Paul DeKoning, MD, MS: A culture of honor is lacking in much of today’s society–it is important to give honor where honor is due and my female colleagues deserve the same respect afforded to male counterparts. I do cringe a bit, however, at the notion of a “hospital policy” on introductions at Grand Rounds. Pretty sure that won’t fix the problem.

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In the not-too-distant future, drones may be used for more than bombs and Amazon deliveries.

According to a recent JAMA study following research from Sweden, drones could become first-responders, equipped with defibrillators. They noted it took three seconds to get dispatch drones whereas it took three minutes to dispatch EMS teams, and drones reached site in an average of about five minutes compared to 22 for traditional assistance. A clinical study is in the works for 2018. Original Article by Mashable.

E. Paul DeKoning, MD, MS: I can just see the news article it now: drone with AED found next to dead man at local mall. Cool idea but still a ways to go. Now, if they could make drones large enough to ride…we could call it a “helicopter.”

William Sullivan, DO, JD: When I read the title of the article, I shook my head. Then after seeing that there is a significant improvement in time to delivery of the defibrillator, maybe it’s worth looking into further. The cynic in me thinks that if an expensive drone is used to bring expensive medical equipment to an unknown person, there may be some calls in which the drone, the AED, and the victim have mysteriously vanished by the time the ambulance arrives.

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