Michael Kirsch, MD – An Emergency Physician Basher Without A Clue

The nice thing about the internet, about having a blog, and about having a Twitter account is that even us peons have the ability to combat censorship.

Here’s a good example.

Self-described “insider” and “whistleblower” Michael Kirsch, MD, who blogs at “MD Whistleblower,” has a penchant for bashing emergency physicians even though his commentary shows that his “inside knowledge” is full of misinformation. You can be the judge of Dr. Kirsch’s veracity, but my opinion is that he is unethically spewing his inside misinformation as fact.

So I called him out on it.

KevinMD re-posted a blog post that Dr. Kirsch made about emergency physicians. Dr. Kirsch’s post initially asked “Are Emergency Rooms Admitting Too Many Patients?” I responded with a longwinded comment. My comment dripped with snark as I pointed out multiple errors in Dr. Kirsch’s assertions and multiple bits of misinformation he asserted were “fact.” I spent about an hour writing it because I thought it was important to show everyone who reads the post how Dr. Kirsch was being unethical as he tried to aggrandize his “inside knowledge” of a specialty he didn’t even practice. Within a few hours, my comment had twelve “upvotes.”

This morning, I woke to an e-mail from a reader telling me that my comment had been deleted from Kevin MD’s blog.

When I went to check, I saw the following:

So I wrote to Kevin and asked him who deleted the comment.

Kevin responded

I wrote Kevin back and asked him what the threshold number of flags was and who determined it. He didn’t reply.

I performed a search of Disqus for the term “flag” and found no mention of how to automatically delete comments based upon “flags”. The only action that Disqus appears to allow for “flagging” is to notify the moderator (i.e. Kevin) that a comment “requires moderator attention.” I also checked my own moderator dashboard for Disqus and wasn’t able to find an “automatic deletion” feature. If someone can point me to that feature, I’ll update this post.

It’s Kevin’s blog, so he is free to choose what comments stay and go.

So now I’m pissed. This Dr. Kirsch, the “Whistleblower” with “insider knowledge” is free to create a post basically accusing emergency physicians of widespread fraud, but when he gets butt hurt because someone points out all of the deficiencies in his “insider knowledge”, the comment mysteriously disappears.

Below, dear readers, you will find Dr. Kirsch’s post and my response, preserved for all eternity on the internet. Dr. Kirsch, Kevin MD, Disqus, and anyone else who is butthurt by my comments have no ability to delete them. I’m cross-posting it on my other blog and pushing it out on Twitter just to be safe. See Streisand Effect.
I fortunately copied an initial version of part of my comment onto a text file, so I didn’t lose the whole thing, but I had to re-write a lot of the comment from memory. Since the comment is version 2.0 and since someone was apparently offended that I would dare call out a “whistleblower”, I added more to the response.

Please do me a favor and pass this post around.

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Dr. Kirsch’s initial post:

Are Emergency Rooms Admitting Too Many Patients?

Every player in the medical arena has found itself challenged by conflicts where one’s self-interest competes can skew what should be pure advice.   This issue is not restricted to the medical universe.  Every one of us has to navigate through similar circumstances throughout the journey of life.  If an attorney, for example, is paid by the hour, then there is an incentive for the legal task to take longer than it might if the client were paying a flat fee.

The fee-for-service (FFS) payment system that had been the standard reimbursement model in medicine has been challenged and is being dismantled because of obvious conflicts that were present.  (This is not the only reason that FFS is under attack, but it is the principal reason offered by FFS antagonists.)  Physicians who were paid for each procedure they performed , performed more procedures.   This has been well documented.  Of course many other professions and trades still operate under a FFS system, but they are left unmolested.   Consider dentists, auto mechanics and plumbers and contractors.

FFS is not inherently evil.  But, it depends upon a high level of personal integrity which, admittedly, is not always present.   In my own life, I often hope and pray that the individual who is offering me goods or services is thinking of my interests exclusively.  Am I living in fantasy land?

The Rand Corporation released a study in May 2013 that demonstrated that emergency rooms accounted for about 50% of hospital admissions during the study period from 2003-2009.  When I have posted on emergency medicine in the past, it has stimulated a high volume of responses, some good, some bad and some ugly.

I think it is inarguable that emergency room (ER) care wastes health care dollars by performing unnecessary medical care.  As a gastroenterologist, I affirm that the threshold for obtaining a CT scan of the abdomen in the ER is much lower than it should be.   And, so it is with other radiology tests, labs, cardiac testing, etc.

I understand why this is happening.  If I were an ER physician, I would behave similarly facing the same pressures that they do.  They face huge legal risks.   They are in a culture of overtreatment and overtesting because they feel more than other physicians that they cannot miss anything.  They argue that they have only one chance to get it right, unlike internists and others who can see their patients again in a follow-up visit.  If an ER physician holds back on a CT scan of the abdomen on a patient who has a stomach ache, and directs the patient to see his doctor in 48 hours, what is the ER physician’s legal exposure if the patient skips this appointment and ends up having appendicitis?

Keep in mind that we should expect that ERs to have higher hospitalization rates of their patients, since their patients are much more likely to be acutely ill.

But even accounting for the sick patients in the ER, I think there is a significant percentage of ER patients who should be sent home and are sent upstairs instead. This would be an easy study to perform.  Compare the intensity of testing between the emergency room and a primary care office with regard to common medical conditions.  I would wager handsomely that the ER testing intensity and admission rate would be several fold higher than compared to doctors’ offices.  Want to challenge me on this point?

Even though I understand why ER docs do what they do, it is a bleeding point in the health care system that needs a tourniquet.

It is clear that ER physicians are incentivized to admit their patients to the hospital.  Of course, they might be “encouraged” to do this by their hospitals who stand to gain financially when the house is full.  Leaving the financial conflict aside, when an ER physician admits a patient, he is completely free of the risk of sending a patient home who may have a serious medical issue. I am not referring here to patients who clearly should be admitted, but to the large group of patients who most likely have a benign medical complaint, but the ER physician advises hospitalization “just to be on the safe side.” These same patients if seen in their own doctors’ offices would never be sent to the hospital to be admitted.

Where’s the foul here?  Here are some of the side effects of unnecessary hospitalizations.

• wastes gazillions of dollars
• loss of productivity by confining folks who should be working
• departure from sound medical practice which diminished the profession
• emotional costs to the individuals and their families
• unnecessary exposure to the risks of hospital life

How can this runaway train be brought under control?   First, let’s try a little tort reform.   Second, pay a flat rate for an ER visit.  Under this model, if the ER physician orders an MRI on a patient with a back strain, the hospital swallows the cost.  Finally, when hospitals are penalized financially for hospitalizing folks who should have been sent home, we will witness the miracle of a runaway train performing a U-turn on the tracks.

While the Rand Corporation’s results are not earth shaking on its face, my intuition, insider’s knowledge and a tincture of cynicism all converge on the conclusion that for too many patients the ER has become a portal of entry in the hospital.  Is the greater good served if the ER is a revolving door or barricade?

Dr. Whitecoat’s Response:
What is it with people who have little or no knowledge of emergency medicine thinking that they have the insight to comment on what factors influence emergency medical care? You assert you have “insider knowledge”? Sounds more like a case of advanced megalomania to me.

First, you make a bunch of assertions without any basis.
“Inarguable” that the emergency department performs unnecessary medical care? OK, doc. Tell me what tests that ED physicians regularly perform that are “unnecessary.” I’m sure that you have tomes of instances of inappropriate care just waiting to be published on your blog. Educate all of us.

You “think” that there are more patients who are admitted who should instead be sent home? What’s the basis for your “thought”? I’m guessing that you don’t admit patients personally. You’re a consultant. You have no basis for making that statement. On the outside chance that you do practice primary care medicine, here’s an idea if you’re inundated with “inappropriate” admits. Drag your whining buttocks to the emergency department and evaluate the patient yourself. Then YOU write the discharge orders. In twenty years, I’ve seen exactly two doctors ever do that.
Another point that you can add to your “insider knowledge”: Emergency physicians don’t admit patients, the hospitalists and primary care docs do. Emergency docs don’t have admitting privileges. So if you’re so concerned with all of the “inappropriate” admissions, realize that it is the primary care docs authorizing them. Point the blame where it belongs. Oooooh. Stop the presses. Emergency physicians and hospitalists are conspiring to defraud the government by making inappropriate hospital admissions. Wait. You wouldn’t make a statement like that because if you pissed off your primary care docs and hospitalists, they wouldn’t refer patients to you. Funny how economic incentives influence your own desire to “whistleblow” “insider information,” isn’t it? Or was it that you were just too obtuse to realize this obvious “insider” fact?

In your little study about intensity of service and admission rates, make sure that you exclude all of the patients sent to the ED from their doctors’ offices with specific instructions to have the testing performed and also make sure that all of the patients who have been to their doctors offices several times with the same problem and who get no evaluation at all get treated as one “low testing” visit, not multiple “low testing” visits. Oh, and since pretty much every patient coming to the emergency department is a “new” patient to the emergency physician, make sure that your study only includes workups that primary care physicians perform on “new” patients to their practices. Not really fair to compare workups that emergency physicians perform on patients that primary care physicians have known for 20 years, now is it? When you’ve compiled your data, you can then compare how many lives that emergency physicians save with their “inappropriate” testing and “inappropriate” admissions … all for about 2% of the health dollars spent in this country.

Your next bit of misinformation states that “It is clear that ER physicians are incentivized to admit their patients to the hospital.” Another clue for you, Dr. Insider: Emergency physicians are paid by intensity of service, not by hospital admissions. If the medical decisionmaking is high and the workup is extensive, we are paid the same whether or not a patient is admitted. So what is our “incentive”?
Oh, wait. You explain that emergency physicians “might be ‘encouraged’ to [inappropriately admit patients]by their hospitals who stand to gain financially when the house is full.” Wow. With your “insider knowledge” you have uncovered yet another conspiracy. Emergency physicians “MIGHT” be colluding with hospital administrators to inappropriately “fill the house.” A little flaw with that theory, though: When the hospitals are full and there are boarders in the emergency department, the throughput slows and we see fewer patients, which actually decreases the hospital’s profits.

You, oh mighty insider, suggest that “when hospitals are penalized financially for hospitalizing folks who should have been sent home, we will witness the miracle of a runaway train performing a U-turn on the tracks.” Look up “RAC audits“. Then look up the “two midnight rule.” Both of these processes cause hospitals to lose significant amounts of money for “inappropriate” admissions. If you know about these processes and just chose not to mention them in your diatribe against emergency physicians, you are being intentionally misleading. If you didn’t know about them, then you are a buffoon for calling yourself an “insider”. How has the “runaway train” slowed? You don’t know because you don’t even know the processes in place or the right questions to ask.

I’ll end with a couple of responses to your criticism that we “ER physicians” advise admitting patients “who most likely have a benign medical complaint” just so that the patients can “be on the safe side.” First of all, we go by criteria and sometimes a gestalt after we actually examine the patient. If you don’t agree with our assessment, then come in and see the patient yourself before the admission, rather than backstabbing us after all the testing is normal because the patient never should have been admitted to begin with. Second, since when is looking out for the safety of our patients a bad thing? I can rattle off story after story about patients who I admitted “just to be on the safe side” who avoided a bad outcome because they were admitted. Yes, many go home with normal workups. Just like most of your endocsopies are normal exams but no one faults you for performing them. If you’re going to criticize me for being a patient advocate, then I’m guilty as charged.

I suggest that you stick to commenting about your own specialty and stop demeaning yourself by creating these uninformed linkbait posts about emergency physicians.

With all of your “insider knowledge,” have you ever written about how often gastroenterologists perform inappropriate endoscopies, there Dr. Whistleblower? When I did my internal medicine training, the GI fellows used to call it “scoping for dollars.” Care to comment?

I didn’t think so.

P.S. It’s an emergency DEPARTMENT, not an “emergency room.” And we’re emergency physicians, not “ER physicians.”  Using 1990s vernacular does nothing to support your esteemed position as an “insider.”