It is a long known fact that Internal Medicine doctors have a deep loathing for emergency rooms docs. “DISPO DISPO DISPO”, the ER doc’s mantra goes, so there is no wonder why Internist and Hospitalists make disparaging remarks about the ER’s complete lack of motivation to diagnose the patient based on the chief complaint before deciding to admit to Inpatient Medicine. When the ER doc says “I have an admission for you”, the Internist wants to know more. If the admission diagnosis is ‘chest pain’ for example, you better believe the Internist is going to be asking what the EKG looks like (and if they compared it to an old one), what value the cardiac troponin is, if the urinary drug screen was positive for cocaine and if the pain is reproducible. You’d be shocked at the number of times I did not have an EKG for a chest pain admission, or that the pain was actually reproducible when I examined the patient. I’d often wonder if the ER doctor even talked to the patient. Is the ER really to blame for another admission? According to a recent report from Truven Health Analytics, more than 70 percent of emergency department visits from patients with employer-sponsored insurance coverage are for non-emergency conditions or conditions that are preventable through proper outpatient care with a primary physician. The answer may lie in the inappropriate use of the ED and docs being pressured to admit. Internists eventually succumb to the ER’s decision and complete the admission paperwork in the best interest of the patient. Grudges are held. Time is wasted. Billions of dollars may be lost by unnecessary tests. Then the vicious cycle begins again. The battle of the Internist versus the ER began long before my internal medicine residency training began. Right about the time when Emergency Room physicians started practicing defensive medicine, deviating from comprehensive medical practice to admit patients just to avoid the threat of malpractice litigation, Internist’s began to feel the burn. What the emergency room doctor may interpret as being ‘cautious’, the Internist may say is defensive. If the Internist thinks a urinary tract infection, for example, can be managed at home, the ER docs thinks the patient requires IV antibiotics and an admission. Half of the problems the Healthcare industry face are only going to get worse as the Affordable Care Act provides 30 million more Americans with Healthcare coverage, and the Emergency Rooms become flooded with more patients that do not have a Primary Care Physician. As an Internist in training, I’d like to believe that the ER has taught me much more than practicing defensively, or not enough sometimes. I have interacted with ER physicians throughout my residency training as the ‘triage resident’, and what I have discovered is their emphasis differs immensely. I am certain that ER docs make fun of Internists. I know for a fact we make fun of them. I am tolerant with the ER, but it is a running joke among Internists that they don’t need a diagnosis – just a disposition. Internists rarely see the ER’s success, but often their errors. The greatest challenge in overcoming the disparity between the two fields of medicine may be easier than we think, lying in the ability – and willingness – to communicate and coordinate care. To further examine this possibility, I will become one of them – ER resident. A required rotation as part of the Internal Medicine residency training program at my hospital, I spend various shifts working in the ED under the supervision of the Attending ER doctor. I can do everything that the ER residents can – put in central IV lines, stitch lacerations, wrap sprained ankles and intubate patients in a code. It is exciting, and it is greatly rewarding. I am observing real medicine, in real time. In a given day I can see a variety of patient conditions from bee stings to gun shot wounds, but the Internist in me wants to always know more. I want to know their social history, if they are up to date on their health screening. I want to know what makes the patient the person that they are, and the puzzle surrounding their complex presentation. However, I wonder if the patient’s primary care doctor could have prevented their emergency room visit. What my experience as an Internist working as an ER doc is showing me is that I am forced to make decisions for different reasons than the Internist in me. The ER’s main job is to figure out who needs admission, and who they can treat and put back on the street. While I once questioned the ER’s decisions, I am now beginning to understand their world and the stresses of their profession. To my own surprise, I’ve discharged more patients from the ED than I’ve admitted; however my ER decision-making suffers bias. Being an ER doctor is much more difficult than I thought, and I respect the ER more and more each day. Internists and ER doctors view the world through different spectacles. ER docs excel in stabilizing those that are injured. They prefer the fast pace. ER docs love gushing blood from a wound, because it means they get to whip out their handy suture kit and sew it closed. They love minor procedures such as packing an I&D, and they get a rush when a non-responsive patient with no medical history is rushed through the doors by the EMS. They thrive on toxicology mysteries. ER docs have a job that I am not trained to do, nor would want to do. ER docs loath talking to the patient with uncontrolled diabetes, high blood pressure and chronic kidney disease – but I love it. If the patient’s brain is hemorrhaging from their high blood pressure, then that is a different story. Internist or ER doc; physicians alike value the process of determining what is wrong with the patient, and how we can help them. It is with coordination between the specialties of the healthcare system that we can operate effectively, and that is what my experience as an ER doctor has taught me. Source
