ccso962

Good point.

Another wonderful post! Gender bias is disappearing, or has disappeared, in most other career fields (last October I had a car wreck and the firefighter who literally broke the door open with their hands was a woman and the LT on the truck -- not too many years ago most people considered firefighting to be a "male" profession). However, from my own experience, gender bias seems to be alive and well in the healthcare field. As you point out Nurse is a career title not a gender. Midwife means "with woman" not that you are a wife. So, in both of these cases naming someone who is not a woman but has one of those careers as a "male nurse" or "male midwife" is inappropriate. Society at large would not stand for someone being labeled a "female pilot" or a "female cardiologist" and, in fact, in most cases you never hear this type of labeling anymore. The internet is full of stories of women who have become upset because they felt pride in being a physician but had a patient ask "are you my nurse". I am sure there are just as many men who are nurses who feel extreme pride in their profession and are more than a little upset to have a patient ask "are you my doctor" or "are you the orderly" (as if we even have people with that title anymore). Several years back I talked to a man who was in school to be a Family Nurse Practitioner he told me that one of the programs he applied to asked him if he had also applied to PA school. When he said no he said she seemed shocked that he was a man and had only applied to NP schools. As if the title NP implied feminine and the title PA implied masculine. OK, sorry to rant, but that is one of my hot button topics. I, like you, agree that a person, male or female, should feel free to choose the profession that best suits them without regards to what gender they are. :-)

Just wanted to supply a personal story that sheds light on what you are talking about here. My wife has been being treated for hypertension for years even though she is not yet 30. Her father actually had a kidney transplant due to kidney failure that resulted from asymptomatic, and thusly undiagnosed, hypertension. About 4 years ago now we were in Florida and my wife began to feel really really bad. We stopped off at a Walgreens Clinic and were promptly told by the NP on site that either 1) I needed to take her to the closest ER or 2) she (the NP) would call an ambulance to transport her due to how high her blood pressure was at the time. I decided to drive her because we were very close to the ER. Upon our arrival my wife told the person at check in that she was having chest pains, a severe headache, had a history of hypertension, and had been sent over from a walk in clinic. This person immediately put her in a wheelchair and rolled her into a room where the triage nurse proceeded to take her BP, performed an EKG, and then promptly told my wife that 1) her BP was only high because she was "nervous" over being in the ER and that 2) "chest pains on a person of your age is NEVER a reason to come to the ER". She then suggested that we "go to a walk in clinic" later if it "keeps up". When my wife told her this was unacceptable we were told "well I will put you in a room, but you will sit there for hours probably waiting on a doctor". She also informed us that "no competent physician would diagnose a patient in their twenties with hypertension or place them on medicine" (even though my wife was taking medicine for hypertension). Well to make a long story somewhat shorter we did NOT wait for hours to be seen. After they hooked her up to the monitor in the room the ER physician came in saw that her systolic BP was now over 200 and that she was having an arrythmia and promptly started care and arranged for her to go upstairs to the monitored unit. The hospital treatment, stay, etc. was well over $7,000. We didn't pay a penny. Why? Well I had a discussion with the hospital administration who agreed, along with the internist who saw my wife in the hospital, that the triage nurse had been in error (I was also reassured, as I already knew, that no one should ignore chest pains ever). I was actually told by the ER Medical Director that 1) the initial EKG performed by the triage nurse showed an "obvious" arrythmia, and that 2) the nurse in question would be removed from the ER until such time that she could show basic competence in the interpretation of an EKG. The implication was obviously that they would cover all charges, and we, in turn, would not sue. So, needless to say I am a big proponent of doing things the right way NOT the way that might be the easiest to the facility or staff.

Yes, the thread has veered a little off course, but not a large amount. The OP was posting concerning the rollout of PPACA and the discussion that has followed has been one based on beliefs regarding how the rollout of PPACA will effect the ER (the veering has come in the form of what is and is not an acceptable and/or legal way to deal with a patient that really does not need an ER practitioner). With regards to BlueDevilDNP's comments the concern I had was the callous manner in which the patient is told "tough luck". There is a right way and a wrong way to go about this. Regardless of whether or not the facility kicks them out prior to an MSE or after (and there was no mention, as you point out, in that post of when the "kick out" occurs) there is NEVER, and I repeat NEVER, any excuse for ANY health professional being rude to a patient. The patient who walks into a podiatrist office complaining of stomach pain is clearly in the wrong place, BUT it would be inappropriate for the staff at the podiatrist office, or even the Podiatrist themself, to tell the patient "hey stupid you came to the wrong place for this now get out of my office and go to the correct place". For what it's worth IF BlueDevilDNP's name reflects a location in North Carolina then this would put the facilities, possibly, in the Research Triangle Area of North Carolina. I just do not believe that facilities in this area, or most any area really, are being this rude to people, especially prior to an MSE, and are not (or have not been) facing a lawsuit from someone. With absolutely no disrespect meant it was the manner in which this was presented (i.e. that being rude in this manner was perfectly acceptable) that seemed, and still seems, very very wrong to me. As you, and others, have pointed out asking for payment after the MSE is done in many many places. Being rude, and harassing the person over not having the money (such as the "save up" response) is not only uncalled for but is most assuredly ample grounds to sue over harassment if not also discrimination. A person has a right to expect to receive competent medical care in a hospital free from discrimination or harassment for any reason. The "save up" line does not meet this expectation, and, as I am sure you are aware, it is this that can, and does, lead to litigation. I think most of us would agree that the ingrown toenail can better be dealt with somewhere other than an ER. This, as I say, should be presented to the patient in a way that "sells" them on the reason it is not best to do it here. One of the easiest is to point out the cost savings to them, the patient, by having the ingrown removed in an office, urgent care, walk in clinic, etc. over the ER. A $120 out of pocket PCP office procedure or a $600 out of pocket ER procedure is a no brainer to most people. Then if the patient really seems intent on paying the $600 out of pocket on the spot . . . well the ER has just brought in a little extra cashflow for the hospital tonight (and immediately too not after 6 months to a year of back and forths with the insurance company). If the patient expresses concerns that they cannot afford either option then "tough luck" is NEVER an acceptable response. Refer the patient to the local free clinic (many areas have one), or ask the patient to wait in the lobby, notify the Social Worker on duty, and have them work with the patient (this is part of their job after all). Once again this is not meant to ruffle feathers, but remember guys, right or wrong, emergent or not, we are dealing with PEOPLE here in a MEDICAL environment. We are not working on an assembly line, and we are not some sort of "ER Police" whose task it is to do away with all patients who do not fit the mold or image of a "correct" patient. Remember that just as with 911 people are told by numerous sources to go to the ER if they need medical treatment. Some, but by all means not most, of the patients may know they have arrived at the ER for a reason that does not require an ER (just like there are people who call 911 because McDonald's miscooked the hamburger but most people who call 911 for a non-emergency have a real reason they need police, fire, etc. it is just not an active emergency). My two cents worth . . .

I can't really comment for other posters, but for my part yep that is what I was saying (even if I said it in a lot more words). Some other posters, however, made it appear that their place of employment was kicking people to the curb, and at least one poster said they actually gave people the "that's a shame" speech and told them to save up their money and go to a PCP when they could afford it. Obviously patients are referred to a PCP, specialist, etc. every day in the ER before they are sent home. I guess what I am saying is there is a MAJOR difference between checking the acuity of the patient, providing treatment (even if not emergent life or death) if any can or needs to be provided at that time, and impressing upon the patient at time of discharge (be that three hours or three minutes after they came into their ER room/bed) the importance of having a PCP and/or the convenience, to them, both in time and money, of an Urgent Care or Walk In Clinic for lower acuity complaints compared to kicking someone to the curb in a rude manner. There is never, in my opinion, ever a reason that ANY health professional should be rude to a patient. In fact the rude "tough luck" approach is a lot less likely to ever change anything. Simply put it is a lot easier to sell an idea to someone if you treat them like a human being and tell them what's in it for them (less wait time, lower costs, etc. in the case of Urgent Care, Minute Clinic, etc.) versus coming across in a "we don't have time for you" manner regardless of whether or not you actually don't have time for them. There is a right way and a wrong way to do these things I guess is what I am saying, and, like you, I do not see PPACA changing much of anything, if anything at all, about ER visits, the type of patients who visit, the wait times, nor the acuity level of those who show up.

100% agree. If you surf the internet you will find any number of forums that supposedly are for "physicians" to discuss issues with their school, practice, etc. What I have noticed is that it is fairly easy to pick out the "internet only physicians" on these sites. What I mean by this are the people who are a "physician" only in the sense that they play one on the internet. These type of people almost always seem to be belittling allied health professions, nursing, heck even many other "physicians" that just don't happen to practice what ever area of medicine they are pretending to work in. Now true, there are probably some who carry around the "doctor's own healthcare" chip on their shoulder who are actually physicians, but I do not believe these are the majority. Simply put most physicians that I have worked with have had a lot of respect for allied health, nursing, etc. if for no other reason than they do not want to, nor have the time to, perform the x-rays, clean the patient, run a CBC themselves, etc (although most recognize that the modern practice of medicine could not exist as it does without all the people who are not physicians that contribute to the field). The problem with the sites that cater, if you will, to the "internet only physician" crowd is that an uninformed reader could very easily get the idea that aside from being a physician there is no way to have a meaningful career in which you contribute to the medical care, health, and well-being of the patient. That is the first "source", if you will, of disinformation concerning medical careers. The second is maybe even a little more harmful. Those are the people who "settled", are now unhappy, and take it upon themselves to spew forth their hate filled rhetoric to any who will listen, or will at least lend an internet forum. These are the people that really didn't want to be a nurse, for example, but "settled" on nursing because of the money, shorter classroom education than medical school, or for whatever reason. Nursing is just an example here. You can really substitute any medical career in here. It also works the other way (i.e. the physician who really wanted to do something other than medicine but "settled" for medical school to make a family member happy, etc.). These too are the people who really never had, and still do not have, any desire to really work in the healthcare field with the sole exception that it is "a job". All of these people contribute to a bias against certain career fields, because they let their dissatisfaction in their career choice influence those who have yet to decide. Included in this group are the people that tried to take a "short cut" to the career they wanted. People like those who really wanted to be an MD but decided to take the "shorter" route of NP or PA. Now they are unhappy with their career not because PA or NP is a bad career but because it wasn't what they really wanted to do. Sadly, many times these people, instead of acknowledging the problem, take the attacking either the profession they are in or the one they truly desire to be in. So, as myself and others have said (others probably more eloquently than me) make a career choice based on what is right for you. Think of things such as work-life balance, what the job entails in the day to day, etc. Spend less time worrying about how you will "look" to others with this or that career, and life will be a lot happier. This is the advice I would give to someone who is looking to decide what career is best for them (healthcare or not).

See this is the kind of thing that to me makes a lot better sense than "sorry you aren't emergent enough for me so here's the door". I think we can all agree that an ingrown toenail is not an emergent condition (even if the pain can be immense). With that said, the local walk in clinics, at least here, at places like CVS and Walgreens do not treat them as is the case with several PCP offices here. A podiatrist would be a good option, but there again there are none close by here. Also the county I live in does not currently have any stand alone Urgent Care Centers (the closest are 25 of 30 minutes farther than the closest ER). That is why the closest ER is, as I understand it, adding an "Urgent Care" area to their set up. It just makes sense. If people are going to stop there anyway then they might as well make money off of their illness/injury/issue. No one is asserting that a lower acuity patient should trump a higher acuity one (and order you arrive of course should have nothing to do with it either), but to flat out tell a person "tough luck" reeks of all that the public perceives is wrong with medicine in this country. And that perception, like it or not, is what leads to the legislation and ultimately the cash flow, or lack thereof.

First, I am sure that elective procedures will grow (they are already a good area of revenue for hospitals). Whether or not a hosptial is under an obligation to treat a specific condition does not mean that they will not. A hospital is a money making institution. If they can make money from treating a condition, obligatory or not, they most likely will. Also, I know of plenty of "non-emergent" conditions that are most certainly treated in ERs. Maybe some places kick out the "non-emergent" but not all. That is the whole point with low acuity areas of the ER, "urgent care" areas, etc. The patient who twisted his/her ankle, for example, is most often NOT an emergent case (as I am sure you are aware there are very few true orthopedic emergencies), but they will be seen and treated in every ER I have ever been associated with. Second, I understand that overall management of asthma does not fall under ER regulations (although I am certain you can find patients who are, and have been, being "managed" in the ER and will continue to do so even after full implementation of PPACA). That said, legal precedent or not, it only takes one case of turning away an asthmatic who does not appear to be emergent who then becomes emergent and dies or suffers undue harm to result in the very legal precedent that may not currently exist. "Best judgement" as defined in the courts is not always the same as what may seem "best" for the ER at the time. That is why every ER that I have personally had any professional connection with at the bare minimum has a doctor see an asthmatic who is presenting. Even IF the asthmatic does not, in tirage, appear to be emergent. They might not be seen in 30 seconds, but they will be seen if they decide to wait. One thing that I have sadly noticed is missing from this whole discussion, and some might say is missing from Emergency Medicine all to often on the whole, is the psychosocial issues effecting why a patient presents to the ER. IF the patient is presenting due to some mental disorder then, somatic emergent illness or not, kicking them to the curb will do nothing to help them nor will it keep them from showing up at your ER again. The patient who calls the ambulance just to have contact with another human being because their family does not come around needs social services not a "this isn't an emergency get the heck out" approach. The same goes for the patient who self presents at the ER. There is very real danger in only doing what is obligatory. Sometimes what is right is better than what makes life the easiest.

I just thought of something else too. How do the "high acuity or the curb" ERs deal with patients who come to the ER at the request of their PCP? How about the patient that doesn't "present" like a "real patient"? As anyone who has ever worked emergency medicine can attest a patient who says they just "don't feel right" but looks OK this minute may be in the resus room the next. So, if Patient A with a history of TIA calls his PCP and tells them he just doesn't feel right will he be "triaged out the door" if he doesn't say the right thing or present in the acceptable way at triage? Will he have the stroke sitting in a chair at the Walgreens waiting to see an NP after he has had time to tell everyone else who is waiting for the NP that his PCP told him to go immediately to XYZ ER but the people at XYZ ER told him "tough luck go to the Walgreens Clinic you aren't emergent enough for us"? Perception is as much a part of maintaining a thriving medical facility as it is in any other business. So, as soon as public perception gets out that you "don't go there unless you want some rude person to tell you go somewhere else" then the policy will change or the facility will close. Either one would improve the quality of care it seems. As always just telling it the way I see it . . .

I think the "Fast Track", "Urgent Care Area", "Low Acuity ER", etc. are all better alternatives to just kicking someone out the door. What those who decide to "boot" need to realize is that if they go to court, and it is a jury trial, they will have jurors who will see this activity as "big medicine" trying to step on the little guy. Need an ER at that exact point in time or not. Medicine is NOT an assembly line job, and the "you fit the mold or you're out" approach seems too much like QC on an assembly line to me. It is also true to say that while some ERs are busy hour to hour with "actual" emergencies, there are plenty that are not. Furthermore, I would assert that there are probably very few ERs that have more "real emergencies" every minute than they can handle (and if so they need to expand the ER). Far from using PPACA as a way to get rid of ER patients, as I say, many ERs in the Southeastern part of the US where I am from are adding beds, low acuity areas, etc. to prepare for even more patients now that more people will have insurance (in my part of the country people are still prone to use "home rememdies" if they can't afford a doctor's visit -- ER or otherwise -- so these people will be moving from "Dr. Mom" to the ER to treat acute sickness once they have insurance). And I agree with you concerning chronic conditions. I don't know how many decent ER Physicians would kick an asthmatic out the door (or to the local CVS or Walgreens) who feels they need to be seen active asthma attack or not (not, like I say, if they want to keep their medical license).

This is the thing that a lot of otherwise well intentioned people seem to miss I think (and again I believe that many miss it completely in error). IF you have more people who want an item BUT you cannot charge more for the item (i.e. such as in traditional supply and demand theory) then you going to find a way to bring in that extra money somehow. One way to do so is in the way you just mentioned: see more people over less time. This does not increase the care the patient receives. It might not diminish the care either (depending on the provider), but it does not automatically increase the care the patient receives just because they now have insurance when they did not before. This is just another one of the "cause and effect" fallacies that is so very present in so many facets of society these days. Another thing to consider is this: the patient who yesterday was not paying for insurance might have accepted care at a level they will not tolerate now that they are paying out $250+ a month to insurance. "Working me in" and making me wait for hours on end to be seen might be acceptable when I know you are going to make less from me, because I do not have insurance and you are cutting me a deal. However, once you are making the same off of me as you are the next guy well then I will get seen on time thank you very much. So, I think we might actually see an increase in lawsuits with more and more people having insurance. As always just my two cents worth . . .

I am aware of several facilities here in the Eastern US that have actually included an Urgent Care, Fast Track ER, Low Acuity ER, call it what they will into their existing hospital structure. Patients that do not require, as you point out, a more traditional ER setting are sent over to this other area. This has more than one benefit for the hospital. First, it prevents the hospital from being sued or charged with violation of EMTALA (like you I have not found any data to suggest that PPACA does away with EMTALA). Second, and perhaps most important to the hospital administration, it brings in money from patients that under a "tough luck go elsewhere" approach would take that money to other providers. Again it is important to assert that regardless of perception at least in my experience with ER patients just as many patients who have insurance show up at the ER for situations that may not require a "traditional" ER environment as do those without insurance. Now I have heard several midlevel providers complain elsewhere on the internet that relegating them to "urgent care" takes away their skill sets. I do not intend to make this an argument or discussion on where midlevels should work nor even if the term midlevel is right or wrong. All that aside, however, midlevels like physicians have a choice of where to apply to work. If working "urgent care" cases versus "traditional ER" cases is not your thing then apply to work elsewhere (although in my experience midlevels, stationed in an urgent care or traditional ER, still see lower acuity patients unless they are the only provider available at the time a higher acuity patient comes in). Another concern for the ERs that might employ the "we don't treat that here now get out" approach is the perception of discrimination. All it will take is someone to feel that they have been asked to leave based on some protected status (age, race, sex, ability to pay, national origin, religion, etc.) and a willingness to hire an attorney who can find that more people who fit their protected class we sent elsewhere than were those who do not fit into their class and well you have a perfect lawsuit. So, in short, ERs who employ this tactic must make sure that they are sending away equal numbers of whites as they are blacks, equal numbers of haves as they are have-nots, equal numbers of religious people as they are non-religious, etc. Otherwise they are setting themselves up for some nasty problems in the future. Then again, high acuity patient or not I would not want myself or any of my loved ones being seen in an ER where someone was callous enough to give the "tough luck" approach to any patient to begin with (keeping in mind that there are plenty of chronic conditions that could warrant a visit to the ER: asthma, COPD, and HIV/AIDS just to name three).

I used to work as a 911 Emergency Communications Officer. At one place I worked there was a man who always liked to take the newbies "under his wing". What he really wanted to do was mostly tell them who and what was wrong with the place. If he ever got the hook in deep enough though to get them to agree with him then he turned on them like a rabid dog. I was advised to be leary of the man when I was a newbie there, but I had already kind of picked up on this myself during our first meeting (he had made a comment that "I am sure you will quickly see there is room for improvement here"). Sadly, some would not heed the warning (and for reasons unbeknowest to lowly little me he was allowed to stay employed there -- always felt this had a lot to do with the union but I could be wrong). So, what ended up happening is some new person would, with his leading, make a suggestion of how to fix a problem (maybe it was even a really good suggestion), and then this man would lead the charge to point out "they just started here and they already think they know better how to do things than those of us that have been here for years". Of course he didn't do this to their face, but he lived for the drama. He created problems to relish in them. Had the person simply, as you suggest, taken some time to learn the dynamics of the place they would have quickly learned which supervisor was the most receptive to new ideas, which team members were not the best to share secrets with, etc. As it was, warnings or not, many walked themselves right into a label they could have done best without.

I don't know that I agree that everyone who has not taken the "pat em on the back and smile" approach is conversely wishing to making them feel like anything bad (or expletive as you say). I know that has not been my intention. I have a saying that goes like this "the truth is truth nothing more nothing less". That has been my motto in many situations in jobs. This has not always made me the most liked person on the job, but my coworkers have all known that they don't ask for my honest opinion on something if they don't want it. So, in this case the truth is that someone who walks in off the streets and starts pointing out areas for change creates a negative vibe around themselves in many people's minds. This does not mean that the newcomer needs to just go along with something that they feel is wrong just for the sake of going along, but it does mean that they should be prepared to get lip back if they start pointing out all the "wrongs" they see. For what its worth I would never condone a coworker shunning or backstabbing any other coworker, new or not, because they disagreed with them. Likewise, I can't really stop a coworker from doing those things. As I have said before, for me it all seems to ride on this idea that you are supposed to make a suggestion, get a bad reception to said suggestion, and then loose the fire and have to question your choice of career. Also if the newbie can't handle criticism from the coworkers how are they going to handle a patient that flat out tells them where to put it when they are suggesting the "right treatment" for them? I guess what I am saying is that people can and will say whatever they want to to you, but you have the choice to let what they say ruin your career or not. Maybe I am just trying to make it too simplistic or something . . .

And it is entirely possible also that I just completely misunderstood what exactly you were making comment to as well, so since that appears to be the case then I apologize. That said, I still firmly believe that there has to be an understanding, new professional or old, that change does not have to be about recognition. That is why I believe that if the change had been intended for the correct reasons then you just don't up and give up. In fact, I find very little in history where a person made substantial change, for the good or the bad, by folding under criticism or a lack of acceptance on their proposal the first time out. That is why I say that you can't rely on this feeling of "the fire" to base your decisions on in a career in the first place, and especially not if the changes you feel are needed are really truly needed. Maybe this all just seems like rambling or shunning behavior, but I do not intend for it to be. As others have said we sometimes have to pick and choose our battles and this involves not only which ones to fight but also how to approach the fight in the first place. Sometimes this might even mean that you have to understand the "enemy" a little more before you attack. I also think that is what some others were trying to say.