Just Who’s Care is Being Measured? by Alfred Sacchetti, MD
Wednesday, January 13, 2010 
Alfred Sacchetti, MDSeems like every month or so, some researcher reaffirms just how incompetent Emergency Physicians by conducting a chart review of select Community Hospital ED records. Using a set of standards from some national organization to create their own definition of optimum care, these dedicated scientists are able to identify key management errors common to all emergency physicians. Some studies identify errors of omission others errors of commission. My particular favorites and the subject of this blog, are those papers that point out the liberal use of diagnostic studies by community emergency physicians in the management of pediatric patients.
Pretty much the standard conclusion of these studies is something along the lines of: “Our review of the ED records of these children confirms that community general emergency physicians order many unnecessary (pick one: CBC’s. electrolytes, CXRs, CTs, U/A’s, Blood cultures, and repeat temperatures).” This statement is usually followed by a discussion explaining why these EP’s have such liberal ordering tendencies. Explanations of this irrational behavior include: lack of comfort with pediatric patients, ignorance of recent management recommendations, poor training, the fact that pediatricians just know more about children and the realization that community practice is just inferior to that of an academic center.
What I never quite understood about these studies is why none of them have ever looked beyond the ED to find other factors that impact on emergency physician’s management decisions. How many of the CBC’s ordered on children in the ED are at the request of a consulting pediatrician. Every try to admit an infant with bronchiolitis without a CBC? Good luck getting that one, onto the ped’s floor.
The academicians at the tertiary care Children’s Hospital deal with high powered consultants who may be very supportive of no diagnostics in their patients. In fact, many of these docs may be the driving force behind these minimalist recommendations. However, in the community hospital, the pediatrician admitting a child with asthma is much more likely to request a set of labs or a chest x-ray as part of the admission process. As a gesture of good faith, most emergency physicians will generally comply with such requests and order them as part of the ED visit. Obviously, there are certain therapeutic or diagnostic demands that will cause even the most docile of emergency physician to object, but for the most part, no reasonable request is ever denied. Hence, the problem.
A retrospective record review cannot tell just who really ordered that CBC or that dose of Rocephin. Was it the decision of the treating emergency physician or was it a request from the admitting pediatrician. Unfortunately, this point is never mentioned in any of the limitations sections of these articles. It is simply assumed that it was the emergency physician’s idea and he or she is purely to blame. This makes it very convenient for the authors of these papers to publicly lambast those incompetent community emergency physicians.
So the next time you come across one of these EP bashing publications, ask yourself, just who’s care is really being measured here?
Reader Comments (1)
In many ERs including my own “advanced triage protocols” are in force. Lab tests and Xrays are symptom generated. For example: Oh you have chest pain and SOB then I think I’ll choose a chest pain protocol from column A and a D Dimer from column B. This led to a workup of a 23 year old patient that I treated 2 days ago, that had a sore throat and some occasional chest discomfort with inspiration, that included a CBC, lytes, CXR, tox screen, D Dimer [that was positive], serial troponins and EKGs. A reviewer could have a field day with this one. Go figure! There are many reasons that the art in our practice is undermined. This is just one example.