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Mindful EM

Mindful EM

Never Apologize for ‘Patient Dumping’

Hazan, Alberto MD; Haber, Jordana MD

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doi: 10.1097/01.EEM.0000490515.07080.cc
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    Dumping can mean to dispose of something (like garbage), to knock down (a boxing term), or to make something available in large quantities (like the stock market).

    But dumping in medicine is most commonly associated with a potential complication of gastric bypass surgery, a constellation of abdominal pain, malaise, dizziness, weakness, and flushing that usually occurs after eating and results in the rapid emptying of the stomach.

    Dumping when referring to patients, however, takes on a whole new meaning with appalling and disheartening implications. Patient dumping can occur when a hospital capable of providing a service refuses to see a patient or chooses to transfer a patient to another facility because of a patient's inability to pay his medical bill.

    The Emergency Medical Treatment and Labor Act (EMTALA) has prevented this sort of dumping from occurring as frequently; it requires all Medicare-participating hospitals to conduct a medical screening exam and stabilize any patient seeking treatment in an emergency department, regardless of his socioeconomic status. If an illness is present, treatment must be provided until the emergency medical condition is resolved or stabilized. Violating EMTALA can lead to serious consequences, including but not limited to fines of up to $50,000 per violation, termination of a physician's or hospital's Medicare provider agreement, and civil lawsuits for personal injury.

    Most of us don't violate EMTALA, but emergency physicians are routinely accused of patient dumping. This type of dumping, however, has nothing to do with refusal to see patients who can't pay their medical bill or with negligence for not providing a proper screening exam.

    Don't Feel Guilty

    Many of us are often accused of patient dumping by the ancillary medical staff, usually by our internal medicine colleagues, whenever they feel we admit a patient to the hospital for inappropriate reasons. Examples include but are not limited to social admissions for the elderly, homeless, or alcoholic; admissions for chronic abdominal or back pain management; and admissions dealing with psychiatric or suicidal patients.

    This type of patient dumping in many ways is the exact opposite of what hospitals are sometimes guilty of when they violate EMTALA. Instead of refusing care, emergency physicians admit these patients to ensure they get proper medical attention. Our colleagues working upstairs may get upset (or unashamedly angry) at being involved in the care of such patients, which are deemed to be “dumps” because they usually don't require anything more than social services.

    Often when we start our training, we feel guilty about getting our medicine colleagues involved in the care of these routine and nonurgent medical conditions that sometimes lead to lengthy hospital stays, but emergency physicians should never apologize for admitting these patients. They are not a failure of our work but a failure of the system in general. Many of these patients lack the resources that would have kept them out of the hospital in the first place. Fortunately, many hospitals have been able to prevent unnecessary admissions by providing certain services from the emergency department. But those of us without case managers, social workers, and visiting nurse programs have no choice but to get the rest of the hospital involved.

    One can argue, however, that society in general is guilty of patient dumping on the emergency department on a regular basis. There are approximately 150 million ED visits a year in the United States. Some are patients brought in by police for being drunk or high. Many are the homeless brought in by EMS after being found sleeping on the sidewalk or the elderly with dementia who are dropped off by family members because they “can't take care of them anymore.” A significant number of visits are the result of the many voicemail recordings from doctors' offices that state, “If you are having a medical emergency, call 911 or go to the nearest ER.”

    Most of us went into emergency medicine because we didn't want to bother thinking about who we were treating or how they would pay us. We went into this field because we wanted to treat people without judgment or discrimination. We need to be grateful for that privilege and treat everyone with equal compassion by doing what is best for the patient and disregarding how the admitting team or consults may think of us for getting them involved.

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