I came out of residency before the time of metrics. My focus was on getting the correct diagnosis. My mantra: “Please don't let me hurt anyone.” I thought that was enough to worry about.
But we've transitioned since then. What drew me to EM was the art and science of medicine. What most of us didn't bargain for was the business of medicine. Like it or not, it's a package deal. Most of us have a family, future goals, or debt we need to pay. To be successful, we need to make it work. My struggle is how to find the right balance. How do I practice thoughtful medicine and keep up with the pace expected? How do we keep the pendulum from swinging too far?
I hypothesize that most of us got into this field for many of the same reasons. At some point, we liked what we were learning. We were good enough academically to give it a go. We cared about people. We liked fixing, healing, helping. The job was reliable and respectable. We solved riddles, erased pain, and maybe even saved a life.
At some point, we were introduced to the game of numbers, AKA metrics. Much of this is fueled by third-party reimbursement. How many patients can you see per hour? How fast can you admit or discharge a patient? How long did this patient wait to be seen? Like any business, we need to see where we can be more efficient. In our business, maybe more than others, “time is neurons,” after all. Beds mean business, and they also mean people aren't hemorrhaging in the waiting room. It makes sense.
But it doesn't stop there. Insurance companies have a stake in the game. Did you document enough ROS? Is there an eight-point physical exam? Have you maximized your billing? Your contract and paycheck depend on this.
Funny, none of those numbers is a vital sign.
As we try to fulfill the parameters set up by insurance companies and hospital administrators, I wonder if this can incentivize the wrong behavior. Why would I think this? Are we a little competitive by nature? How can I see more patients per hour? Maybe spending less time with my patients. How can I cut down on documentation time? Maybe with preformed exams to immediately import into the chart. The problem is I'm coming across patients who are not getting touched at all, and a full physical exam can be documented just by walking into a room and looking at a patient.
What a shame. There's healing in touch.
I had a patient with abdominal pain. She came in frequently for pain, and it was her third visit that summer. Before this visit, she had an endoscopy showing an ulcerative disease and a failure of gastric bypass sutures. When I examined her, I saw mottled skin from chronic heating pad use, an effort to control her pain at home. When I examined her, she started to cry. I apologized for causing her pain, but that's not why she was crying. She said I was the first person in three ED visits who had examined her. No one had touched her stomach. She left without any narcotic pain medication and thanked me for her care. She felt better emotionally and physically.
An article this year in the Journal of Emergency Medicine by Musher, Hayward, and Musher called “Physician Integrity, Templates, and the ‘F’ word” found multiple cases where the “medical record cited facts from history that were not elicited and findings from physical examination that was not performed.” (2019;57:263.) “This is fraud,” the authors wrote. They recommended that physicians push back against third-party payers who demand irrelevant information in the chart. I've had colleagues indicate that they have seen EMRs completely filled out by providers before seeing a patient at their institution. When I used a complete preformed physical exam, I found I would sometimes forget to edit the form with all the physical findings. These records have many advantages, but like the article suggests, we also have to discuss the dangers of the system we have embraced.
Ultimately, be careful.
Be careful not to document something you haven't done.
Be careful not to worry more about the boxes on your chart than how your patient is feeling.
Be careful not to value speed over accuracy—these are lives in our hands.
And that will be good for business.
Share this article on Twitter and Facebook.
Access the links in EMN by reading this on our website, www.EM-News.com.
Comments? Write to us at email@example.com.
Dr. Ellisis a nocturnist at community hospital in Baltimore. Follow her on Twitter @kellyellis90.