Peer Review

Dear Dr. Chairman:

I am sorry to hear that Ms. Doe ultimately succumbed to her terminal illness. However, I am uncertain how to respond to your inquiry. I note that the committee did not mention any specific concerns regarding my medical treatment of the patient, so I assume you would like me to respond to the complaints by the patient’s family member.

I believe that my treatment of this patient was completely appropriate. I disagree with the committee that there was a clear indication for admission of this patient, but obviously that issue is irrelevant since I arranged for her admission regardless of the absence of any absolute indication to do so. I will use our apparent disagreement about that particular issue to help you try to understand what really happened that night, and how it relates to what happens every night.

A sodium level of 129 is not an indication to admit a patient, as you well know. A fall in an elderly patient is not an indication to admit either, nor is vague generalized weakness. Obviously a urinary tract infection is not an indication for admission, particularly in the absence of vomiting. If anyone on that committee truly believes that any of those findings are a "clear indication to admit" a patient, I wish that you would notify the entire medical staff of your specific recommendations so that we can expedite such admissions in the future.

Personally, my philosophy is that any elderly patient who “just doesn’t feel good” and requests admission should be admitted to the hospital regardless of laboratory findings, but as you are doubtlessly well aware, many physicians disagree with such a conservative approach. Certainly the presence of several minor abnormalities of laboratory studies or a general impression that a patient might benefit from a little tune-up in the hospital can outweigh the absence of an obvious admission criterion, and that consideration was essentially the reason that I arranged for the admission of this particular patient. After receiving intravenous fluids and antibiotics, if she had decided that she wanted to go home or if she were denied admission by her physician, she could have been seen in the office the following morning without any adverse outcome, so this was essentially what many would consider to be a “soft” admission.

When I told Ms. Doe that her own doctor was not on call, I did not intend to imply any sort of refusal or inability to treat her, but instead my purpose was simply to inform her that the covering physician might not be familiar with her specific situation. When I stated that her tests did not show any abnormalities which required admission, it was to prepare her for the possibility that the on-call physician might not agree to admit her. This is an approach that I have occasionally found to be helpful because many physicians at this facility are often hesitant to admit patients unless they meet specific criteria, despite the patient’s or family’s preference for inpatient management. As I mentioned, I would personally favor admitting every elderly patient who falls, feels weak, has mild electrolyte abnormalities, or just doesn’t want to go home. The challenge that I and my fellow emergency physicians routinely face is to convince another busy doctor to admit such a patient, particularly when we must awaken them after midnight.

The post hoc “clear indication for admission” as determined from the midday setting of a Peer Review Committee conference room is often not so clear from the perspective of the typically exhausted on-call physician who is awakened from the comfort of his warm bed by a BEEPBEEPBEEP after a full day’s work, multiple other admissions, and a long list of complicated patients still to be seen in the morning. So I occasionally warn certain patients that they “might be able to go home” in order to ease their potential disappointment when, as often occurs, I am forced to send them home against their will, dragging their prepacked suitcase behind them.

I therefore am certain that I never said “I’ll admit her” to the family because I don’t have the authority to admit any patient. As a lowly emergency physician contracted to manage the night shift in the ER, I am always required to find another physician on staff who is willing to accept my patient to their service; consequently the patient, their concerned family, and I are always dependent upon the judgment, whim or mercy of the attending physician on call. In reality, every physician is less likely to be agreeable when asked to accept relatively “soft” admissions, if they are on “no doc” call, if they have already admitted many patients that day, or if they are covering their partners’ patients overnight (among other factors). Some other physicians just prefer to admit as few patients as possible no matter what the specific circumstances happen to be. These are incontrovertible truths.

Keep in mind that I have zero incentive to discharge any of the patients I see in the ER...in fact, it would be much easier and less risky for me to just admit everyone that comes in. I’ve never received any pats on the back, financial incentives, or glowing letters of commendation for admitting fewer patients than the average; nor have I ever been chastised for admitting too many patients. Yet every patient that I discharge has the potential to get sicker, have a bad outcome, or get angry at me because their symptoms were not adequately controlled in the outpatient setting, so the allegation that I grudgingly agreed to admit this patient only after multiple protests and threats by the family is totally absurd and completely untrue. I don’t recall her family ever threatening to take Ms. Doe to Big City Hospital, but such a statement would not have caused (or enabled) me to change my management in any way. I am the patient’s advocate, not their adversary. Their true adversary is usually at home sleeping while I stay awake all night doing his dirty work for him. Some of our physicians on staff at Our Little Hospital can, and do, refuse this type of admission, believe it or not.

I would confidently wager that every practicing physician on your committee has refused an admission from me at least once during my ten years in practice at Our Little Hospital. It is also probably fair to say that many of those patients that I was forced to send home wanted to be admitted every bit as much as Ms. Doe did that night, and that their families were probably just as upset that their expectations were unmet. In reality, those rebuffed patients were probably even angrier since they actually were discharged, as opposed to Ms. Doe, whose relative was apparently upset with the very discussion of the possibility that she might have been discharged, despite the fact that she was ultimately admitted and given the best treatment that our facility could offer her. The difference, of course, is that the sine qua non of this particular complaint was the family’s grief and frustration at the loss of their loved one, and I therefore do not begrudge them the opportunity to vent their emotional release towards me, even though I feel it is undeserved. I understand their frustration, I sympathize with their loss, and I forgive them for their misdirected hostility.

I hope and pray that every member of your committee thinks about Ms. Doe and the anguish of her family before refusing an admission from me or from any of my emergency medicine colleagues in the future. I wouldn’t even bother to call and ask another physician to admit a patient unless there was a good reason to do so. There are only a handful of physicians at Our Little Hospital who have never refused an admission from me. If any of them happen to be on your committee, I would like to tell them this: that you have my eternal respect and gratitude, and it is truly my pleasure to work with you to provide the best possible care for our patients. You make my difficult job significantly easier, and you provide a welcome sanctuary for those of us in need. Thank you and God bless you. To everyone else, I pray that you can understand how you might be somewhat complicit in fostering complaints of this nature, and that you might deign to be a little more receptive when your mercy is sought henceforth.

I will be happy to answer any further questions or concerns you have about my involvement in this case or to discuss any other ways we can improve the care we provide to our patients. Thank you very much for your understanding.