The extra stuff

The basic stuff is most important. You have a problem that concerns you enough to come to the ER. Maybe it's a cut, or a cough, or some sort of pain. I happen to have the training to be able to quickly listen to you, examine you, and make a diagnosis. My real job, as a contractor who is staffing the emergency department of the hospital, is to decide if it is safe to send you home or if you need to be admitted. For some problems, I might need to do a test (or twenty) to confirm my diagnosis. No biggie, I work at a facility that can do it all. Most of the tests I order are just to cover my ass against litigation, or to try to support my clinical impression that you should be admitted. The admitting docs like to make really sure that you need to be admitted, and my clinical impression alone isn't usually sufficient. So those additional tests are the first layer of extra stuff.

That basic decision-making process only takes a couple of minutes at most. What follows is more extra stuff which takes much longer. You see, I have to document my findings in the medical record. A simple note isn't enough, because "the government" has decided that they will only pay me if I document certain things. So I have to ask you various things that I don't really NEED to ask you to make my diagnosis, and I have to examine parts of your body that have nothing to do with why you came in. We have special forms we use to help us make sure we have done all that extra stuff, that a company charges us extra for. Lots of little boxes to check off. So if you are wondering why I'm looking in your ears or asking you how much alcohol you drink, now you know.

I only need a pen and a stethoscope, really. I travel light. The stethoscope is to listen to your insides. I could put my ear to your chest, like I do with my daughter, but the stethoscope allows us both a to have a little more dignity. Plus, it looks cool. The pen is to write your prescription when I send you home, to justify my bill to your insurance company, and to protect me from your potential lawsuit.

I might need a pair of sterile gloves, or an ACE wrap, or a suture kit to fix your problem. Of course, I can't just go get these things off the shelf, because we have to charge you for them. So they are kept in a big electronically-controlled bin with dozens of little drawers that pop open when the item is requested under your account number. What do you have to type into the machine so that the "ACE wrap" drawer opens? "Elastic" or "bandage?" The staff confers while I wait.

If I've ordered any tests, the results will soon be available on my computer. Of course, in order to protect your privacy, I have to log in with my super-secret password each and every time I want to check. Hmmm, not back yet, so I'll go see another patient. When I return, I have to log in to the system once again, because it's been more than two minutes since I last logged in. In those two minutes, some sinister person might sneak into the nurses' station, sit down at my desk, and learn that you have a urinary tract infection. Ha, not with our top secret security system, they won't!

Once I have all of your tests back and I have discussed the plan with you and written your prescriptions, it's time to document more stuff in your chart. Again, to cover my ass. Prescription given....check. Patient informed of need to follow up....check. Diagnosis and labs discussed with patient....check. Discussed with Dr. _____, will see patient in the office in _____ days. X-rays discussed with radiologist. Even though there are typed X-ray and laboratory reports that will become an official part of your medical record, I still must write it all down myself so that your attorneys can see that I actually reviewed it and the insurance company can see how complex the case was. Then I sign and date my note, the lab order sheet, the medication order sheet, and all of the prescriptions.

So what could take only a few minutes takes much longer because of all that extra stuff. Don't worry, I know that you had a lot of extra stuff that you had to sign when you checked in too, so I don't expect any sympathy. We can share our frustration with all of that extra stuff. Did that visit seem to take longer than you expected? If we could eliminate some of that extra stuff, maybe we both would be happier. Unfortunately, the "powers that be" only seem to create more and more extra stuff each year that puts up walls between us. The patient-physician interaction is getting smothered in a sea of bureaucracy.

Music Meme

Ack!!!!!!

Nurse Ratched tagged me for this, so I'll play along. She's pretty convincing, lol.






These are songs I have been enjoying recently:

She's So Cold - Rolling Stones
- this song reminds me of my first girlfriend in high school, and I love the licks Keith Richards lays down in this one.

Paralyzed - Ted Nugent
- the Nuge rocks. He's never tried a recreational drug, so he claims in his book.

Nice Guys Finish Last - Green Day
- I've been listening to the International Superhits disc on the way to work lately, to get me hyped up. Awesome collection.

Crack the Code - 311
- I wish I could transmit my feelings sometimes. This song is a good example of the 311 style.

Cold Contagious - Bush
- this list is starting to look depressing! Awesome guitar work in this one though.

Hero of the Day - Metallica
- I'm running out of things to say. Load is one of two Metallica discs I own.

Heart-Shaped Box - Nirvana
Kurt Cobain was a genius, and his voice gives me the shivers.

I'm not going to tag anyone else though....I guess I'll have bad luck now.

How much is a good doctor worth?

Sometimes I worry about the future of medicine in this country. We hear more and more often about the panacea of "socialized medicine," or "universal healthcare," but what most people don't realize is that we already have it and the extent to which it adversely affects our lives.

EMTALA guarantees that any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". If he is, then the hospital is obligated to either provide him with treatment until he is stable or to transfer him to another hospital in conformance with the statute's directives.

In practice, at least partially because of the litigation crisis in this country, what actually occurs is routinely far more involved than a simple medical screening examination. The full services of the hospital are often brought into play regardless of the ability or desire of a patient to pay for their care. Guaranteed entry into the system plus fear of litigation = universal healthcare, enforced by the government. That is socialism, pure and simple. Worse yet, EMTALA is an unfunded government mandate, which makes it even more intolerable and unreasonable.

But wait....there is more! Every adult over 65 is eligible for Medicare, the government socialized insurance program. If a hospital or physician agrees to accept Medicare payments, then they become obligated to follow the extensive and restrictive guidelines and payment schedules stipulated by our government. And the prices are strictly fixed. This is the worst form of socialism: the most talented and experienced physicians in the country receive the same payment for each given "relative value unit" of service as those who are inexperienced and barely competent.

The jerk with the horrible bedside manner who you can hardly understand and who rushes you through your visit receives the same payment per encounter as the kindly concerned physician who takes his time to listen to you. Whether you come to the ER at noon or 3 am, the payment is the same. Pretty scar or ugly scar....same payment. Good results or no improvement....same payment. Nice office or strip center....equal under the law. Welcome to assembly-line medicine.

And even worse, the insurance companies use the Medicare RVUs to set their rates, so everyone is socialized. If the government told all restaurants that they could only charge $10 for a steak dinner, whether they were Golden Corral or Smith and Wollensky's, what do you think would happen to the quality of the dining experience? Is that really what we want our country to be like?

I wonder if we somehow were able to revert back to a free market system of reimbursement whether the overall costs might decrease, and whether patient and physician satisfaction might improve. It seems like even with the amount of socialized medicine we have now that few are happy with the situation. I think that increasing socialism further is not likely to help.

UPDATE: Crisis in the Emergency Department, via GruntDoc.

UPDATE #2: The Choice: A Longer Life or More Stuff, via DB's Medical Rants

Living in a society that spends a lot of money on medical care creates real problems, but it also has something in common with getting old. It’s better than the alternative.

It’s easy to be against high costs, and it will no doubt be hard to come up with a broad health care solution. But the way to start is by acknowledging that an affluent society should devote an ever-growing share of its resources to the health of its citizens.

Free Delivery!

The Houston Chronicle reports:

Rising numbers of undocumented immigrants from Mexico and Central America are streaming into Texas to give birth, straining hospitals and costing taxpayers hundreds of millions of dollars, health officials say.

Doctors and health officials say they are overwhelmed by both the new arrivals and those immigrant mothers who already are in the state. Even Houston's feeling the pinch. An estimated 70 percent to 80 percent of the 10,587 births at Ben Taub General Hospital and Lyndon B. Johnson General Hospital last year were to undocumented immigrants, administrators say.

Harris County Hospital District officials say their policy is not to question patients directly about their citizenship.

"We do not explicitly ask if our patients are illegal, but we do ask them for proof of Harris County residency," district spokeswoman Shannon Rasp said. "Often citizenship status becomes clearer when billing issues come up."

I'll bet it does.

ER Dogma

1) Everyone's pain is 10/10, get in line. If you aren't screaming, it isn't a 10.

2) Chronic back pain patients often forget their narcotic medications when they go out of town. And their doctor goes out of town a lot too, but he'll be back on Wednesday.

3) If you want me to take your upper respiratory infection more seriously, tell me that your temperature usually runs low. So when your temperature is 98.6, that is really a fever. In you. Because you know your body.

4) If three or more family members check in together with upper respiratory infections, they have Medicaid, thus no copay.

5) Riding a motorcycle while wearing shorts is a bad idea. Really.

6) The longer your list of allergies to medications, the more likely you are to have a psychogenic cause of your physical complaints.

7) If you think you have a "high pain tolerance," you probably don't. If you think that you have a low pain tolerance, you are likely correct. People with a high pain tolerance don't even mention that term.

8) If you are concerned about any symptom at all, I don't mind if you come to the ER. I'm happy to give you my advice, and I will not chastise you. Just understand that the longer you have had your symptom and the less obvious it is on examination, the less likely it is to cause you harm, the longer you will have to wait to be seen, and the less likely I am to be able to figure it out or make it better. No, I don't know what that little bump is. Bye.

9) It doesn't matter how slow the ER has been all day....as soon as the second doc leaves it's going to be crazy for the rest of the night.

10) If a physician hasn't returned a call after 30 minutes, as soon as I page a different physician they both will call back at the same time.

Lingual Nerve Injury

I personally had never heard of this complication before. Now I am intimately familiar with it.

My latest dental visit was proceeding smoothly: the nitrous was flowing, the headphones were playing a pleasant assortment of contemporary rock music, the temporary crowns were deftly replaced with their smoother permanent counterparts without the need for an anesthetic.

Then my dentist started on the other side. I was to have two fillings placed in the lower molars, so in preparation for the drilling, I received a nerve block. Not being a dentist, I'm not sure if the inferior alveolar nerve or the lingual nerve was the intended target, but I immediately felt a hot burning sensation to the ipsilateral tongue. I suspect that I winced a bit. I was already all tensed up (as usual given my fear of dental work), so perhaps it went unnoticed. But I certainly noticed that this injection was more painful than previous ones.

The actual drilling and filling seemed uneventful, and other than that one second of sharp shooting pain, relatively painless. After my recent dental visits, the anesthesia would wear off a couple of hours after I left the office. This time, my lip and jaw stayed numb for most of the day. The side of my tongue felt scalded, as if I had burned it on some really hot soup.

The next day, I awoke with my tongue still feeling the same way. So I did what any internet addict would do, and I searched for information on the net. In the process I was alarmed to discover that this paresthesia might be permanent. I called my dentist to let him know how I was feeling, and to ask him if there was anything I could do about it. He said that unfortunately I just have to wait and see. Most of the time, it will get better in a few days. Or occasionally a few weeks. Or sometimes a few months. Or......

It really doesn't hurt, it's just annoying. I can't taste anything on one side of my tongue, and it feels burned. But if I had known that permanent nerve damage was a potential complication of the procedure, I might have inquired about other anesthetic options. I had no clue that such a thing was possible. Apparently there is some controversy regarding the use of Septocaine for mandibular blocks.

That's why I'm telling all of you.

UPDATE: after a bit more research, I'm optimistic (though my tongue is still numb after 2 1/2 days):

Prognosis
Patients with nerve injury after dental injection, regardless of the presence or absence of electric shock sensation, have a good prognosis. Spontaneous complete recovery from the altered sensation occurs within 8 weeks in 85% to 94% of cases.

The inferior alveolar nerve often carries a more favourable prospect of recovery because of the confines of the bony canal and the lack of mobility relative to the lingual nerve. Patients with paresthesia lasting beyond 8 weeks after the initial injury have less chance of full recovery.

UPDATE (10/5/06): I get several hits per day from people searching for information on lingual nerve injuries, so it's obviously a more common problem than we realize. My tongue is still numb, but it seems to be slightly better, maybe halfway back to normal.

UPDATE (11/21/06): My tongue is 95% back to normal. I don't really notice it unless I think about it. And the only time I think about it is when I look at the sitemeter and see all of the Google searches that people find this post by searching for information. Welcome, fellow lingual nerve-injured patients! There is hope!

Homicide in the ER?

I think this ruling sets a bad precedent.

A woman dies of a heart attack in the waiting room of an emergency department, and her death is ruled a homicide by a "coroner's jury."

All the details haven't been released, but it's a huge leap from medical negligence to homicide in my opinion.

UPDATE: Details of the patient's ER visit are here and here.
Apparently an ECG was not done in triage.


More stories of deaths related to ER overcrowding here:

"My emergency department was crowded with patients awaiting inpatient beds. A patient came in with chest pain, and no beds were available. While awaiting a bed, the patient collapsed and died of a heart attack in the waiting room. The family sued.

A 50-year-old man came to an already overcrowded emergency department complaining of chest pain. The initial EKG showed no signs of heart attack. He had to sit in the waiting room because no beds were available. His pain worsened and his primary care physician met him in the waiting room and waited with him. He arrested in the waiting room and died while waiting for a bed.

A young man about 30 came to my emergency room late in the evening with fever and malaise for the past two days. He never registered, but asked how long the wait was. We will never know what exactly was said, however he declined the option to be seen when he heard how long the time would be, and left. The following day he was dead.

A 10-year old boy in Arizona had a severe asthma attack and couldn't breathe. An ambulance was called, but all the hospitals near his home were full and on diversion, including two children's hospitals. The closest open hospital did not admit children, but opened to take him, even though it was also overwhelmed. While waiting for a treatment room to open up, the child waited in the hallway on the ambulance gurney for several minutes. He died in the hallway, before he could be seen by even a nurse, because all the staff were overwhelmed caring for other critically ill patients."

Are those cases "homicide" too? Obviously not.

Work and Pleasure

These are the things that made me happy during a recent shift:


1) The three patients who not only thanked me for helping them, but also told me that they felt sorry for me that I was the only doctor on duty and had to work so hard. Really.

2) Removing the sac from the infected sebaceous cyst. Oooooh, yeah.

3) Learning about metacarpophalangeal dislocations. They are much different than interphalangeal joint dislocations, I discovered.

4) The perfect spinal tap: one stick, 0 RBCs, 0 WBCs, 100% lymphs. A benzodiazepine-laden patient is a still patient.

5) Suturing the second-grader's foot without making him cry, as he told me about catching his first big fish. Watching his dad's apprehension vanish when he saw his son was comfortable.

6) Seeing the brave little girl whose abscess I drained skip away happily, stickers in hand. One for her brother.

7) Sitting down with my last patient of the night, an elderly retired nurse, and hearing her life stories. A two time cancer survivor, she's too tough to let her bad heart slow her down much. Her bad knee is the only thing that keeps her from driving, and if her doctor would OK the surgery she'd lick that problem too. She doesn't like to have to depend on her family to drive her around. Her husband was a Cardiologist, she said, and he used to make house calls. As she prepared to go home, she thanked me and said "I hope you get everything you want out of life."

It's patients like her that help make it so.



Things that frustrated me:

Only that dislocated finger. I was not much consoled to read that many MCP dislocations require open reduction in the OR. It looked like it should have popped right back in. I hate failed procedures, but I did the best that I could. It still bugs me.

The Missing Gauze

It seems like as the years pass, I am seeing more and more abscesses in the ER. Hardly a night goes by that I don't incise and drain at least a couple of boils, and occasionally I'll see a couple more "wound checks" of abscesses previously drained by another doc. More often than not, these abscesses will have been packed with iodoform gauze. Just pull the string, pat the patient on the back, and move along.

Not this time. The gentleman in room 5 has already removed his dressing to reveal a one cm incision without any gauze sticking out of it.

"Looks pretty good," I said, thinking this patient would be even quicker than the typical wound check. Not so.

"I can't find the packing," he said. "I think it's inside there somewhere. I checked the bandage, the floor, everywhere." At home, of course, where he had removed the dressing.

I looked closer at the wound, gave it a little squeeze. No pus, just some blood tinged oozy stuff. Definitely no sign of any gauze. I wondered aloud how much gauze the other doc had packed it with.

"It seemed like a lot," said my new patient.

Hmmmmm, thought I...no way in heck is there any gauze in that wound. With a teeniny little incision like that, the gauze is much more likely to have come out than worked it's way inside...but I can't just not check.

"I'll have to numb you up a bit so I can look around in there." So I give him a local, I gently spread apart the edges....nothing. I scooped across with forceps....nope. Irrigated a bit, then dissected gently, then probed some more, finally extended the incision, looked harder, probed deeper....nothing. It just wasn't there. But maybe it was, how could I be sure?

So I told him to come back to see the guy who packed it originally, since only he knows for sure how much gauze he packed the wound with.

Two Books Worth Buying

I don't read much hardcopy anymore, since there is so much interesting reading on the internet for free. But I recently purchased two books, and I would like to recommend them.

I found the first one, Cutting Remarks: Insights and Recollections of a Surgeon by Sidney Schwab MD through our interactions on the medical blogosphere. While the more famous House of God got bogged down towards the end such that I lost interest and never even finished it, Cutting Remarks kept me interested throughout, I read it in only two sittings, and I can't wait for the sequel. Dr. Schwab wields the written word as precisely as he dissects through delicate layers of tissue, and the end result is a successful operation indeed.

The second one, The Blog of War, is a collection of blog articles written by the greatest heroes of our generation, those American military volunteers on the front lines in Iraq and Afghanistan. From the back cover, because I can't say it any better: "There are powerful stories of soldiers in combat, touching reflections on helping local victims of terror and war, pulse-racing accounts of medevac units and hospitals, and heartbreaking accounts of spouses who must cope when a loved one has paid the ultimate price." This is a powerful book, and I highly recommend it.

BIPAP is a wonderful invention

I recently treated an elderly man who was visiting from out of town, brought by ambulance for shortness of breath. He'd had some indigestion-like pain the previous day, and now at 2 am he was gasping for breath, his entire body heaving, unable to speak, his eyes alone revealing the terror he must have felt.

He had no known cardiac history, but he was taking antihypertensives. He had not previously documented "end of life" issues nor spoken about them with his family, but those who were present asked that we not take extreme measures, specifically intubation. He looked like he desperately needed assistance with his ventilation, because he was dying right in front of us all, drowning in his pulmonary edema.

His blood pressure was 200+/100+, with a heart rate of 130, sinus tachycardia with some lateral ST depression on the ECG, questionable borderline inferior elevation. Oxygen saturation by pulse oximetry was 88% initially, improving to 100% on a nonrebreather mask.

At the very least, this was a hypertensive crisis, perhaps complicated by myocardial infarction. I gave him an aspirin, intravenous enalapril, lasix, morphine, and topical nitropaste, and called for BIPAP. Because he couldn't relax enough to close his mouth, we used a full face mask, with inspiratory pressure of 12 and expiratory pressure of 5. His blood pressure improved, and he seemed a little less labored, but he was still terrified, trying to pull off the mask. He was making minimal urine, so I repeated the lasix (80mg each). My Cardiology consultant had arrived by this time, and recommended intravenous heparin as well. His troponin I was positive at 2.4.

He continued to be extremely anxious despite another morphine injection. Finally, I gave him one mg of versed, which put him to sleep, although he maintained his respiratory drive (thank God). His blood gas showed a pH of 7.2, with combined acidosis. He was uroseptic as well, perhaps precipitating the entire event, so he also got IV antibiotics. Looking back on it, I might have given a glycoprotein IIb/IIIa inhibitor as well. Early administration of that class of drug in the ER can be helpful in acute coronary syndromes.

Amazingly, the next day he was only on a nasal cannula, and he was discharged from the hospital 5 days later, back to baseline. Another BIPAP save.

Chest Pain Equivalent

She was 40 years old, a working mother, a few years post hysterectomy for menorrhagia (heavy periods) but otherwise healthy. She didn't drink or smoke, and she had no family history of coronary artery disease. She took no medications, and although she didn't have a regular physician, she admitted that on a recent life insurance screening her cholesterol was reported as a bit high.

She'd had a stressful week at work as well as at home with the kids, who were just starting school. While driving home one afternoon her left shoulder began to ache, and the pain seemed to radiate down her left arm. Funny, she'd never had that before. Her arm started to go a bit numb as well, and she began to get a little anxious, maybe even short of breath. She didn't have any chest pain whatsoever. Her symptoms lasted about an hour, but then recurred later that evening, so she asked her husband to drive her to the ER.

Her blood pressure was 170/90, heart rate 80, respirations normal and unlabored. Her heart, lung, and abdominal examinations were normal, and her examination of the upper extremities did not reveal any reproducible pain on palpation or movement. There was no peripheral edema or calf tenderness, and her distal pulses were normal.

Her ECG was entirely normal, as were her chest X-ray and laboratory studies, including cardiac enzymes. She had no pain in the emergency department. It had been five hours since the symptoms began. I gave her an aspirin and some IV Lopressor, and called to get her admitted for observation and workup.

The physician on call for the hospital gave me a bit of unexpected resistance. "What do you mean, chest pain equivalent? Does she have chest pain or not?"

Well, I explained, these symptoms could absolutely be consistent with the new onset of resting angina, thus "unstable" by definition. The tests we have done so far are not sufficient to rule that out. Women in particular tend to have more atypical presentations of heart disease. This could be a warning sign of a heart attack about to happen.

"But she's only 40! And she has no risk factors. I just can't justify admitting her," the physician said abruptly.

The fact that she's only 40 worries me more than anything, I said. This is an employed mother of two with a 40+ year life expectancy. With the new tort reform laws in Texas, noneconomic damages in malpractice cases are limited to $250,000. This essentially means that only the most egregious cases or those involving large amounts of lost income are filed these days. Besides, she does have the risk factors of surgical menopause, reportedly high cholesterol, and untreated hypertension. Anyway, if it is her heart acting up then this is potentially life-threatening. She needs to be admitted. You can't justify NOT admitting her, in my book. If we have to admit a hundred patients like her to avoid missing one heart attack, then I think it is reasonable to do so. That is exactly why we have a chest pain observation unit.

He grudgingly agreed to admit the patient, and I moved on to the other patients in the ER.

Pralines

These should have been easy to make, but it took me three batches before I figured out the trick.

one cup dark brown sugar
one cup regular sugar
1/2 cup milk
1/2 teaspoon baking soda
2 tablespoons butter
1/2 teaspoon vanilla extract
1/2 cup nuts, if desired

Mix the sugar, milk, and baking soda in a large pot. Bring to a boil, then add the butter and vanilla extract. Continue stirring constantly over medium-high heat until the temperature reaches 240 degrees F (soft ball stage). You can see it start to thicken at this point, and if you drip a small amount into a glass of water, it will come together in a soft, gluey ball at the bottom. Remove from heat, and let cool for 5 minutes, stirring occasionally. Meanwhile place some wax paper on the counter, and sprinkle it with a little salt.

You can add nuts at this point if you wish. Stir well until the mixture is no longer shiny (this is the most important step!).

Spoon onto salted wax paper...it's going to harden pretty fast, so don't delay. The candy will cool and harden in only a couple of minutes. Remove from the wax paper, and place in an airtight container to store.

The Hospitalist Situation

I'm just wondering if anyone else has this problem or if it's just at our hospital.

We have a team of very capable hospitalists at my facility, to whom I am comfortable admitting practically any medical condition. The problem is that I only work nights, and every other subspecialist at my hospital is as thrilled as I am about our hospitalists' competent medical care. So by the time I come on in the evening, the hospitalist on no doc medicine call has already admitted a huge number of patients (many of whom already have established physicians), and they often ask me to admit any further patients to anybody else but them, or sometimes they just say they can't possibly admit another patient.

So I then must either:

1) call a Cardiologist to admit a soft chest pain rule-out or a Surgeon to admit a weak "partial small bowel obstruction" (otherwise known as gastroenteritis, but whatever works, right?) or a Neurologist to admit an elderly patient with altered mental status or......you get the idea. They will probably ask me to admit the patient to the hospitalist, of course, like all of their colleagues have been doing all day long, thus causing the problem we are now facing at 2 am.

OR

2) hold the patient in the ER until the morning hospitalist comes on call and abuse them with two or three admissions to start the day, thus propagating the problem.

OR

3) Use the ultimate ER weapon, that I tend to save for particularly difficult situations...."I am formally requesting you to consult on this patient. You are on call for this facility, and so you are required to personally come evaluate the patient within a reasonable time and make a disposition or accept the patient to your service. My next call, if I must make one, will be to the chief of your service."

The last choice is a tactic that I would prefer not to ever have to use because I understand the difficult situation each of these physicians are in, and I really don't want to antagonize our future working relationship by forcing the issue. In my opinion, if the specialists would use the hospitalists more sparingly and appropriately during the day, we wouldn't have to make all of these difficult decisions (and multiple phone calls) late at night.

Why should the hospitalist admit a patient at noon who already has an established specialist and who would probably benefit from the specialized care of an expert who is already familiar with them and who will be assuming their care after discharge? And then the specialist gets stuck admitting some patients who really would be better evaluated by a hospitalist?

It just doesn't make sense to me; maybe we just need more hospitalists. After further consideration, however, I think I know why it happens. The patients with established specialists are more likely to be insured, so of course the hospitalists are eager to take care of those patients. And if they "max out" with hits by midnight, and the poor Cardiologist, Surgeon, or Neurologist has to actually evaluate a nonpaying patient, then that is just how the cookie crumbles. When in doubt, follow the money.

Another problem is that we don't even have an unassigned Gastroenterology or Pulmonary Medicine call schedule (despite very active services by both specialties), so typically patients that could be admitted to those specialists are instead routinely admitted by our hospitalists. I'm not sure how those specialists get away with not taking unassigned call, but they do, so our hospitalists get slammed with all of the GI bleeds and asthmatics too. I can't use the last arrow in my quiver against a specialist who really isn't "on call" because his shield is impenetrable.