09 August 2008

Direct Admit?

Dear Mr Jones,

I writing you in response to your letter of the tenth. I understand that you do not feel that you should have to pay the ER doctor's bill for the treatment you received in the ER, since you were sent over to the ER from your doctor's office for a "direct admission."

However, it appears that there is some confusion over this point. If your doctor wanted you to be a "direct admission," he (or she) would have sent you to the hospital admitting office with orders to have you admitted under his or her own name, or under the care of the on-duty hospitalist. He did not, but rather sent you to the ER.

It is possible that he sent you to the ER because the on-duty hospitalist refused to accept you as a direct admission, feeling that you needed urgent assessment and stabilization treatment in the ER. Is is equally possible that your doctor sent you to the ER because it was the easiest way for him to get you off his back and pass the buck to another doctor. It is possible that he simply forgot how to arrange a "direct admission" because "just go to the ER" is a million times more common these days. We will never know because a review of the ER phone log reveals that he did not call with any instructions for the ER doctors regarding the expectations for your ER visit. Since you arrived to the ER after the close of office hours, your doctor was not available by phone to verify the plan, and the on-call clinic doctor did not know who you were.

A review of the ER record shows that you did receive a full history and physical exam, and that the ER doctor who saw you performed and interpreted multiple diagnostic tests, reviewed your medical records, treated you with intravenous medications, and consulted with specialists before making the independent decision to admit you to the hospital. We feel that the ER doctor's investment of time and effort (and risk) into your care justifies the charges applied to your account.

I know it does not feel like the ER doctor "did" anything because most of the work took place out of your sight, and because you had already told him that you were there to be admitted. However, most patients sent to the ER under similar circumstances in fact are sent home, either because they turn out to not have a medical problem requiring admission, or because their illness can be diagnosed in the ER and treated as an outpatient. So, in fact, the ER doctor did provide a valuable addition to your care.

We apologize for any annoyance or irritation you have suffered, and hope this writing finds you in good health. Please remit payment at your earliest convenience.


Shadowfax, MD

cc: Primary Care MD

(Addendum: In fairness, I often do reach the PCP by phone who informs me that he did not send the patient to the ER to be admitted, but to be assessed. Somehow patients reliably misinterpret being sent to the hospital as implicitly meaning 'for admission.")


  1. great letter.

    i think the best part is
    I know it does not feel like the ER doctor "did" anything because most of the work took place out of your sight

    outside of surgeons and procedure heavy specialties, i think most docs can understand this. there's plenty we do for patients that aren't seen by them.

  2. Excellent letter!!!

    How about this one...

    Dear Dr. Feelgood

    With regard to your patient, Mr Jones, whom was sent from your pain management clinic to our Emergency for breakthrough pain control of his chronic fibromyalgia. As we could not contact you after hours, we wish to inform you that the patient was displeased with our care. We were uncomfortable giving the requested 375 mg of Demerol in a single dose, and an additional 100 mg if the initial dose was unsuccessful, as the patient was already on a Fentanyl patch and Oxycontin. Mr Jones became agitated when informed him of the addiction potential of these drugs, and indicated that only you understand his pain. Further, the expletives he used when informed of the potentially fatal interactions of his mediations was inappropriate, as my mother was not a member of that species.
    In light of this, please find enclosed an application for hospital privileges and outpatient privileges so that our hospital can meet the needs of your patients. We look forward to having you on our call schedule.

    ER Doc with 30 in the waiting room

    (To be fair, many pain specialists have pain contracts with their patients. But few have hospital privileges...)

  3. Did the patient present with a positive Samsonite Sign?

  4. Anon-
    You have a documented case of a man with "fibromybodyachesineedopiates?"

  5. Perhaps this should be automatically generated paperwork for those sent to the hospital by their doctor. Including those sent by ambulance with explicit, well meaning, and misguided orders that we just transport the unstable patient.

  6. Hey there, Dr. ER, it rolls both ways...

    I never, repeat NEVER, send a patient to the ER without a minimum call to the triage nurse.

    The last patient I sent via medics, with copies of my office notes, medication list, and the patient's problem list. I called the ER doc to explain my concerns, as no one could have surmised them without such a call. Part of the problem is that with 6 hour waits in the ER, not only is my office closed when the patient is assessed, the ER doc I talked to is sipping margaritas.

    The patient was indeed admitted. Clearly, no one had seen any of my notes. All her meds were wrong. My primary concern remained unaddressed. She even had a family member with her that seemed to get what was going on.

    I don't know where the ball was dropped, but don't always assume it was the PCP. We're tryin', man, really tryin'.

    (I will accept criticism that if I admitted to the hospital, the care would have been more seamless. Alas, I can't be everywhere.

  7. Anonymous PCP,

    I'm not frustrated with all primary care physicians, but venting about those who do make our lives, and our patients' lives, more difficult. There are some who are great, but some do not understand and don't seem to make an effort to understand what is best for the patient.

  8. "outside of surgeons and procedure heavy specialties, i think most docs can understand this. there's plenty we do for patients that aren't seen by them."

    Perhaps you should spend some time explaining that to them?


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