29 June 2007

Pissed off PCPs

It seems my last post pissed off the primary care docs, based on the comments left. Not really my intent, but hey, it won't be the first or last time I'll unintentionally piss off a whole class of practitioners.

Every ER doc has had to deal with the patients who come in with the "positive suitcase sign," meaning that their presentation is not only not an emergency but that they took the time to pack the suitcase before coming in (more than occasionally by ambulance). It's no fun to try to turn that into a satisfying patient experience when you are going to have to deny their initial expectation of hospital admission. Sometimes it's due to a 'patient issue," which is to say that either they just decided that they are not going home, or they willfully misinterpreted what another doctor told them. Nothing we'll ever do about that. But often, they come with the maddening statement "my doctor told me I was being admitted," when no such arrangements have been made. That's much more frustrating for all parties, and easily preventable.

Both the ER and the PCPs can play a role in mitigating this problem, I think. For the PCP's, I would ask the following:

  1. If you are sending a patient to the ER, please call us in advance and tell us what it is you want. We're all about customer service, we just have to know what it is you want us to do.
  2. Don't send a patient to the ER if they do not need to be seen in the ER. Seriously, if they are stable, make them a direct admission. It saves everybody time and money.
  3. Make sure the patient is clear on the expectation. Don't tell them they need to be admitted unless you are the decision-maker regarding the admission (in which case, see #2). If they are being sent for a work up, please make sure that is clear to the patient.
In our ED, we keep a phone log of every patient referral we receive, including the referring doc's expectations (i.e "just deal with it" vs "admit" vs "do X and call me back"). Every ER should do this. It works great, and even better, the phone log gets mated with and imported into the permanent medical record (Ibex/Picis). So if a referring doc wants a patient admitted, there's a record of that, too. All you have to do is pick up the phone and give us a call.

Somewhere out there, Flea is smiling.

27 June 2007

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.")

26 June 2007

Note to Nursing Home Staff

When your resident falls out of bed and breaks their hip, it is OK for you to pick them up and put them back in bed while you wait for an ambulance to arrive.

It is not, however, such a great idea to feed them a full meal while you are waiting for an ambulance.

The consequences of this are a seriously-pissed orthopedic surgeon and your resident's surgery being delayed by a day.

Thank you,

The ER Doctor

25 June 2007

That which does not kill me . . .

Only postpones the inevitable.

I spent a lot of time postponing the inevitable last night. It seemed like every patient was a severely demented octogenarian, non-verbal and non-ambulatory, either septic or with a lower extremity long-bone fracture. (Or, in some cases, both!) Blessedly, most came in with valid DNR papers, so I did not have to pursue heroic measures, but (as I have had to explain to several hospitalists) "Do Not Resuscitate" does not mean "Do Not Treat." So I went and tanked them up with fluids, cultured them from stem to stern, poured in gorilla-cillin and got the relevant consults, all the while shaking my head at the sheer futility of it all. It could have been worse -- the families were all either absent or present and realistic -- no frantic insistence upon unreasonable interventions. But it seems like even the most reasonable families still have a problem withholding antibiotics. They're down with the notion of "no life support" but "just let Granny die" seems too cold for them, especially when contrasted with the seemingly non-invasive IV fluids and antibiotics.

I was lucky, though, that admidst the wreckage there was one beautiful shiny satisfying "Emergency Medicine" case. As good as a Nursemaid's Elbow. Healthy, happy patient, grateful parents, ER doc looking like a hero.Yes, she swallowed a dime. No, she's going to be fine -- 99% of them pass within the week. If you like you can examine her stool, but realistically, you can do nothing at all as long as she has no symptoms. If you like you can follow up for a repeat x-ray at her pediatrician's office in a week, but even that is not necessary in the absence of symptoms.

That case put the smile on my face to get me through the rest of the shift.

22 June 2007

Advice for EM Interns (Part Four)

Moving the Meat -- Part Four

Yesterday, I tried to give some tips on efficiency in the ER using generalities and philosophic concepts. Sometimes it helps to be a little more concrete, both in terms of the chronology and the mechanics of the patient interaction. This is how I try to function, and how I advise our new hires:

BEFORE you see a new patient

  • Make mental rounds on your current service
  • Dispo any patient who is ready before picking up a new patient
  • Skim the chart rack and pre-order obviously needed studies on waiting patients; medicate patients in pain
  • Order rooms set-up in advance for laceration repair or pelvic exam
  • 30 seconds with the old records is worth 10 minutes with the patient
WHILE you see the patient
  • Keep your history “On Track”
  • Document in real time at the bedside
  • Determine the patient’s “agenda” and address it expressly (especially if narcotics are a point of contention)
  • Determine a treatment plan and disposition and TELL THEM before you leave the room
IMMEDIATELY AFTER you see the patient
  • Know your decision tree
  • Determine the rate-limiting step and make it priority #1 in the work-up
  • Order the bed for obvious admissions
  • Tell the nurse what you are going to do
  • Start therapy early – a medicated patient is a cooperative patient
  • Order all tests in parallel and not serial manner
  • Utilize Point of Care Testing when available
  • Utilize evidence-based standards for ordering tests
  • Minimize screening tests
  • Defer necessary but non-urgent work to another setting
  • Staged therapy – write orders for progressive medications based on defined criteria. Involve the nurses in the plan and encourage them to take initiative in managing the therapy.
  • Set triggers – in the orders set a trigger where someone will notify you when a decision point has been reached
  • Delegate: RNs may titrate meds; techs can irrigate, dress, and splint; Physician Assistants can suture.
  • Anticipate obstacles for discharge – road test the patient early, call NH or family to ensure the patient can go back, etc.
  • Minimize unnecessary consults or those without an action plan attached
  • Avoid the “I want to run this by you” conversation – know what you want the person to do before you pick up the phone, and begin the conversation with “The reason I am calling you is that I need you to do X…”
  • Don’t play ping-pong – know who you want to do the admit, and if they balk, ask them to call the other service to negotiate the admission.
  • Make sure the patient’s agenda has been addressed
  • Address the 3 Golden Needs: They feel better; They are reassured; They know the next step.
  • Discharge them yourself if possible (Nurses will love you!)
  • Redirect Office consults to direct admits when possible
  • Lower threshold to admit patients with expected prolonged work-ups or ED therapy
  • Admit earlier; write admit orders immediately to ensure the patient goes up immediately
  • Make a strong sales pitch to hospitalist, intensivist, and specialist colleagues: get the admitted patients to the floor ASAP
  • Look at the schedule and talk to the next-leaving doc to determine whether they need to stay late, or call in an extra body early
My $0.02. Again, this is not all original material (the bit about the 3 Golden Needs I vaguely recall from an ACEP lecture) so I cannot take full credit.

20 June 2007

Advice for EM Interns – Moving the Meat

Part Three

I am one of the more efficient docs in our group. Not the most efficient, but I do pretty well. Because of my leadership position within the group, I spend a lot of time thinking about operational processes and efficiency, and because of my reputation for being a “fast doc” I field a lot of queries from partners on how to do better. So I thought I would share some of my thoughts with you. The ability to move the meat effectively is really a win-win-win – you do better (both reputation and financially), the ED flows better, and the patients are happier and get more timely care.

Be motivated
It sounds stupid, but if you are not coming to your shift with energy and a strong motivation to clear out the rack, you are not going to. It’s not always easy to get yourself in this frame of mind every day, but the way I think of it is that we are paid more than 95% of all Americans to do this job, and it’s not supposed to be easy. You need to take a moment before you walk in the door to put on your game face and get yourself just a bit psyched up. Leave your home life at home. Most importantly, pay attention to your productivity – know what most docs at your facility do, know what you usually do. Set yourself a goal, and a stretch goal. Track your progress – within the shift, and over the longer time frame as well. If only via the Hawethorne Effect, this alone should increase your operational efficiency.

Be organized
“Never begin a shift with an empty stomach or a procedure with a full bladder.” So sayeth a wise elder partner. Try to bring a consistent approach to things. This is idiosyncratic, but find what works for you and do it every shift. Show up a few minutes early and spend some time assessing the state of the department before leaping into the fray. Make sure you have your favorite pen, or PDA, or whatever gadgets/accessories you find useful. I carry an index card with the name and sticker of every patient I have seen. This allows me to keep track of the patients’ progress, to-do items, location, etc. I do mental rounds with my list every twenty minutes or so. Whatever works for you. Pay attention to your work environment. Make sure your charting station meets your personal needs.

Focus with unwavering intensity upon achieving the disposition.
I joke, but it's not really a joke, that I am an unusual type of doctor, because I am not looking for a diagnosis; I'm looking for a disposition. Direct your workup towards the life threats and emergencies. The moment you know the patient cannot go home, start the process of bed assignment and transfer of care to the inpatient team, as these are usually the rate limiting steps. Avoid “the long goodbye.” Many times I have seen someone waste hours chasing their tail with multiple consults and tests when it was perfectly clear the patient needed to be admitted for a work-up. It’s a radical new concept in American medicine that the work-up does not end at the elevator. Note: this may take a little salesmanship. The admitting docs like things neatly packaged. See this post for advice on how to make the pitch to your consultants.

Initiate Treatment Early
A medicated patient is a happy patient. The sooner you get pain meds, anxiety meds, diuretics, etc, into the patient, the sooner they will feel ready to go home – and the higher your patient satisfaction scores will be! Every patient who comes in has some sort of agenda. You should be able to figure that out in the initial point of contact, and address it explicitly. Especially so if they are drug-seeking and you intend to decline to provide narcotics. Say so up front, get the fight out of the way, and you won’t find yourself hamstrung when it comes time for discharge. Stage your orders and let the nurses know what the plan is (i.e. Toradol and vistaril, if no relief of pain in 30 minutes, then dilaudid 2 mg IV q30 min till relief). That way the therapy can proceed on autopilot while you are doing something else, and you will have fewer interruptions.

Be selective in your testing strategy
When able, utilize point of care testing – istats and the like. Don’t order a full lab panel if the only data you care about will be in the istat. Don’t order ANY test unless a) it will be resulted while the patient is in the ED, and b) is required for the correct disposition. Defer urgent tests to the outpatient setting – that chronic pelvic pain patient doesn’t really need the ultrasound at 2AM. Enlist the PCPs, when available, as your allies in setting an outpatient work-up in motion. Be evidence-based in your ordering rationale. The toddler with a cough and fever doesn’t need that CXR if their oxygenation is 99% and the lungs are clear.

Your productivity is measured in patients per hour. This is impacted by your average length of stay and also by the number of patients you carry at a time. I think of it as water flowing through a pipe – the rate of flow and the diameter of the pipe determine the total volume capacity. Pay attention to the size of your pipeline and learn to carry one or two extra patients at a time. It can dramatically improve your personal throughput. When possible, try to intercalate all your complex patients with a couple of simple ones. It makes the shift more interesting and allows you to fill some idle time while waiting for the mega-work-ups to finish. And if allowed, cherry-pick like crazy the last hour of your shift. It can clear out the bottom of the chart rack and really put your productivity over the top wile helping you get out more or less on time.

Of course you should apply the usual caveats and disclaimers – not all of these prescriptions are applicable to all cases, all facilities, all practitioners. Look at your practice and see where the opportunities for improvement are. Use your judgment and pick the items from this list that make the most sense for you and your practice. Also, I should give credit where it is due: much of this as been cribbed from talks given at various seminars on ED operations. I don’t recall the lecturers’ names, and this is my own synthesis, but I cannot take credit in toto for the contents. More later.

Part One
Part Two

19 June 2007

EMTALA's Unfunded Mandate

A few months ago I posited that the unfunded mandate of EMTALA might be unconstitutional. I had my ass handed to me was corrected by those who know more about actual, you know, laws and things. There is, however, little disagreement that EMTALA's obligations are an unfunded mandate. This year, ACEP is advocating for a bill in Congress, the "Access to Emergency Medical Services Act of 2007." Its aims are modest but the potential benefit is significant. Essentially, this bill would do three things:

  • Create a bipartisan commission to study implementation of the recommendations of last years IOM report, "Emergency Care: At the Breaking Point."
  • Direct CMS to create hospital quality measures to end the practice of boarding admitted patients in the ED.
  • Create a 10% bonus payment to physicians delivering EMTALA-mandated care to Medicare beneficiaries.
It's important to note that the Medicare bonus would a) apply to physicians of ALL SPECIALTIES, not just ER docs, b) not be offset by any reduction in other Medicare reimbursement, and c) not cause any increase in premiums for Medicare beneficiaries. The bill (HR 882 and S 1003) is beginning to develop significant momentum. There are as of this writing 86 co-sponsors to the bill in the House, and 7 in the Senate. People smarter than me say that the critical mass for action on a bill such as this generally is over 100 co-sponsors in the House and about 20 in the Senate. So we are getting close. A complete listing of the bill's sponsors can be viewed here.

If your Senator or Representative is not listed as a sponsor, please give him or her a call; use the links for contact info. Ask to speak to their LD (Legislative Director) for health care policy. Let them know that as an ER doc (or whatever sort of unique perspective you may have), you are concerned about ER overcrowding, patient boarding, ambulance diversion, and the lack of availability of on-call specialists. Ask them to review the bill and consider signing on as a co-sponsor. Given the political environment in Washington just now (i.e. a narrow majority and the pre-presidential season), there is no likelihood of any more sweeping reform, but a limited, focused bill like this does have a chance.

Please let me know if you actually call, and what the response is. If the staffer you speak to expresses interest or has detailed questions, offer to have ACEP's political affairs office get in touch with them. Then let me know and I can put them in touch.


The reason is not kown to me, but there is a tradition in our ER that if all the patients are discharged and the ER is empty, then the doctor has to buy donuts for the entire staff. Given that our facility sees over 100,000 patients annually, you can guess how often that happens.

It's 4 AM, and I just ponied up for donuts.



Some of you may be unaware that the PVRP has been transformed into the PQRI, which starts up as of July 1. Acronym-phobic? OK, I'll elaborate. Last year, CMS -- the Center for Medicare Services -- was setting up the "PVRP," or "Physician Voluntary Reporting Program." This was essentially a pilot program of a data collection system for reporting of physician-specific quality measures.

Well, the 'voluntary' part of that didn't last very long. Now the program, as modified by the "Tax Relief and Health Care Act of 2006" is the Physician Quality Reporting Initative, or PQRI. Basically, when Congress froze the medicare cut last year, the price they exacted was to begin tying dollars to quality reporting for doctors. The amount is small -- this year it's 1.5% of your total medicare reimbursement, and is structured as a bonus on top of your regular Medicare reimbursement. It probably will amount to a few hundred dollars per doc. At this time, the bonus will be paid just for reporting the data, regardless of whether you did a good job meeting the "quality standards" or not. CMS is really just interested in testing their data collection system. As of 2008, CMS is required to have the system in place and larger dollar figures will be tied to the quality reporting (though it is likely this will be pushed back to 2010); more ominously, the reporting system will probably deduct dollars for measures not met, as opposed to the current bonus payment for reporting.

The measures which are tied to Emergency Medicine this year are:

  • Non-traumatic Chest Pain: EKG Performed
  • Acute MI: Aspirin given
  • Syncope: EKG Performed
  • Pneumonia: Vital Signs documented
  • Pneumonia: Oxygen Saturation documented
  • Pneumonia: Mental Status documented
  • Pneumonia: Antibiotics prescribed
  • Advanced Care Directive: plan documented
(Note -- ischemic stroke is no longer a measure for the ED!)

You might think that these are pretty easy quality measures to achieve. That's no accident. ACEP's Reimbursement and Coding committees have been involved in this process and the idea was that we should pick our own measures or somebody else would pick them for us. They deliberately set the bar very low. (Don't say ACEP never does anything for you!) In order to qualify for the bonus, you need to report 80% of the time on 3 measures of your choice. As long as you are aware of the requirement and document the data, your coders should be able to extract it and apply the relevant G-codes.

More information on PQRI can be found here on the CMS web site.

Truly, P4P is here and is not going away. They are too far advanced down this road to back off. This is, I think, only the first of many cost-containment measures thinly disguised as 'quality' measures. It is also an example of the most compelling arguments against a single-payor system: when there is only a single buyer of services, there will be persistent downwards pressure on prices.

Oh, brave new world!

18 June 2007

Professional Courtesy

I drive too fast. It’s a bad habit I have, and I am unapologetic about it. At least I could say that until recently, I had never bent sheet metal. (And that event occurred at less than ten miles per hour!) As a result, I have had many opportunities to discuss the various nuances of the traffic statues with law enforcement authorities by the roadside. One of the perks of my profession is that the police tend to take a lenient view of my infractions, especially if I was traveling to or from work. We work together a lot in the ER, and that does buy you some license (deserved or not). For example, we see a lot of patients brought in by the police for a “pre-incarceration medical screening exam,” or what the nurses call an “okey-dokey for the pokey.” And we make sure to give them special service – in and out, no waiting.

So I was pretty chapped not too long ago when I actually got a speeding ticket. I was tired and not paying attention after working a night shift, but I can’t complain – it was 76 in a 60. The conversation went like this:

“Hi, I’m Trooper Jones with the State Patrol. Do you know how fast you were going?”
“Well, sir, I’m not sure there’s a right answer to that question.”
(Taking in my scrubs and stethoscope around my neck) “Are you going to work?”
“No, sir, I’m on my way home. I was the overnight doctor in the ER at The Big Hospital.”
“Ah, I see. May I have your license and registration?”

And so on. I was annoyed, but busted fair and square.

But then, two days later, around midnight, who should come into The Big Hospital with an “OK to book” but Trooper Jones! I saw him and said hi; he didn’t recognize me at first. “Remember?” I prompted, “Saturday morning on the trestle, 76 in a 60?” His face went white. He remembered.

But I am a consummate professional, and also not a complete dickhead, so I was resolved to get the trooper back out on the street ASAP. Also, I wanted to get my revenge by being extra nice and service-oriented, to make the cop feel guilty for ticketing me. But I was busy with a couple of actually sick patients, so I ordered an x-ray on the prisoner and made a mental note to get back to them shortly. As it happened, my partner (we are double-covered overnight) signed up for the patient in the interim, so I figured I was off the hook. Oh well.

Three hours later, I walked past the room and noticed the trooper sitting there with a forlorn look.

“What on Earth are you still doing here?” I asked, stunned.
“I don’t know,” replied the trooper. “They came and took an x-ray and never came back.”

I went to my partner. “Bill, what are you doing with the trooper in room 8? He’s been waiting forever!”
“What trooper?” Says he. “There was one in room 7, hours ago, but they left.”
“No, Bill, they’re in 8, and still waiting!”
“Oh, shit!”

So Bill rectifies his error and gets them promptly discharged, belatedly. On his way out, the trooper approaches a nurse he knew socially: “Did I have to wait three hours because I gave that doctor a speeding ticket?” She explained what he really happened, and I am glad, because I would not have wanted him to think I was so petty and vindictive.

But I am glad he got to sit and think about it for a couple of hours…

06 June 2007

Ars Scribendi

I would be interested to hear whether any ED docs out there have used scribes in their practices.

Our group is always looking to improve efficiency, and there are a number of folks who are downright evangelical about using scribes. They certainly sound good, but I take that information with a grain of salt, coming as it does from the true believers.

So I would be interested to hear from a more unbiased (or at least disinterested) audience. Do you or have you used scribes in your ED practice? How do you use them? What sort of things do you have them doing? (other than just, you know, writing.) Where did you recruit them and what sort of training (if any) did you give them prior to starting? What were the common pay scales?

And of course, most importantly, how do you view the experience? Did it impact productivity in a positive way? How did the doctors like it? I think some of our docs are uneasy about the notion of having a "personal assistant;" others are downright salivating at the prospect.

We will be looking at the concept over the next couple of months. If you have experience, please have at it in the comments (or over email).


03 June 2007

Kids' Life

This morning I sent First-Born Son out to get the newspaper from the driveway, so I could read it with my morning coffee. (It's nice when they get to the age where they can do stuff for you.) Second-Born Son, of course, follows his brother out the front door, since he must do whatever big brother does. I notice that they do not come immediately back inside. Since we live (for the moment) on a street with relatively high traffic flow, I do not like to allow the 4- and 2-year olds to be outside unsupervised for very long. So after a couple of minutes I walk to the front door to check on them, and find the two of them walking carefully back and forth across the front lawn, staring intently at the grass, having completely forgotten about the newspaper.

"What are you doing?" I ask.
"Looking for bugs," comes the answer, as they continue to scrutinize the lawn.
"Oh, I see."

So I leave them to their task and get my own paper. Because even I have got to admit, the
search for bugs is way more important than the newspaper.

01 June 2007

Another one bites the dust (sigh)

TrenchDoc is gone. GruntDoc, as usual, has the lowdown. This brings the body count of prominent medbloggers in the last couple of months to, what, five? TrenchDoc, Flea, Barbados Butterfly, CharityDoc and Fat Doctor (thankfully resurrected). I might be missing one.

I started thinking about this issue a little while ago when I agreed to allow my real name to be used in a certain prominent publication. I knew beforehand that, as Flea recently learned, anonymity is a thin veneer in the blogosphere. Anyone with a bit of diligence and a good understanding of Google can figure out your real identity. So I was not too apprehensive about letting the cat out of the bag, since it was never really in the bag, was it? So I keep up the pretense of anonymity primarily to remain HIPAA compliant. As Scalpel noted, as long as you have no identifying patient info on the blog, you are probably OK. Well, that includes geographic area (smaller than a state), and putting my name on the blog would, I think, narrow the geography enough that individual patients (if not fictionalized) probably could be recognized.

But beyond that, there are far more powerful forces at play. All politics are local, no? Trenchy and Barb appear to have been canned due to local reactions to their blogs. It's not exactly a secret in my circle of professional friends that I am blogging, and I suspect that there are people at my institution reading this, who I never would expect to do so. So I try to write as if my identity were open, and so I would not be embarrassed if my mother and hospital CEO were to read the blog. In fact, my mother does read the blog. (Hi, mom!) While it's nice to feel like you can say anything you want under cover of anonymity, it's important to recognize that anonymity is an illusion, and you can and will be held accountable for anything you write, especially if you piss off the wrong person.

So, mindful of the example of our fallen blogger brethren, I decided it was time to come clean. After a brief discussion with counsel, I called up my hospital CEO and told him about the blog. (Hi, Larry!) I should note that I interact with him on a regular basis and have a good working relationship, so while I felt like I was taking a calculated risk, I had good reason to feel like I would get an open-minded reception. I followed up with this email:

I am writing you to let you know about something I have been doing as a hobby, not because I think you need to know, but because I feel that trust begets trust and I would like you to be aware, though you may have little to no interest in the matter. I have been maintaining a weblog, or “blog,” for a little over a year; this is a personal web site, which is sort of an online journal.

On my blog, which is irreverently titled “Movin’ Meat,” I reflect on life as an ER doctor, politics, national health policy, my personal life, current events and pop culture. I publish anonymously, and neither I nor the hospital nor any other identifying details are evident. Additionally, I am scrupulously compliant with HIPAA, and any clinical cases I describe are generally fictionalized either in whole or in part, and no protected patient information has or will ever appear on my site.

I started the blog on a bit of a lark, but have come to enjoy it. It is a pleasant creative outlet, and a useful forum for me to advocate on political topics which I have a passion for – universal healthcare being a major item. As it is a “journal” of sorts, I publish on good days and bad, and there are items which are irreverent or off-color or reflect frustration and cynicism. I do not really self-edit in this regard. Nevertheless, I am proud of the overall body of work thus far, and I feel that it reflects well on me, and, were the relationship known, would reflect well on the hospital.

At this time, I have no intention of removing the veil of anonymity. It would not, however, take too much detective work or inductive reasoning to make an educated guess to my identity or my practice site. I wanted to voluntarily disclose this activity to you so you were aware. There have been cases of bloggers who have run afoul of their employers, and I feel that prevention is the best medicine. I have attached the URL of the home page below, as well as links to a number of representative posts for your perusal.

I believe that this activity in no way conflicts with my role within the medical staff or the physician leadership for the hospital, or with the mission of the organization. If you have concerns in this regard, I would be happy to meet with you privately to discuss them in detail.
To my delight, the response was "I love it! Don't stop!" He did refer it to the hospital compliance office for review, but as I have been careful about HIPAA, I think I should be OK on that point. This is actually a great relief for me. I would hate to do anything which would unwittingly get me in trouble, or more importantly, jeopardize the relationship our group has with our most important customer -- the hospital. It is, of course, no protection against bad behavior. If I should pull an Imus, that support would evaporate right quick. But to a certain degree I feel like it provides me with a degree of inoculation against the sort of local blowback that bit Trenchy et al.

I particularly like the notion that 'trust begets trust,' that by voluntarily disclosing this activity to administration absent any negative feedback, I create the trust within the relationship such that, should there ever arise a question regarding the existence or content of this blog, the administration is already aware of it and has no objections in principle. And also, I defuse the "surprise" bomb; I have never met an executive who likes surprises, especially those that accompany complaints.

Medblogging is an interesting and unusual beast, and I think it's going to take a while before well-accepted standards of acceptable and ethical behavior develop. I suspect, sadly, that we will see a number of other blogs go down in similar fashion as things shake out. Conversely, the growth rate seems to far exceed the attrition rate, so I do not share GruntDoc's concern about being the last man standing. The way I see it develop is twofold. The "named docs" on their blogs will probably be more or less prohibited from ever discussing a real case, unless highly fictionalized or temporally distant from the incident case. The "nameless ones," on the other hand, will enjoy a bit more freedom but perhaps a higher risk profile, since I predict that the illusion of anonymity will continue to induce them to speak more frankly than may be healthy.

And Flea, Trenchy: you will be missed. Hope you can find a way to come back, but if you can't, well, thanks for sharing. I enjoyed reading your stuff.