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.")


  1. It is tremdously upsetting to have to make large payments of money to people in a system that you don't understand, particularly when it appears that someone you reasonably trusted messed up.

    I would be inclined to ask my primary care physician what happened and ask if he took a short cut as the letter implies. But then I'd have to pay the large bill. (I assume it is large.)

    Maybe I'm dumber now than I used to be, but it seems like a familiar phenomena to be just going along doing things as you believe you are supposed to be doing them, only to be charged an outrageous fee. I think this is the only way banks and credit cards make money, for instance.

    "Oh, you leased this car? Well that's totally different . . ."

    "We deported your husband and you still weren't able to get him to court?"


  2. Ah, so true. And this patient at least NEEDED admission. How many have you seen who's history starts with some variation of "Dr. Smith is supposed to meet me here and admit me?" And then, once all is said and done, and you can't contact Dr. Smith, the patient doesn't meet any admission criteria that you can see...

    How 'bout a little help out there, outpatient docs? A phone call. A report to the on-call doc that you sent someone to the ED for such and such. Something.

  3. What's worse is when the pt's PCP DID send the patient in, and tells them "Just go to the ER, they'll send you right upstairs to a bed" but doesn't bother to talk to admitting to in fact ascertain whether there is an appropriate bed for the patient in the hospital. Then the patient has to deal with being in the ED for hours (and even days) until a space upstairs can be found for them. It's awful for the patient, because the ER is an unfun place to be, and it's worse for the RNs and MDs in the ER--they have to deal with the (justified) wrath of the patient and family when they hit hour 12 in the ER without an end in sight.

  4. If I had a dime for every patient that told me that I could retire. I usually tell them "Well I'll call your doctor and check, but what they usually mean is 'go to the ER and they'll do all my work for me.'"

  5. Has every ER doctor lost their mind???

    The ER doesn't just subsist on trauma and fractures and acute MI's, as much as the ER docs would like that.

    If a primary is seeing 20 to 30 patients in the office and dealing with all their paperwork, and then gets a call from a patient saying they feel sick as hell, and you can't see them urgently, what should he do? And if he has no time or doesn't even know whcih ER they are going to, how can he contact them?

    And on those occasions I HAVE called the ER, the signout never gets transmitted. So I wasted my breath.

    I'll say it again: for every bad story you can name for a PCP, I've got an EXACT opposite nightmare ER doc story. Difference is... I don't write them. Because I know that the system is a little screwy, but it's working to a fair degree. I don't like fighting with other specialties, since we're all at the same disadvantage.

    But go ahead, keep ripping PCP's, who provide the few patients with insurance to the ER. Or do you just like all the crack addicts and alcoholics and homeless patients with no insurance. Isn't that why ER's are going broke? Indigent care?

  6. There is truth in the last comment above. I occassionally refer a patient I am seeing to the ER for an evaluation, usually for a acute abdomen or something requiring urgent radiology. In my local hospitals, direct admits dont get radiology until the next day, because there are "emergencies" to be handled first.

    No, my name is not Smith, it is significantly less common, but there are three of us at the local hospital. So when I call, inform the ER charge nurse and ER doc that I am sending a patient, subsequently receive a call from another ER doc who knows nothing about the previous call I made, and give admitting orders in my deep, male husky voice to yet another nurse who is unfamiliar with my previous call, only to find later that the patient was admitted to "Lucy Smith, MD" rather than "Michael Smith,MD," I wonder why I bother to call at all.

  7. the disconnect between primary care and ED, though not new, keeps widening...when the doctors should bond together, friction in interactions just get rougher

    are the ER nurses , triagers, mid-levels , administration getting the divide wider...so they can rule the roost better?

    ER nurses rip the docs...who does the ER doc rip in return? the 'invisible' primary doc who can't defend him/herself is an easy target, always!

    what a mess!

  8. My hospital must be different but it is a small rural hospital. I have had several emergency room visits over the last couple of years for lower right pelvic pain. Two in 2006. Then 2 in 2007. Both times they called my obgyn at home and consulted with him. I evntually had a lap and was found to have adhesions which my dr took down. This time for 2007, occurred in the same week. I called my obgyn's office and the nurse told me to watch it for a month and see how it goes. I had had excruciating pain the whole weekend and tried to AVOID the Er. So at 2pm, I called my pcp and she agreed to see me. I was crying it hurt so bad and she sent me to the ER for eval of appendicitis. Appendicitis was negative but they thought I had a ruptured ovarian cyst. I didn't want to go but she said the ER was the only place that could run the cbc and cat scan asap. She did call ahead and talk to the chief of EM for me and they WERE expecting me when I came in and I was taken straight back. I still had awful pain all week. Had a few additonal symptoms that showed up on a Friday night that was of the come back to the ER if you have this. I did. My obgyn was out of town. They ended up running all the tests. They really thought they had missed appendicitis the first time. Same diagnosis. Ruptured cyst with adhesions that have developed as a result. I am currently scheduled for a lap on 7/3. The times that my drs have sent me for evaluation (OBGYN - eval for endometritis after I had my daughter on a 4th of July weekend two years ago) and appendicitis this year. They have called and said I was on the way. Then the ER drs coordinated care with them. When I had endometritis, they called my obgyn at home and started me on iv antibiotics and fluids. The said if I had waited till the following Tuesday to come in (I was there on a sunday morning) I would have had to be admitted.

    It must be terribly upsetting that the drs don't work together. It seems where I am at that they do.

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