You May Not See a Doctor in the ER

I read about a patient who received a $20 million malpractice award from a Massachusetts hospital after a patient lost his leg when a blood clot was misdiagnosed as sciatica. The construction worker had gone to the hospital emergency department complaining of left leg pain. He was seen by two nurses who documented that his foot was turning purple and was cool to the touch. He was then examined by a physician assistant (PA) who didn't read the chart and diagnosed sciatica and sent him home. Six days later he returned to the ED with 9/10 pain and was again seen by two nurses and a nurse practitioner. He was again sent home. Four days later he saw his Primary Care Doctor who ordered an immediate ultrasound and diagnosed a deep vein and arterial thrombosis. A CT scan revealed his leg was necrotic and it was amputated above the knee.

This horrifying story is really outstanding because he went to the ED but never saw a doctor. Unfortunately this scenario is not uncommon. Most people expect (after waiting for hours) that they will be evaluated for their emergency by a physician. What is happening?

One explanation is that emergency groups are being acquired by private equity (PE) companies. PE companies pool money from wealthy investors and slash expenses and attempt to flip a company profits within 3 years. They are the darlings of Wall Street. Nearly $1 trillion in private equity funds have gone into almost 8,000 health care transactions over the past decade. The only reason a PE company would purchase a practice group is because they think they can cut costs and rake in money. And that's exactly what they do. If the company employs fewer doctors they can save money and increase profits. This staffing change has permeated hospitals across the country and they are reducing their top expense; labor, to make more money. The shift of staffing away from highly trained MDs to nurse midlevels is happening in emergency departments, ICUs, and surgi-centers.

A paper published in October by the National Bureau of Economic Research, analyzed roughly 1.1 million visits to 44 ERs throughout the Veterans Health Administration, where nurse practitioners can treat patients without oversight from doctors. Nurse practitioners and physician assistants are among the fastest growing occupation in the nation. With limited training they are staffing Emergency Departments with little or no physician oversight.

This trend may be one reason why physicians are leaving the specialty of Emergency Medicine.The bigger issue is that the public is not aware that they may never see a doctor in the ED. Major trauma, collapsed lungs, ischemic limbs, pregnant women with preeclampsia, strokes and myocardial infarctions are serious business and are seen daily in EDs. These conditions require skill and training. I am dismayed at what is happening in the name of higher profit.