Not news – dermatology is hot!

Concerning radiology controlling your hours:

There may be some practices where this is true. For most of us, however, it is 24/7. Fortunately, I agree, in some places, certainly, not all and certainly not the “hot” spots, the reimbursement may be sufficient to help with staffing, but there is a significant shortage of quality radiologists, and if you are out here in middle America, it’s like pulling a good tooth to get somebody to look at your job, let alone take it.
I, in no way want to take away from you or many of the other hard working and dedicated internists and family practitioners out there, but one of the reasons our jobs have become next to near intolerable, is the fact that very few physicians, actually see patients when they are on call. That is what our ERs are for. Many doctors’ practices now do not even offer an out of hours service for their patients. If a sick or usually not so sick patient calls after hours, they are referred by the doctors’ answering machines directly to the ER. The ER then contacts the doc, usually after they have seen the patient, ordered labs, and usually a CT before or even if the private doc gets called. Our practice does more CT’s after 4 PM and before 7 AM than we do during the day, and this is at two busy hospitals.
I think this behavior relates to the issue you discuss about people wanting to control their hours. The result is a tremendous expense of unneeded studies. My biggest concern , right now, is the rising diagnostic medical radiation dose. Our new CT scanners, which certainly capable of tremendous feats, CT angio, and the like, are certainly not low dose. We have absolutely no ability anymore to screen who gets done and who doesn’t get done, and if an ER physician orders it, it gets done. This is how we end up with every young woman which a chest complaint coming to the ER who is or who has been on hormones or an oral contraceptive in the past, nots a CT chest to rule out PE at tremendous dose. Blood gases are never drawn, D-dimers are not drawn, etc. We have had women have as many as 6 of these negative studies in as little as 4 weeks, because they keep presenting to the ER at off hours, and these are patients with regular doctors who cannot figure out what’s wrong with them.
Unfortunately, this behavior is spreading outside our GPs to our surgeons, who will never even consider, seeing a patient in the ER until a CT of the belly has been done and reported especially given the number of negative abdomens that get done.
I apologize for griping, but the situation is becoming a real problem, and I agree this all has to do with lifestyle control.
My private doctor is one of the few people I know, who insists, that you do not go to the ER unless you are dying or dead, and are instructed by them to call them first, so they at least can meet you there if there is a problem.
I can tell you, first hand, when I am there at 3 AM, it is usually just me and the ER doc there with the patient, the referring physicians, or Private MD’s are not.

Dave, I’m not sure what you mean when you say few physicians see patients on call. Are we supposed to keep our offices open to schedule patients and walk-ins 24/7? This certainly wouldn’t be practical or feasible from a monetary standpoint. My last group was big enough to have a 24 hr nurse line to field live calls but that’s expensive. And it’s not realistic to have the doc field all calls or you’re going to be up all night telling mom what dose of tylenol to give little Billy. Hence most of them just resort to an answering machine that tells people to go to the ER.

Every practice I know of has a doc on call after hours and admits that practice’s patients when they need it. In our hospital most of them are up in the wards and ICUs , that’s probably why you don’t see them in the ER.

Regarding the radiology call however, I know where you’re coming from. I have a friend in radiology and he’s up all night on call reading head and abd CTs (he does it from home though). I think a lot of the CT scans done in the ER at night are the result of defensive medicine and patient expectations. All it takes is one case where you miss a PE and someone dies and you’ll be ordering a lot more in the future (I agree they should have a blood workup first in most cases). Parents can be pushy for head CTs for every little bonk, despite a normal exam. People on drugs or alcohol, or elderly patients with dementia fall down at all hours of the night – no reliable neuro exam so it’s off to the scanner. Most surgeons I refer to want a CT for an appy before they cut. Once technology like this exists it’s hard not to use it and I don’t think FPs or internists trying to cut their hours back is going to change that. I know derm sounds pretty good at 2AM when I’m admitting that same guy with alcoholic pancreatitis again.

Teleradiology, unfortunately is a necessity. It is the only way one person can cover two hospitals at the same time. Sometime I do this as much as possible from my home, where I grant you I’m not sitting in the comfort of my home, but at a special office built in my basement to handle this. We are in the house for every trauma, and we still have to cover the other hospital, while this is going on. Teleradiology is the only way we can do this as there are not enough people to cover both hospitals separately. We are in the house when the numbers of cases and the severity of the patients requires extremely rapid interpretation.
No, I don’t feel bad sitting at home monitoring these cases, with the phone ringing every 5 to 10 minutes to read Cts for every headache, incidental head bump, chest pain, and chronic abdominal pain, or for the cancer patients who just had a study 2 weeks ago, but their internist just has to know if their metastatic disease has progressed at 3 AM. I am there however, for the real stuff and quite frankly I don’t mind being there for that stuff, because you can really make a difference for a very sick patient. It’s the ever increasing background noise that is making it very difficult for both us and the ER docs to take care of the very sick as efficiently as we’d like.