Ethics
                                ======

þ Withdrawing care
 same ethically as witholding care (source:  Jim Adams, 1993 Emergency Care
 Ski Conference)

þ suggest that for emergency medicine, use the term "decision-making ability"
  instead of "competence" to avoid complications with legal competence.

This thread comes down to the basic question facing the health care system
today:

What is the value of a human life?

Some physicians are less conservative, and send home more "borderline"
patients.  They save the patients money, save the health care system money.
They earn the respect of their colleagues, the HMO's, and at teaching
institutions, the undying gratitude of the residents covering the inpatient
services.  Undoubtedly, in rare cases they send home a patient to die or
have major morbidity that was preventable.  They are looked at as "excellent
clinicians" provided that they don't send too many people home to die.

Other physicians are more conservative and admit more "borderline" patients.
Residents at teaching institutions dread when they are on.  They cost the
patients and the system money, and HMO's hate them.  Perhaps their
colleagues (in and out of EM) compare them to an "ED clerk" who
indiscriminately admits.  Undoubtedly their conservative nature allows them
to diagnose things that their less conservative colleagues might miss
(earning them great respect from those patients).  It also prevents them
from sending home some of those patients who might otherwise suffer
catastrophic results  - some of these will be patients that the less
conservative physicians would have sent home.  

Is the cost savings by the less conservative physician worth the life
savings lost? This is hard to answer, as society places irrational values on
different human lives - spending millions to rescue a child who falls down a
well, yet allowing other children to die of starvation for lack of $3/day
worth of food.

I cannot judge other physicians on their decision to be more or less
conservative - I can see both sides.  To my mind, however, I cannot practice
in a less conservative way because:

1) My conscience has spoken -  I feel bad when people I cared for die,
especially if it was something I might have prevented
2) Society has spoken - "Save money on everyone else, but for me I want
everything!"
3) The law has spoken - saving money is never a defensible reason to avoid
doing something that might be beneficial for a patient.
4) My non-EM colleagues have spoken - though they all are happy when I send
home a patient, they are also quick on the draw to criticize any bad outcome
that occurs.  Hence, the oft heard phrase, "You'll never guess what those ER
docs did..."

I count the number of lives I have saved that others might not have, and I
feel that outweighs not having my non-EM colleagues think I'm a "cool" guy
who saves money and doesn't make them work too hard.  If they are working
hard because I have admitted a lot of patients, I reciprocate by not
complaining when they send me a lot of patients to treat.  I note to those
that say "even the ED clerk can admit all the chest pains" that even the ED
clerk can send all the patients who don't look too sick home.  It is the NOT
obviously sick patient that stresses the ED physician's brains.

I try instead to save money by:  following the Ottawa ankle rules, avoiding
wasted knee x-rays with the rules found in a recent Annals of EM, choosing
inexpensive antibiotics over the "big guns", not x-raying every low back
strain, not ordering Chem-7's and CBC's on young healthy patients with a day
or two of gastroenteritis, getting just a chest x-ray rather than rib films
on young patients with rib fractures, not IVP-ing every young healthy kidney
stone patient, dipping urine as a screening test rather than microscopy on
every urine sample, etc. etc.

There are plenty of ways to save money that don't put a patient's life on
the line.

One final point:
How would your non-EM colleagues react if you:
1) Called them up, or called up their directors to complain that they
inappropriately sent a patient to the ED for an evaluation because they were
worried about the patient.
2) Called them up to complain that they were wasting health care dollars by
ordering expensive tests and expensive treatments on patients that later
came to see you.
3) Called them up and filed a complaint because they ordered inappropriate
tests on a patient that later came to see you in the ED.

We should not accept this garbage from our colleagues when they clearly
would not accept it from us.  The fact that this discussion even exists, and
that so many can "see the point" of the cardiologist suggests that many of
us as emergency physicians still do not have enough self worth to be
outraged at this kind of second-guessing judgemental behavior.  If they will
let me refuse to see their patients, then I will let them refuse to admit mine.

I won't comment on this thread further unless it takes a different turn,
because I think the issues are clear, but the answers are not - what is left
is just opinion, and I have stated mine.

Jon
Jonathan A. Handler, MD
jah505@nwu.edu