Monday, March 19, 2007

Redirection is what’s required

Sometimes we shoot ourselves in the feet in internal medicine by overly glorifying the blocking of ER admissions. Granted, it takes a strong resident to convince an ER attending that the patient actually doesn’t need admission to the medicine service but in fact would be better served either on another service or back in his or her own bed. The feat therefore confers some distinction on the resident who accomplishes it. The euphoria of pulling it off, in fact, can be quite intoxicating; besides marking your growing strength as a resident, it means you’ll have one less patient to admit and comforts you that occasionally justice and reason can prevail even in the ER. It’s easy to proudly notch the block on your belt and think about how you’ll tell the story to your medicine buddies in the morning. The problem, though, is that going into each admission evaluation wanting to block anything possible does a poor job of addressing patient needs and creates a hostile atmosphere in the emergency room.

The ER attending, after all, can sniff a block attempt from miles away. We complain that they can’t be talked to—that they won’t listen—but it’s hard to blame them entirely when we are the ones that have conditioned them to be that way. Sometimes you can almost see them bristle as you approach them, and that’s because they know your intentions exactly. Just as a Washingtonian knows when approached on a walk by a street person that the request will be for money, so too does an ER attending know when approached by a medicine resident that a block is desired. Maybe the admission was legit, or maybe it was soft—a “review of systems” admission (based upon an incidental finding on the history and physical questionnaire) rather than a “chief complaint” admission. In any case, the attending’s better judgment is being questioned, and a notch on your belt is one against him or her. In all fairness, a bit of resistance should be expected.

I’m not sure all the tension is necessary, though. There don’t have to be notches at all, and there doesn’t have to be a medicine versus ER mentality. Just thinking of ourselves all as members of the same patient care team opens the door for communication and the sharing of our respective expertise. That’s why I don’t celebrate blocks or high five my intern in front of the ER attending when a patient planned for admission gets dispo’ed home. In fact, the block is a maneuver I’d like to wipe out of both my playbook and vocabulary. I’m the last one to wish for unnecessary hospitalizations, but sometimes redirection, rather than obstruction, is what’s required.