Poetic Justice: One of the constant tensions between specialists and generalists (pediatrics, internal medicine, and family medicine), is the battle of the admission. Many times, when a patient with a known problem that is followed and treated by a specialist, comes to the emergency room with an exacerbation of that problem, the specialist refuses to admit the patient. Instead, they request that the primary care doctor admit the patient and "they'd be happy to provide a consult." They do this because payments for consulting are higher than payments for admitting, and because consulting requires much less paperwork. It's very aggravating from the generalists' viewpoint. The specialist makes all the treatment decisions. The generalist is just left with meaninigless paperwork. And because most insurance companies won't pay two doctors to see the same patient the same day for the same diagnosis, they often don't get paid at all.

So, it was no suprise early this morning when the emergency room called about a man with a long history of coronary artery disease who had come in with chest pain. He was fine now, and everything looked OK on his testing, but he really needed to come in for observation and more testing to make sure his coronary artery disease wasn't getting worse. When I asked the emergency room physician if she had contacted his cardiologist, I could hear the exasperation in her voice. You know how they are. They won't admit. They only want to be consulted. I gave in and accepted the admission, more than a little exasperated myself.

But then, fifteen minutes later comes another call. The patient left against medical advice. He had a bankruptcy hearing to go to this morning that he couldn't miss. He said he'd just stop by his cardiologist's office after the hearing. Ha.

That made up for the 2AM call about insect bites. A mother had taken her child to her physician and to the emergency room about these bites and just couldn't understand why the child was still getting them.(I don't know. Maybe because there are still insects in the world?)