I once played a game in which there was this boss called the Gatekeeper who was extremely hard to defeat. Nobody could get past him, but if you got a group together, you could sneak someone by. (You would think there was a paradise beyond that bridge, but unfortunately, it was a dead end. Why we were so fixated on beating him I never figured out).
In any case, the emergency department often acts as a gatekeeper to the hospital. Most patients pass through the ED to become inpatients. Thus, ED physicians have a huge responsibility and burden to triage patients correctly. With defensive medicine, increasing complexity of problems, overwhelming patient burden, and decreased time, ED physicians are starting to get conservative on who they admit. I've found on the medicine wards that we often get "soft" admits: patients who we don't think need to be in the hospital. They stay for a day, we get a few tests, and we send them out the next day.
This is a quandry. On the one hand, hospitalized patients are the most expensive patients, and inappropriate admissions cost the system a great deal of money. We have a shortage of hospitals and hospital beds, and even physicians are becoming an increasingly rare commodity. Filling hospital beds with healthy patients takes away from those who need our attention the most. Even "easy" and straightforward patients come with a mountain of paperwork (oh, discharge summaries) and pages.
On the other hand, I completely sympathize with the emergency department. They are overflowing with patients and they must make snap judgments without being able to go through all the past medical records. The medico-legal climate does favor conservative decisions such as admitting to the hospital even just for observation. It is not easy being an emergency medicine doctor.
I have no good solutions. But I feel that if we do not nudge the pendulum the other way, we will be spending resources on patients who do not need them. The emergency department is the gatekeeper to the hospital, and they have that extraordinarily difficult job of wading through the patients flooding the gates and determining who needs that precious hospital bed.
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In ancient Greece, the asclepion was a healing temple dedicated to Asclepius, the God of Medicine. Asclepius learned the art of surgery from the centaur Chiron and had the ability to raise the dead. The Rod of Asclepius is a roughhewn branch entwined with a single serpent.
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Hi! I am Craig Chen, a third year resident physician in anesthesiology at Stanford Hospitals and Clinics. I went to medical school at the University of California, San Francisco. Prior to medical school, I studied philosophy and biology at Stanford University, along with a minor in creative writing.
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