I'm Not A Doctor; I Just Play One In An ER
I recently got quite ill when I was out of town and had to go to an ER for treatment. Instead of a doctor, I was treated by a physician assistant, who, as it turned out, misdiagnosed me and sent me back to my hotel sicker than before. The next day, I went to a teaching hospital where I was properly treated by doctors. Meanwhile, I just received a bill for the PA's 'exam,' for $519, and a mind-blowing defense from his office explaining that if is diagnosis was incorrect, there 'could have been a problem with the communication.'
I had an infection in my lymph nodes in my neck which caused unbearable pain on the right side of my face and swelling, leaving me unable to open my mouth or swallow. The PA ordered CATscans that cost thousands of dollars and then sent me home and told me to take some sudafed.
I asked the PA (who is part of the Berkeley Emergency Medical Group) for some antibiotics. But he refused. The sudafed increased the pain and the swelling. At the teaching hospital the next day -UCSF--they properly diagnosed me and gave me antibiotics which knocked the infection out in a manner of days.
My own doctor told me that PA's are the wave of the future. Emergency rooms, where the most expensive care is provided--and often the most necessary, since there are often people there who have no other recourse to health care, many of whom actually do have communications problems due to language barriers, education barriers, etc., will increasingly be at the mercy of people who are not doctors but who have been rehearsed by doctors to answer questions and guess at diagnosis.
Health care reform can't come quickly enough!!
P.S. After reading some of the comments, I want to make clear-I am not disparaging PAs as a group or profession. By no means. Of course there are bad doctors (and I, like others, have been treated by them), as there are good and bad PAs--my point was about the system, not about the person. The fact is that ER's are cutting down on expenses by employing PAs instead of doctors, but the costs are still being passed to the consumers and clearly-with a whopping $519 bill for service-that cost is way-inflated. And-I do think that there is a cause for concern-as I found in my case--when there isn't adequate care available to deal with what was actually a simple diagnosis that was misdiagnosed. The reason for a scarcity of doctors in that ER was cost-savings, for the hospital.
My worry is that "healthcare reform" will result in better care for people with insurance and the same old result for those without it, or with some minimal access that doesn't amount to much. The impression that there was new access, not a reality.
March 12, 2009 10:20 AM | Reply | Permalink
Oh yeah, we're all looking forward to rationing.
March 12, 2009 10:44 AM | Reply | Permalink
We already have rationing. If you can't afford it, you can't get it.
March 12, 2009 1:26 PM | Reply | Permalink
shooter,
again you fail to see reality; as the man said; "we already have rationing."
March 12, 2009 4:00 PM | Reply | Permalink
my dad has been a PA for over 20 years, working in clinics and emergency rooms, and I can tell you that he's far more than a person "rehearsed by doctors to answer questions and guess at diagnosis."
Sorry you had a bad experience with an unqualified PA, but don't you think it's a bit unfair to condemn the whole class for the fault of one idiot? I imagine there are plenty of doctors out there who make dumb calls, too.
March 12, 2009 10:46 AM | Reply | Permalink
I can only second Koopa's comment. First of all, you could just as easily have had a bad doctor treat you, or an inexperienced intern (happens in ER!). PAs are usually highly trained, and RNs to boot. However, they should always have access to an MD if they are uncertain of a diagnosis. And if you are uncertain, ask to see another doctor!
March 12, 2009 10:51 AM | Reply | Permalink
So ---
What was the PA's diagnosis? And did you ever undergo the CAT scans?
Many, if not most of these emergency services in ERs are run by contracted doctors who treat the business as ancillary to their primary care practices which are often miles and miles and miles away from the hospital ER. Your complaints should probably be directed to the primary contracting facility -- the hospital -- as well as to the contracted doctors.
March 12, 2009 10:52 AM | Reply | Permalink
This is true. I believe that all of the hospitals here in O'town use this approach. Not sure exactly what the motivation is, but I would bet that one reason is to defer some of the malpractice problems that might come their way.
Just a guess.
C
March 12, 2009 11:03 AM | Reply | Permalink
I have been treated by Dr.s , PAs and RNPs and it's the experience and training that matters more than the letters after the name.
In fact there is an old RNP who works through my Dr.s office who has a better batting average than most Dr.s I have seen.
C
March 12, 2009 10:52 AM | Reply | Permalink
This must have been a nightmare. But you figured it out. There are some who would remain at home much longer thinking that they did not need another opinion.
Doctor or nurse or assistant, we must take responsibility for ourselves no matter what health care system we find ourselves in. Ask questions. Look up some things on the net.
At least your story has a happy ending.
Oh and if you are looking for a place that wants health care change, you found it here.
March 12, 2009 12:00 PM | Reply | Permalink
Having spent an immeasurable amount of time in NYC hospitals (because of my grandmother's stroke, and mother's battle with cancer, which she ultimately lost in november...) I can completely sympathize.
Sorry to offend those of you who are, or know someone in the medical field, but as far as I'm concerned at least the system in new york needs to be destroyed, and rebuilt from the ground up.
I've seen it all... laziness in the nursing staff "they expect us to work for what they pay us?" (as if they'd do a better job if you paid them 3 times as much). Stupid interns "how can you tell she has a fever?" (I asked her to feel the forehead...). Useless PAs "I'm just waiting until the doctor comes back", and craptastic doctors "there's no point in treating you, you're going to die you know. But we all die, I'm going to die". "get her out of here, it's a hospital not a hotel". "I'm going on vacation for 3 weeks, but I don't foresee a problem." "it's all downhill from here". Not to mention auxilary staff "I've got a car waiting here, where are we taking her, place A or Place B?" (we had a deal to postpone that transfer and they still forced it).
The number of people that were intelligent, hardworking and helpful could be counted on the fingers of one hand. I don't know if that's because so many people went into medicine for the money, or because there was no other job, or what, but if you ask me if you have no desire to help people you should be automatically disqualified.
And if they expect us to pay huge sums of money for this "care", I say bring on universal healthcare.
March 12, 2009 1:54 PM | Reply | Permalink
That's what makes me laugh when people claim that government provided health care will be inferior to private health care - it's only when people suffer a major health crisis that they become aware of how broken the system is - it's a nightmare of costs, waiting times, tests that may or may not be reimbursed, high drug costs, surgical fees, surgery room fees, hospital fees, equipment fees, lab tests fees, physicians fees and on and on and on...
March 12, 2009 3:24 PM | Reply | Permalink
Hi Joanne. In 1994 my father walked into an academic medical center and was told by an attending level gastroenterologist that there was nothing wrong with him, without ordering a single test, when, in fact, he had terminal cancer.
PAs are the wave of the future. They have to be. We desperately need more primary care capacity and we are not going to train enough physicians to cope with that need anytime soon, unless we poach the rest of the developing world's supply and thereby destroy what little access they have. Notwithstanding, PAs are supposed to be supervised by physicians. In addition, no PA should have the authority to order thousands of dollars of tests. What this PA did any physician might have done as well. When you walked into UCSF they already had the history of your experience with the PA and the fact that your condition did not improve.
As for the bill, do what my mother did: write a letter noting that the practitioner grossly misdiagnosed and that subsequent physicians immediately understood the gravity of your claim. Note that PAs are SUPPOSED to be supervised by physicians and that you did not see any supervising physician on site. On that basis, state that you are refusing to pay and see what they do. The UPMC doctor who saw my father never followed up for payment for her so-called services. You can push back.
March 12, 2009 2:27 PM | Reply | Permalink
They're not going to reform health care, the object of this govt. push is to reform the consumer's access to purchase insuramce to use the health care system.
Hospitals maintain emergency rooms because they're income generators for the hospitals. Their profit comes from referrels to specialists (the major reason why the cost of health care has risen so high) and testing such as ct scans and mris which are highly lucrative. Hospitals love to pretend that they operate emergency rooms as community service and often point out the very low operating margin of ERs, but they pay the freight for the hospitals' other departments. Contrary to public memes, emergency rooms don't provide the most expensive care, they provide the cheapest care, but since most consumers become aware of the high cost of health care through emergency rooms, they think (and hospitals carefully propagate this opinion) that the care is the most expensive. Now hospitals are becoming more and more dependent on ERs to generate cash, not just income. Most of them now require at least some cash for service and if you cannot pay that service fee, they turn you away. It doesn't matter if you have insurance or not, they need that cash flow. (That was the point of the incident related by Hillary Clinton during the primaries - the pregnant woman who died was turned away from the hospital because she didn't have the $200. required for admittance to the emergency room - the less insurance, or no insurance that you have the higher the emergency room fee.)
As to the bill for $519. no one can have an informed opinion as to the reasonableness of that fee because you provided no information. What did it include, what did it not include, did you receive a separate bill from the hospital and the labs (and I'm assuming that blood and urine tests were done as a matter of course) did it include a physicians' review of the PA's report, because remember, a PA works for a physician and that PA fee also includes a physician's fee. We don't know if you were in a city with a high cost of living - there are just too many factors to form an opinion.
You know, if you are really interested in health care reform, demand that congress legislate upfront fees for services information BEFORE they are given those services - for example a fee for a ct scan can cost as little as 5 to 600 or as much as 12-1500. depending on who is providing the service, mris are even more expensive and can vary in price from 1500 to 3000. or more, but most people don't know that, because health care providers aren't forced to provide consumers with that information. Many people don't understand that their insurance companies negotiate discounts with health care providers in advance of need - they'll receive a bill for the difference in the list price and the negotiated price and assume they're responsible for the difference - and most of the time, hospitals don't inform them otherwise. That would be a handy piece of legislation right there - truth in billing. It would also be nice if there was a true breakdown of health care costs before we begin to reform the system - Americans spend per capita, 6800. per year on health care, most of that in outpatient services, but that includes ambulatory surgical centers, elective surgery (like cosmetic, one of the fasted growing fields of medicine) dental care, including cosmetic dental care, physical therapy, drug and alcohol abuse clinics, over the counter drugs and health and beauty aids (and I'm not saying this is uneccesary) so a true breakdown in costs would give us a better picture of what really is at stake here and how those costs are managed. No industry is more in need of transparency in cost than the health care industry and it is the most clouded in hidden costs and fees.
This is the true beginning of health care reform - not instant legislation transferring the cost to the taxpayers without true reform.
March 12, 2009 3:11 PM | Reply | Permalink
I work in the area of health care insurance (without elaborating, I don't work for an insurance company). There is a lot wrong with health care and one change that could make the system much more consumer friendly is simply to require providers to post prices and provide pricing information for patients for all proposed tests. They will scream and loudly, but if your auto mechanic can do it, so can they, or at least they can if you are not insured or they do not participate in your plan's network.
Right now, providers are always screaming about how hard it is to get information from insurers, but they will fight to the death to hide as much as they possibly can from consumers about the way they charge for things.
March 12, 2009 3:27 PM | Reply | Permalink
Exactly right. How can we call for universal health care without information about the cost?
March 12, 2009 5:01 PM | Reply | Permalink
Many, if not most, US doctors end up in private practice, as businessmen. Their bottom line is most improved by extensive use of services and clinics in which they have ownership interest, as well as repeat visits by the patient. Thus the AMA is a business organization.
It is true, of course, that resources are finite, intervention not always cheap, and people die eventually, anyway. We ration the duration and quality of life through economics, largely. It could be rationed in other ways, but dogs that have food in their bowl growl at anyone who approaches., not interested in sharing.
When we had no knowledge of or control over our health, some died, some lived. What will happen when we get more significant life-extension capabilities than we have now? Will we have immortals that will end up owning everything, since they will be there before any newcomers? Could get messy.
March 12, 2009 9:02 PM | Reply | Permalink
rb6:
Which price do you mean? The one they charge to big insurance companies, the one they charge to little insurance companies, the one they charge medicare, the one they charge the uninsured...?
March 12, 2009 4:00 PM | Reply | Permalink
The price they plan to stick the patient with, so the patient has fair warning of what they are looking at.
March 12, 2009 4:14 PM | Reply | Permalink
If you had to create the worst possible way for people to get health care, you would put a large number of for profit, capitalist insurance companies with their attendant bureaucracies, myriad forms, myriad co-pays, myriad deductibles between the patient and their care.
March 12, 2009 4:06 PM | Reply | Permalink
Not to mention myriad fees, penalties, and greed.
March 12, 2009 8:44 PM | Reply | Permalink
Health care reform can't come quickly enough!!
What makes you think that we can have affordable healthcare reform without the number of PAs doing what was formerly doctor's work going up?
All of this talk about how single payer will improve health care and at the same time will save us all of this money by getting hospital costs under control does not ever seem to consider how single-payer is going to save money. No one seems to ask "why would single payer be cheaper?" They ignore the fact that in any system, single-payer or privatized, you save money by denying care.
Perhaps if we had 90% income tax rates and spent twice what we do now in health care, we could have single payer where everyone can get a well-qualified doctor. Or we could have a single payer system that costs far less, as Canada's and the UK's systems do, and probably have half of all the work done today by doctors be done by PAs.
But you seem to think that health care reform will magically give you everything.
Isn't gonna happen that way.
March 12, 2009 6:31 PM | Reply | Permalink
we could have a single payer system that costs far less, as Canada's and the UK's systems do, and probably have half of all the work done today by doctors be done by PAs
Odd, since in neither Canada nor the UK is "half the work done...by PA's", and, as G. remarks, their systems cost far less than hours (about 1/2 as much per cap.)
G. seems to have overlooked the 20% that private carriers charge for the job of "gatekeeping" care.
Given that we spend 18% GDP, one half from Gov't, that leaves roughly 2% GDP, or about 200 billion dollars, available for providing health care as opposed to denying the same.
disclaimer:numerical values from memory, quibble at the margins if you wish, but google for yourself if you want.
March 12, 2009 8:11 PM | Reply | Permalink
My father was misdiagnosed with esophagitis by an emergency room physician who was also a cardiologist. My father was having a heart attack. He died. He was 64 years old. I am a Nurse Practitioner, and I think it was a misdiagnosis. If it had been a PA who had made the misdiagnosis, what would that prove?
March 13, 2009 8:29 PM | Reply | Permalink