I graduated from medical school in 1995. I completed an internal medicine and pediatrics residency in 1999, after which I spent three years in private practice, then moved on to a hospitalist practice for the next four years. From there, I transitioned to an ER job, where I have been for the last seventeen years.

In the ER, my role initially involved expeditiously seeing patients and only performing what was absolutely necessary to rule out an emergency condition. However, the landscape has changed over time, and I am now dealing with an absurdly increasing amount of primary care questions.

The ER has progressively become a source of primary medical care. For some people, this is the only place they receive care. Although it’s not ideal, it is the reality. When I encounter a patient with a clear medical problem that requires further evaluation, I try to get them admitted to the hospital. Unfortunately, the pushback on this has accelerated in recent years to a frankly ridiculous point.

It seems that no one is genuinely interested in figuring out what’s wrong with a patient. The role of diagnosticians has become a thing of the past. Unless a patient requires a financially lucrative procedure, such as a total joint replacement or cardiac ablation, today’s medicine is primarily focused on getting the patient out of the hospital as soon as possible. Whether or not they have outpatient follow-up doesn’t matter; they just need to leave, and quickly.

The discharge recommendation often includes instructions like “Follow up with rheumatology.” However, it makes no difference whether the patient has actually been given contact information for a rheumatologist or has the means to get to one. The hospitalist has determined that there is no longer a need for inpatient care, and everything can be done as an outpatient, so the patient should leave the hospital. Unfortunately, what often happens next is the patient reappears in the emergency room in a few days or weeks with the same problem because no real solution was obtained.

Let me give you a specific example. Recently, I saw a 33-year-old man who presented with left-sided chest pain, which was quite characteristic of acute pericarditis. This was his second visit to the emergency room with the same symptoms. Both times, he had an EKG that was consistent with acute pericarditis, and his pain clinically matched the diagnosis. However, he had not received any outpatient follow-up in the meantime. While I was able to identify his pericarditis during his visit with me, the underlying cause was unclear, and he had not undergone an echocardiogram to determine whether he had a pericardial effusion complicating his pericarditis. I contacted a hospitalist and requested admission for additional treatment and evaluation. Unfortunately, the hospitalist declined, stating that this should be done as an outpatient workup. Fair enough, if it would actually happen. I reached out to the cardiologist on call, who believed that the patient needed to be admitted for an echocardiogram and further testing. I felt reassured that the patient’s needs were going to be addressed, and based on the cardiologist’s recommendation, the hospitalist admitted the patient.

However, just a few hours later, I noticed that the hospitalist had already dictated a discharge summary, pending the results of an echocardiogram, with the recommendation for outpatient follow-up with a rheumatologist. No additional testing had been conducted.

How difficult is it to order studies that could potentially shed light on the cause of this man’s condition, such as viral studies, ANA, RF, TSH, or TB screening? Why is there no interest in finding the answer? Where is the diagnostic thinking? Is the only goal “length of stay” metrics?

Our health care system has become so overwhelmed by metrics that the intellectual aspect of medicine has been left far behind. This situation makes the hospitalist appear lazy. They are likely not lazy but driven by the pressures to keep their numbers in line.

So what happens to the patient? He will be started on colchicine, which is the appropriate treatment for his condition, but he will never know why it happened. He will probably show up in the ER again with a new problem related to the first one, which wasn’t identified in a timely manner initially, and once again, he will be told to “follow up with rheumatology,” and the cycle will continue.

Danielle Reznicsek is an emergency physician who blogs at Stories from the ER.