The Curbsiders podcast

#65: Scott Weingart of EMCrit on Emergency versus Internal Medicine: The Devil of the Gaps

October 30, 2017 | By

Fighting with Emergency Medicine colleagues is stupid. Learn how EM doctors think and avoid the petty infighting with tips from Dr Scott Weingart, MD FCCM FUCEM DipHTFU, of the EmCrit podcast and Clinical Associate Professor and Chief, Division of Emergency Critical Care at Stony Brook Hospital, NY. We discuss heuristics, how to avoid anchoring bias, the devil of the gaps, why the elderly always get admitted, how to build relationships with the ED, and Scott’s pet peeves.

Correspondent, Dr Shreya Paresh Trivedi joins Matt, Paul, and Stuart!

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Clinical Pearls:

  1. Let’s be honest. There are bad EM docs and bad hospitalists.
  2. EM specialty is very competitive/selective. Don’t mislead yourself, they get the best and brightest.
  3. System one thinking = Intuition/gut instinct = An essential tool for EM docs. Experienced physicians must use system one to safely, reliably, and quickly make decisions.
  4. Heuristic: “any approach to problem solving, learning, or discovery that employs a practical method not guaranteed to be optimal or perfect, but sufficient for the immediate goals” e.g. intuition, rule of thumb, guesstimate (Wikipedia)
  5. EM docs in academic centers should not be seeing more than 2.5 patients per hour, but in practice often see 5 per hour. They don’t have time to perform frequent reassessments so changes in patient status might be missed.
  6. Blast away anchoring bias: Don’t get a story unless the patient is sick. Asking too many questions forces EM doc to make things up.
  7. The Devil of the Gaps: Post-test probability (PTP) of serious disease after a workup in ED: Between 10-100%, everyone happy to admit patient. Between 2-10%, IM says WTF!, but DC too risky. Between 0-2%, DC home. Low risk, but lawyers may still sue if something bad happens.
  8. Older, sicker, frail patients live in the WTF gap (PTP 2-10%). EM trained to admit these patients. Don’t fight it!
  9. Hypertension in the ED: Asymptomatic patient with chronic HTN can safely be sent home with any blood pressure…BUT if being admitted, then EM/IM docs forced to give meds to lower blood pressure. This is stupid and dangerous! If patient is asymptomatic, then don’t do anything  rash.
  10. Patients sent to ED by primary care doc: Risk dynamics change in ED. Testing will be performed. Threshold to send patient home is very high. Think twice before sending patient to that environment.
  11. Collaborate with EM: Create pathways for conditions that lead to unnecessary admissions e.g. chest pain. Meet w/EM clinical director over drinks and create a solution.

Goal: Listeners will conceptualize how emergency medicine physicians think about admissions, avoid conflict, and better collaborate between specialties.

Learning objectives:
After listening to this episode listeners will…

  1. Define system one thinking
  2. Avoid anchoring bias
  3. Explain the devil of the gaps and which patients need admission
  4. Recall why older patients almost always get admitted
  5. Collaborate with EM colleagues to overcome points of friction

Disclosures: Scott reports no relevant financial disclosures.

Time Stamps
00:00 Intro
01:10 Picks of the week
05:28 Guest bio
07:00 Getting to know our guest
12:00 Do EM and IM docs hate each other?
14:04 Where conflicts arise.
17:05 System 1 versus system 2 thinking
20:19 When the patient doesn’t match the story
23:55 Why does every 85 year old get admitted?
26:05 Transitions of care: form ED to medical ward
32:08 Is face-to-face signoff only needed for sick patients?
36:28 The devil in the gaps
41:03 Scott’s beer recommendation
42:17 BP cutoff for discharge home
43:44 Scott’s biggest pet peeve with primary care
45:04 How to make friends and collaborate with your EM colleagues
47:14 Take home points
50:35 Outro

Links from the show:

  1. The Venture Brothers (cartoon) on Adult Swim
  2. Shreya recommends Internal Medicine!
  3. Music Studio for iPad
  4. Thinking, Fast and Slow (book) by Daniel Kahneman. Describes system one and system two thinking.
  5. FUCEM and DipHTFU titles explained by Life in the Fast Lane
  6. A Guide to the Good Life: The Ancient Art of Stoic Joy (book) by William B Irvine
  7. Getting Things Done: The Art of Stress Free Productivity (book) by David Allen
  8. Carmel, A et al. Rapid Primary Care Follow-up from the ED to Reduce Avoidable Hospital Admissions. West J Emerg Med 2017 (FREE).
  9. ER and internal medicine docs, arguing over a patient admission. 2011
  10. Why do Emergency Doctors have a reputation of being “dumb”? from Student Doctor Network forum
  11. Article using PERC rule to decide who shouldn’t be tested for PE and citing a miss rate under 2% as acceptable. Annals Emerg Med 2010


  1. November 1, 2017, 3:38pm Bill Cantrell writes:

    Scott mentioned a 2% significant illness miss rate in emergency medicine as it related to over testing... Is there a reference or study supporting this percentage?

  2. November 6, 2017, 1:35am Casey writes:

    Great listen, thanks for this podcast!

  3. November 11, 2017, 5:38am tom fiero writes:

    i am an ER doc. have been since 1986. first: extraordinary work, team. i shall try to follow future pods, and catch up on old. second: i think so many good points were brought up here; too often there seems to be less than a team spirit amongst the EM and IM folk, sometimes , as scott said, a fault of the team players. but sometimes, simply a different way of seeing the same patient. communication at some point is probably a very good thing, for lots of reasons. overall, i feel this pod was not only entertaining, but also clarifying. thanks, team. tom fiero

  4. November 13, 2017, 7:32am J writes:

    "The Devil of the Gaps: Post-test probability (PTP) of serious disease after a workup in ED: Between 10-100%, everyone happy to admit patient. Between 2-10%, IM says WTF!, but DC too risky. Between 0-2%, DC home. Low risk, but lawyers may still sue if something bad happens.Older, sicker, frail patients live in the WTF gap (PTP 2-10%). EM trained to admit these patients. Don’t fight it!" TThank youuu!

  5. November 20, 2017, 11:18pm Andrew W writes:

    Great episode guys. I'm a huge fan of the podcast. I'm a dual trained EM/FM doc and acutely aware of the pain on both sides of the admission process. The point I try to hammer home to the residents and students I teach is that admission to the hospital is not a benign thing. From the risk of nosocomial infections to medical errors, there are risks to being an inpatient...especially for the frail elderly. I make every student/resident answer the question "What will this patient get out of an inpatient evaluation that they won't get as an outpatient?" Usually, the answer is pretty obvious, but not always. And when it's not, we have a serious discussion about the feasibility of safely sending the patient home. It is my hope that the new generation of upcoming ED docs will do a better job of understanding the risk/benefit ratio of admission vs discharge and maybe together the ED and Inpatient team can do a better job for our patients. Thanks again for the great podcast. I never miss an episode. You guys rock. AW

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