Disability issues in emergency physicians

We have described 3 cases in which emergency physicians have unexpectedly experienced severe disabilities. Not much is known about the numbers of emergency physicians who are currently disabled and unable to practice their chosen specialty. The impact on the physicians, the group, and the institution can be substantial. Legal aspects and risks for each differ. Unfortunately, a disability can pit the disabled physician against his or her employer as each attempts to protect and advance his or her own interests.All 3 physicians profiled above were unable to return to clinical emergency medicine. In all 3 cases, the absence of a long-term disability income policy would have been financially catastrophic. Emergency physicians who do not already have a long-term disability income policy are strongly urged to obtain one. Group policies are available through national medical organizations such as the American Medical Association and the American College of Emergency Physicians, as well as through many state medical organizations. Additionally, individual coverage is available directly from private insurance carriers.

Conclusion

As the average age of emergency physicians increases, it is likely that a variety of potentially disabling conditions may require emergency physicians to consider whether or not to continue clinical practice. Understanding the basic issues of disability will be important as emergency physicians attempt to resolve the dilemma of continued practice in the face of a potentially disabling condition. Emergency physicians who do not have access to a group long-term disability policy as a benefit of their employment should purchase their own individual policy from a reputable and financially healthy carrier.     

Redefining the emergency physician's role in do-not-resuscitate decision-making.

In summary, Wrenn and Brody's [14] study raises important questions about the appropriate role of emergency physicians in discussing DNR decisions in the emergency setting. Their approach to DNR orders expands, appropriately we believe, the traditional role of emergency physicians. We suggest that it is desirable for emergency physicians to give patients and family members the option of DNR status when there is a significant likelihood that the patient will experience cardiopulmonary arrest before the admitting physician can address the DNR issue and the patient is profoundly debilitated or terminally ill. In addition, emergency physicians have a heightened obligation to promptly address DNR status when appropriate decisions about resuscitation have been reached previously, as in the following cases: (1) when a clearly valid portable prehospital DNR order is in effect; (2) when the patient's primary physician clearly indicates to the emergency physician that the patient is DNR; (3) when an incompetent patient has an advance directive that explicitly precludes CPR and unquestionably applies to the current situation; (4) when a clearly competent, informed patient requests that a DNR order be entered. Finally, we advise emergency physicians against using the principle of futility as sole justification for DNR orders except in situations in which cardiopulmonary arrest is expected, and outcome data suggest that survival is virtually unprecedented.     

Medicaid and access to care among persons with systemic lupus erythematosus

OBJECTIVE: To evaluate the associations between Medicaid insurance and distance traveled by patients to treating physicians and health care utilization for patients with systemic lupus erythematosus (SLE). METHODS: A total of 982 adults with SLE were recruited between 2002 and 2004. We calculated the distance between patient homes and physicians using Mapquest, an Internet mapping program. We then assessed the association between Medicaid status and distance traveled to the primary SLE provider, presence of > or =1 physician visits, and the number of all physician visits, with and without adjustment for demographic and medical covariates. RESULTS: On an unadjusted basis, Medicaid patients traveled longer distances to see their primary SLE provider. This effect was pronounced for patients under the care of a rheumatologist. Adjustment reduced, but did not eliminate, these differences. With adjustment for covariates, Medicaid patients were equally as likely to see a rheumatologist as non-Medicaid patients. However, Medicaid patients were more likely to be seen by a general practitioner or in the emergency room for their SLE, and reported more visits to general practitioners and the emergency room for SLE. CONCLUSION: Medicaid patients with SLE traveled longer distances to see an SLE physician, especially rheumatologists. They also reported a different pattern of health care utilization. These results suggest that Medicaid patients may face barriers in obtaining comprehensive medical services in proximity to their residences.     

Prehospital DNR Orders: What Do Physicians in Washington Know?

OBJECTIVES: To assess whether physicians know of Washington State's prehospital do-not-resuscitate (DNR) policy, 6 years after its implementation. DESIGN: Cross-sectional survey. SETTING: Washington State, April 2001. PARTICIPANTS: Four hundred seventy-one practicing physicians. MEASUREMENTS: Multivariate logistic regression was used to determine relationships between physician and practice characteristics with knowledge of policies governing advance care planning. RESULTS: Among respondents, 60% did not know that Washington State requires an emergency medical service (EMS)-specific DNR order authored by a physician. Seventy-nine percent did not know that patient-authored advance directives apply only in hospitals and medical offices. CONCLUSION: The findings in this study suggest that most physicians in Washington State lack knowledge about the documentation needed for EMS personnel to forgo pre-hospital attempts at cardiopulmonary resuscitation. Further study is needed to determine whether physician education or legislative change is necessary.     

Brief report: Physician discomfort and variability with disability assessments

BACKGROUND: Completing a disability assessment is a common physician task; yet, little formal training is available. OBJECTIVE: To assess physician comfort with disability assessments, and evaluate their consistency. DESIGN: We conducted 2 separate surveys. The "Comfort" survey asked physicians to rate their comfort (1 = very uncomfortable to 10 = very comfortable) with 12 potentially uncomfortable tasks, including disability assessment. The second survey described 2 different patients requesting disability assessment, 1 with acute and the other with chronic back pain; participants assigned each a level of disability. PARTICIPANTS: Resident and staff physicians at an urban county hospital. RESULTS: For 54 physicians returning "Comfort" surveys, disability assessment had the lowest average comfort rating (4.3, SD 1.9) compared with all other tasks (mean ratings ranged from 4.8 to 8.0). For the 73 physicians returning the "Disability Cases" survey, 88% found Case 1 qualified for limited employment, but varied on the types of limitations imposed. For Case 2, 39% assigned no disability, 39% limited employment, and 22% full disability. CONCLUSIONS: Our pilot studies support the hypothesis that physicians are not comfortable with disability assessment, and their assessments can be highly variable. Physician discomfort and lack of training may contribute to variability in disability assessments.     

To tell or not to tell: why people with HIV share or don't share with their physicians whether they are taking their medications as prescribed

This qualitative study examines whether HIV-positive people (N = 79) tell their physicians whether they take antiretroviral treatment (ART) as prescribed and why. Interviews, analyzed with qualitative content-analysis, asked about taking/not taking ART and, if taking, whether they shared their reasons for non-adherence with their physician. Patients are more likely to inform physicians why they take than why they do not take ART (p<0.01). Only half of those not taking ART shared the reasons for their decision with their physician. The six motives were: anticipation that physicians will not support the decision, cannot discuss feelings, lack of trust in physician's opinion, unable to discuss spiritual/moral issues, no need for physician to know, and not seen physician yet. Of those taking ART, 21% did not tell their physician why they missed doses. The five motives were: not viewed as important, physician not asking, not seen physician yet, rarely non-adherent, no indications in surrogate markers. A significant proportion of patients are not taking their medications as prescribed and are not telling their physicians. To facilitate the chance that patients communicate with their physicians, physicians need to ask no need for and, while giving the patients medical information, create a non-judgmental, respectful atmosphere where patients feel comfortable sharing their personal view.     

Successful Treatment of Neurotoxic King Cobra Envenomation in Myrtle Beach, South Carolina

The growing trend toward the collection of exotic snakes by private collectors increases the likelihood that emergency physicians will face the challenge of treating an exotic envenomation. We report a case involving a professional reptile handler who sustained an extremity bite from a king cobra (Ophiophagus hannah ). Rapid, progressive neurotoxicity developed as manifested clinically by bulbar and respiratory paralysis requiring endotracheal intubation and mechanical support. After infusion of Thai Red Cross Society monospecific king cobra antivenin, all neurologic sequelae rapidly resolved within 7 hours after the bite. In treating an exotic envenomation, the emergency physician should contact personnel at the regional poison control center or local zoo. Both are prepared to assist the physician by facilitating the timely acquisition of exotic antivenins and by arranging consultation with experts experienced in the management and treatment of exotic envenomations. [Gold BS, Pyle P: Successful treatment of neurotoxic king cobra envenomation in Myrtle Beach, South Carolina. Ann Emerg Med December 1998;32:736-738.]     

Admission Decisions in Emergency Department Chest Pain Patients at Low Risk for Myocardial Infarction: Patient Versus Physician Preferences

Study objective: Patient involvement in medical decisionmaking is accepted as an ethical and a legal imperative. Medical decisions are based in part on individuals' knowledge and acceptance of risk of adverse consequences. It is unclear whether actions taken to protect against low risk of poor outcome reflect patient or physician preferences. We sought to test the hypothesis that emergency department chest pain patients presented with a hypothetical situation involving a low risk of myocardial infarction are more willing than ED physicians to accept the risk associated with discharge from the hospital. Methods: We prospectively surveyed 89 ED patients with chest pain and a cohort of physicians in the ED who had been presented a hypothetical case in which the risk of AMI was quoted as 5% and the risk of death or disability if the patient was discharged was 1% and .2% if the patient was admitted. All the patients had presented to the ED with a chief complaint of chest pain; the 31 physicians, all residents, were approached at a teaching conference separate from their clinical duties. Results: Twenty-eight patients (31%), compared with 2 physicians (6%), chose discharge for the hypothetical patient with chest pain (25% difference; 95% confidence interval [CI], 6% to 41%). Forty-four patients (49%), compared with 30 physicians (97%), correctly identified the risks associated with admission and discharge (46% difference; 95% CI, 29% to 63%). Of the subjects who correctly identified the risks, 19 patients (43%) preferred discharge, compared with 1 physician (3%) (40% difference; 95% CI, 18% to 60%). Conclusion: ED patients with chest pain appear to be more likely than physicians to accept a small risk of poor outcome in a hypothetical circumstance. Many patients cannot identify the risks associated with their decision. [Davis MA, Keerbs A, Hoffman JR, Baraff LJ: Admission decisions in emergency department chest pain patients at low risk for myocardial infarction: Patient versus physician preferences. Ann Emerg Med December 1996;28:606-611.]See related editorial, Shared Decisionmaking: Easier Said Than Done     

When does a guideline become a standard? The New American Society of Anesthesiologists guidelines give us a clue

So when does a guideline become a standard? The answer is when an inexpensive, reliable device comes onto the market, the technology and concept of which have already been adopted by a group who specialize in the concept of intubation—anesthesiologists. A guideline becomes a standard of care when the device behind the guideline is available and readily usable as a practical matter by members of other medical specialties who have cause and reason to consider its use.By the time a piece of technology is recognized by legislators or insurance company underwriting departments as a necessary tool in the arsenal of a group of medical professionals, essentially as a standard of care, it is too late in the sense that the damage will already have been done because the malpractice suits that motivated the legislative or underwriting change already will be inescapably present.The mandation of a standard of care by legislative or insurance underwriting fiat certainly ensures the existence of the standard and will serve to require the use of the procedures, techniques, or technology so mandated. Before the mandation by law, however, the profession must recognize the matriculation of the idea to the guideline to the standard. Waiting for adoption of the standard by law or insurance company underwriting departments gives the plaintiff's trial bar “an edge,” in that they are able to assert that a standard exists that the physicians are ignoring.From a legal point of view, a physician, EMT, or paramedic who does not use a disposable end-tidal CO₂ detector in the process of intubation, in the absence of electronic capnography, is not acting as the average reasonable reputable physician, EMT, or paramedic would under the same or similar circumstances in the same or similar location and therefore may be said to have breached his or her duty to exercise reasonable care. If the failure to use the device results in a catastrophic untoward result secondary to esophageal intubation, the physician, EMT, or paramedic may be said to be a “legal cause” or “substantial factor” in the outcome and thus responsible for the damages determined to be present.     

Influencing physician response to prenatal substance exposure through state legislation and work-place policies

Little research attention has focused on ways to encourage physician response to prenatal substance exposure. We report initial results from a study examining the impact of state laws and work-place policies on physician response by combining legal analyses and data from a national physician survey. Our findings indicate that the message that laws and policies exist usually does not reach physicians. However, when the message does come through, some physician behaviors are influenced. In particular, physicians in states with clearer policies and behavioral expectations are significantly more likely to know and understand the law than physicians in other states. Further, believing that a work-place protocol on prenatal substance exposure exists is associated with significantly increased likelihood of an active response in case vignettes portraying prenatal substance exposure. The findings suggest that state legislative behaviors may increase physician response to prenatal substance exposure, but that response depends on the nature of the policy and on efforts to disseminate it.     

Physician response to a prediction rule for the triage of emergency department patients with chest pain

Objective: To determine the response of physicians to a noncoercive prediction rule for the triage of emergency department patients with chest pain. Design: Prospective time-series intervention study. Setting: A university hospital emergency department. Participants/patients: 68 physicians, all of whom were responsible for the triage of at least one of 252 patients presenting to the emergency department with a chief complaint of acute chest pain. Intervention: A previously validated algorithmic prediction rule that was attached to the back of patient data forms in the emergency department. Measurements: Patients’ clinical data were recorded by the examining physician in the emergency department or by a research nurse blinded to patient outcome. The physicians recorded their own estimates of the risk of acute myocardial infarction and their reactions to the prediction rule in a self-administered questionnaire completed at the time of triage. Main results and conclusions: The physicians reported that they looked at the prediction rule during the triage of 115 (46%) of the 252 patients. The likelihood of using the prediction rule decreased significantly with increasing level of physician training. The most common reasons given for disregarding the prediction rule were confidence in unaided decision making and lack of time. The physicians reported that of the 115 cases for which the prediction rule was used, only one triage decision (1% ) was changed by it. Future research should explore how prediction rules can be designed and implemented to surmount the barriers highlighted by these data. Received from the Section for Clinical Epidemiology, the Division of General Medicine, the Cardiovascular Division, Department of Medicine, the Department of Emergency Medicine, and the Clinical Initiatives Development Program, Brigham and Women’s Hospital and Harvard Medical School, and the Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts. Dr. Lee is a recipient of an Established Investigator Award (900119) from the American Heart Association. Supported by a grant from the Agency for Health Care Policy and Research (5R01-HS0452).     

Use of rapid tests and antiviral medications for influenza among primary care providers in the United States

Limited data are available about how physicians diagnose and treat influenza. We conducted an internet‐based survey of primary care and emergency physicians to evaluate the use of influenza testing and antiviral medications for diagnosis and treatment of influenza. In April 2005, an electronic link to a 33‐question, web‐based survey was emailed to members of the American College of Physicians, American Academy of Pediatrics, American Academy of Family Physicians, and American College of Emergency Physicians. Of the 157 674 physician members of the four medical societies, 2649 surveys were completed (1·7%). The majority of participants were internists (59%). Sixty percent of respondents reported using rapid tests to diagnose influenza. Factors associated with using rapid influenza tests included physician specialty, type of patient insurance, and practice setting. After controlling for insurance and community setting, emergency physicians and pediatricians were more likely to use rapid influenza tests than internists [odds ratio (OR) 3·7, confidence interval (CI): 2·3–6·1; and OR 1·7, CI: 1·4–2·1, respectively]. Eighty‐six percent of respondents reported prescribing influenza antiviral medications. Reasons for not prescribing antivirals included: patients do not usually present for clinical care within 48 hours of symptom onset (53·0%), cost of antivirals (42·6%) and skepticism about antiviral drug effectiveness (21·7%). The use of rapid tests and antiviral medications for influenza varied by medical specialty. Educating physicians about the utility and limitations of rapid influenza tests and antivirals, and educating patients about seeking prompt medical care for influenza‐like illness during influenza season could lead to more rapid diagnosis and improved management of influenza.     

Is the professional satisfaction of general internists associated with patient satisfaction?

BACKGROUND: The growth of managed care has raised a number of concerns about patient and physician satisfaction. An association between physicians’ professional satisfaction and the satisfaction of their patients could suggest new types of organizational interventions to improve the satisfaction of both. OBJECTIVE: To examine the relation between the satisfaction of general internists and their patients. DESIGN: Cross-sectional surveys of patients and physicians. SETTING: Eleven academically affiliated general internal medicine practices in the greater-Boston area. PARTICIPANTS: A random sample of English-speaking and Spanish-speaking patients (n=2,620) with at least one visit to their physician (n=166) during the preceding year. MEASUREMENTS: Patients’ overall satisfaction with their health care, and their satisfaction with their most recent physician visit. MAIN RESULTS: After adjustment, the patients of physicians who rated themselves to be very or extremely satisfied with their work had higher scores for overall satisfaction with their health care (regression coefficient 2.10; 95% confidence interval 0.73–3.48), and for satisfaction with their most recent physician visit (regression coefficient 1.23; 95% confidence interval 0.26–2.21). In addition, younger patients, those with better overall health status, and those cared for by a physician who worked part-time were significantly more likely to report better satisfaction with both measures. Minority patients and those with managed care insurance also reported lower overal satisfaction. CONCLUSIONS: The patients of physicians who have higher professional satisfaction may themselves be more satisfied with their care. Further research will need to consider factors that may mediate the relation between patient and physician satisfaction. This work was supported by a grant from the Harvard Risk Management Foundation. Dr. Haas was the recipient of a Clinical Investigator Award from the National Institute of Child Health and Human Development (K08-HD01029) at the time that this work was initiated.     

Single-payer national health insurance. Physicians' views

BACKGROUND: Forty-one million Americans have no health insurance and, despite the growth of managed care, medical costs are again increasing rapidly. One proposed solution is a single-payer health care financing system with universal coverage. Yet, physicians' views of such a system have not been well studied. METHODS: We surveyed a random sample of physicians (from the American Medical Association Masterfile) in Massachusetts, regarding their views on a single-payer health care financing system and other financing and physician work-life issues that such a system might affect. RESULTS: Of 1787 physicians, 904 (50.6%) responded to our survey. When asked which structure would provide the best care for the most people for a fixed amount of money, 63.5% of physicians chose a single-payer system; 10.7%, managed care; and 25.8%, a fee-for-service system. Only 51.9% believed that most physician colleagues would support a single-payer system. Most respondents would give up income to reduce paperwork, agree that it is government's responsibility to ensure the provision of medical care, believe that insurance firms should not play a major role in health care delivery, and would prefer to work under a salary system. CONCLUSIONS: Most physicians in Massachusetts, a state with a high managed care penetration, believe that single-payer financing of health care with universal coverage would provide the best care for the most people, compared with a managed care or fee-for-service system. Physicians' advocacy of single-payer national health insurance could catalyze a renewed push for its adoption.     

Supreme Court to rule on application of ADA

Four of eleven recent court cases cited the Centers for Disease Control and Prevention's (CDC) 1991 Federal guidelines governing the treatment of HIV-positive health care workers. These guidelines have helped define the scope of an infected worker's job responsibilities and restrictions and whether a worker has adhered to the outlined practices and precautions. Another key issue in the courts is whether the Americans with Disabilities Act (ADA) applies to individuals who are HIV-positive or hepatitis B-positive, and if these individuals are considered disabled. Two recent court rulings in cases showed that these individuals are disabled, yet could still perform their jobs. The courts are not as clear in cases involving health care employees, and need to determine how to define disability as it relates to HIV-positive patients. Currently, the Supreme Court is considering if asymptomatic HIV should be deemed a disability, particularly in light of the new combination therapies that enable many patients to continue working. Lawrence Gostin, a professor of law at Georgetown University Law Center and an advisor to the CDC, speculates that the Supreme Court will not make a blanket ruling, but will make decisions on an individual basis.     

Death in the Emergency Department

Issues regarding the deaths of patients in the ED arise on a regular basis for emergency physicians. These issues include physician discomfort with death notification, the approach to families after ED deaths, autopsies, donation of organs and tissues, and procedures on the newly dead. If physicians were more comfortable with death notification, not only would families be better served but benefits to society could be realized through the increased use of autopsy and organ/tissue donation. The controversial topic of physician education through practice of medical procedures on the newly dead weighs the benefits to society against the rights of the individual. Improved physician education, including the need for a death notification plan and enlistment of the support of nursing personnel, social workers, and clergy, may improve the experience of events surrounding ED deaths for physicians, families, and society. We review the literature and give recommendations on approaches to deal with these issues. [Olsen JC, Buenefe ML, Falco WE: Death in the emergency department. Ann Emerg Med June 1998;31:758-765.]     

Physician perspectives on the ethical aspects of disability determination

OBJECTIVE: To evaluate physician’s attitudes and responses to the ethical conflicts involved in certifying patients for welfare disability. DESIGN: A mailed questionnaire survey that used case scenarios and general questions. SETTING: Massachusetts. PARTICIPANTS: A random sample of 347 internists and family practitioners and a convenience sample of 100 neighborhood health center physicians from three large cities (NHC sample). The response was 53% and 76%, respectively. MEASUREMENTS AND MAIN RESULTS: Physician responses to case scenarios representing difficult decisions about patient requests for welfare disability determination and general questions about the welfare disability system. Physicians reported a willingness to exaggerate clinical data to help a patient they thought deserving of welfare disability benefits (39% random sample; 56% NHC sample). Physicians did not report confidence in their ability to determine who was disabled as measured by a visual analog scale (4.4 cm random sample, 4.6 cm NHC sample; 0=very confident, 10=very uncertain). They did feel burdened by their participation in welfare disability determinations when compared with other administrative chores as measured on a visual analog scale (2.8 cm random sample, 2.5 cm NHC sample; 0=more burdensome, 10=less burdensome). Eighty-two percent of the random sample physicians and 86% of the NHC sample physicians thought that filling out a disability form could adversely affect the physician-patient relationship, and 62% of physicians in each sample thought that it represented a conflict of interest. Eighty percent of physicians in both samples thought that it would be better if an independent group of physicians were designated to determine disability. CONCLUSIONS: Physicians perceive an ethical bind as they try to satisfy the conflicting demands of patients and the welfare disability system. They will frequently decide in favor of their patient’s interests. This has implications for welfare policy planners. Received from the Department of Medicine, The Cambridge Hospital, Harvard Medical School, Cambridge, Mass. Supported in part by a grant from the Milton Fund, Harvard Medical School.     

Influenza and pneumococcal vaccination in the emergency department

Objective: To assess the numbers of high-risk adult patients presenting to the emergency department (ED) who have not been vaccinated against influenza or pneumococcal disease and whether emergency physicians are willing or able to routinely provide vaccination. Design: A survey of patients in the ED considered to be at high risk for morbidity and mortality from influenza or pneumococcal disease; an anonymous, mail-back survey of emergency physicians. Setting: The ED of a university-affiliated hospital with an annual census of 50,000 patient visits. Participants: A convenience sample of adult patients visiting the ED for any complaint who fulfilled the American Thoracic Society and Centers for Disease Control and Prevention requirements as a highrisk patient requiring vaccination with influenza or pneumococcal vaccine. The physicians surveyed were identified from the membership role of the state chapter of the American College of Emergency Physicians. Measurements: 1) Influenza and pneumococcal vaccination rates for high-risk patients presenting to an ED during influenza season; 2) reasons for lack of immunization; 3) patient willingness to be vaccinated in the ED; 4) vaccination practice patterns for ED physicians; and 5) reasons why ED physicians are unwilling to give these vaccines. Results: 212 high-risk patients were surveyed. 57% and 75% of these patients reported not having received the influenza vaccine and the pneumococcal vaccine, respectively. The main reasons for not being immunized included not being informed they needed it, a prior adverse reaction, and procrastination. Of the unvaccinated patients, 54% were willing to be vaccinated in the ED. Of the surveyed ED physicians, 89% and 93% never or rarely gave influenza and pneumococcal vaccines, respectively. 51% of the ED physicians were willing to give the vaccine. Unwillingness stemmed mainly from: 1) the perception that ED physicians are not primary care providers, 2) inadequate time or personnel; and 3) concerns about adverse reactions or medicolegal liability. Only 5% of the physicians reported organized case-finding mechanisms in their EDs. Conclusion: Significant numbers of high-risk patients who are unimmunized against influenza and pneumococcal pneumonia present to the ED. There is hesitancy among ED physicians about assuming the primary care task of providing such immunizations. Any attempt to institute a large-scale vaccination program in an ED setting needs to be carefully planned in a way to involve primary care providers and to decrease ED physician concerns and reluctance. Received from the Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.     

Universal access: its potential impact on emergency medicine.

The nation's current economic conditions, the first time in 60 years that a recession has adversely affected the middle class, might well be the actual trigger mechanism in the passage of a US universal access plan. When enacted, it would provide emergency medicine and other basic physician and hospital benefits to the currently uninsured patients now seen in hospital EDs, in doctors' offices, and as inpatients. It will, thereby, enhance current physician-patient relationships and enable many of the working poor and their dependents to receive medical care. Conventional widsom suggests that such a social insurance plan could significantly reduce the number of routine visits to hospital EDs, assuming that additional, accessible, and high-quality alternative primary-care services are developed. In any case, a universal access plan should improve the percentage of billed charges collected by emergency physicians. The nation's 1,500 third-party payers, with their managed care strategy, will have difficulty (for the reasons outlined) in micromanaging such external pressures as ensuring high-quality patient care, more benefits (including tertiary services), and less cost to the private and public sectors. As there is more micromanaging by third-party payers to reduce expenditures, it will be increasingly difficult for emergency physicians to find specialists willing to accept previously uninsured patients, except at public or teaching environments where the delivery of services to uncompensated patients has been the pattern for several decades.(ABSTRACT TRUNCATED AT 250 WORDS)     

COBRA: implications for emergency medicine

The potential impact of COBRA is staggering and must be confronted. The ultimate scope and effects will take shape quickly. Federal regulations will provide some of the rules, but the most important definitions under the law will develop in court. Because of a lack of understanding hospitals may not have been in compliance with COBRA's strict terms since August 1986 and may only become educated on COBRA through the legal process. Currently, one COBRA lawsuit has been filed in the Chicago court system, and at least one physician group in California has paid a $25,000 fine for COBRA violations. Litigation in the initial phase of COBRA is likely as most hospitals continue to be unaware of the implications of COBRA legislation. EDs, emergency medical services programs, and interhospital transport programs must begin an immediate effort to examine and develop policies to comply with COBRA. Without an effective educational, compliance, and risk management effort, any emergency medical services program or hospital may become a defendant under COBRA legislation. Delays in understanding and implementing the requirements of COBRA may adversely affect the health care system rather than improve it.