Steven,
Thanks for your post and the view that only an FP and ED doctor could give. I have to say with all due respect that I couldn't disagree more. Granted, it would be a little uncomfortable and to the patient it would appear as though you are "double-dipping" so to speak to send them back to you. But, for the average PCP seeing the patient back who inappropriately went to the ED ear pain, especially when one dose at 10PM will make little or no difference in the outcome or pain.
One of the main way people learn is through consequences. They can get a letter from Medicaid over and over, but if they realize that they will have to be seen twice, they will think again before going to the ED inappropriately.
And, if a patient goes to the ED for something chronic from three weeks to three months, I find working that up due to medicolegal reasons is simply not good medicine. Most chronic conditions require a long history and physical with an algorithm approach that saves money and avoids needless tests. The responsibility for the patient going to their primary care doctor is on them, and I don't think there is any medicolegal pressure on the ED. In fact, our ED sometimes does the appropriate thing by calling me and making sure the patient follows up the next day. There are very few things that cannot wait 18 more hours before being seen by the PCP.
