A recent study ( http://www.ncbi.nlm.nih.gov/pubmed/22849819) talked about when disagreements between the ER diagnosis and the inpatient diagnosis. It goes on to say how the ER over-diagnosed pneumonia and urinary infections in older patients. All I have to say is, "You bet I over diagnosis." The ER is like a fish bowl. It is a clear glass bowl that every one can look into and criticize what you are doing but they never come in to try it themselves. This criticism usually comes after all the crap has been clean off the fan. I feel (and know because I do it) that a lot of these over-diagnosis come from just trying to get the patient care. If I call a hospitalist with an admission, they ask "what is the diagnosis?" Many times I want to tell them – "I do not have a firm diagnosis but they just do not look good." The hospitalist would laugh and tell me to call them back when I have a real diagnosis. So what do I do to avoid this, I over-diagnosis. In the ER, we call it throwing out a big net. We go and see patient. We come out of the room thinking the patient needs to be admitted but I cannot quite put my finger on why. We then throw out a big net ordering a lot of tests hoping that something comes back positive so we have a "reason" to admit the patient. The easiest are pneumonia and urinary infections. Almost all old people have a dirty urine or something on their chest xray that I can construe to be a pneumonia. Once I have one of these, I have an admission. Is this the best practice?? No. But it is what we have to do in this environment. I have to find something to get the patient admitted. There is no more admitting the patient just to watch them. The hospital and doctors will not get paid without a firm diagnosis. Also, I do not get penalized for over-diagnosing. I get penalized for missing that 1 in a million case. Old people like to hid bad disease with only small complaints. They also like to die quickly if they are missed. We find a diagnosis, give them antibiotics, and admit them. As long as the pay structure is how it is and malpractice is how it is, there will always be ER over-diagnosis. And once the ER has stabilized the train wreck patient, the rest of medicine will always critique a day later why I did not do this or that.