Emergency medicine, we can do better

When someone gets sick, what are their options?

They can try to make an urgent appointment that day, but how many of your doctors actually offer that? Most people will have to wait for weeks, if not months, for a regular appointment. Even if you go to a walk-in clinic, the wait will likely be hours, and you’re not sure if clinics can take care of everything, so you head to the emergency room, thinking that you will get urgent care because of the word emergency in it.

And you will, after various amounts of wait time, but what do you give up in return?

To answer that question, let’s see how the emergency room works.

When patients come in, they are triaged based on severity and afterwards shuffled to different parts of the ER accordingly. ER doctors then ask you just enough questions and draw just enough labs to make sure you do not have immediately life-threatening conditions. The ER does not necessarily address your chief complains or the main reason you come to the ER – it only makes sure you don’t die in the immediate future. Everything else is left to be dealt with by the admitting doctors or your primary care doctors – if you have one.

That means you will have to explain your medical problems at least a few times over, if not more, and the more times you tell it, the more interpretations of the story you will have, resulting in contradicting information and decreased quality of care. Moreover, that fact that there are more people involved in your care – admitting doctors, ER doctors – means that there are more hand-offs, resulting in more errors, disagreement on management, miscommunication, redundancy, waste of efforts and resources.

Why do we set ourselves up to do the same work twice? Have patients repeat their stories over and over? And most importantly, why do we subject patients to risks and low quality of care?

There must be a better system, where we work together instead of separately at separate times, redoing each other’s work. There must be a better triage mechanism that screens for better information that will allow doctors to collaborate as soon as patients enter the system and long after they leave the hospital. There must be a better system that allows health care personnel to get rid of their short-sightedness and view patients as a person, with identities other than medical conditions that immediately kill and worries that must be addressed other than their health. Instead of looking to finish just our responsibilities and deferring the rest to others, we should think about how to deliver complete care to patients as a group. Thinking about how to make lives easier for our colleagues will help patients and reduce work for ourselves, because we will reduce inefficiency and redundancy all around. The whole system will be more lean and happier for it.

There is no formula to a better system – we must find out through trial and error, but first we must recognize that separated we will fail. We cannot just save ourselves anymore – the world is too connected and too strained for resources for one person to make a fortune without making others poorer, and human beings by nature will not tolerate continued marginalization. It is the source of conflicts and violence in our world – war, terrorism, burglary, revolution – so let’s save ourselves some agony and start giving instead of taking.

In the end, it’s the individual who’s not interested in fellow men who has the greatest difficulties in life and provides the greatest injury to others.

“angienadia” is an internal medicine physician who blogs at Primary Dx.

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  • http://natickpediatrics.net Rob Lindeman

    “The ER does not necessarily address your chief complains or the main reason you come to the ER – it only makes sure you don’t die in the immediate future”

    Not true. Fortunately, or unfortunately, they DO deal with your chief complaint, even if it is not an emergent one.

    Here’s an idea for a “better system”: Why don’t my colleagues start answering phone calls and emails? And for Heaven’s sake, please take down those voice mail messages that triage clients to the ED!!!

  • Mike

    What in the world are you talking about? Why don’t we teach every doctor every specialty so one will only have to see one doctor for the rest of our lives!

  • doc99

    Did you see the shocking decrease in the number of Emergency Departments over the last 20 years?

  • http://fertilityfile.com IVF-MD

    Dr. Angienadia

    I can see the truth in your description of how the typical ER system works today. OK. But then I re-read your post and I’m still unclear on what sort of alternative solution you are proposing. What would make things better? And why are those things not happening already?

  • angienadia

    When NASA first started, they realized that pens don’t work in space because there is no gravity to pull the ink down, so they spent tons of money inventing new pens.

    The Russians came along and used pencils to write in space.

    I think sometimes we get so stuck in the current framework that we can’t think outside the box, that we miss the actual purpose of why things were created to begin with, and I think that may be happening with medicine.

    Currently, internal medicine docs and ER docs see/manage patients separately, and I maintain what I wrote – “The ER does not necessarily address your chief complains or the main reason you come to the ER – it only makes sure you don’t die in the immediate future” – necessarily being the keyword (as in not absolute), and I did not adequately elaborate to bring this point across. Let me explain with the following typical ER case:

    A patient with a history of asthma comes in with shortness of breath because she was not taking her medications appropriately. The ER docs give her nebulizers, maybe admit her if shortness of breath is profound. They call up the internal medicine docs for admission, give a brief history, book her for the floor. The internal medicine docs walk down, start from scratch and take the whole history all over again (sometimes many times over if you have medical students), they write another note on top of ER notes, everything is repeated, resulting in more opportunities for errors. And in the end, most of the times none of the ER docs (and sometimes not the internal medicine docs) address the root cause of her hospitalization – educate patients on how to take her medications appropriately.

    The solution is not obvious (or we would be all rich), but can we humor ourselves and think about how we would build the system if we could start from scratch? When patients come to the hospital for urgent care, can they be seen by just one group of doctors? If they need to be admitted, can that same group of doctors continue to care for them inpatient without signing off to another team? I mean, I don’t think it’s too far-fetched to say that internal medicine doctors and run codes and intubate patients, and I don’t think it’s too far-fetched to say that ER docs can manage asthma exacerbation – ER residents rotate through regular medicine floors, MICU, CCU, all types of inpatient services.

    Doc 99 – thank you for that link, I did not know that fact before I wrote the article, but I’m not sure how it pertains to the current argument – I am not attacking emergency medicine, or anyone for that matter – I just think that we can come up with a better system where we don’t repeat each other’s work and become more efficient at what we do.

    • http://natickpediatrics.net Rob Lindeman

      angienadia, If you meant to say that ED docs address chief complaints you should have said so. If you meant otherwise, you should have said otherwise. “Necessarily” is never a key word in any sentence.

  • http://www.fertilityfile.com IVF-MD

    Dr. Angienadia, I agree and I love your idea of thinking outside the box and trying something that is better, even if it is different from “the way it’s always been done”. We can either build new ways from scratch or at the very least, boldly modify our current way and not be stuck on tradition, especially a tradition that is seemingly inefficient and stagnant.

    If we are in agreement that unleashing the creative power of 1000 new entrepreneurial minds is a good way to find better ways of doing things, then let’s ask ourselves the next logical question.

    Why do we have so many different websites and web applications? Why do we have so many choices of restaurants and dining experiences? Why do we have such a rich variety of great blogs and podcasts?

    BUT why do we only have essentially one way of caring for patients with urgent/emergent problems?

    When we can answer this question, we will be one step closer to some good solutions. Can you venture any guesses?

    One way to start is to think what is stopping someone with trying out your great idea of softening the line between “he/she who sees the patient first in the ER” and “he/she who cares for the patient from admission to discharge”. If this might be a good idea (and I’m inclined to believe it’s worth a try), then why isn’t it being tried?

    Perhaps we can start there and get closer to some improvement.

  • angienadia, MD

    If I were to venture a guess, I would say these experiments are not happening because most doctors do not usually think about efficiency. We select people for medical schools based on medical knowledge, we teach medical students focusing on medical knowledge, we train residents honing in on medical knowledge – rarely in a journey to medical licensing do we talk about patient safety, economics of health care, process improvement. Curing cancer is a hot topic, but if a medication is not given on schedule, most doctors simply workaround, re-order them and move on without a twitch – we are not trained to think about why things don’t get done, and how that affects patients. Why, today I just talked to a medical student who was taking care of a patient who was intubated from hypercarbic respiratory failure because he did not get CPAP, even though it was ordered 4 days ago. The medical student looked sad, but he had no plan to do anything about it – he said that’s the way things are in the hospital.

    I love your optimism – I seem to lack it even at this early point in my career.

    Rob: Thank you for your comments. Most things are not 100% in medicine – the same applies here. Let me be clear: MOST ER doctors DO NOT address the chief complaint – they really rule out life-threatening causes and triage patients. Health is a multifactorial beast, influenced by multiple factors like socioeconomic status, insurance issues, environmental factors, etc. If you look at most patients coming in through the ER today, the underlying reason why they came to the hospital is NOT medical (running out of medicine, do not have health insurance, having chest pain from cocaine). The ER docs usually tie the patients over medically, but they do not delve into the root cause (i.e. they do not connect patients to social worker, they don’t do substance abuse counseling) – they leave that for the admitting team.

    • rob lindeman

      Angienadia: either I don’t understand the meaning of the expression “chief complaint” or you don’t.

      I will take your word that you practice medicine, but if you do, I’m confident you don’t practice anywhere near my office. Roughly 4% of ED visits to my local hospital result in admission. That means 24/25 individuals go away without the “root causes” of the visit being addressed by the admitting team.

      Among the parents in my practice, the majority bring their children to the ED for chief complaints of trauma or fever. These complaints are always addressed by the ED staff, usually in a manner that is best described as overtreatment.

      I agree with the commenter who takes issue with your criticism of multiple interviewers. If the patient has come to the ED for a true emergency, his care will more likely than not be improved as a result of multiple focused histories. If it isn’t an emergency, it won’t matter how many times the questions are asked: the patient shouldn’t be there and is more likely than not to be harmed as a result of his mistake.


    • http://fertilityfile.com IVF-MD

      Dr Angienadia,

      There are at least two ongoing discussions here. One is the “separate discrete ER doctor” vs “admitting doctor triages and treats” debate and I will stay out of that for now. The second discussion is the “doctors actively seeking to improve with new ways of doing things” vs “doctors just sticking to the same old way” debate.

      By the way, I totally identify with your med student story, because I see that with some of our med students too. They almost have that DMV-worker “that’s not my responsibility” attitude. It has something to do with the reason why many doctors don’t actively seek to improve the system. It has to do with incentives. If, as a doctor, you are paid a base salary, regardless of how happy your patients are, regardless of how many patients you see, then would it not be reasonable to expect that you might tend to move slowly and do the minimum possible, so as not to get fired or get in big trouble? If, as a doctor, you are rewarded with more money by billing your CPT codes more efficiently, you actually WILL try to improve. You’ll not necessarily try to improve your quality of care, but you will try to improve doing things to bill more codes and bill them more profitably.

      In my field (high tech infertility treatment), the majority of our reward comes directly from the patient, both in terms of payment and in terms of referrals. Except in mandated states, we have to compete for our patients. There are many other Reproductive Endocrinologists competing with me, so you can bet that I AM super-motivated to constantly experiment and find new ways to do things more efficiently. If I succeed, then I can give better care to more patients which results in more revenue and more referrals.

      So my point is this. You said “If I were to venture a guess, I would say these experiments are not happening because most doctors do not usually think about efficiency.” And then you went on to describe how med students don’t learn about patient safety, medical economics nor process improvement. My point is that most people who have made it into med school are smart and if the incentives are healthy (let’s naturally allow the free market to reward improvement) then you will get improvement and innovation. If instead you rewards CPT coding, then you will get more diligent CPT coding.

  • John

    “they write another note on top of ER notes, everything is repeated, resulting in more opportunities for errors.”

    Why cant this sentence be “they write another note on top of the ER note, everything is repeated, resulting in more opportunities for IMPROVEMENT” Why is multiple doctors seeing a patient always bad? And medical education is a totally different issue (this is how people learn).

    And in regards to adressing the root cause of the problem – Yes this needs to be addressed but upon admission? Shouldnt their acute illness be treated first? And do you think the ER does not talk about appropriate medication use?

    Our system is not perfect and not always optimal. But do you agree that doctors that look for emergencies are important to have? Do you want an internist to take care of trauma victims? Do you want an ER doc to take care of chronic diabetic medication management? I think you are undervaluing the importance of ruling out life-threatening illness as a cause of patients symptoms.

  • PedDoc

    I have always been excited to read the posts on KevinMD because they make me think, analyze, and reassess my practice of medicine. This post provided none of those opportunities to me.

    As a pediatric emergency medicine physician, I make my living in an academic center not only “triaging” patients, but treating them to the best of my abilities.

    Your comment of “The ER does not necessarily address your chief complains or the main reason you come to the ER – it only makes sure you don’t die in the immediate future” is offensive. I am obligated to care for ALL of your medical/non-medical concerns….even the fever of <1 hour duration, your desire for a pillow and a Lunchable, or your frustration with the inability to see a GI doc as quickly as your or your PCP would like.

    My subspecialty and hospitalist colleagues work together to care for our most ill patients as quickly, efficiently, and correctly as we are able (~70,000 patients in our ED last year). Would I love the opportunity to turn over the care of these patients earlier, or even not see them at all? Of course. Is this a possibility? With the waits to enter subspecialty clinics and the lack of generalists willing/able to accept new Medicaid patients, my census will only continue to grow…

    In addition to my clinical duties, I am active in Quality Improvement in the hospital by developing clinical practice guidelines (CPGs) and research of pre- and post-implementation of these CPGs. Although I am unable to sit in the Ivory Tower of Hospital Medicine from which the author is able to view my pediatric ED, I am (like many of my colleagues across the country) able to work to actively improve the care and processes hospital-wide.

  • Pudortu

    Am I the only one that thinks that the EMERGENCY physician’s job is to address the immediate life-threatening complaint? It’s the PCP’s job to make sure they take their meds. I’m not your mommy. I didn’t sign up for this to hold your hand. You are an adult. If I tried to address everyone’s ‘root’ problem, then I’d see maybe 20 patients in a 9 hour shift. I’d bring the ED to a standstill. I think Dr. Angie is confusing us with PCPs.

  • Dr. J

    There are a couple of older family docs who work out of my hospital who see their patients through everything. When I see their patients in emerg they want to be called, they then talk to their patients on the phone and come in often even when the patient is not admitted. If the patient is admitted they do the inpatient care, if the patient goes to the OR they do the surgical assist, they do deliveries.

    They are very old school and want to see their patients through everything, and they are really up on their stuff for older doctors. They are also on call 24/7/365, and they have both told me that they don’t mind it at all. They can’t recruit any new partners though and when they retire (which they may not) they won’t be able to give their practices away.

    So in summary, I don’t think the idea of one doc seeing everything through is a bad one, but there are no young docs who want to do it, our licensing bodies are uncomfortable with this level of generalism, and I can’t see how we can go back to this model.

  • Mp

    I live in Pittsburgh, pa and 1 possible solution to this is to have urgent care centers that are not true emergency rooms but facilities where some one who has an immediate non life threatening problem can walk in and be seen and the cost to the patient is only author bit higher than a regular pcp co-pay.

  • Smart Doc

    ERs are rapidly disappearing due to uncompensated EMTALA insane mandates, the out of control Trial Lawyer Industry, and declining insurance coverage.

    ObamaCare will only worsen the the situation as Massachusetts has taught us.

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