My flirtation with the ER has made me more sympathetic to patients

As emergency physicians who are trained in acute resuscitation and thrive in high-stress situations, we tend to roll our eyes at the less acute complaints our patients come in with. “Back pain for three months? Headache for a week? Why are they here now?”

Patients, too, complain about this. “Can’t they see it’s not a real emergency and go see their primary care doctor? This must be costing our healthcare system a fortune!”

A couple of months ago, something happened that made me question this so-called “inappropriate use of the E.R.” Let me tell you about a previously healthy young woman, an emergency physician, who came back from her shift at the Brigham & Women’s E.R. feeling a bit under the weather. She was a little nauseous, but was able to eat the Chinese take-out dinner that her husband brought back. Right after dinner, she went to bed, but couldn’t sleep because she developed a gnawing abdominal pain. Then, she began throwing up, and kept throwing up at least ten times in the next hour.

Being a physician, she came up with a differential diagnosis. This was most likely stomach flu: a simple viral illness. However, stomach flu generally involves diarrhea, which she didn’t have, and she really didn’t have other viral symptoms. It could be bad food, but her husband ate the same thing (and she, being Chinese, was sick of Chinese food always being blamed as the culprit). Any woman could be pregnant, and though the suddenness of her symptoms made that less likely, an ectopic pregnancy was theoretically possible.

So she set about to self-diagnose and self-treat. She sent her husband to the local 24-hour CVS to buy a pregnancy test and to pick up a nausea medication that she prescribed herself. The test was negative and the medication made her vomiting stop, but as the morning came, her abdominal pain was still there. In fact, it was now localized more to the right lower side, and it hurt her to walk.

I’m sure you see where this is going. You’re probably thinking to yourself whether you would have bitten the bullet and gone to the E.R. to make sure you don’t have appendicitis. Well, this young woman was me, and I was trying to avoid checking in as a patient, getting the radiation from a CT scan, and burdening our overtaxed healthcare system. Fortunately, I was able to call and find out the E.R. attending that day was an ultrasound specialist. She did me a favor to ultrasound me, and found that my appendix looked fine, but my intestines looked inflamed—consistent with stomach flu. I got my diagnosis and over the next few days, I recovered with no radiation and my appendix intact.

Had someone like me actually checked in as a patient, I could see how there might be grumbling from the providers. “A young woman with stomach flu who’s actually getting better—why is she here?”  “If she doesn’t want a CT, why did she come to the E.R.?”

What I learned from this experience is that it’s always easy to say in retrospect that the patient didn’t have to come to the E.R. In the moment, when the patient is scared and in pain, it’s not so clear. Even as an E.R. physician myself, I couldn’t tell if what I had was something benign that would go away on its own (stomach flu) or an acute process that required urgent intervention (appendicitis). How can we expect our patients to know whether their chest pain is the same angina as usual or a heart attack, or whether their swollen ankle is a sprain or fracture?

My flirtation with the E.R. has made me more sympathetic to our patients who come in with seemingly “non-E.R.” complaints. It also has me thinking on the larger scale about proposed policies that impose penalties to our patients for using the E.R. Don’t get me wrong; there is a need for more primary care doctors, and our patients will benefit from increased access to primary care. However, patients don’t always know whether they have primary care versus emergency complaints. So I turned out to have stomach flu, something a primary care doctor can address. But had I been a “normal” patient, I wouldn’t have been able to treat my own symptoms and then walked into get a favor from a specialist physician—surely, I would have had to check into the E.R. to be seen. Would it have been fair to penalize me for that E.R. visit when it turned out that I had a less-than-emergent illness?

It’s important that our policy-makers consider that even well-informed patients with good access to primary care need the E.R. For our part, we as emergency physicians need to stop complaining about our patients and embrace our duty at the frontlines of medical care, sorting out all patient presentations and working to diagnose and treat all of our patients.

Leana Wen is an emergency physician who blogs at The Doctor is Listening. She is the co-author of When Doctors Don’t Listen: How to Prevent Misdiagnosis and Unnecessary Tests.  She can also be reached on Twitter @drleanawen

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  • Guest

    Thanks for sharing your experience with us. I had a very similar experience a couple years ago–including a negative ultrasound in my ED after a couple days of right-sided abdominal pain. I came back 36 hours later and checked in as a patient, with much eye-rolling and groaning by the nursing staff and physicians, all of whom I had known and worked with for the last four years. I was the well-appearing, healthy bounce-back patient who kept saying, “I know I look good, but I’m telling you that something’s wrong.” I did get the CT that evening and went to the OR a few hours later for my appy.
    I’m quite a bit more sensitive now to the patients who come to the ED with a perhaps-overblown concern and ultimately end up needing only reassurance. We frequently call for payors to stop applying a retrospective standard of medical necessity to emergency services. We could probably be better about doing the same.

  • Sean

    Thanks for sharing your experience with us. I had a very similar experience a couple years ago–including a negative ultrasound in my ED after a couple days of right-sided abdominal pain. I came back 36 hours later and checked in as a patient, with much eye-rolling and groaning by the nursing staff and physicians, all of whom I had known and worked with for the last four years. I was the well-appearing, healthy bounce-back patient who kept saying, “I know I look good, but I’m telling you that something’s wrong.” I did get the CT that evening and went to the OR a few hours later for my appy.
    I’m quite a bit more sensitive now to the patients who come to the ED with a perhaps-overblown concern and ultimately end up needing only reassurance. We frequently call for payors to stop applying a retrospective standard of medical necessity to emergency services. We could probably be better about doing the same.

    • http://twitter.com/DrLeanaWen Leana S. Wen MD

      Thanks, Sean. I agree with you. The “retrospectivescope” is so easy to apply, but so often wrong. It’s far better to be present and empathize with our patient “in the moment”.

  • Richard Koffler

    My daughter went to the ER with appendicitis symptoms. The ER doctor argued GI trouble, the ER nurse argued appendicitis. The doctor won and sent my daughter home for a stool sample. She was back in the ER 12 hours later with a burst appendix. Ruling out appendicitis with a CT would have been nice. Or better yet, getting an ultrasound machine for the ER and training staff to use it.