How can patients assess what is a true emergency?

Hi.  This is doctor Rob, and you have reached my blog.  If you are here to read my blog, then continue to do so.  If this is an emergency, please call 911.

That is one of my pet-peeves.  Every single doctor’s office I call I am told the same thing: “If this is a true emergency, please hang up and dial 911.”  I even got that message when I called the ER.

When I called the OR, though, the message was different: “If this is a true surgery, please hang up and call the operator.”

Not really.

Clearly, the message is put on every office phone system to cover their collective tuchuses. They are protecting these sacred parts from when a patient having a stroke sits and listens to the 21 options (“as the options have changed”) and then listens to 20 minutes of 60′s classics lovingly interpreted by Kenny G.  Scientific evidence shows that after listening to muzak for long enough, even people without an emergency will eventually hang up and dial 911.

But I don’t put that warning on my phone system (and have opted for folk music instead of Kenny G).  It’s not because my patients are smarter (although they clearly are), nor is it because I don’t value my tuchus.  I wouldn’t mind getting rid of a little of it, but overall I value that part of my body.  The reason I don’t put the “moron repellent” message on my service is because we answer the phone.  If we cannot answer immediately we try to answer as quickly as possible. We are also available to our patients via messaging, email, or whatever other means they want to reach us.

When you think about it, a lot of patients aren’t really sure they have a true emergency and are calling to get advice about whether or not they should call 911, make an appointment, or just take some Tylenol.  To make this decision, the patient has to run the gauntlet of the typical medical office’s doctor protection plan:

  1. The patient calls, and listens to all 21 options (as the menu items have changed).
  2. Listens to Kenny G (in the South, it’s sometimes Travis Tritt) for an indeterminate amount of time.
  3. Speaks to a front desk person who is assigned to phones (usually a newer staff person who is not a clinically trained).
  4. Either is offered an appointment for some time in the next few weeks, get transferred to the nurse (or her voicemail), or be told to go to the ER (if it’s a true emergency).
  5. If lucky enough to talk to a nurse, the nurse will give the same three options.
  6. See the doctor when the next appointment is open (after 2 hours in the waiting room).

But what if it’s a “true emergency” and the patient takes option 6?  Then the “moron repellent” message about 911 protects the doctor from the patient’s bad decision — a decision based on not knowing when something is worth worrying about and what is not.

The keys to good care are:

  1. Care that is accessible.
  2. Care that is based on accurate information.

Our health care system puts a huge wall between doctor and patients — a wall made of inane messages, voicemail, Kenny G, front desk staff and clinical staff.  Doctors are reluctant to speak to patients about their problems because they are too busy seeing people in the office, and because they are not interested in giving away care for free.  We physicians force people to come to the office because it is the only business model that works.  While the PCP has the most information about the patient, they are not accessible.

So people then go to the ER (or prompt care) because the incredible frustration they feel dealing with most doctors’ offices.  Yet while the ER is more accessible, it is not based by good information about the patient.  The doctor has to get to know the person’s medical history quickly, assess whether or not this constitutes a “true emergency” (requires hospitalization), take care of those with “true emergencies,” and giving a temporary solution to those who don’t qualify, with instructions to follow up with their PCP.

This obviously poisons people’s trust in the medical system, as nobody offers care that is accessible and informed.  Nobody can answer the patient who wants to know if they have a “true emergency,” yet isn’t that one of the most critical questions to answer?  Isn’t that the key to reducing unnecessary emergency visits?  Isn’t that (as was the case twice this week in my office) the way to keep patients with “true emergencies” from sitting at home wondering and actually getting the care they need?  Avoiding unnecessary treatment and getting necessary treatment promptly are two keys to reducing the cost of care.

We are far to quick to blame patients for their bad decisions.  The system forces patients to assess themselves as to whether their conditions constitutes a “true emergency” before they get a chance to talk to anyone.  Patients use the ER unnecessarily because the it’s a pain in the tuchus to deal with their PCP, and when they actually sit in front of their actual doctor, that doctor is tired, getting their tuchus whipped by CPT codes, ICD codes, and meaningful use criteria.

Do I have to say it?  There is a better way.  Just ask my patients.  Their tuchuses feel just fine.  They don’t have to listen to the “moron repellent” message every time they call (or Kenny G), and actually get my help in deciding if they should call 911.  I know them, they know me, and they have access to me when they need me.

It’s a novel concept that my patients have to adjust to: I want to talk to them.  I want them to call me.  My door is open.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at Musings of a Distractible Mind.

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  • guest

    Hear hear. I rarely visit the doctor myself (thankfully) but I have to take my kids in regularly. Just to make an appointment and going through these automated messages is enough to make you want to pull your hair out. God forbid my kid was really sick or was having an emergency and I wasn’t savvy enough to clue into it.

  • Martha55

    I call my insurance companies nurse line and get advice on what’s wrong, on how urgent the situation is and what to do about it. The doctor’s office won’t give advice over the phone and tell you to make an appointment or go to the emergency room.

    • Gibbon1

      My gut feel is the problem is insurance companies and policy makers created this problem by 40 years of trying to squeeze payments to PCPs, despite that they have d*ck all to do with rising health care costs.

      A rational system would pay PCP’s according to a set of scales based on the fact that a PCP is the second cheapest method for providing heath care. (Cheapest would be a RN working behind a counter at Walmart).

      A PCP should get paid something just for being a patients PCP whether they have appointments or not. Paid for phone consults, everyone else gets paid for that why not doctors? Seriously. Paid for scheduled appointments, paid more for drop ins. And penalized when a drop in goes to the ER instead.

      Problem is the Specialist side of industry is so large now that switching things back is likely unpossible.

    • JR

      I have better luck getting to my doctor – when the office is open.

      But having the option to call the nurses line 24/7 is great, I’m glad my insurance company has set that up too.

  • FriendlyJD

    Oh my god those automated messages. Recently I got a voice mail from a doctor’s office around 4pm on a Friday, asking me to call back about lab results. I, of course, didn’t get the message until after 5, and if you call after hours you are given the option of 1) going to the ER, 2) calling back later, or 3) having a physician paged urgently. Well, since they left no info in the voice mail (despite the fact that I have signed 10+ waivers saying they CAN leave medical info), I just hung up and waited until Monday. After bouncing through automated phone system tag for a week (never once did I reach the holy grail of actually speaking to someone after waiting 30 minutes on hold), I found out they wanted so send me to the ER based on my lab results. Face palm.

    • Dr. Rob

      Good/horrible story. Perfect example of a “stay away” system.

  • Ron Smith

    Hi, Rob.

    I too hate phone trees! All phone trees! But some are really necessary to get to the right people.

    Accessibility is the key like you said. I have one nurse who does nothing but phone triage. She answers medical questions and solves those common medical care side issues that plague doctors. She is also the only non-provider staff that can generate prescriptions.

    Our parents tell us they love the accessibility that she provides. She is able to handle many of the smaller problems, plus if a child needs to be seen she can break the schedule when necessary and work them in if we don’t have slots.

    The other thing that has helped me tremendously is being available by email. All of the providers in the practice are. That kind of access is fairly uncommon, but I encourage docs to not equate giving out your practice email address. It is not like giving out your cell phone!

    Accessibility and availability are primary. And I’m not talking about after hours clinics either, which we don’t do.

    Thanks for the great article. Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • Dr. Rob

      This sounds great. How do you do it in a fee-for-service model where we are rewarded for making people only get care in the office? I tried to be accessible in my old practice, but it was always doing good for patients = doing bad for business. It’s OK when a practice is not full, but we had all the patients we could handle. In my new practice I am rewarded for keeping people home.

      • Ron Smith

        Hi, Rob.

        What I have found is that being accessible and doing things that I can do has actually increased office visits, not diminished them.

        You would think that this ‘free’ care would have some effect on the bottom line. It has actually increased it because patients have so much trust that we aren’t trying to squeeze them for money, that we always have a steady stream of new patients who have heard about our practice.

        We tell our patients that we really, really like them, but we don’t want them to have to be in the office if they don’t need to be.

        There are times when I can’t really give them an adequate assessment by email, but I say this and then when I tell them that I really need to see their child, or if by such and such time if you don’t see this, then I need to see them, parents respond. It is almost as though telling the not to come in when they don’t need to prompts them to come maybe more. They know I’m not gouging them.

        That level of honesty and caring attention reaps benefits. I am constantly getting new patients and not just newborns, but children 4 years and up who have been cared for by other Pediatricians. They come to us by word of mouth.

        Warmest regards,

        Ron Smith, MD
        www (adot) ronsmithmd (adot) com

  • PamelaWibleMD

    Here’s how I help patients understand what a TRUE emergency is:

  • medicontheedge

    As an ED worker, my paycheck is dependent upon all the non-emergencies that my hospital, and many others, who directly market.. KaChing!

  • Patient Kit

    I certainly agree with the frustration of doctor inaccessibility, crazy phone trees and also doctor’s offices who pick up right away but put you on hold and never get back to you. I also agree that too many people go to the ED for non-emergencies like sore throats and earaches.

    But on the subject of what constitutes a “true emergency”, are you really saying that only things requiring hospitalization are “true emergencies”? There are plenty of serious medical situations that require immediate attention but not, ultimately, admission to a hospital. A ruptured Achilles tendon or fractured leg, for example. If you can’t get an appointment to see an orthopedist right away, shouldn’t you go to the ED if your leg is broken? Or what about people who have chest pain that may or may not be a heart attack? Or severe breathing problems or a knife cut severe enough that bleeding won’t stop? We’re not even hospitalized for most surgery these days, so “requires hospitalization” doesn’t seem like the right criteria when peeps are trying to decide whether they have a “true emergency” or not.

  • Gaspere (Gus) Geraci

    There is no black and white solution. I’ve had patients walk in to my outpatient office “Feeling bad, can I get checked out?” and code. And I’ve had patients I’ve seen in the ER who had a rash for three months that was now, “Itchier than ever, Doc!” However you set the threshold on the bell curve between people’s perception of emergency or not, some true emergencies will be missed, and some not. Like wearing a seatbelt, we’re being semi-mandated to move farther along the curve to help those who felt they needed permission, whether they get a live person or a phone tree. Glad you chose your path, but we use that same line on the message for tenants who call a non-clinical rental line cause you can’t fix ignorant in a phone call.

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