Practicing convenience medicine in the ER

It’s easy to get frustrated in the ER. First, you’re at work. Second, most of your patients don’t want to be there. Third, many (if not most) of your patients don’t need to be there. Finally, by the time you see them, most of your patients are tired of being there.

It’s easy to become jaded when you trudge through this never-ending mire of patient after patient, and indeed ER docs can be known as a jaded lot. We order tests whether they’re needed or not, because, if we don’t, the patient will think that we didn’t do anything. Some react to this enigma by blaming the patient. For a memorable example of that attitude, see Dr. Thomas Doyle’s 2009 article, “Treating a Nation of Anxious Wimps.”

It’s easy to blame someone else for the faults of our system. We live in a society obsessed with hedonism, consumerism, individualism. We don’t care about cost containment when it comes to our medical concerns. We can’t accept pain as a part of life. We want results that we can see, and we want them now.

One of my colleagues once remarked that we don’t practice emergency medicine, we practice convenience medicine. Our ability to provide easy access to tests and their results is often what drives people to seek care from EDs.

We have all seen patients with minor or bizarre complaints that make us scratch our heads and wonder, “What did you think I can do about this tonight?” We’ve all seen folks with palpitations with a normal heart rate and EKG. We’ve all seen folks with chronic chest pain that want to be told it’s all okay. It is now common for parents to bring an unruly child to the ER because they are “out of control.” We’ve all seen vague dizziness, paresthesias, or patients with non-specific abdominal pain who want to know why they feel the way we do.

Sometimes it’s all too easy to default to reactions like Dr. Doyle’s: blame the patient (or our society). Yet still we order bloodwork, imaging, etc. to rule out an emergency condition. We do this because we have a hard time admitting that sometimes there is no single identifiable cause for the way a patient feels or behaves.

There is more to life than our physiology but our training is limited to that arena. However, these visits are likely the byproducts of our culture, rather than physical ailments. If we have become wimps, where did our strength go, and where did it come from in the first place?

It came from our community, but our individualism has shattered our communities and left us alone amongst a swarm of strangers. Whether that community is your religion, your family, or your nation, something greater than yourself is needed to make it through the tough times and tragedies of life. When that source of inner strength is lacking, we turn to the nearest most convenient source of help; and these days that is the ER.

When there is no experienced grandmother to say that babies get fevers, parents come to the ER.  When there is no pastor/rabbi/imam/priest/monk to make sense of the challenges in life, people come to the ER. When everyone gets a trophy and no one is ever told to suck it up, people come to the ER. When our needs supercede the needs of our nation’s fiscal needs, people come to the ER.

We are there for those who have no one else. Unfortunately, these days, despite our crowded highways and spreading cities, the number of people who feel alone in this world is ever increasing.

So who’s at fault? Who cares? We all are and none of us are at the same time. The more pressing question is: What are we going to do about it?

As people we can all act to strengthen our communities. As emergency physicians, we must first recognize our limits. While society treats us as doctor, confessor, therapist, counselor and priest, we should stick to what we know and admit what we don’t. Once an emergent or medical cause for a patient’s symptoms has been excluded, we should use reassurance and education as our most powerful therapy. Instead of another prescription or specialist or test, we should refer patients to support groups or other active communities where they can gain new personal strength.

Medicine, especially emergency medicine, is about making people better, and to do that effectively, we must help them find what they need, and often, it’s not a pill.

Michael Perraut is an emergency physician who blogs at The Shift.

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  • buzzkillerjsmith

    Link it to an urgent care. Might not work at 2 in the morning but it will help with the 9 pm nuisance cases.

  • Patient Kit

    I continue to be amazed at the percentage of ER visits that doctors say are non-emergent. I seriously have a hard time grasping why this is, apparently, so rampant.

    First, if the patient’s issue is very non-emergent, won’t they be triaged to the end of the line after all the actual emergencies? How is waiting for hours in the ER to see a doctor considered convenient?

    If you’re saying that a huge amount of people use the ER as a community center — as someplace to go when they feel alone and in need of attention and being taken care of — how is that a permissible use of very expensive healthcare services? We can’t call the fire department when we feel like some attention from a firefighter might make us feel better. Why can people (mis)use the ER that way?

    I’m going to guess that the hospital corporations actually love it and encourage people to use their ER for non-emergencies because it’s a very lucrative revenue stream for Corp Med. But why doesn’t whoever is paying for it balk?

    Finally, on a personal note, I avoid the ER like the plague. I’d go if I really thought I was having a stroke or heart attack or if I couldn’t breathe or stop bleeding. But anything less than those extremes and I’m not going to the ER where I know I’ll wait for hours, be forced to have expensive tests and then advised to see my doctor or a new specialist. On Thanksgiving weekend 1999, I waited until Monday morning to go see my orthopedist instead of going to the ER over the weekend because I figured that seeing my orthopedist would be an ER doc’s advice anyway. So, I endured the pain in my leg until Monday. I don’t know whether that makes me the opposite of a wimp or whether it makes me an idiot. My femur turned out to be fractured (although there was no reason to think it was fractured until after the x-ray on Monday morning). Obviously, if I knew (or even remotely suspected) that my femur was fractured, I would have gone to the ER.

    • buzzkillerjsmith

      Hi Kit,

      It’s not very convenient at all, but it’s better than waiting days or more to see a regular doc. And they will often have to go to the end of the line.

      Why is this so? Pretty simple: A big doc shortage. Plus if you’ve got Medicaid you often can’t get into a regular doc’s office at all. it’s the $.

      CVS or suchlike is another option. Not sure what their hours are.

      CorpMed income stream? You betcha– for insured pts. Not sure about Medicaid. Any ER docs out there know?

      • Patient Kit

        Hi Doc Buzz. Just to be clear, that fractured femur non-ER visit of mine happened while I was still covered by comprehensive employee-based Blue Cross. I didn’t use the ER much while I still had good insurance. And I haven’t used the ER once in the 1.5 years that I’ve been covered by Medicaid.

        I can certainly understand people going to the ER when they really have no other option. But even while on Medicaid, if I needed to see a primary care doc, I went to the hospital’s outpatient medical clinic, not their ER. I have not even tried to find a private practice doc while on Medicaid. I just picked a good hospital and get all my healthcare there until I’m off Medicaid. Once I have insurance again that private practice docs take, I’ll go back to some of them. But I’m sticking with my hospital-based GYN oncologist for as long as I need a GYN oncologist. He’s really earned my loyalty. I’ve recommended him to a few women too and will continue to do that.

        From reading KMD, I’m really appreciating that, even as a Medicaid patient, I have not had unreasonable waits for anything at the hospital. Even when I needed a CT scan as part of my 1-yr post-op OVCA checkup, I had it done at an independent imaging center, not affiliated with the hospital, that is in my home neighborhood. My doc did not pressure me to have it done at the hospital. In fact, it was his suggestion to do it closer to home the first time in February because it was cold out and it would be more convenient for me. I got the precedt authorization at 5pm on Thurs and had the CT done the next day on Friday at 1pm. On Medicaid. I realize the wait times are much worse in much of the country. Doctors and hospitals here seem to be competing aggressively for patients. I guess because there are so many docs and patients. NYC is apparently a good place to be sick.

        • William Viner

          You are fortunate that you are in a large city and there is not likely a shortage of providers. In smaller areas the percentage of Medicaid patients per a given practice can be quite high and reimbursement for office visits are extremely low.

    • Chiked

      “But why doesn’t whoever is paying for it balk?”

      In one word, lawsuits. You can balk all you want, but one bad case that hits the press can erase years of business logic.

      The same thing for doctors. No matter how silly the ER visit is, not one of them will dare send a patient home because there is always a 0.00001% chance that that paper cut may be a flesh eating infection. No doctor wants to risk his or her career.

      You want to end unnecessary ER visits, get rid of the lawyers. Better still, stop electing lawyers as presidents.

      • Patient Kit

        Unfortunately, I don’t have the power to get rid of the lawyers. But, at least, I use the ER sparingly and responsiblely.. And I’m the least suit-happy person you’ll ever meet.

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