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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