I wrote a post a few weeks ago about House and Greys and ED overusage. Here is a comment from that post:
Nice theory. I'd like to add on to it.
If you're pretty sure you've got a complicated problem, the LAST thing you want to do is go to your regular doctor.
Why? You call your regular doctor. Now you have an appointment tomorrow (if you're lucky). He decides you need a specialist. Now you have an appointment for a specialist next week (if you're lucky). The specialist decides you need some imaging/lab tests. Those tests get run within the next two weeks (if you're lucky). You don't get the results for a month, which is when you are scheduled to see the specialist again. Maybe you find an answer. Maybe it's more appointments, more specialists, and more tests.
All the waiting between appointments (presumably while feeling poorly) plus all the time off from work plus the travel time to/from plus the "doctor is inevitably running late" time plus all the fragmented care (just to MAYBE get to the bottom of your constant abdominal pain) equals frustration with the current system.
When I have a choice between waiting eight hours for an answer or waiting for nearly two months, I would rather wait eight hours, thanks. I'm tired of doing year-long dances with doctors ten minutes at a time until they finally stumble headfirst into an answer.
WHOA!!!!!
Now Cathy, I'm sure you're a wonderful person, and maybe this was all sarcastic and tongue-in-cheek, but for the sake of this rant, I'm assuming you are serious. It is disheartening how many people truly believe exactly what you speak of and have no idea the consequences of their actions.
We have become a selfish, "right now" society. I believe it is one of the main contributors to ED overcrowding. We have decided that we must have everything from our hamburgers to our medical diagnosis' RIGHT NOW. It doesn't matter the consequences it may have on ourselves, our neighbors, or our society. We need to know RIGHT NOW.
People from all walks of life view the EMERGENCY room as one giant "right now" clinic. Simply show up at any time of the day, talk to the magical, all knowing Dr. and he/she will fix you.
Never mind that he/she was trained in EMERGENCIES and has very little knowledge as to the differential diagnosis of your vague symptoms.
Never mind that the EMERGENCY room is for EMERGENCIES. People consistently show up at ER's all over the country expecting us to cram in 8 weeks worth of tests into 8 hours regardless of the acuity of the problem. They "cant wait" for numerous doctors visits. They HAVE to know now. Their belly has been hurting for 3 weeks but TONITE they NEED to know.
Never mind the fact that the bed you take up could have been used for the septic cancer patient who's waiting in the waiting room. Her vital signs not bad enough "yet" to bring her back to a room. So she waits as you, Cathy, take up a bed in the EMERGENCY room because you couldn't stand the multiple Dr.'s visits.
Never mind that by the time we do your 8 hour work up and discover nothing, convince you to utilize the system properly and see your Dr and get you out of the room, she's tachycardic and has a marginal blood pressure and was robbed of precious hours of fluids and antibiotics because you had to know "right now".
Never mind the time spent explaining to you that this is not an EMERGENCY and despite your desire to "know right now", we most likely cannot or will not come to a diagnosis in the ER.
Never mind the fact that those minutes could have been spent deliberating subtleties of an EKG that may or may not have led to a life threatening, EMERGENT diagnosis.
Never mind the time you spent on our CT Scanner getting your pseudo-emergent scan and the time it took to get you off the scanner so we could scan the head of a potential stroke.
Never mind that those precious seconds could be the difference between full recovery and life in a nursing home.
Never mind THOUSANDS of extra dollars it takes to do this work up in the ER instead of as an outpatient. The insurance companies pay for it.
Never mind the fact that those dollars get spread back to you and eventually forces a single mom to drop her coverage, lose her PMD and leads to her bringing her 4 year old to the ER for an earache thus completing the cycle.
Never mind the fact that the EMERGENCY doctor was looking up the differential diagnosis of your vague symptoms instead of picking up the chart of the "chest pain".
Never mind that it turned out to be a patient with an aortic dissection who ended up coding and dying because his blood pressure wasn't controlled on time.
Never mind any of those things, Cathy, because you need to know right now...........
31 comments:
You could use the same logic to argue that doctors who do plastic surgery (for example) are immoral. After all, they could be in the emergency department helping scan the potential stroke too. And "high-end" doctors who see fewer patients and charge more are also being immoral under this logic.
You see this kind of asymmetry in a lot of morality-based arguments. The fact of the matter is that people should either be incentivized to go to their doctor for financial reasons (or by having the emergency department just refuse to treat non-emergencies), or the EDs should scale to a size such that the people who want to get treated that way. You can blame a particular group of people for not doing the "right thing" even if it isn't in their interest, but what about everyone else, in all of those other situations?
the problem with that, anon, is that the ER CANNOT refuse to see non-emergencies.
There's a law called EMTALA which says we have to see everything that comes through the door.
One of the other bloggers out there has a nifty triangle shaped diagram that has 3 words on it....Fast, cheap and good. BUT, the catch is that you can only pick 2...so you either get it fast and cheap, fast and good, or good and cheap....but you can't have all 3.
Americans as a whole want all 3 but it's not feasible to do without stressing the system.
Nevermind the fact that the patient in ICU who critically needs lab work, or radiology has to wait because ER patients are done first.
Nevermind that the ICU nurse is trying her best to keep that patient alive while some selfish, childish, person thinks her time is more valuable that other's lives.
Right on response Suburban Doc.
In response to the original post.
I agree the internet and TV shows and media sensationalism add to it but....
Haven't you heard? George dumber-then-a Bush encourages it!
Let me talk about health care, since it's fresh on my mind. The objective has got to be to make sure America is the best place in the world to get health care, that we're the most innovative country, that we encourage doctors to stay in practice, that we are robust in the funding of research, and that patients get good, quality care at a reasonable cost.
The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.
http://www.whitehouse.gov/news/releases/
2007/07/20070710-6.html
Paragraphs 15-16
Amen Suburban Doc!
Reading through the Med Blogs, it seems this truly isn't local or regional, it's every dang ER in every town and city all across America. You state the struggle so clearly that we all face. I don't get too frustrated dealing with "paineurs" of all varieties, when I'm not worried about the little old lady 10 charts deep in triage, especially with all the BS from the "clickity-shoes" crowd to "immediate bedding" for every lame excuse for an emergency that piles in at 1am. At its worst I want to take the whining sprained ankle by the hair and drag them into the trauma bay and let them see some protruding bones. OR the folks you do a cardiac workup on 10-12 times a year (with a dispo of NCP every time) and let them see a person ashen, diaphoretic, vomiting and getting what is needed when truly time is muscle. The 6 wk pregnant teen (not named Bristol, my tax dollars already paid for her 6wk US) who has "cramping" without discharge and has already had an US last week when she came in for nausea, should have to help the mother having a miscarriage and needs 2 wide open IV's, and a frantic attempt to get blood from lab, while what seems like gallons pour from her while any attempts at pressure, packing do little to stem the flow.
Each night I try to count the "real emergencies" those who would truly suffer death or permanent disability by delays in care, and sadly I average about 15%
as always, I remain professional, pretend to really give a rats about the band-aid-able <1cm lac, from yesterday morning, and blast through the intake as fast as possible to get back the the little old lady. Of course then the clickity shoes chart vultures (never a shortage of those, but wheres another dang nurse or tech?) send me nasty-grams that i didn't sign the third page of the chart and write the strength and last dose of the lac pts stool softener on my JackaHo med rec form. Thanks again Suburban Doc, You Rock. I still wouldn't trade my job for most others, it is a practice in suffering, that we as ER workers may someday transcend the fleeting, blip in time we experience as our lives, and hopefully come through into a greater unified consciousness...
bahh sorry to ramble its late and I need to rest.
may the LawdHaveMRSA on our souls...
Here in Israel our system works thus:- If you go to the ER when the health services are open _without_ a referral then you pay (except for specific cases). If you go via the health service (diversion via centre + wait of a reasonable time (not that it seems reasonable to the patient) then you're OK. If you call an ambulance and it's not medically needed - you pay. If it's OK medically, the health fund pays. If you want to see a GP you can normally see one the same day or max after a few days. For specialists - after a few days - and sometimes the same day (depending on workload) - only a few of them require an actual referral. Blood tests - referral from GP - next morning tests - results via internet.
We all complain non-stop - but it works well.
Hmmm, that Israeli system sounds pretty reasonable. People who PAY when they abuse the system? NZ has a good system too. Perhaps we in the US, Canada and Britian need to look more into those systems, since the ones we have certainly aren't sustainable forever.
Man, that was awesome. It's like watching a tank returning fire on a pea shooter. I applaud you.
EMTALA demands a medical screening exam to determine if a state of emergency exists. I would like to see more in-and-out visits (actually I don't know because nursing responsibilities are very front-loaded) where the doctor determines the relative danger that the patient is facing, and then 85% of the patients get kicked right back out the door, maybe stopping by x-ray on the way out.
The problem: lawyers.
Save the healthcare system. Shoot a lawyer.
Dead on, Doc.
You alluded to this in your answer, but I think it needs emphasis:
Cathy, the reason that your personal medical doctor (PMD) sent you to a specialist, and the specialist sent you off-site for tests, and the whole process takes a long time is, that is the way to give YOU the best care. Your PMD probably had a very good idea what was wrong with you, and how it should be treated, on that first visit. Several decades ago, he or she would have prescribed treatment that same day, and off you would go. Very convenient, and far less expensive than modern medicine. So why do we do all the other, time-consuming stuff? Here’s why: Specialists in medicine used to be very rare, now they are common. Elaborate diagnostic tests (too technically complex to be administered in your PMD’s office) did not exist in past generations, now they do. Today’s doctors can do so much more, diagnose so much more accurately, and treat with so much better results than thier predecessors. However, doing more and doing it better does take more people and more time, which does require some inconveniences for the patient. It also means that more lives are saved and more bad outcomes prevented. It’s a trade off (like everything else in life). We think that those extra lives saved are worth some inconvenience. But hey, that’s just us.
What do you think?
I absolutely agree that Emergency Departments should be used for genuine emergencies only, and never for one's own convenience. I hope my family and I never abuse the system.
OTOH, the current refer-test-refer-test algorithm can result in a ridiculously long wait for diagnosis and appropriate treatment. For example, it took well over a year to get a dx of (now chronic) costochondritis for my 17-year-old daughter. That was incredibly frustrating.
Last ANON, we've been working our daughter up for about a year now for vague complaints. You know what? It is frustrating. But to take her to an ED wouldn't be any better, because those docs wouldn't help anyway with vague, difficult to diagnose complaints. Not to mention, by waiting, you get the advice of people who have trained for countless years (fellowships are avg 2-3 yrs above and beyond) to look at one organ or system. How could and ED doc match that expertise? And that's before I even echo the utilization argument above. Perhaps you already know this, if so sorry for the rant.
As a species we gravitate towards simple, dramatic situations. I love ER diagnosis because they are big questions--is this person dying? If so, which system is affected? If I get that, how best to treat it? That's it.
Even as a young resident I've already gotten my 'we don't know what you have but we know you DON'T have this' speech down.
Well written Suburban Doc. Just when I thought you'd run out of steam, you just kept on going. Hurrah.
First anon, your argument about plastic surgeons doesn't work. Although you could argue that the number of docs is limited, on a per-patient basis at a given time the number of docs trained in EM is not the limiting factor, rather the resources of a specific microcosm ED. The patient that has no emergency directly affects the care of all other patients in that microcosm adversely. There are good studies to show that crowding adversely affects care without any sustainable level without some loss, see Annals of EM a couple years ago.
So there is a direct effect on measurable, finite resources. The number of physicians who choose EM is not the problem. And it's not a moral argument, it's a resource utilization argument.
You know I never thought that the people coming in to the ED were overracting, hypochondiacs. I use to be like Cathy and I thought that the people who came into the ED were those who had a real reason to be there and those who had no insurance and they waited till they were in dire need of care to go to the ER.
Now don't get me wrong it's really not my fault it's people who told me for years that the people in the ED were noninsured, poor people and illegal immigrants, which I found out that it can't be illegal immigrants because they are too worried about getting deported.
I use to be one of those people who were ready to go to the ER for some thing that might be minor, not that I have gone to the ED but if I in the middle of the night had an issue I would go on webmd.com and do my own diagnosis and there have been a few times I was ready to go to the ER cause I thought it was something serious from the list of problems and diseases that they show. So far I have just waited out till the morning and called my doctor for an appointment, happy that it was just some minor problem and I was only overreacting to what I saw on webmd.
I think from now on when someone asks mr why I think the ED number of people is rising I will throw out there the minor problem overreacting people.
Tyro,
You're right, of course. I never took my daughter to the ED for her costochondritis because we knew it wasn't an emergent or life-threatening problem. I'm just lamenting the alternative route, where you sometimes have to see a number of specialists over a protracted period of time just to get a dx of a (thankfully) benign condition.
I suspect if the rib hadn't actually popped out of place a couple of times, and if she had responded to the first course of prednisone, our primary care MD would have dx'd her easily. I also think we complicated matters by taking her to the (referred by our PMD, I swear!) chiropractor for so many "treatments." I suspect the repositioning may have exacerbated the inflamation, complicating the dx.
So I guess I was just venting my frustration that the process took so long, and expressing that I could understand why some people might think the ED could offer a quicker "fix." You absolutely make a good case for why this isn't true. Thanks for the reminder. :)
I hope your daughter is feeling better soon.
(the "LAST" Anon)
Beautiful rebuttal!
OK, now add these 2 other HUGE frustrations: our ED director is worried abiut losing"business" to even the CVS clinics! So smile, it's all about "the customer". New stae law: no more ED diversions starting in 1/09.......some of our "customers" are experienced enough to call EMS for things like chronic back pain in hopes of trumping those in the waiting area....
I've brought my daughters into the ER to be seen in fast track for mild sprains because I can't get them into the pediatrician's office within 24 hours, and if I send them to school without a doctor's note they can't wear an ace wrap, they can't have any advil or tylenol, and of course the school nurse treats me like a child abuser, because the only reason to not take your kid to the ER for a minor sprain is that you caused the injury yourself. (Of course this is also the same woman who assures me that all of my daughter's ortho and orthotist appointments for her scoliosis can be made outside of school hours.)
I wonder how many other parents end up hauling kids to the ER for things they know aren't emergencies, just to cover themselves legally.
There's another side that I'm surprised has not been addressed here, and that is OTHER DOCTORS who abuse the services of the ER. Let me explain.
Recently, several PCPs decided that they were going to go on vacation. However, instead of arranging for coverage and on-call services, they instead told all of their patients that if they had any problems to go to the ER.
Need a medication refill? Go to the ER.
That medication I prescribed last week is making you puke? Go to the ER.
You're still having problems with that UTI? Go to the ER.
These are all minor issues that could have easily been taken care of by a covering/on-call physician, but instead, these physicians all told their patients to go to the ER.
The ER was fit to be tied.
I would also like to address the raelity of Cathy's post. Yes, I know people abuse the ER. I've heard of some REALLY stupid stuff, but on the other hand, we have had patients who DO call their physician for a relatively serious problem and are told that they next appointment the PCP has is in two weeks. My own aunt was in contrast-induced renal failure, puking her guts up, and bloating up like a puffer fish. She developed this condition after an MI and cath, but her PCP kept blowing her off and telling her it would be 2-3 weeks before she could be seen, patronizing her, and telling her to just keep taking her medications. When she finally saw her cardiologist for follow-up, he took one look at her, drew a lab panel (creatinine of 6!!) and sent her straight to the ER.
My point of that is this: What responsibility do OTHER PHYSICIANS have regarding ER abuse? Shouldn't there be sanctions against physicians and health-care providers who are too lazy to secure vacation coverage or arrange for on-call service after 5 p.m. so instead send all their patients to the ER?
It's easy to beat up on patients, who really and truly may not understand the process than to look at *all* the reasons people scurry off to the ER for even minor problems.
Yeah, there are the frequent fliers, but I'm talking about the others. The one who called the pediatrician at 9 p.m., saying their kid was screaming with an earache, and the pediatrician acted like the mother was stupid and told her to go to the ER. THAT'S what I'm talking about.
~Anon third person.
My comment was not tongue in cheek. It was a legitimate expression of why I think many people will go to an ED instead of a PCP. It was not an expression of why I, personally, go to an ED.
The part where I said I would choose to do such a thing was meant to be made more clear -- such that it would appear to be the thoughts of a generic person and not specifically my thoughts. I take responsibility for muffing that.
The non-hospital medical system is seriously broken. It's gotten beyond all reason. The doctors in private practice (and the specialists) all want to work the same hours as the general public. There are precious few places one can go to get timely care when it is not possible to take much time off work.
To have meaningful reform of ED overcrowding issues means to re-work US health care so that things can be done in as few appointments as possible, at hours convenient to the patient. This is not about a "right now" culture. This is about people who can't afford to have a long, fragmented series of daytime appointments because of their work environment or their situation in life. My mother once used up every last hour of her paid vacation one year taking my grandmother from appointment to appointment, from specialist to follow-up to lab test to specialist to follow-up to PCP, repeat.
If people could just call in sick one day, go to some magic place where most of the lab equipment and specialists were available same-day under one roof, more people would probably do this. But the local hospital is the only place these days that can do something like that, because hospitals remain centralized instead of spread out into specialist enclaves all over the bleedin' landscape.
Now I hope I made my point clearer.
Cathy says:
"If people could just call in sick one day, go to some magic place where most of the lab equipment and specialists were available same-day under one roof, more people would probably do this."
There are plenty of places like this. Look up Group Health or Kaiser Permanente to start. Also, many diseases are not "curable" in one visit no matter where you go.
Braden said:
"There are plenty of places like this. Look up Group Health or Kaiser Permanente to start. Also, many diseases are not "curable" in one visit no matter where you go."
News flash: Kaiser isn't everywhere, and neither is Group Health. Please do not assume that because something is available in your area, it is available everywhere.
We live in a rural area. The closest ANYTHING is an ER at a rural hospital. There are some PCPs surrounding the hospital, but that's it. Good luck getting an appointment within 3 weeks, and if you go there, oftentimes your insurance or other provider requires that lab be drawn and sent to an outside lab or that the patient travel a significant distance to a CT scanner or MRI.
With the economy the way it is right now, people can't afford that. They can't afford the time off work, the gas it takes to drive some 50 miles and back for a CT scan that they'll have to wait a week for the results and only then can find out what they are at their PCP's office.
I personally have been told, when I had to take my child for a follow-up for a serious medical issue, that I was very close to being let go, and yet I had almost two weeks worth of time off available to me. Illegal? Yes, but when you live in a state with at-will employment, taking time off to spend hours in a physician's waiting room can mean the difference between having a job and keeping your house or getting that sinus infection cleared up. Some people will live with it and become more ill; some people will show up at the ER or Urgent Care.
Physicians and healthcare providers need to stop this passive-aggressive attitude and just start TALKING to their patients and offering feedback to their fellow physicians and providers. Find out WHY patients are doing what they are doing. Tell your buddy that it really angers you because he sends all his patients to the ER after hours. Get INFORMATION. Educate people, "Why did you come to the ER instead of calling your primary care physician?" No, I am not assuming that people don't. There are some who do, but for many there seems to be an attitude that it is safer to assume that someone is an ER abuser rather than looking at a patient who is at their wit's end and just needs someone to make it better.
People need to quit living in a fishbowl and making claims based on their own personal views because otherwise it might require looking and living outside the box. And before someone accuses me of doing the same, I've lived in a huge metropolitan area and seen the abuse, but I've seen the desperation as well.
My queestion is: Who has the guts to try to fix it rather than complain about it?
I guess my question is is there anyway to bypass the EMTALA? Something like a privately owned emergency room - tied to a urgent care unit - that requires patients to sign disclaimer/waver of some legal rights to receive medical care.
That way the ER has the power to say "NO!" to non-emergency freeloaders with out being sued. And for those who need "non-immediate attention" they are given an appointment with the urgent care (which holds non 8 to 5 hours to cover the 8 to 5 workers) and thus sent home.
Or is this completely erroneous? Any ambulance chasers browsing the site who can shoot this down?
Or how about sticking a PA/NP in triage who can fulfill EMTALA requirements of a full examination and can quickly dismiss "frequent flyers" to reduce costs? Just bouncing ideas here folks... not wearing my flameproof underwear, so please be kind to an ignorant pre-med, ok?
A lot of places already have a PA or even a Doc in triage to do just that. The problem is that in today's CYA lawyer-ridden society you can't forget the other part of EMTALA that requires not only a medical screening exam, but also "stabilizing treatment" and if patients come in complaining of neck or back or abdominal pain and you just send them out the door without radiology or blood tests, there is always room for a particularly smarmy lawyer to squeeze in.
reading this post i must agree with you. yes there are many people who will abuse the ER. but it doesn't help when the hospitals stop offering urgent care and simply combine it with the ER, which only increases the wait times and frustration. i try not to use the ER however it cannot always be avoided. such as when you fall and break a leg on a saturday night, with no chance of getting seen otherwise before monday at all.
I work in a 60+ bed, inner-city ER and Trauma center and I can't tell you how much I want to kick people in the teeth when they come in with pseudo-emergencies. Let me offer a few examples: 1. 1 20 something male comes in at 3 amd with his sister and her 3yrs old daughter literally demanding to see "the dermatologist on call" for acne. 2. A pathetic, ingnorant 19 year old female wants a pregnancy test. She hasnt taken a test at home, but she thinks she's pregnant because her boyfrien ejaculated in her 2 weeks ago and she "must be pregnant". 3. A 30 yo female calls 911 and comes in by ambulance because her cat scratched her face in the middle of the night. 4. Another wants her coumadin level checked because she didnt follow up with her doctor 2 weeks ago and she needs to know "NOW" what the level is even though she DENIES any symptoms. 5. And my all-time favorite complaint "my finger doesnt make a fingerprint"!!!!!!!! So, because we cant refuse to see these patients, those with real emergencies suffer. It is upsetting to know that we waste our time with this crap when we should focus more on those with strokes, heart attacks, organ failure, gunshot/stab wounds,etc.
Two words: URGENT CARE
For those who feel like their urgent but nonemergent issue needs to be addressed immediately, the the urgent care center instead of the ER. They tend to flow much quicker, and you won't be waiting in line because you're also competing with a spot that an emergent patient needs. And even if you don't have health insurance, urgent cares can be as cheap as about $50 per visit versus the several hundred dollars you pay for a nonemergent ER visit.
People need to realize that we are MD's not GOD's. Sometimes people have diseases/problems which we just do not have a solution for or know what it is. So expecting to ALWAYS get an answer in a one shot visit is naive and unrealistic. And to go to an EMERGENCY room for a non-emergent issue is just plain dumb. An emergency specialist is trained to do things like intubate, put in central lines, keep someone's blood pressure up when they're septic, take care of a heart attack, etc... So going to the ER hoping for a one shot diagnosis on a rheumatologic problem for examble isn't going to happen since we didn't train in rheumatology. We're just going to send you right back home and refer you to a rheumatologist. Besides many diseases require time to "tease out" and diagnose, and medicines take time to work and need to be re-evaluated over several weeks.
For the record:
Don't tell us "you have that in the computer." How do you know what we have in our records; Are you the one typing them? And no, not all hospitals use computers, not everything about your prior visits are stored in the system. Also most ER systems don't have your inpatient records or outpatient records either, only your ER visits.
Don't tell us what to order, esp. MRI's. Most ER's don't have access to MRIs unless "approved" by a specialist or radiologist who are usually unavailable in the middle of the night. Also, if you are better than the ER doc at deciding what sorts of tests you need, then why the hell did we go into debt for $150k+ to study all those years, and work for less than minimum wage as a resident slaves afterwards?
if the hospitals around here still had there urgent care then it would be used by many students that i know. however about 9 years ago the hospitals in Tucson made the lovely decision to merge there urgent care and ER into the same department so that it's even worse then it was before. even a middle-schooler in extreme pain from a nasty ear infection could tell that it was a bad idea. *shakes head* just makes me glad my dad has the sense to not take my sister the the ER if he can get an appointment with her pediatrician.
Boy, if that doesn't sound like your typical suburbanite, insisting that you get them into the office ASAP for a sniffle and get their child's acne medication filled immediately because it's "just a box" ahead of the two year old with a chronic ear infection who's been screaming for the last hour or the family member of the transplant patient who is patiently waiting for a slew of medication to be filled so their family member may be discharged.
Medicine is NOT a "right now" thing. If you are so lucky as to have insurance to provide you access to all those specialists and tests, stop looking that gift horse in the mouth.
Seriously.
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