Bring It On

Hello, GruntDoc readers! This is my first guest-blogging stint, but I’m a big fan in general of neighborly community behavior. We have friends pick up the mail for you when you’re away, maybe feed the cat, so why not maintain the online presence, as well?

Especially when the online presence is that of GruntDoc, who’s been a dedicated supporter of medical blogging in all its forms, including Grand Rounds (he is a three-time host, I interviewed him once for Medscape). GruntDoc has also been a source of tips and commentary to MedGadget, another blog I contribute to (in fact, when we got the tip about this cricothryroidotomy keychain, I immediately thought of him).

GruntDoc encouraged me to rant during my stint here — I think he’s trying to keep things lively, or maybe he knows how much I have to reign it in usually, as an intern blogging under my real name.

I’m not sure this is a rant, but I do want to address Symtym’s assertions on what’s really an emergency. He quotes a figure I’ve heard, and verified — 100 million visits to US Emergency Departments each year (I’m getting numbers from Richardson AEM Vol 40, p 388).

100 million A huge number, to be sure, especially given the US population of 300 million. So it’s easy to say we’re in crisis now, everything is an emergency, forces have conspired to make people think they should use the ED for hangnails and stuffy noses. right? guess Well, guess how many visits were logged fifteen years ago: 90 million.

OK, now maybe there was wild misuse of emergency services in the early 90’s, too (I wouldn’t really know,  I was in high school). It seems, though, that the problem isn’t that there are more people using ED’s  inappropriately, or at least, this isn’t a terribly new issue. Rather, it’s that there are fewer ED’s around, so we’re all feeling the crunch more.

As for those 100 million visits, does that really mean that one third of all americans go to the ER each year? Of course not. Me and my two friends sure don’t, least not yet this year. Meanwhile, I can personanly vouch that some of our "regulars" chronic homeless alcoholics use the ED 100 times a year. How big a problem is this? I’ve blogged about it before, it’s a big problem and accounts for a substantial fraction of ED expenditures.

What about all the 70-year old diabetic hypertensives with chest pain? They come in every three or four months with disturbing symptoms. The 80-year olds who feel week and dizzy, maybe they blacked out for a second. These are real complaints, real emergencies, they need workup, every time. 

As for the hangnails, the inappropriate use of ED services, it’s actually notoriously hard to calculate how many are seen inappropriately. People have tried (Richardson, again — maybe I’ve worked with her, once or twice). The bottom line is, it’s hard to measure inappropriate ED use, and efforts to deny care to non-emergent situations may end up costing more, and/ or causing bad outcomes. Researchers try to quantify it, but existing denial of care methods just don’t seem to be worth it, and the estimated savings may be exaggerated as well.   

You can blame "themes of entitlement" and whatnot, and I’ve found doing so provides some comfort when you’re stressed and feeling put-upon by those few demanding, unappreciative patients. But, when you really look at it, it’s hard to blame the patients.

And, you know, as an intern, I’m going to get paid the same living wage whether I see a dozen patients a shift, or two dozen. But I keep trying to move quickly, providing good care and pleasant bedside manner, because I want to see as much as I can, and I’d like patients to get a favorable impression of our hospital and ED. If they end up realizing that we, in the ED, can provide services faster and more completely than if they just showed up unscheduled to their primary care doc, well, good for us.

Look, I’m not trying to debate ED access or government incentives to waste — that argument sprouts up every few weeks on the blogosphere and there’s already a good iteration / continuation in progress over at Grahamazon. I’m just trying to, well, figure out the right mindset and perspective to approach my job, and avoid becoming as jaded, down the road, as some others appear to have become.

— Nick


  1. Goatwhacker says:


    I think you’re mixing two questions and that makes it harder for me to understand your conclusions.

    The first question is the one you answer, namely how should you act on an individual basis towards patients. Your answer is correct, you try to be nice, prompt, capable, a good representative for the hospital, etc. That’s absolutely right, your main responsibility is to be a good doc and all that entails. The fact that you may feel they are misusing resources doesn’t justify rudeness or doing a half-assed job.

    The second question is how should we feel about ER misuse in general, does it exist, how much, etc. Even though you say you don’t want to debate the issue a large part of your essay touches on it, indeed a lot of the post seems designed to minimize it. It’s a problem, not only financially but also in that most docs, including ED docs, would agree the loss of continuity of care in patients using the ED as their primary physician is detrimental to the patient. If you ask a patient who his regular doctor is and he names an ED resident, that’s a problem.

    So when you say “we, in the ED, can provide services faster and more completely than if they just showed up unscheduled to their primary care doc, well, good for us” – yes it is good for you and reflects well on you but unfortunately it perpetuates a much larger problem. It comes awfully close to saying “ED docs are going to be the primary docs for everyone, and that’s fine”.

  2. I think you need to contrast how an ED works compared to a private physician’s practice, in terms of how and to what extent problems are dealt with.
    It is not necessary to track down every single symptom and satisfy every single medical question that might come up. There has to be a sharing of responsibility with the patient, that they are told, “Ok, we’ve ruled out serious, life-threatening problems as well as we can, but you need to follow up with your primary care (or other) physician.”
    One thing I’ve noticed in ED notes is a trend toward using either paper checklists or computerized clicklists — two versions of the same thing. Often it’s hard to discern what history was obtained, what exam findings were present.

  3. Sorry, Goatwhacker, that I wasn’t clear. I guess what I’m trying to say is the following:

    1) the question of ED misuse is a complex one — there’s certainly more to the story than just saying “only 16% of presentations are true emergencies” or “100 million visits a year is too much”.

    2) For people to conclude that there IS widespread misuse (as opposed to just general overcrowding) from this conflicting data is just glib and potentially corrosive — while the jury’s still out, I don’t want to believe my services are being abused, that 84% of my patients shouldn’t be in the ED.

    So what are the options? I guess it’s either: denying care to some, fighting to change the culture of entitlement, or, you know, maybe providing some primary care in the ED (along with an appointment to the primary care clinic and a speech about the benefits of continuity of care).

    I’m happy with the third option, while wishing the best to those developing safe denial-of-care schemes, and those trying to change incentived behaviors.

  4. TheNewGuy says:

    If I’d wanted to do primary care, I’d have gone into FP or Internal Medicine. The fact that I end up doing a lot of Primary Care is not the point… it’s not what I was trained to do.

    When I was a resident, it didn’t matter how many non-emergent patients I saw either. It also didn’t matter in the military, since the ER was basically a late-hours peds clinic, and I was under the thumb of my commanders. However, when I joined my democratic group, one which does its own billing, I actually saw how much these folks cost the hospital AND us. It doesn’t mean you treat them like dirt, or lower your standard of care, but you can certainly call a spade a spade.

    Perhaps I’m a voice in the wilderness here, but I believe the ER exists for actual emergencies; we are poorly set-up to provide the type of continuity that complex multiple-medical-problem patients require. We are also a very expensive alternative to a regular doctor’s office… which doesn’t bother patients who aren’t paying for their care, but IS a problem when that higher cost gets shifted onto others.

    Some non-emergent complaints may ultimately make some money for the hospital (though medicaid now routinely denies our level-1 charges across-the-board), but those patients take up beds and clog the waiting rooms, and are a distraction from the critically-ill patients that are the focus of an EM physician’s training and expertise (particularly when they stand, arms-folded-and-scowling in the hallway, bugging your nurses about their discharge paperwork).

    We are not a convenience clinic… and the fact that people treat us that way doesn’t mean we should accept it. It’s also axiomatic that those patients who use us as in that fashion are those who complain the loudest about the wait… they came to the ER for convenience, and anything that inconveniences them further absolutley incenses them, causing nasty evaluations to the administration, resulting in yet more wasting of resources.

    I quit lecturing; it doesn’t ever work, and many of these folks never attend their follow-up appointment. There are people in the world who have no shame whatsoever, and if it doesn’t cost them anything, they could care less. The only way to change their behavior is to turn them away, or increase the apparent cost. “Free” anything is a HUGE lure… why go to a walk-in clinic that requires payment up-front?

    Doing a MSE in triage, and advising them that they will be seen for their non-emergent problem, but that it will cost them X dollars? They’d vanish like smoke.