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.

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.

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”.