The Clinic

Sometimes it’s a bit bothersome to work in the ED, especially when working a late night shift.  I’m referring, of course, to the ‘clinic visits’.  “Vagnial discharge for 5 months”, “rash for a year”, “back pain for 5 years”, “cough for 9 months” are hard enough to see when the sun’s up*, but when they present after 1AM they’re utterly toxic to the soul of the Emergency Physician. 

Look, we’re all circadian creatures of a sort, and it’s utterly crazy to think that at some point that morning your patient decided ‘you know, that problem I’ve had for months?  I think I’ll take it to the the ED, because it’s an emergency now’.  When these patients introduce their complaint to an ER doc who’s up not because they want to be but because they have to be, the doc might be forgiven for thinking “I’d be in bed were I you”, or occasionally worse.  These same patients who present at 2PM are mildly bothersome, but not really an issue; the same complaint at 2AM will get the doc’s attention, but in entirely the wrong way.

I’m of the opinion there’s not enough of a night-time charge for ED visits, but that’s back to the $5 to be seen, but we’ll give you $5, and by the way, there’s a $5 ice cream machine by the lobby door conversation.

I’m just tired of being an emergency physician who works an expensive after-hours clinic.  The case that set this off was “I have a toothache for three weeks, and I want to be checked for a discharge I’ve had since my miscarriage”.  How long ago was your miscarriage?  “5 months”.



* Like in any ED you can tell if the sun is up.  Every one I’ve been to is like a submarine, it’s the same inside day in and day out.


  1. Anonymous says:

    VERY timely post! I just got off an 11p-7a in the basement myself, and had the exact same discussion with my fellow residents, when, at 4 am “skin rash” popped up on the board!! Why in god’s name is that a) an emergency and b) and emergency at 4am???

  2. Ugh. One night I had a patient with cc: butt twitching x 3 months. How do we make them go away? They need to be penalized somehow for using up valuable resources – Mr. Butt twitching kept me from Ms. disecting AAA. Thank God she made it…

  3. If they are polite and don’t complain, then I don’t mind seeing (and treating) them after I’ve evaluated everyone else. But if they start mouthing off then they’ll get the “medical screening exam” and OTD.

  4. Anonymous says:

    How much does it cost them to go to the ER?

  5. I usually tell the triage nurse to have them return at noon when fast track is open. But the nurse never listens to me.

    I am a lot more tolerant if these people have waited 4 to 6 hours to be seen by a doctor. These folks I can respect. I feel if they are desperate enough to wait so long then I can be nice enough to pay attention and care. I also think they need to get a real job too. Because no one with real responsibilities will spend so much time in the ED for something so trivial.

    But I always have in the back of my mind that one these patients may have an actual medical emergency, but most times I am sorely disappointed.

    I have always said I went into Emergency Medicine because it had just the right amount of primary care.

  6. We are located next to a major sports arena and got a 20 year old kid with an emergency “heat rash” from “sitting on his sweaty butt” for too long. The triage nurse gave him some complementary butt cream and sent him away after a lecture on how inappropriate his visit was.

  7. How much does it cost them to go to the ER?

    It’s based on the acuity level of the patient and how many drugs/treatments/equipment/time/supplies were used. 4 stiches for a small finger-cut is $700 at my facility, for example. It would probably be $150 or $200 at an urgent care clinic.

  8. TheNewGuy says:

    It’s remarkable how ugly people get when given the MSE and out-the-door treatment. It’s one of the things that leads me to believe that socialized medicine is inevitable in this country.

    People are convinced that they need every medical whim indulged, at any hour of the day, for absolutely zero money, and they’ll show their butt with gusto when told otherwise. The righteous indignation they manage to muster is truly impressive.

  9. As a resident in a military center, we see out share of crap complaints, maybe more than most given our relatively healthy population. For you private guys, (can’t wait to join you!), how do you go about doing your MSE and OTD. Can you give me an example of what you do and say? I’m still not sure about what the MSE entails. For example, rash x 4 months. Is it just vitals, glance at the rash, see it’s not emergent, and say solly cholly? I hate these with a passion, but it seems that since you have to document anyway, it would be more cost effective to just give a dx, add the rx for steroid creme or whatever and bill a level 3. Am I way off base? My time has already been wasted talking to the DB anyway.

  10. I couldn’t agree more – these people drive me insane. What’s worse is when you get a 3am toothache who comes in when there are loads of other sick patients (and you’re the only doctor on) AND they are impatient and rude and get upset about having to wait for 30 minutes while you take care of the heart attack next door.

  11. Well I don’t know about you guys but at my hospital these people either have the Gold Card (medicaid) or they are self pay, which means ‘no pay.’ We give several million dollars a year in charity care for complaints that in nobodies stretch of the imagination meet the definition of emergency. That means the physicians are working for free also. To top it all off, we got a 24 year old guy on permanent disability for chronic back pain who came in at 2 am asking to have a wart on his finger removed. Said wart had been there for several years, no changes and he just decides all of the sudden that it is an emergency and has to come off. The doc was not amused to say the least and he gave the patient the old ‘heave ho.’

  12. Steve,

    You can stop the work up anytime you think that no emergency medicine condition exists and send them out the door. For most of this dumb stuff though you might as well take one more minute and write a prescription of hydrocortisone cream and bill for the visit. The customer service complaints and hassles from administration are usually not worth being an A-hole. Yes, it is like feeding the bears and occasionally you have to give one a good beating with a stick.

    I was a military ER doc. There are certain things to enjoy in the military before you enter HMO, PPO, self pay, medicaid, EMTALA, panel call problem hell of private practice.

  13. I prefer to let them get so mad they LWBS so I don’t have to waste time talking to them. Sometimes they’ll figure out I’m the doc though, and they’ll come up to the desk while I’m charting and vent at me. That’s when I tell them their condition is nonemergent and that they can wait or not. You have to be blunt with them. I tell them I’m not a dentist or I’m not a dermatologist; I’m trained to evaluate patients for life-threatening conditions and their sinus infection is not an emergency. A chart review documenting a nonurgent complaint, stable vitals, and an exam revealing a patient who can walk and talk (loudly) is a medical screening exam.

    You don’t even have to touch them to bill a level one. You might have to look in their throat or listen to their heart to get the physical exam points needed for a level 2 or 3, so if I have to go into their room and lay hands on them, I’m going to do that stuff. For many of those patients with no insurance, you aren’t going to get paid no matter what you do, so it doesn’t really matter. And these are patients that are going to complain anyway, so you don’t have to worry about that.

  14. Paying to be seen in the Emergency Department?
    A dream come ture, and welcome to the wonderful world of Emergency Medicine in the British NHS.
    If I got paid for every stich I put in all the random drunks’ heads on a Saturday night, I would stop worrying about our mortgage….
    Our guys do not pay and therefore have no qualms whatsoever to pitch up in the middle of the night (and my night shift) for example to enquire whether it’s safe to go to sleep with a productive cough (I kid you not).
    Oh dear God of Young Doctors, can you please make the Brits recognise the error of their ways and of health care “free at the point of delivery”?
    Alternatively, could we mak a questionnaire mandatory? some thing along the lines of “was this an accident? is it an emergency? If you answered no to any of these questions, leave now or else…”?

  15. Well I was a E.D. nurse for years and I finally got past my breaking point. I worked in a few large urban hospitals the last one being a level 1 trauma center. The problems like gsw’s or a knife in the eye I could tolerate, but they are 1 in 20 the rest being found down drunk for the 5th time this week and it’s only Friday or the homeless people who want the three hots and a cot (they usually got my boot). Sometimes it was though the whole world thought that we were their personal maids and butlers attending to their bull—- complaints. And whenever the “patient” complains it seemed like management always sided with them even though the were a WPOS. I did have a lot of respect for some of the physicians because they saw through the cloud of complaints and didn’t order every test to confirm what we already really knew, drug seeking, lonely, or just plain nuts. I have now went to the other side and became a D.O.N. at a rehab facility, at least these people are really sick. So believe me every health care worker has seen the abuse of the system and we’re all sick of it.

  16. perhaps if enough non med types read this stuff they will eventually believe it. i can’t believe it myself when i see it but thes patients are everywhere i’ve ever worked. later.

  17. Well, if you were in pain, unable to sleep, what would you give yourself. You can delve into the stocked cabinet and give yourself what you need. Some do not have that luxury. Compassion has gone out the window! They do not teach compassion nor bedside manor in med school any longer. Just a bunch of chronic complainers who make a boat load of money for putting in a few stiches…then complaining about it! YOU all took the JOB!

  18. Reading all your threads actually made my stomach turn and feel that I cannot even trust my own Doc! Is that what he is thinking when I go in for a check-up or exam, or have a burning pain that will not subside, and/or not being able to get ANY sleep due to being uncomfortable! If you were in pain, could not sleep, or had a itch that drove you insane, ask yourself how you would want to be treated…or better yet, what meds you would give YOURSELVES??
    I read about this log in the press, I still cannot beleive how many docs out there have NO compassion, no empathy, or feel as if patients are lower/sub-human for having aches and PAIN, or, yes, an itch….or perhaps a bleeding finger that WOULD require a few stiches…or would you want them to BLEED all night, until it is OK with you, or better for YOUR schedule and needs…UNREAL!
    Just my opinion.

  19. I feel you all need to do a little soul searching and ask yourselves if this is the way you would like people to
    perceive YOU?? All of you DO NOT sound human, you sound as if you are all Demi-gods, or perhaps greedy, ruthless, cantankerous life haters! You make patients look like CRIMINALS for taking up what you feel is your valuable time! UNREAL!
    Yes, my job can be annoying also, but I do not think or feel half as harshly about the general public as you all do! I would not think of my CUSTOMERS as bothersome! Esp, when they are the bread and butter of the business and make up my payroll each week…

  20. Perhaps when you visit your own Doc, he will send YOU out the door, kick you to the curb and tell you to come back when it is convenient for HIM or when he is done eating his lunch or taking his break! Just wondering what you would say or do if you were treated sub-human like this, or perhaps when he examined you and just ROLLED his EYES at you for bothering him!….lololol

  21. That’s exactly what I figured! All of you are SPEECHLESS!

  22. Ann Marie,

    If I’m speechless, it’s because you’re the first to leave 12 comments on multiple different posts (and thanks for the 6 exact duplicates of the same comments on six different posts), and to do it all in less than 2 hours! Believe it or not, even I don’t visit here that often, so two hours isn’t that long.

    Frankly, for someone so appalled at the site contents you have spent a lot of time here. Thanks for visiting, but please don’t post duplicates in comments again, or all your comments will be held pending approval.

  23. Ann Marie T./ATGR04,

    Wow…someone really needs to chill out and realize what we’re actually talking about here. We’re talking about completely unnecessary visits to the EMERGENCY room after hours for problems that can easily be handled during a normal office visit.

    Even minor emergencies, such as sutures for a cut finger, are warranted at 3AM; however, problems that people have had for weeks, months, and even YEARS often arrive at the ED at all hours of the deep night. These are things that could very easily be handled if one had simply the foresight to realize that this is a problem that should be checked out and scheduled an appointment with their doctor. It’s ludicrous to think that your rash that has been itchy for the past 6 months suddenly got worse that night at 0315. You just suddenly got tired of it, and wanted a fast fix. Unfortunately that fast fix is much more expensive, and will probably end up taking much more of your time than an office visit that you could’ve scheduled 5 months ago. Let’s keep the emergency room available for real emergencies (heart attacks, acute strokes, diabetic comas, major trauma, broken bones, and even simple lacerations), and take your clinic complaints to a family doctor. I’ve recently been on the other side of the medical system as a patient and I guarantee you that in several (more than 5) office visits I waited less time and paid less money than one ER visit for a nonurgent problem.

    And if you want to cry about not having a family doctor because your job doesn’t give you insurance, look into the public health system. There are millions of taxpayers giving you free medical care at excellent facilities that you don’t want to take advantage of because you are too lazy to make an appointment. Like so many Americans today you want it NOW, you want it to be the BEST, and you want to pay NOTHING for it. Now who is the hypocrite?

  24. Ok, I perhaps agree with you on the subject of Urgent Care, should be what it is..Urgent Care, however, what is a person to do if they REALLY cannot sleep due to an itch? Suffer until morning?
    I am one of the lucky few who have good health insurance through my employer, and no I do not make urgent visits, in fact my own doctor has an “urgent visit” option for daytime appointments. I cannot help but think of your elderly patients, who sometimes only have YOU to resort to. They have no one left in this world, but YOU, to listen to their complaint and make them feel better (remember when you were a child, fell off your bike, ran home crying to your mother to get your sore bandaged and some TLC from your mother?). Do you recall how that made you feel and how LARGE you really thought that sore was? I think that is what these people are in search of and you are simply all they have left that will listen, understand, and perhaps give them a little TLC and make them feel a little better with those few moments of care. Or better yet, if your own mother was in a nursing home, and the NA had an attitude such as yours, did not want to be bothered, without changing her bed pan (she did not feel it was important enough or URGENT enough)would you want your mother, wife, family to be treated by a doc with such a bad attitude? You would want the BEST care for them. Yes, some abuse the system, but some are REALLY in need? Not all are out to ruin your day, or night shift. Correct me if I am wrong, but I can’t help but feel that this blog should be educational to enlighten other docs, not spreading a rotten attitude like a growing cancer that feeds off itself and gets larger, and larger… I think this is all part of the growing moral decay of our society. I’m just someone from the outside looking in and letting you know what I see.

  25. As far me being the “hypocrite”, you turn my comments into something that fits your needs, so you can keep complaining about your inconvience of patients. These days Med schools should call it just that…the hypocrite oath. If you did not want patients to complain, make urgent visits for minor injuries, or kick them all to the curb with some cream, why didn’t you become a VET?

  26. And for EJ: You sure assume alot, I’m sure you do the same with all those late night annoying patients! To assume the following comment you made regarding me was a real knee slapper! Goes to show how much you THINK you know about me. You just ASSUME we are all the same and you are the Demi-god above us all!

    And if you want to cry about not having a family doctor because your job doesn’t give you insurance, look into the public health system. There are millions of taxpayers giving you free medical care at excellent facilities that you don’t want to take advantage of because you are too lazy to make an appointment. Like so many Americans today you want it NOW, you want it to be the BEST, and you want to pay NOTHING for it. Now who is the hypocrite

    And yes, my profession allows me to spend 2 hours on a blog, I would think YOURS is MUCH more important and time consuming than mine? According to your entry you don’t want to waste valuable time on annoying late night patients, and yet you have all the time in the world to BLOG your nasty comments? I must say that some of the comments look almost like a young angry teenage boy sitting in his bedroom at his parents house blogging about his anger at the world and attempting to get everyone he can to jump on his bandwagon to RANT and COMPLAIN about how bad life is…..
    Just calling a spade a spade….

  27. Have any of you thought about getting down to a personal level with your SUBJECTS ie: patients? My own physician & I share stories, I ask how his golf swing is, his tells me he has only been married for less than a year, he is concerned about recently having to place his mother in a nursing home…etc. In return he listens to me. It goes both ways gentlemen. You GET what you GIVE!

  28. And having said that, does EJ take ownership and personal responsibility when you walk into the exam room and see that person? (not subject) Has the thought crossed your mind to actually educate the patient on what you feel is urgent and unnessesary and to (kindly) refer them to their daytime doctor for future visits? Perhaps you would not be so angry toward the general public and assume so much if you actually gave these people half a chance and educate them, rather than kicking them to the curb with their butt cream and referring to your blog to vent all your hostility and anger about this person…..

  29. DETROIT FREE PRESS ARTICLE: Doctor’s posts raise concerns of privacy. Highlights on the article I am refer to, The law on patient privacy, ie: HIPAA law, privacy regulations protect medical records and individual identifiable health information, whether ot is on paper, in COMPUTERS or communicated orally.
    Critics find the BLOG trend troubling, not only becuase of the risk of compromising patient privacy, but also because of potential LIABILITY for hospitals. Some blogs (such as this) do not abide by privacy laws and are disclosing BIASES. Some of the doc blog posts seem crude and graphic. Although many bloggers stick to innocuous subjects that don’t involve patients, others make patients the forcus of their writings. The risks are far reaching and ultimately could damage the medical profession.
    Patients now have another issue to consider: Is my doctor going to Blog about me?

    I’m sure this will start another heated debate between all of you!

  30. Okay, Ann Marie. You appear to need a time out. So, You’re going to get one.

    Six straight comments? Please find another place to complain about us mean old docs.

  31. Well on that note, I thank the good Lord that I am one of those blessed people that has little verbal control ….. a thought enters my mind and I go with it…..often to the dismay of the recipient. It’s my way of short circuiting the “Ignorance Syndrome” – and I’m sure you can’t stir things up any better than the verbal havoc I create.
    Now I’m sure you are a self respecting individual of stature, but I will not apologize for misguided, unfortunate, or what you may consider STUPID assessment and comments.
    Looks like the damage is already done & that’s one more horse out of the proverbial Doctor barn.
    Sorry, you’ll have to deal with it.
    I can only imagine the fireworks to come!

  32. AMT: Speaking of “a young angry teenage boy sitting in his bedroom at his parents house blogging about his anger at the world and attempting to get everyone he can to jump on his bandwagon to RANT and COMPLAIN about how bad life is…” Please read over your previous 12 comments and make your own assessment. Mirrors exist.

    And in regard to the last paragraph of my earlier post, I was not attacking you personally. I was simply covering my bases since in every debate about the ED, if you assert that it should not be for nonurgent problems then someone inevitably comes back at you with the “well what ’bout the people without insurance?” line. You can be used in a general sense. Sorry if that came off not as I intended.

    I don’t know why you carry the biases that you do, but being prejudiced and stereotyping an entire profession is difficult for me to understand.

    And I’m not an ED physician; just a casual observer who has spent a lot of time in the ED. And you’re not letting any new “horses out of the Doctor barn”. Many carry these thoughts for one reason or another and frustrations abound from every side. Fortunately, the medical system just continues to do its best to care for everyone compassionately and professionally. There’s not going to be an end to this debate, which is a good thing as discussion will breed ideas for improvement of a broken system. However let’s all make this a dialogue instead of a one-sided “RANT” in 6 consecutive posts.

  33. EJ, I agree with you on your comment. However, I do not carry a Bias toward the entire profession. Prior to reading the posts, I have had nothing but a high regard, respect and satisfaction from ALL physicians/health care providers I have come in contact with. In fact, I have several relatives working in the health care system. I sympathize with their plight in having to deal with the people that DO abuse the health care system, making worse for the people that do have a legitimate complaint in ER, but having said that, it seems there is a Bias toward everyone that walks into the ER, guilty until proven innocent attitude. “Prove to me you have a legitimate reason to come here at 3am, and I will give you the best care you deserve”. Yes, I agree that someone should not be seen for a minor itch that has persisted for months/years at 3am, but having said that, I also feel they should be educated rather than being kicked to the curb with rolling eyes. And yes, those folks that abuse the ER are the few bad eggs that ruin it for the rest that DO have major medical problems. But they are people too, no matter how unstable or nutty you perceive them as. I realize the health field has more to deal with than the rest of us, and yes I feel for what they have to listen to and hear time and time again…adding to the broken system. Getting down to a personal level makes it more pleasant and enjoyable for both persons involved.

  34. The problem is people end up thinking it is normal to go to the ER with these small complaints because they are not accountable for the cost. I do have a problem with ER doctors with bad attitudes ( not suggesting you have a bad attitude GruntDoc) and suggestions there is free care that will help people with emergent conditions.

    Up until a year ago I had very good insurance, which came in handy, as I am a diabetic. I lost my job and could not afford cobra payments as my income on unemployment was approximately 40% of my former salary. While insured I went for regular checkups and kept my condition under control and did not use the ER as a clinic but once you lose your insurance how do you take care of little things like a gum infection/ toothache.

    Doctors and dentists like to be paid, as they should, but without any information on how much a visit will cost without insurance, how do you scrape up the money to pay. I have called around and I can never get a straight answer.

    So I put off normal check ups and dental visits. My income was too high from unemployment and to low to afford medical care.

    So I am broke and without insurance and I get a toothache on a Wednesday, usually these do subside, and try to wait it out. At first the abscess was small and I hoped it would clear on its own, as it did in the past. It did not so I went to the ER on Sunday night.

    I received great care for the most part but your post and others like it bothers me because it taints patient care. New doctors go on the net checkout a few blogs and are already dreading dealing with patients, fearing drug seekers, drunks etc. It makes it hard to receive respectful care.

    I make this point,for outside frequent fliers, do you really know what brought a someone in until you exam them. Ten years ago I had a case of pneumonia that was resistant to penicillin, I sat for four days, my condition growing worse, because I had know reason to think a doctor would treat me well in my 20s. When I finally went into the ER I got to stay a week to recover and was close to death. Most people look up to MDs and i think doctors should respect patients a bit more.

    While i did receive very good care for my abscess, it took 4 and 1/2 hours to get a room, so I could wait to see a doctor. I expected this but by that time the Advil had wore off and i was in serious pain. Now I did expect this and took a book to read, I would of appreciated if the nurse would of offered an ice pack before my wait.

    My doctor was a younger resident and offered me an apology for the long wait. He took a look at my mouth and said he would be back. He came back shortly after and told I had an abscess and asked how much pain I was in on scale of 1-10. I said about 8 but I was not worried about that, i just needed an antibiotic and was not at the ER for pain medication. That changed his entire attitude and while he was asking about how costly a prescription I could afford, he told me he would get me a couple of vicodin for pain. This made my earlier hunch feel correct, that the doc only thought I was there for opiates. It is these little prejudices that make patients so angry.

  35. Mike,
    thanks for the post, but you’re deluded if you think new docs are going to form their opinions on patients from reading any blog, let alone this one. They will, like all the docs before them, form their opinions based on their own personal experiences, just as I have.

    By the way, nothing written here has ‘taint(ed) patient care’. Nobody here is advocating treating patients badly, either medically or socially. We’re just tired of the continuous tide of patients with non-emergencies that treat the ED like a big convenience clinic, with the added benefit that it’s free.

  36. Goatwhacker says:

    Mike makes a decent point though. I know I have a very high index of suspicion for drug-seeking in people coming in with toothaches. The legitimate patients probably end up paying the price a bit for the fakers, but I don’t see a way around that. As Gruntdoc mentions I’m acting on the basis of previous experiences. This doesn’t justify being rude, but I’m going to have some level of skepticism that is warranted based on experience.

  37. Mike,

    In the perfect world, nobody would ever develop skepticism. Unfortunately, we do. Patients are skeptical of doctors as well. Many times they feel the doctor is just there to rake in the dough instead of really treating them so the doctor gets the 3rd degree from the patient. Or reported for no reason other than skepticism based on a few past experiences.

    It’s a screwed up system because doctors get blamed for handing pain meds out like candy. They also get blamed for not giving pain meds. They’re blamed for not getting to patients quickly enough and then blamed they don’t spend enough time with them. The patients who don’t pay have the ability to sue them for every dollar (I have yet to hear a non-paying patient say thank you to the doctor). This breeds a judgmental attitude which is almost necessary for survival.

    You want to be skeptical of your resident (you have no idea why his attitude changed-maybe he found completed labs on your chart which makes any doctor happy), but you don’t want your doctor to be skeptical of you?

    As for the non-emergent patients…
    I’m a po’ broke student and a few weeks ago, I needed to see a doctor badly. I had a raging sore throat and a temp flirting with 104. I called one of those urgent care clinics since there wouldn’t be any PCP’s open on the weekends. They wanted $130 up front just to see me…even though I have insurance! That doesn’t include the strep test I knew I’d be getting. I suffered a day and a half, popping advil like candy, until I could get into a PCP where I’d just pay my co-pay. It absolutely sucked to be that sick and not able to see anyone. But I can be a soldier if it’ll save me $100 bucks.

    I think walk in clinics who don’t require your left arm as a deposit would make a killing and would lessen the load on the ER. Of course, the EM docs would take a hit on billing without the 70% of non-emergent patients they’re seeing.

  38. This message is from the fed up E.R. nurse, who went to the other side (DON, message posted 3/15/07). Wow I haven’t visited in a few days and saw the comments about how we lack compassion and concern for our fellow man who has a butt rash at 3 am. If some of these bleeding hearts would spend a few hours observing as we attempt to take care of the three vent patients who were medical codes (plus the other patients in the module) that the ICU can’t accept because they don’t have enough nurses, while the drunk in curtain 5 wants something to eat and the vaginal discharge who refuses the gyn exam, or the seizure patient who hasn’t taken his dilantin because he spends all his money on crack, they might see the abuse of the system that we witness every night. What’s wrong people, is the reality to much for you. We don’t lack compassion for someone who really needs help, that’s why we do what we do, it’s the 50% of the bull—- that spoils it for real patients in our eyes.