My specialty is emergency medicine.
If you've ever visited the emergency department (ED) at a hospital, you may have noticed that not everyone there has a life-threatening problem. Some people are there because they think they need to see a doctor and don't have a routine source of medical care or cannot get an appointment in the time frame they prefer.
Perhaps you have a fever and a bad cough, and it hurts ("right here," pointing to an area of your chest) when you take a deep breath, and you are concerned that you might have pneumonia. You tell me about your symptoms, I ask some questions to elicit additional information, and I examine you, with particular attention to your heart and lungs, listening for sounds that might suggest you do have pneumonia. I may recommend a chest x-ray.
You could see your doctor in the office for this - if you could get an appointment today, or even this week, and then you might be sent from the office to the hospital radiology department (right next to the ED) for an x-ray. Not quite as convenient as just visiting the ED.
Your medical problem is not an immediate threat to life or limb, but you need to see a doctor, and the ED is your best bet for timely and effective evaluation and treatment.
On the other hand, if you come in saying, "I have a cold," I will wonder why. Not why you have a cold. (I know plenty about that.) Not why you have chosen to visit the ED for that. No, I will wonder why you want to see a doctor about a cold.
You see, that falls into the realm of what a doctor calls "an acute, self-limited illness." That means an illness that is going to go away by itself without any sort of intervention. You may have heard the old saying that a cold will last seven days, or if you see a doctor (or implement any other sort of intervention), it will last a week. That doesn't mean there is nothing you can do about the symptoms. There are many cold remedies you can buy in a drugstore, and some of them actually make you feel a bit better while your immune system is fighting off the cold virus. But there is nothing a doctor can prescribe that is superior. (OK, maybe there is one exception: if you have a terribly distressing cough, prescription cough medicines, which are narcotic, are more effective than the OTC stuff at making you feel better.)
The point of this blog entry is not that you shouldn't see a doctor for a cold - although if you didn't already know that, it is a point worth noting. Rather, the point is that people go to see doctors (and not just in the ED, but in primary care offices, urgent care facilities, and "retail clinics," where you can see a nurse practitioner) for lots of problems that are very unlikely to benefit from medical attention.
This has become part of our culture: health care seeking behavior that is unproductive or ineffective. It happens for many reasons, and an exposition on that subject would make a very long essay in itself. I have not seen any good scientific studies examining the question of how much money we, as a society, waste seeking health care for conditions unlikely to benefit from it. But I think it's a lot.
I agree 100% with everything you have pointed out. I see so many patients in the pre-hospital setting that don't need any type of medical care, let alone EMS transport to the ED. So many of these patients tell me, “If I go in the ambulance, I’ll get right in and be seen right away!” EDs should be used for emergencies only, not the sniffles and primary care.
ReplyDeleteHow do we drive this point home to people who, as you say, use the ED (and EMS) out of convenience? So many of them seem to feel as if they are entitled to immediate service for anything they desire, not just healthcare. They want what they want, and they want it now... Breaking through that caustic mentality will be the tough part.
I think it would be nauseating to know how much money is truly wasted in the ways you have examined.
On one other note, I am very glad that you specialize in emergency medicine, because well... While I may bring you many routine patients, I have watched you save the severely ill or injured from the greedy jaws of death. That makes it all worth it in the end, I'm sure.
ReplyDeleteI think the approach has to be a broad educational one. Efforts to teach patients about appropriate utilization on an individual level are rarely well-received, as patients then think we are being dismissive or judgmental. And we practice in a consumer-oriented environment in which the customer is always right.
ReplyDeleteAlso true... As I have progressed through my final regular semester of my undergraduate degree, the word 'customer' seems to replace 'patient' and I can't help but think that's where healthcare went wrong.
ReplyDeleteI agree that a lot of people use the ER/ED (ED is an acronym with multiple meanings hehe) are using it for Primary Care. And the argument of "These people don't have other health care so they use the ER/ED when they get sick" rings true. And the idea of "Hospitals cannot turn the sick away" vs "I have to pay a Doc in the Box $60 for MAYBE telling me to go to the ER?" (some people want to skip steps, bad science methodology there).
ReplyDeleteI think those reasons above plus lack of knowledge on body functions/illness symptoms/terminology has a lot to do with overuse of a place meant for "Bodies with Stuff Spilling out of Them"
I've stumbled across your blog this evening (as a result of your post on "Anniversary Reactions" and decided to begin at the beginning). This post resonates with me as I work in a social services setting and simply can not count the number of times that I have discussed with clients why their situation does not necessarily warrant a trip to the emergency room only to realize that my completely sound logic falls entirely upon deaf ears. They appear to have grown up in settings where they have always gone to the ER for routine issues because they have never been faced with a bill for the services they receive so they truly believe that there is no difference between this and going to a PCP for care.
ReplyDeleteKatie, I'm delighted that you found one of my essays sufficiently interesting to make you want to read more. Assuming that, having begun at the beginning, you are motivated to keep going, please feel free to post more comments as you go.
DeleteNow, to your point. People who visit emergency departments know the sign says "emergency," and they know what it means, but some nevertheless use the ED as though it is a 24-hour, primary care, walk-in free clinic. The lack of awareness of different prices for care in different settings surely plays a role in that, as you suggest. And many in health care, and health policymakers in government, worry that creation of an English-style National Health Service in the US would so disconnect people from cost that it would be impossible to control utilization. But I believe education is the key. In New Zealand a public education campaign has been effective in getting people to understand when they should seek care in the ED and when other settings are more appropriate. Here in the US, we really have much work to do in that area.