Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments

The “Expensive, Overused” ER

I’m always fascinated by the complaints that the emergency department is so overused and expensive. I admit that it is used a lot, and that care can seem expensive. But I want to make it clear that the reasons are myriad.

Whenever we in the specialty say that we feel that patients abuse our services, someone in academia reminds us that only a small number of those patients do not actually have serious illnesses. Whether or not that’s true, one of the reasons we are overused is due to none other than other physicians.

I’ve been paying attention lately to the way physician referral patterns happen. I suspect it’s the same in other facilities.

Here’s an example. Local physician, who does not admit to the hospital, sees patient in the office. Patient has uncontrolled hypertension and is having some chest pain and shortness of breath. Local physician contacts hospitalist. Hospitalist who could reasonably direct admit patient, says, ‘better send them to the ER first.’

Now, I’m glad to make the money, but why do we need to interpose the emergency physician?  The explanation I have received is this:  ‘you never know, they might be sicker and I don’t know what sort of room to put them in yet!’  Of course, they could be admitted and moved if necessary.

Another:  surgeon sees patient who has complication of complex surgery a few days prior.  Patient calls with complication.  Surgeon says:  ‘Go to the ER and get checked out.  They can call me.’  Admittedly, most times I don’t mind, but ‘back in the day,’ a surgeon would never have trusted my infidel, non-surgical judgment.  And I end up reassuring the patient that all is well, because the surgeon will be operating all day.  And because none of the surgeons would dare ask another surgeon to check their patient during office hours.  (’I don’t want to bother him!’)

Or this one:  patient is having outpatient cardiac catheterization or stress test.  The test is positive.  The patient has a physician, who could be contacted.  The cardiologist says, simply, ’send them to the ER.’  Why is this?  Why couldn’t they be admitted directly?

Here’s another.  Unnecessary labs and scans!  Surgeons insist on CT scans of the abdomen for abdominal pain, almost always without first examining the patient.  Internists often are very upset when we order minimal labs for simple entities.  Some of my patient simply can’t be admitted without a comprehensive metabolic panel.   Psych commitments invariably require CBC, Liver function tests, urinalysis, pregnancy test, blood alcohol and drug screen no matter what.  (Why?  ‘You just never know.’)  Well, in a 30 year old, known schizophrenic, it all seems like a waste of money.)

When I asked why the little old lady with a humerus fracture (whom orthopedics wouldn’t admit), required a series of labs, I was told, ‘there might be something else.’  Admittedly.  But where do we draw the line on labs and tests?

And it’s not  just doctors.  I recently saw a woman for a benign condition.  When I asked her who her doctor was she said, ‘I don’t have one.’  I explored further and it turned out she actually had about three.  ‘I go to her for simple stuff like a runny nose, and I go to him for my blood pressure, and…’  But rather than call any one of the three, she came to the emergency department.  Her daughter rolled her eyes.

Patients with long, complex problems will completely circumvent their physicians and come to the emergency department because, ‘well I’ve been to Mayo Clinic and to Duke and nobody can figure out why I hurt.  And tonight, something has to be done!’

We in emergency medicine commit our share of sins against efficiency.  But some of the accusations hurled at us are not our fault.  We are simply the path of least resistance for too many providers and too many patients!

I know that there will be sound reasons offered for many of the things I’ve complained about, but I just want everyone to think, before saying the ER is overused and too costly, ‘am I overusing it, or making it more costly?’

Thanks for thinking about it!

And thanks for your business!

Edwin

*This blog post was originally published at edwinleap.com*


You may also like these posts

Read comments »


Comments are closed.

Return to article »

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »