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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!


*This blog post was originally published at*

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