Monday, August 6, 2012

Why Do People Go to the Emergency Room?

     Why do so many people go to the emergency room?  I've been trying to figure this out.
     There must be a myth about emergency rooms--that they're full of bright, eager, savvy medical detectives and Marcus Welby types who can hone in on problems with lightning efficiency, and fix them--and then shower patients with all the attention they need.
     There's also the momentousness of saying to one's family and friends:  "I had to go to the emergency room"--that's how bad it was.  No one else was there for them, is the subtext.
     I worked as an emergency room physician in Missouri for eighteen months.
     Ninety percent of the patients who checked in didn't have emergencies at all--not even close.  They should have gone to a family doctor who knew them.  The other ten percent had problems which, in the hands of a well-equipped family doctor, could have been managed without a hospital at all.
     Emergency rooms are unnecessary institutions.  They foster the illusion that patients will get the best of care.  Maybe TV shows have something to do with this, or maybe it's all about the psychology of people who feel deprived.  But the idea is false, false, and false.
     Emergency rooms are simply a huge cash base for hospitals.  For this reason they are unlikely to disappear any time soon.  Batteries of tests get ordered there--at three times the cost of any place else, and most are, to my mind, unnecessary.  Of course, hospital admissions are generated by emergency rooms, too, and they provide downstream revenue.   Hospitals are corporations, after all, with a vested interest in luring and holding patients hostage for as long as insurance companies will pay, and for this reason  hospitals will never exert effort to reduce emergency room visits.
     According to a study in the Annals of Emergency Medicine published in June, there was a 15% increase in emergency room visits from 2001 to 2008, outpacing America's population growth by 60%. The long wait times patients seem to endure with an attitude of profound resignation, were reported to be associated with bad outcomes.
     It's common sense that bad outcomes are associated with long periods of sitting in a confined space with sick, coughing, contagious patients.  Everyone knows that institutions like hospitals and jails are incubators for extraordinary new forms of virulence.  Even worse, emergency rooms are located inside hospitals, which are notorious for doling out incurable infections like MRSA, pneumonia, and c. difficile.
     Today in frustration I asked a patient, "Why did you take your mother to the emergency room--for a minor complaint--when I told you I'd see her in my office?"
     I see walk-in patients every day.  No patient has ever been put off with "The next available appointment is in two weeks."  What might happen to a smoldering appendicitis or pneumonia in that time?
     "If I didn't have to wait in your office," the daughter answered, "maybe I would have brought her."
     "Let me ask you," I proceeded, "how long she had to wait, before being seen in the ER?"
     I thought I'd cornered her with that one.  After all, patients report delays of three to twelve hours in emergency rooms.
     "Oh, not long at all!" she exclaimed victoriously.  "I called the ambulance, and they got her in right away."
     This patient hadn't had so much as a urinary infection, but she went home with the trophy of antibiotics anyway.  And the ambulance fee--$750?  And the emergency room fee--$600?  No worry--it's all covered by Medicare.
     Most ER attendants will tell you that the patients they see all day and night could be managed by outpatient doctors.  The blood tests, x-rays, ultrasounds, CT scans, IV fluids, and nausea medications ordered there are not special--and are usually overkill.  The cardiac testing and IV antibiotics, for which patients end up being admitted to the hospital, could be administered in a plain old clinic.  Family doctors are capable of taking care of these patients at a fraction of the cost, and most of us would be happy to do it--if we weren't being threatened by government, malpractice, and insurance behemoths.
     Doctors like me, who "do it all" in the office, are physician outliers.  The word itself conjures up the idea of outlaws.  It derives from the fact that we bill for more tests and procedures than average doctors.  But we don't just bill more for the heck of it--we do more.  We get paid more, but our outlay for costly machines is higher, and we work more.   Does America have a problem with this?
    Yes, I think it does.  The American government has a problem with doctors who make more than "average," even if they accomplish more.  America has a problem with physicians who strive to keep people out of emergency rooms, out of hospitals, and free of disease.  The work to accomplish this herculean task doesn't come for nothing--stress tests, x-rays, splints, casts, ultrasounds, IV antibiotics, bone density tests, IV Reclast, surgeries, physical therapy, and balance training have a price tag--but it's a fraction of the cost of waiting for calamities.  And cost/benefit calculations consistently show that family doctors save America a lot of money.
     The solution to the problem of overcrowded, underperforming emergency rooms is family doctors.  We need more of them, and we need them to do more in their offices.  We need them to stay open later, and we need them to accommodate patients who want to see them now.
     How can we attract more family doctors to medicine, and how can we get them to do more in their clinics, so that emergency rooms become a thing of the past?  Here are my ideas:
          1) Deregulate American medicine by repealing legislation that permits the government to use terrorizing tactics that deter doctors from have a broad scope of practice;
          2) Encourage doctors to use high-level diagnostic equipment and treatments in their offices, so patients have confidence they can get what they need without going to the hospital;
          3) Acknowledge family physicians as key figures in the prevention of disease, and in lowering the overall cost of American medicine;
          4) Reduce reimbursement to emergency rooms for non-emergency care; 
          5) Eliminate co-pays that serve as obstacles for patients needing to see their family physician (most ER patients have no co-pays);
          6) Stop insurance companies from harassing doctors with endless records requests, audits, denials of payment, unfounded insinuations of fraud, and insurmountable "guidelines" for billing and coding;
          7)  Reclaim from insurance companies the power for making decisions about what patients do and don't need to be healthy, and give it back to doctors;
          8)  Close all the hospitals and emergency rooms in the country, and replace them with outpatient surgery suites, small overnight clinics for observation of risky patients, and lots more sensible, thoughtful, caring family doctors.      


  1. I'm not sure how the ER will fare under Obamacare, but I am sure that Patient care will suffer. Anything the Gubment touches is doomed to chronyism, fraud, abuse, bullying, terror tactics by regulatory agencies, and ultimately, failure. I am happy you have found Larry McDonald videos on you tube.The real powers in charge feared him so much they took him out even though Jessie Helms was had missed the plane in 1983.

  2. An estimated 63 million new patients are expected to be added to the rolls once the Affordable Care Act kicks into action. Where are we going to get doctors to see these patients? Where are we going to get doctors who are willing to make themselves vulnerable to attacks by the government, which "uses" statutes in an unintelligent and unethical fashion, as a means to recuperate money from citizens? I know the government's finances are flagging, but come on! Do you pay your bills by stealing from your employees' paychecks?