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This article was posted in a medical forum I read regularly and had a lot of responses. General themes expressed by people that work in ED's included:
1. We need more PCP's.
2. Frustration about patient abuse of the ER (and abuse of ER staff by patients, TBH).
3. We need more PCP's.
4. Lack of support from hospital administration and hyper focus on customer satisfaction, Press Ganey scores etc etc.
5. Need more mental health resources.
6. Did I mention needing more PCP's?
The incomprehensible, impenetrable health care financing system in the US produces perverse incentives, with the result in many cases that ER is the best known option for the uninsured or hapless very high deductible premium payers.
Even if there were more PCPs, are the offices or clinics open 24 hours a day, seven days a week? Where are they located? Do people know about them? Would they really be less expensive than an ER visit or even an urgent care clinic (which, in my experience, are not open 24/7, have loooonnnngggg wait times, and still cost $500 just to walk in the door)?
The incomprehensible, impenetrable health care financing system in the US produces perverse incentives, with the result in many cases that ER is the best known option for the uninsured or hapless very high deductible premium payers.
Even if there were more PCPs, are the offices or clinics open 24 hours a day, seven days a week? Where are they located? Do people know about them? Would they really be less expensive than an ER visit or even an urgent care clinic (which, in my experience, are not open 24/7, have loooonnnngggg wait times, and still cost $500 just to walk in the door)?
And would they not continue to direct patients who call the office to "call 911 if this is an emergency", or direct them either to an urgent care or the ER for a complaint because no one is available to see them on short notice?
In response to the several posts here claiming "unnecessary tests" were done: A good clinician can narrow the possible diagnoses down to just 3 or 4 choices based on the pt's first sentence of history. With a little more history and physical exam, that list is down to 1 or 2, with knowledge that 1 of the possibilities is most likely.
Testing is then done for two reasons: first, to quantize the situation to help determine treatment (eg- knowing the exact BS so the right dose of insulin can be given), but secondly, and most importantly now-- TO DOCUMENT the clinician's opinion. The doc has to PROVE to 12 people too dumb to get out of jury duty that he knows what he's doing. "Good clinical judgement" is no longer rewarded, but punished.
Re: calling the doc's office at off hours-- a smart doc will not treat over the phone. Too many pts can't even get their own symptoms correct, and the doc has no opportunity to examine the pt. The only wise advice he can give is for you to be seen right away. It's better to go to the ER when it turns out you didn't have to, than to stay home when it turns out you should have gone.
Last edited by guidoLaMoto; 12-25-2019 at 07:47 AM..
And would they not continue to direct patients who call the office to "call 911 if this is an emergency", or direct them either to an urgent care or the ER for a complaint because no one is available to see them on short notice?
Doctor's offices are not supposed to function as emergency rooms or urgent care centers. Patients are directed to those places because that is the appropriate place for them to be seen. Most offices can get a patient in within a few hours during the day for something urgent, which is also about how long you might wait at urgent care or the ER. If your problem is more urgent than that, you do need to go to one of the above. Usually a the wording is something like "if this is a life or limb threatening emergency, hang up and call 911 NOW". At that point it is up to the patient to decide if it's a life or limb threatening emergency.
A patient who is 45 years old comes to the hospital complaining of chest pain. A careful history reveals that the patient is susceptible to heartburn and reflux. Further, the patient has been taking an antibiotic that does cause stomach upset. No shortness of breath is observed. Yet, an EKG is ordered and performed. The patient is observed for several hours before being allowed to go home. The patient's family doctor just shakes his head when he hears all this. He tells the patient that chest pain is actually fairly common and tells him never to go to the ER again unless his symptoms are worse.
Honestly, the old cliche about "taking two aspirin" and calling your doctor in the morning makes a lot of sense.
I have been an R.N. for 42 years and the majority of my first 20 years working in the profession was working in hospital ERs including a Level 1 trauma center. And I can tell you over this very long time span I have taken care of quite a few patients that were in their 40s that had MIs. And additionally my own late husband had a fatal MI 18 years ago at the age 49. As far as I know my late husband was not having the classic MI symptoms of chest pain, sob, sweats, etc., but I do recall he did complain of some GI distress which he attributed to our spicy dinner that night and I witnessed him take a few Tums before I headed to bed. When I woke up the following morning my husband was not in bed. Figuring he fell asleep in his recliner which was not uncommon for him I did not find him there either. From there I headed to my kitchen and found my husband in cardiac arrest on my kitchen floor. Despite my CPR efforts along with the intervention provided by the paramedics when they arrived none of these interventions could save his life. So 40 +/- year olds do have and die from MIs and many especially women, the only symptom they have is heartburn.
With all the above said, in my professional opinion you are way off base in what you relayed above ^. And since you don't have any professional expertise as a healthcare practitioner I don't except you to know that chest pain can herald a warning symptom of other potentially life threatening issues not just heart attacks such as endocarditis which can happen in very young adults who will likely die without ER intervention which would include having an EKG. And I can't think of one of the hundreds of doctors I have worked with over the years even the mediocre ones that would tell any patient having chest pain regardless of their age to "take two aspirins" and call them back in the morning.
Doctor's offices are not supposed to function as emergency rooms or urgent care centers. Patients are directed to those places because that is the appropriate place for them to be seen. Most offices can get a patient in within a few hours during the day for something urgent, which is also about how long you might wait at urgent care or the ER. If your problem is more urgent than that, you do need to go to one of the above. Usually a the wording is something like "if this is a life or limb threatening emergency, hang up and call 911 NOW". At that point it is up to the patient to decide if it's a life or limb threatening emergency.
The physicians' offices I am familiar with all start their phone recordings with, " If this is an emergency hang up and call 911"...... I haven't heard any qualifying as to the nature of the emergency. It's entirely up to the patient to decide whether it's a life threatening emergency. And you don't have to be out there very long to know that to *some* patients, anything that happens to them is such an emergency. That or they arbitrarily decide that today, now, is when a ingrown toenail, or cough they've had for two weeks becomes a true emergency and must be addressed in the ER.
And geez, I worked in the medical field for well over 40 years, I understand as well as any medical professional the limitations in a doctor's office for taking care of true emergencies, and the need to go to an ER ( or possibly Urgent Care depending on the nature and seriousness of the complaint).
I have also seen a tendency on the part of some PCP offices to instruct patients who call them for a same day appointment with a problem that could be treated by the physician, to go to an urgent care center as they have no available appointments that day. I can understand how this might occur sometimes, but I have seen it happen not infrequently with my daughter's PCP, and have heard other people complaining about the same thing. This is more likely to occur around here in the winter months, when we are inundated with seasonal visitors ( snowbirds) who virtually swamp our medical facilities, along with the infrastructure and other amenities.
Fortunately, I've not had the same experience with my PCP, but I can recall only one time I called to see about a same day appointment. I got a same day appointment with one of their nurse practitioners, and I was very grateful to get it.
More and more people can't afford healthcare, which is why ER visits skyrocket. Many people don't have insurance, so they can't afford to go to a doctor. So they get sicker and sicker until it's a matter for the ER. Even if it's not life threatening, the ER may be the only place that will see them. Most doctors require payment at the time of service. The ER doesn't. So for someone who doesn't have hundreds of dollars lying around (not including prescriptions and tests), the ER is the only place that will treat them.
And even for people who do have insurance, many have co-pays and deductibles so high, they still can't afford to see a regular doctor.
More and more people can't afford healthcare, which is why ER visits skyrocket. Many people don't have insurance, so they can't afford to go to a doctor. So they get sicker and sicker until it's a matter for the ER. Even if it's not life threatening, the ER may be the only place that will see them. Most doctors require payment at the time of service. The ER doesn't. So for someone who doesn't have hundreds of dollars lying around (not including prescriptions and tests), the ER is the only place that will treat them.
And even for people who do have insurance, many have co-pays and deductibles so high, they still can't afford to see a regular doctor.
According to the NIH article linked by Katarina Witt in her post (#9 in this thread), it's not the uninsured that are swamping ERs. In that article, it states the stats show the there are more ER visits by Medicaid patients than uninsured patients.
The physicians' offices I am familiar with all start their phone recordings with, " If this is an emergency hang up and call 911"...... I haven't heard any qualifying as to the nature of the emergency. It's entirely up to the patient to decide whether it's a life threatening emergency. And you don't have to be out there very long to know that to *some* patients, anything that happens to them is such an emergency. That or they arbitrarily decide that today, now, is when a ingrown toenail, or cough they've had for two weeks becomes a true emergency and must be addressed in the ER.
And geez, I worked in the medical field for well over 40 years, I understand as well as any medical professional the limitations in a doctor's office for taking care of true emergencies, and the need to go to an ER ( or possibly Urgent Care depending on the nature and seriousness of the complaint).
I have also seen a tendency on the part of some PCP offices to instruct patients who call them for a same day appointment with a problem that could be treated by the physician, to go to an urgent care center as they have no available appointments that day. I can understand how this might occur sometimes, but I have seen it happen not infrequently with my daughter's PCP, and have heard other people complaining about the same thing. This is more likely to occur around here in the winter months, when we are inundated with seasonal visitors ( snowbirds) who virtually swamp our medical facilities, along with the infrastructure and other amenities.
Fortunately, I've not had the same experience with my PCP, but I can recall only one time I called to see about a same day appointment. I got a same day appointment with one of their nurse practitioners, and I was very grateful to get it.
My physicians' office, a large group practice, specifies "life or limb threatening emergency". Yes, there are patients like you describe. That's why sometimes, a triage nurse will ask, "how long have you had this problem?" However, a two week cough does need to be seen; though, you are correct, probably not in the ER.
You "worked in the medical field"; tell us what you did.
The office where I worked as an RN had a policy that anyone who called by 4:30 PM that needed a same day appointment was seen in the office. It would be a totally rare circumstance to send someone to an urgent care during the day. Some may not want to wait the several hours until they can be seen and choose to go to urgent care, where they may wait several hours as well. In fact, when I worked triage, I told patients that occasionally. I think you should take your concerns about "snowbirds" to a different thread, and keep in mind their contribution to your economy.
When my daughter was about 5, I took her to the ER on a Sunday for a bad stomachache. They diagnosed her with a UTI and sent us home with an antibiotic. I had my doubts (her stomachache cleared up before we even left the ER) so I held off on giving it to her... the next day, took her into the pediatrician who tested her urine and saw no sign of an infection. He told me then, don't go to the ER unless it's life-threatening... the ER doc's goal is to keep you alive until you can see your regular doctor.
So, I've kept that in mind and we have only used the ER a couple of times since.
One of those times, my same daughter, age 13, had chest pain. We actually went to urgent care (I assumed it was bronchitis because she had had a cold). The urgent care doc looked at her and said "call 911" to his nurse. He said he was probably acting out of an abundance of caution, but something about her "didn't look right" to him. He didn't have an EKG machine in the office and didn't feel comfortable letting us leave. So she went via ambulance to the local ER with me close behind. While there, the ER doc said he wanted to run a test for cardiac enzymes out of an abundance of caution. Healthy, athletic 13-year-olds don't have heart attacks, but something "just didn't seem right." Sure enough, it came back positive... not a heart attack, but viral myocarditis (a virus attacking the heart). Spent a week in the cardiovascular ICU at the pediatric hospital 90 miles away, had restricted activity (no exertion) for six months, saw a cardiologist regularly for two years, had a few cardiac MRIs, and now we are just on yearly visits (EKG and echo) where everything has been described as perfect and no signs of any damage. Phew!
I was really glad for the "abundance of caution" testing and reaction. Some of it, I'm sure, was just a hunch on the part of the doctors. The ER doc said that her heart sounded just fine and there was a minor irregularity on the EKG. When we got to the children's hospital, the cardiologist listened to her, ran the EKG, and said "let's check her troponin levels again... I think there was an error on the last test because a child with that level of enzymes wouldn't be in good spirits, walking around, talking, etc." Nope, the test was right and she was actually quite sick and in need of treatment. The urgent care and ER doctors very well might have saved her life.
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He said he was probably acting out of an abundance of caution, but something about her "didn't look right" to him. He didn't have an EKG machine in the office and didn't feel comfortable letting us leave. So she went via ambulance to the local ER with me close behind. While there, the ER doc said he wanted to run a test for cardiac enzymes out of an abundance of caution. Healthy, athletic 13-year-olds don't have heart attacks, but something "just didn't seem right." Sure enough, it came back positive... not a heart attack, but viral myocarditis (a virus attacking the heart). Spent a week in the cardiovascular ICU at the pediatric hospital 90 miles away, had restricted activity (no exertion) for six months, saw a cardiologist regularly for two years, had a few cardiac MRIs, and now we are just on yearly visits (EKG and echo) where everything has been described as perfect and no signs of any damage. Phew!
