ER readmissions would make a great next book by Atul Gawunde
30
A few years ago, I ended up in the ER for a really painful rash. It was so painful I could barely walk. I tried first to see my dermatologist during office hours as well as my primary care physician. Neither would see me for a week. This was the problem. I went to an urgent care first where I saw an NP. The rash was getting worse, not better, so I went to a free standing ER where I knew I could at least see an MD—this doctor suggested I get immediately to a hospital with a burn unit and an on call dermatologist. I spent 5/6 hours in the ER just to see a dermatologist (who had to be dragged in on call). I tried my best not to go to the ER and had I been able to see my dermatologist in her office in a timely manner—I was in a lot of pain and distress and had what looked somewhat like Steven Johnson’s Syndrome—I could have avoided the ER. I needed urgent treatment by a specialist and the only way to get that was the ER.
107
Roads and schools are essential services, crumbling as they are in the US. Healthcare is also essential. Until the US gets healthcare right, we really ought not tell other countries about the superiority of democracy.
83
the answer has two parts:
we must pay doctors less and make more doctors.
the only solution: nationalization of the healthcare system and ending fees for MD training.
only this would allow us to control the outrageous private insurance system that drives all hospital costs. it would also allow us to prevent the crushing debt that justifies such high salaries for medical doctors, as well as the exclusivity at medical schools.
taxpayers are already footing the bill for all of this through state subsidies and federal support for basic medical research.
nationalize!
49
@adam zientek What exactly do you mean by "ending fees for MD training"? That is not what drives the crushing debt when people complete their residency. What exactly is "high salary" for doctors? People don't seem to have any problem with lawyers charging $250/hr (minimum) and asking for $20k retainer before he/she even looks at your chart. But doctors?! For whatever reason, people expect doctors to do their job out of pure goodness of heart. There is no profession where one provides service and then hope to get paid afterwards. Try that with your plumber.
123
@Sadie
And how about what CEOs and CFOs of hospitals earn?! Millions per year. There is no income in a hospital without medical care providers offering their expertise to patients.
67
I would love to have the option of Urgent Care; in Japan, where I live, you have no choice but hitting the ER if you get sick after hours. And people hit it - and use ambulances - for EVERYTHING. Since Japan has national health care, people have been trained to see the doctor for the tiniest things. There are campaigns on now to try to discourage this, to decide "do you really need an ambulance," and so on, but habits die hard and the healthcare system is laboring under a lot of deficits.
13
During my MPH course at Columbia back in the early 1990s I took one class on the weekend ‘executive ‘ track with students who were mostly health professionals. We heard many stories from them and from our faculty about the huge human and financial toll taken by a health care system that was unable to meet patients’ needs outside the hospital. As the daughter of two public health professionals, and with over 15 years of my own experience in very low income countries, these stories were not a surprise. It’s tragic that the system has made so little progress since then.
28
The line about keeping ER beds available for a school shooting stopped me in my tracks.
Yes, that is our reality but what have we come to as a country?
How much longer will we put up with this?
What will it take to change?
72
Writing to thank ER docs, nurses and staff who work under these difficult-conditions —especially those at Newton Wellesley hospital and Boston’s Brigham and WoMen’s Hospital. Thanks to them my father quickly received life saving treatment — brain surgery to remove a bihemispheric subdural hematoma — (bleeding on both sides of his brain), and is well along the recovery journey. He had fallen and hit his head on the corner of a wooden chest. His doctor said to go straight to the ER when he could no longer walk or stand on his own
49
Last month, I fell at home. I'm 64 with health insurance. I landed on my shoulder which swelled to twice its normal size in 30 minutes. At first, I thought I could just ice it and get by but as the pain increased I recognized that an ER visit was required. I spent 5 hours in the ER, was X-rayed, showing that I had broken my arm. I was given a sling and sent home with a referral to an orthopedic surgeon. I think I was lucky. I recognize that 5 hours in an ER in some urban areas would be considered miraculous.
18
Regarding the woman with chemo side effects and the elders at risk, there are visiting nurse associations and programs all over the country and some have palliative care NP's. I was a home care and hospice nurse for most of my 40 year career and am frankly shocked that this ER doc is not recommending this incredible resource. Medicare, Medicaid and many insurances cover home care as long as there is a skilled need. Visiting nurses, CNAs and social workers collaborate to help patients of all ages stay at home if at all possible.
23
I don't recommend NPs for anything. No matter how benign the problem.
20
Tough to arrange at 2a.
19
If you build it....they will come...
8
The ED personnel and medical staff do great work. God bless them.
39
ttps://www.ajmc.com/journals/issue/2015/2015-vol21-n2/emergency-department-use-a-reflection-of-poor-primary-care-access?p=2
"Inadequate PCP availability after usual working hours, the low rates of providers speaking languages other than English, a lack of cultural competence, and substandard customer service, on the one hand, combined with 24/7 ED availability, the perception of high quality of care in the ED, and the convenience of “one-stop shopping,” on the other, may all contribute to patients choosing the ED as a source of primary care."
The issue is complicated, the absence of even the possibility of a PCP (primary care physician) has to play a large role.
19
Dr. Scott Campbell, an Emergency Doctor in San Francisco and President of the San Francisco Emergency Physician's Association, discusses these issues in this informative and timely podcast: https://resources.lifelink.com/perspectives-from-an-urban-ed-a-conversation-with-scott-campbell-md-mph
8
Our health care system and the profit-driven establishment that supports it CLEARLY needs to be overhauled. The debate should not range between the status quo and Medicare for All, but between Medicare for All and nationalized medicine (what I was fortunate enough to have had for twenty years in Europe). Unfortunately, our "public option" refers now to a government-run HEALTH INSURANCE option, when it should refer to an option for government-run HEALTH CARE. Our health insurance industry is the smallest part of the changes needed to the "medical-pharmaceutical industrial complex" if we want our citizens to have medical care like that of most other developed nations. We simply need to de-monitize health care (and education) for our people, as most advanced nations have managed to do over the past 40 years.
31
We need at least least some of these incredible ED physicians to become full-time Hospital Administrators/leaders in the field. Medicine is the only big time American business that is not run by people who came up from the ranks. Think of Jack Welch, Bill Gates, Steve Jobs, etc.
19
This recalls the day I took a friend to the University of Chicago Hospital emergency room. We got there at 3 pm and he didn't see a doctor and get a bed until 6 am. People with colds and flu were taken before him. 15 hours sitting in the ER with 6 broken ribs and head trauma and absolutely nothing one could do about it. And no sandwich.
35
I went to the E.R. with a couple broken ribs last winter. There were tons of respiratory patients and they trumped the agony of my ribs. After six really painful hours, an E.R. doc finally checked my Xrays and confirmed my cleanly broken ribs. Then she asked what meds I’d taken. After indicating 3 Tylenols, she included counseling for Tylenol abuse in my discharge papers.
27
@Tom, I have broken ribs three times in my life. One of those times, probably ten years ago, I was given a kind of velcro-closing girdle thing for my chest. The last time I broke ribs (about a year ago), I was told that the current practice is not to wrap them. I left the doctor’s office (my primary care doc, since this was not an ER matter) with nothing for my troubles. No scrip for pain relief. Just the knowledge that I had broken ribs.
11
"As far back as I look in her records, I find no visit with a primary care doctor. Like many patients in the E.R., especially younger ones, she doesn’t see any other doctors regularly."
This is a huge problem, even for those of us who are well-insured. The industry has created such an incentive for specialization that it's virtually impossible to find a good GP.
So, I'm in my 40s and I don't do preventative checkups. If I get sick I'm going to the urgent care center or the ER.
23
I had a few ER visits the last couple years and appreciate the perspective. Two weeks after a giant cell tumor was discovered in my knee, I crashed on my road bicycle and broke my leg. Nine months later I had knee surgery after tumor treatment. Surgery went well but I was dizzy for 1-2 months afterward. I never found out the cause but someone thought it was likely the epidural for surgery which removes some chemicals from the brain. Once I went to my son’s soccer game and was laid out on the sidewalk afterward. Physically it was too much for me so I was whisked away in an ambulance. A week later I was waiting for an x-ray not 100 feet from the ER when I started feeling like I was about to lose consciousness. I flagged someone in the hall to call for help and they rushed me to a room where they monitor patients post-surgery. Boy were those scary when you don’t feel in control of your body and you feel yourself start letting go in your head. In the hospital I thought I was going to die.
But I have profound respect for hospitals. The touch of a nurse’s hand after they give you morphine for an unstable leg after fracturing your femur and they have to move you into yet another bed. It’s the smallest things that make a difference like a young nurse nonchalantly encouraging me to grab a pinch of belly fat and plunge a needle into my stomach. I didn’t know I would have to give myself an anti-blood cot shot! To all who work in hospitals thanks for your tireless work.
29
I have been having serious issue with my insurance company. As I am trying to resolve it I Googled the company and came across an article saying that profits were up hugely for this company in 2019, and that the CEO received a 23% raise as a result.
That, my friends, is where our health care dollars are going.
131
The most obvious way to improve this is to somehow divert the huge percentage of non-emergency patients away from the ER. We need many more accessible, insurance covered or reasonably affordable walk-in clinics that can deal with the migraines, back spasms, common colds and bloody noses and free up the ER for true emergencies. This, along with the pilot programs mentioned in the article about diverting chronic "frequent fliers" away from the ER, could result in gigantic cost savings that could be diverted into better patient care. But under the current model, apparently there's no incentive to actually fix problems. The US health care system is broken and needs massive reform.
24
For the uninsured, underemployed, or medicaid eligible patent, there is a solution -- Federally Qualified Health Centers. Medical professionals provide primary care before to prevent emergency room visits and (when necessary) after ER visits to make sure the patient has support with medications, chronic illnesses and more. More and more hospitals are connecting their software to the FQHC where the patient has a provider to make the vital follow-up visit days after discharge. These are not free clinics, but rather, charge a sliding scale based on income. FQHCs are in both rural and urban settings and are filled with experts who can assist patients with other resources.
15
Where else can one go? The ambulatory care centers which were to take some of the work from the ER, now close rather early. In many areas, it's too dangerous for them to stay open later. They are also very limited in what they can do. No x-ray machine to see if that arm/ankle is broken, no ability to give fluids to someone who is dehydrated from vomiting and could avoid the ER if they could be re-hydrated and given some anti-nausea meds.
And then there are ones own physicians. Apparently, today's doctors think they work in a bank and don't want to get calls at nights or on weekends. Call your doctor's office after hours, and one will be told to go to the ER. In the past, ones doctor could phone in a prescription to an all-night pharmacy or give some comfort and advice.
We need options other than the ER.
33
Suggestions: 1) All hospital need to open 24/7 urgent care centers next door to the ER, channeling the non-emergent patients to those instead of the ER; 2) Cities should require health care providers to open a minimum number of 24/7 urgent care centers per capita the population, spread out to cover each district of a city, including 24/7 pharmacy availability; 3) Cities could establish mental health emergency teams, sans police, that are called out in ambulances to mental health emergencies and have those patients routed to psychiatric hospitals instead of ER's; 4) build and staff more mental health facilities nationwide.
42
I am a retired Emergency Department Physician. FACEP if you will.
37 years of experiences like those outlined in this piece.
The answer to the posed question is NO!
6
I am a board certified ICU MD but worked very busy inner city ER's for years. My take on this article is 1. well written 2. accurate in the respects it discussed 3. not a bad place to work, as far as ER's go. There is no simple answer to the questions raised, but my take on the problem is the lowest denominator is access and followup.
Hospital corporations and insurance companies don't want to get involved because they tend to think short term; get the patient out of the ER ASAP. If discharged home, a large per centage of them will not return, mostly because they improved but some because they died, went to another ER, etc.
Go with a type of Colorado model with close followup at home with mid level providers, RN's, health aides, social workers, and phone calls. This has been shown to drastically diminish return visits as the above personnel can often handle questions and medical problems before another ER visit is needed, or the patient can be directed to their pvt. provider, urgent care, clinic, etc.
But the providers must be paid on a scale to make it attractive to qualified, caring people, and they must be, to a large extent, indemnified so they aren't having a lawyer looking over their shoulder every step of the way.
I, and others who have published research in this field, believe this investment is necessary to keep ER's open and functioning for the purpose they were created for, and it will be cost effective in the long run.
38
I graduated from the School of Nursing,University of Toronto,Ontario ,Canada in 1959 and moved to Washington, DC. in 1960. As a health nurse public health nurse i worked very hard and enjoyed my work. Preventive medicine is not being practised here because we have neglected and refused to realize that preventive care and education are cost-savers and life-savers.
24
Interesting to see the many comments on the ER being "free." Texas -- where I used to live -- has many free-standing emergency rooms that people confuse (and are meant to confuse) with urgent-care facilities. Their charges are horrific and insurance often won't cover much. Also - not sure about anyone else's insurance, but mine 1) charges a pretty high ER co-pay and 2) investigates ER visits to make sure they are "necessary." Unnecessary? the co-pay is 2K. Plus, most urgent care facilities simply aren't covered, as they're quite costly.
9
Does the public realize how broken our healthcare system is? I feel sick for this doctor and at the same time applaud the quality of care she is delivering in the circumstances she faces. But it cannot last. Not for her, not for anyone. The solutions are multi-pronged, no doubt. We need to tackle one issue at the time - and do it well. For starters, primary care should be SO MUCH BETTER. A relationship based care team will keep lots of patients out of the hospital/urgent care. Stop paying primary care by volume. It only encourages shoddy care and increases trips to the ER. It’s at least a start.
18
Our area of smallish towns has, over the past 15 plus yrs, seen two hospital linked walk-ins, and one nurse created "Primary Care Center", open. The hospital walk-ins and the nurse created "wellness center" are all 9-5 facilities, not actually primary care w/ 24/7/365 coverage, and all subsidized by federal or state funds. Is it any surprise that three primary care physicians have left the area, two more have joined large hospital groups, and one two physician private office is barely hanging on? So, with few exceptions, there is no PCP to field calls after hours, suggest a change in RX, or meet the patient at the hospital for admission. Hospitalists ( employed by hospitals) make it impractical for office based docs to see the dwindling number of in-patients, most now admitted from ER's by, and followed by, the hospitalists. It's the new norm.
7
The statistics about ER reuse can be indicative of short-term gaps in care for even those who are well cared for. My son had leukemia with 4 years of relapses and complications prior to a stem cell transplant. Then there were other unintended consequences which led to lung failure and a double lung transplant. We were regular visitors to the ER at his primary care hospital (UCLA) as a place to stabilize the crises and start new diagnostics. The onco docs weren't on call 24/7 and appreciated the assistance of the ER in providing continuity of care, made more viable by good data management in their central computer system.
The author does touch on the "capacity" issue and it is not limited to the ER. Hospitals, even Not for Profits, can't support budgets and physical plant that has a great deal of unused capacity; they need revenue. The net result of course is that we live with a more fragile balance of emergency healthcare than we realize. If we suffer another pandemic or even natural disaster, the healthcare system will be maxed out within literally hours or at most a few days.
14
You are a gifted writer and must be a more than competent doctor.
Thank you for your thoughts. I visited an ER several days ago for a severe breathing problem and was thankful for the professional and courtesy treatment.
You are blessed
23
Here’s the thing. For people who can’t afford, or don’t have access to a primary care physician, or a good walk in clinic, the ER is their first line of medical care. Consequently, those who do need emergency care and those who really don’t all sit together in the waiting room, and their advancement along the conveyer belt depends on the seriousness of the malady, and the number of beds available. And the number of beds available depends on the beds available “upstairs”, which may also be full.
Two weeks ago my 90 year old mom fell, breaking her arm in half. Bones protruding every which way, blood everywhere. She came in by ambulance but lay in an ER bed, no morphine, for 5 hours, until a bed “upstairs” was free.
Last year, my dad, who is 93, had us take him to the ER; he had a very painful intestinal blockage (he had had them before). We sat in the waiting room from 8:00 p.m. to 2:00 a.m. when we took him home because he could no longer sit up and was falling over. I refused to sign the discharge papers because he may have been “admitted”, so to speak, but he had never been treated. The admittance people went apeshit because we were leaving against medical advice. I said fine, we would just sue them. One of the nurses took me aside and told me that in the future, to call for an ambulance if my parents needed help, that ambulance patients always get an ER bed.
Fine. Seven ambulance trips in the last year, all paid for by Medicare.
How does that make sense?
49
The only solution, to maldistribution of health care, the sad state of the financial aspect of all care, and the decreasing quality of care and the public health ramifications thereof (i.e. increasing morbidity and mortality), is single payer. Sooner or later, we must come to that.
13
Yes, we have a healthcare problem in this country. Hospitals are overwhelmed and costs have gone through the roof. It wasn’t always like this, so what’s changed? Two factors come to mind:
1. Population, or rather ‘overpopulation’. Too...many...people.
2. For-profit healthcare...aka greed.
16
@Susanna, yes, too many people. What is the solution? Soylent green?
3
If America had socialized medicine, we could subsidize 24-HR urgent care to take the load off emergency rooms.
13
@Skip Bonbright
And probably save money overall.
8
Right. But then the Medicare bean counters would rule the 24 hour Urgent Care too expensive and close it! You are assuming they care about outcomes. They, like their current counterparts, will mainly worry about cost. Socialized medicine will not eliminate price pressure. It will simply (and maybe forcibly) reallocate it.
3
Hey NYT -
You need a column that presents a “better way” to handle our big problems.
We know that other nations manage disease care better (and at less cost per capita).
I think a concrete example we could implement (with $ translated from the other country) would energize many folks, who get the message from your vignettes that there are no well established paths to follow out of our hellholes.
I would be happy to help work on these (at no charge).
Stephen Rinsler, MD
12
Good information. Do Times readers need all the graphics?
@Virginia
What's wrong with having the graphics? Jeez ....
3
“Jeez” is right. Why does everybody have to nitpick?
4
I have had several ER or ED experiences:
Elderly father sent to ER by assisted living facility with bronchial issues. Had to beg ER doc to admit him as assisted living not equipped to provide round the clock care. Then, when well enough to be released, had to beg hospital doc to release to assisted living with private aide I hired so he wouldn’t be stuck in nursing home. Damned if you do or don’t!
13 year old Son cut his wrist opening package. ER intern in July (FYI new interns start in July - buyer beware), was quick to want to stitch him up. I insisted on bandage, called in a hand surgeon who had to preform micro surgery to repair nerves and tendons. He would have lost full use of hand if intern stitched up.
I was diagnosed with cancer on a Friday, couldn’t get appointment with oncologist for a week. Called my one Doc at university medical center who told me he couldn’t admit me as not his area of practice so go to emergency room in order to be admitted. I did and was admitted where I received top level care and on the day I would have seen oncologist, was already being operated on. Five years in remission! But I do question why I had to go through ER to be admitted.
Bottom line, advocate for yourself. Insist on care and if you are not critical, go to urgent care so ER can do their job for those who need it. Sadly all bets are off if you are uninsured. Everyone needs to advocate for available health care for all!
Daughter-Med school Prof & Researcher
27
Dr. Siddiqui, Thank you for a well written account of a night shift in an ED. After an EM residency, EM board certification, three recertifications, and forty years as a night ER doc, I retired. I worked in ED's that had yearly censes of 16,000 to 240,000. I worked for non-profits and one for profit organization. I humbly offer only one piece of advise: continue your obvious empathy and compassion for your patients and their family. My career began before CT scanners, ultrasound, MRI's EMR's, HIV, meth, Press-Ganey, and the industrialization of health care. I saved lives, delivered babies, cried with bereaved families. I worked a night shift while having a bowel obstruction, vomiting into a blue emesis bag as I cared for my patients and awaited the day shift doc. Good luck and keep fighting the good fight.
39
My friend who works in E.R blames understaffing by blood sucking corporations who run many hospitals now for a lot of the problems.
33
For 37 years as a "real doctor" specialist, I cared for people at high risk for complications or deterioration, both from their surgery and from their inherent disease. Everyone knows that many of the scenarios noted in this diary are preventable, or, at least, can be modified for severity. To do so requires robust primary care and specialists who understand how to keep a patient out of the ER. I never found an administrator in any hospital system who understood this challenge. If we put a bit more work into care in the outpatient sector, or if we spend extra time in diligent coordination of a patient's problems when transitioning after inpatient care, there is a huge payoff. The patient has less risk of readmission and has greater confidence in the process of care. Costs are reduced. There is less stress on physicians and nurses. For years, I had the lowest readmission rate within my group of doctors, but no one ever asked me how I achieved that outcome. There was also no direct reward from the system, but I can assure any young doctor that among the most wonderful outcomes is to receive a smile from a patient or family when a crisis is averted, an ER visit omitted or a hospitalization prevented by diligent care. The first step to get to that goal is to instruct one's office staff that when a patient calls for an office visit request with what seems to be an urgent concern, the answer is always "yes".
24
ED visits will fall when people have primary care physicians with time to see them, appointments available quickly, and time off from work to go during office hours.
They will fall more when people are educated about what constitutes emergency care; but even urgent care centers aren’t open in the middle of the night.
And as a physician who struggles with seeing 40-50 patients a day for routine appointments, when I get a call for an urgent visit while I’m already an hour behind and have grumpy patients and a day care deadline to get my kids....it’s easier for me to say go to the ER. When my work load gets less crushing, I can keep my patients out of the ER, too.
43
Couldn't the author have sent "Up" a consulting note suggesting the catheter change for Jon Luc? This lack of continuity in care is part of the problem.
4
Ugh. I just knew someone would find a way to blame the person who was trying the hardest.
12
@JR
That wasn't my intention. She's obviously a compassionate physician doing her best in an untenable situation. But she also could have passed along a note.
5
Broken, broken. Vote in November for a chance to get a decent healthcare system.
18
The motto in the ER is “treat ‘em and street ‘em.”
2
I imagine that one cause of high ER utilization is that it is nearly impossible to get medical care outside of an ER at night and on weekends. I just googled urgent care centers in my area and none are open past midnight, most close at 8pm.
What are you going to do? You might not have a life threatening issue (a common reason for insurance to deny coverage of an ER visit), and yet you are in pain/bleeding/injured and you need attention. The ER is your only option.
281
@cpf, no one said that people shouldn’t go to he ER if they need medical care immediately. The problem is that so many people demand immediate care for issues that can wait until office hours. A chronic bad back, for instance. A rash that has been there for days. A chronic UTI (without fever or pelvic pain). A minor sprain. People do abuse the system of emergency care. All the time.
A few months back a woman appeared at work with an elaborate (crazy expensive), ER-issued splint or soft cast on her leg, fully encasing her foot and calf, up to her knee. She had one of those scooter things that you put your knee on (rented, paid for by insurance). I assumed that she had broken her ankle, but no. She told me she had a small fracture on one of her foot bones. No displacement. Just the faintest line on the x-ray. She’d landed badly on her foot and rushed to the ER, and that’s how they had treated a minor injury that should have seen nothing more than an ace bandage. I‘ve fractured foot bones, toes, fingers, and ribs and just dealt with the injuries at home. The truth is there are a lot of people who love drama and like to feel special. and the rest of us pay for that.
38
@Passion for Peaches -- most people don't really know what does or does not require an ER visit. Some of your examples make sense, but how in the world would the woman have known that it was "just the faintest line on the x-ray" until she got the x-ray done? If you are in pain and cannot walk, you are going to go to the ER--and if you don't, then your doctor might well tell you, the next day, that you *should* have gone to the ER, and not doing so damaged something, and now you're going to have arthritis!
Instead of blaming people when they are in pain and scared, why not work to set up a system of hotlines, or nursing clinics, that can provide immediate *consultations* 24 hours a day?
81
I have never, ever taken myself or any member of my family to the ER because I “love drama“ or “want to feel special.“ We have gone to ER because we were in circumstances that we were unequipped to deal with at home as laypeople, or because symptoms seemed to be getting worse and It seemed unwise to wait until Monday, or because we called our primary physicians office and were told to do so, or because we needed help with something that an urgent care clinic is explicitly unable to handle. What my husband’s orthopedist once referred to as “punitive casting,” as you have described here, is what is offered by the physician to the patient, who lacks the knowledge to make an informed decision about whether that is really necessary. Goodie for you that you have dealt with broken bones on your own; to suggest that every civilian who is unprepared to do likewise is somehow lacking in moral fiber and gaming the system is both ridiculous and cruel.
68
I feel like the vast majority of articles like this in magazines and newspapers are from the MD's point of view. And then there is a smattering of articles by and about RNs. How about getting some input from social workers? I assure you that they are often the ones doing the heavy lifting when it comes to patients with issues related to behavioral health, substance use and social problems.
12
ER volume could be significantly improved if health systems didn't attempt to increase their revenue. Putting Urgent care next door and diverting lots of folks who are more appropriate for this [lower cost] setting would very much help ER docs....but it would lower the revenue for the ER which charges higher rates to insurers....
11
Here I Mass. we have some ERs that have an urgent care center attached, and a large number of self-standing private urgent care centers staffed by MDs, some with CTs and MRIs. We have the rules on the books for these to be reimbursed by our Health Connector plans. We have no-fault coverage for automobile victims.
Why not in CT, and in Yale of all places?
Yet even then, rather than lack of primary care, and even before primary care, I will add another factor: loneliness and lack of support from family and significant others.
6
@Yoandel, my local ER splits admissions into “real emergency” (to the right) and everything else (left). The side of the ER that deals with everything else is sort of like an urgent care with extra services. In theory, this split makes sense. In practice, I question some of the decision making in triage. I‘ve been sent to the left when it should have been right.
The Urgent Care I use is where my primary care doctor works, so I know it’s reliable and has good record keeping. But the quality of UC facilities is variable. A relative of mine died (horribly) from poor medical care, conflicting and incorrect diagnoses, and from being prescribed medications that were incorrect for her conditions. in the year before she died she had been going, increasingly often, to a notoriously bad UC center near her home. It seems that no one there bothered to collate information from her previous visits, before prescribing yet another inappropriate scrip. No one sent records to her primary care doctor. No one oversaw her care. She was not referred for follow up. They just looked her up and down and issued another prescription. I don’t think it is overstating things to say that they killed her.
1
My 70+ year old wife tripped and hit her head on the driveway at 11 pm on a Friday night. The bloodstains were on the pavement for days. After 4 hours in the ER (where they cleaned up the blood and took her BP). We were told at 3:30 am that there would be an additional 4 - 6 hour wait, and that we would have to leave the triage area and go back into the waiting room. We went home, without treatment, without knowing whether she had a concussion, and with a permanent scar on her forehead. We are health professionals. Something is wrong.
43
@Allen Goodman Sorry to hear about this ordeal. It sounds like you chose the wrong ER, which can be a fatal mistake. Of course most laypeople don't have a feasible way of knowing where they should go for emergency care.
4
As a nurse who has worked in "Up" I am sad to report he minute the patient arrives on the floor (assigned a bed) the push (insurance company, hospital management) is to get them out. The better hospitals have case manager/discharge coordinators who work heroically against time to set up community services. There have been many times I have been on the phone setting up services to return to the bedside to find the patient has been discharged with no followup plan in place.
35
@Warriorsaint - I can beat that:) I went to visit a sick friend last year in the hospital. The nurses told me which room she was in and that, yes, visitors were okay. I went back to the room to discover an old man, not my female friend. There was a nurse in the room wondering what happened to his patient (my friend). She had been moved to another room. But she wasn't there either. Turns out she had been taken to another floor for tests but not even her nurse was aware of this. After 20 minutes or so, they found her in their own hospital.
Reminds me of the time I was in the ER at another hospital after an epileptic seizure. The ER was busy so they had me in a bed at first in a dark room but someone forgot to put up the side bar and I had another seizure and flopped out of bed onto the linoleum. Then, they moved me out to the nurse's station because they were busy. I listened to them discuss what happened to their missing patient. They had lost someone in their own hospital.
Perhaps hospitals should consider some kind of dog collar with a chip or something since losing patients is not uncommon.
6
God bless this doctor and all those in the healthcare field. Next time I’m stressed about my job I’m going to read this article again. Happy Holidays to all in healthcare field best wishes
28
@Lisa S Thanks for your kind words, Lisa!
3
I second that. I went to the ER with a terrible sore throat and vomiting one morning in September. I was treated and sent home feeling better - only to return to the ER later that night with a ruptured brain aneurysm! Thank God they figured out what was going on and I made a full recovery!
1
NYT you need to ask us nurses where healthcare costs can be cut TV advertising is number 1, second lower doctors schools costs (their debt will keep DX costs high) stop these insurance company executives from making millions, and like CA was trying to do with dialysis they are charging way more than needs too there is no one right answer but the above makes a huge dent
Medicare for All
41
Three cheers for this ED physician! Struggling mostly against hospitals as profit centers and specialists as independent entities who do not communicate with one another about their chief mission, and a medical bureaucracy run by MBAs, she showed her humanity when she filled out the death certificate for an asthma patient and revealed the current medical system as a massive profit center weaponized to suppress the sick's symptoms without understanding or caring for their causes.
16
It's the health care delivery systemic problem, stupid! I keep informed about life in other advanced countries and join with other perceptive people in continuing to shake my head in wonderment. If information from those other places could get through the insurance and establishment medical system propaganda here to show how much people elsewhere benefit from their delivery systems, maybe finally we'd have people her in the streets fighting to support policies that are distorted as so radical--those as from Sanders and Warren.
12
@Richard Hahn I'm having trouble understanding your last sentence. Are you for Bernie's and Elizabeth's policies, or against them?
I am for them myself,
1
Current ER nurse, good article, also dramatized. Couldn't eye roll harder when she writes that she handed a patient a sandwich... no never. The nurse, tech, orderly, anyone else but the doc would've done that. Also the medics don't just hand paperwork to the docs and walk away, they call en route with report taken by a tech or nurse, then give a hand-off report to an RN. I doubt this doc sifted through papers to find a hidden note from the nursing home suggesting the urine was foul, likely they called the medics because the urine was foul, medics passed this info on to the nurses who would've triaged and sent a urine sample to the lab before this doc even saw or knew about the patient, also a urinalysis is usually standard lab work done on most ER patients. Just my 2 cents.
10
I’m an ER doctor. I give patients drinks, sandwiches, and blankets everyday. I routinely sift through mountains of paperwork from nursing homes. These tasks are not beneath me or for my other colleagues who routinely do them. We’re all on the same team in the ER and that’s what I love about emergency medicine.
91
@Matt Stensland, good for you for doing that, but I have never seen an ER physician hand out blankets, drinks or sandwiches. I’m my local (ER) and the ERs I have been in in other places. Nurses and nurse assistants are the ones who notice and attend to personal needs (when they do notice at all). You and other ER staff commenting here have to realize that if someone feels bitter about ERs in general (me, for instance), it’s based on really bad experiences they have had, or witnessed.
4
I am an ER Doc and we do these things all the time
25
America doesn't have a healthcare system. It has a sick-care system. And that, only barely.
23
American hospitals need to go all in on their uniquely degrading notion that healthcare is merely a product that only those of financial means should be granted the opportunity to “purchase.”
Turn away the uninsured, the underinsured, the unemployed, the poor, the desperate. Force them to die in the street, outside, and let the bodies pile up. After all, you are a business. Only a business. You exist to make a profit.
Then we can strip away the veneer of civilization and see this system for what it really is, and the people who work there for what they really are. Racketeers, profiting from pain and misery. And then the rest of us can decide whether we should permit it to continue to exist in its current incarnation. Or whether we should join the rest of the world and run healthcare for the greater good and not for narrow financial gain.
14
The one gentleman with the UTI sounds like my fathers case. It escapes me the nexus what the doctors call "The Cycle", where in the end you return to the hospital more and more until it over. But he was a double amputee and what we suspect really killed him was the catheter leading to the UTI, which in turn had spread throughout his system (Sepsis). So not only is the ER story ringing true, the nursing home is as well. You would think at $6.000.00 a month the nursing home would do better. Once a client dies, you are requested to gather their belongings ASAP to make room for the next client.
10
I had horrific pain, screaming-level pain, worst I'd ever felt--no clue what it was--so went to the ER--it was a kidney stone. If I'd known what it was, could I have toughed it out overnight and made an appointment with--who? Did I need the ER? I wish I knew.
When you don't know what's wrong, you have to go to the ER.
Education on when to go to the ER and when not to would help--except that would cut into corporate profits, wouldn't it?
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@The Poet McTeagle
There is a tremendous difference between the pain of a kidney stone and a cold. You did the right thing on many levels. You could lose a kidney, and you had intolerable pain. It does not take a genius to know that the common cold does not warrant an ER visit in the absence of high fever or severe symptoms in a frail person.
The problem is that it is 'free.' I always joke that the medicare copay (and medicaid has none) is cheaper than going to a movie. People abuse it. And that is a major source of our problem in healthcare finance.
23
@Ny Surgeon What a funny joke! A trip to the ER is cheaper than going to a movie. And, in my experience, it's way more fun. I could regale you with numerous hilarious stories about my mother's hours and hours in the ER. That's why she went there so often. And so cheap!
35
@Susan Udin
That is because you pay!!!
7
Well done, from a retired neurologist who spent a lot of time in EDs at all hours. You have to work fast with limited information on high risk patients. Costs are very high, because you exist to take care of any conceivable problem.
Hospitals EDs and jail are the final stops for a lot of society's failings. They work, but they are extremely expensive places to staff and use because society does not value enough dealing with the root causes of all these problems.
Thank you for being there.
26
My local ER is notoriously awful, so I avoid it at all costs, and fortunately I haven’t had any life threatening emergencies.
I’ve had a number of excellent experiences at my local CityMD, where every doctor and nurse I’ve met was warm and knowledgeable. I got 10 stitches there by a doctor who formerly worked for years in an ER. The bill was much lower than it would have been at that local ER, and he didn’t have to rush.
Many people who end up heading to ERs could go instead to CityMDs or comparable walk ins, as long as their condition isn’t life threatening.
6
20 year ER veteran here, as social worker/mental health crisis counselor, until I got burned out (average time to burn out for crisis counselor is about 3 years +/-).
The ER is the only place many people, even with doctors, can get seen in the same day. My own family doctor started telling me he no longer saw "drop in" patients 4-5 years ago; average wait to see him now 1-2 weeks. Docs have nearly completely stopped responding to after hours needs.
My ER doc girlfriend made over $400 per hour, 15 times more than I made; her medical degree and specialization took just one year more than my training. At those rates, treatment times have to be hours not minutes for all but life-or-death problems out of purely financial considerations.
I watched resources available to people with social, drug, and mental health problems decline and decline more under GOP national, state (Georgia) and local (Atlanta Suburb) leadership (yet taxpayers all demand services for themselves and their family when it comes to their crisis).
Staff are all so severely damaged by PTSD- even by the time they just complete their training- it is nearly impossible for them to respond with emotion and full humanity; so they focus on the immediate problem and meeting minimum standards for care, not addressing root causes. The means for addressing root causes are rarely available-that young woman probably couldn't afford her asthma medicine, for instance. She was likely a lack of insurance death, in person.
13
The ratio of doctors to patients in the US is among the lowest of all developed countries (about 2.5/1000) and well below that of countries in the E.U. where Germany has a ratio close to 4 doctors for 1000 patients and PCO's mkae over $200,000 Euros/year.
Yes, we need universal health care and better health insurance. But that's not enough if we don't have enough doctors. We need to train more doctors in the U.S. and provide incentives to go into primary care -- e.g., provide student loan relief for those we go into primary care.
I have excellent health insurance and recently went to an ER for a minor injury because I hoped they could provide a referral that wouldn't require me to wait until after the holidays. I got the quick referral, but ended up seeing a very inexperienced physician's assistant (P.A.) who misdiagnosed the problem. Fortunately, I also got a referral to a physical therapist who knew what she was doing.
There is a role for P.A.'s ; nurse practitioneers, etc. and most are much better than the one I saw. But we also need more doctors -- without enough doctors, "Medicare for All" will still leave many people without the care they need.
10
Most people in the ER are in the right place.
I’d say from my own experience, as both a patient and hospital worker, at least half could have gotten the care they need at an Urgent Care clinic.
But being sick or in pain can be terribly frightening, and because on the whole ERs deliver the best care that they can, that’s where we go.
Beautifully written article .
8
Should every emergency room have an initial interviewer who would inquire as to what the "emergency" was? If not a real emergency, this interviewer would then refer the person to an Urgent Care Center. In our community we have an increasing number of urgent care centers. They handle routine, non-life threatening problems, expeditiously.
7
Urgent care centers aren't the greatest point of contact for primary care either. I'll admit, if I had a Primary Care Physician, that doctor might have known me better and assessed my symptoms better.
But instead, as a 17 year old high school student with chronic exhaustion, at the urgent care clinic, I was told I had developed "seasonal allergies" and was given a prescription for Allegra. Suspicious, much?
In actuality, I was a typical high school student who instead suffered with mono for months without knowing it, dragging myself to day-to-day activities until I developed a rash severe enough that I visited the urgent care center again, and saw a slightly more attentive physician.
Health care in America definitely needs an overhaul.
13
And yet I'm always seeing billboards advertising the wait in some local ER - usually as something less than 30 mins, whatever that corresponds to. In some hospitals, the ER is big business. A local hospital here set up a "satellite ER" which is basically an urgent care center that charges ER prices. We need more actual 24h (or at least 18h) "urgent care" centers where people with the sniffles and the runs can get decent treatment, and perhaps some followup or at least referrals. The hospitals could set these up adjacent or near their ER's and triage patients to them, but I suspect that the big profits they get from treating non-emergency patients in the ER is a disincentive.
4
This article echoes my experiences with my parents, both of whom declined and died recently. Especially that of my father, who was on a rat wheel of ER visits for unmanaged COPD that the ER and hospital could stabilize, but would unravel the moment he returned home to hospice with its inability to provide IV medication and frankly, competent nursing staff. How to keep him out of the ER was obvious even to my EMT-B training; no adequate bridge for the care gap existed and I could not be there 24/7 to oversee his care. He was not going to survive long anyway, but a better system to address root causes might have kept him more comfortable.
18
I am en ED physician, and we used to be able to triage patients from the ED to the urgent care or primary care without seeing a doctor in the ER for non-emergent causes. It was cost saving for patients and the health system. But now EMTALA prevents this practice, so we are required to see and treat them in the ED, with long wait times and higher costs. We even opened an urgent care center that is open from 3pm-11pm that accepts walk-ins and appointments that is down the hallway from the ER, but patients still come to the ER for non-emergencies, many through lack of knowledge of what an "emergency" truly is. Medicaid patients need to have a copayment for ED visits, and maybe that could be waived if it's determined the visit was truly an emergency, but it's a big reason why people come to the ER over taking the time to try an make an appointment. To handle the increasingly high volumes, my group of ER doctors covering two hospitals has increased from 50 to 90 doctors in the last 8 years, which is completely unsustainable. Our ED, built with 40 beds in 2014 to exceed our anticipated volume, is now constantly lined with gurneys in the hallways for patients who don't need cardiac monitors (or privacy, apparently). On a bad day, we have 80 patients on the census. We expanded into adjacent radiology areas just to handle our less sick patients. And all this is occurring in an integrated HMO/hospital system that is incentivized to keep people out of the ED.
28
@David I am also an ED physician, and I was practicing before EMTALA. when were you told it had changed? If patients come to the ER when they could be seen more quickly at the urgent care, i suspect the urgent care is just as backed up or the urgent care is asking them for cash they don't have. EMTALA does _not_ require that triage be done by an MD. If the urgent care is not charging more, why did you set it up as a separate facility? Merge it with your ER into a single department and just triage the less serious patients there. And take a little time to educate them. Many have been treated as if they are stupid when they are actually uneducated. Do you support medicare for All so they could actually see primary providers?
3
@David The problem with urgent care centers is they're not prepared to handle urgent care needs. I'm a 72 y.o. and had calf pain following a 3 hour plane trip. I was advised to go to urgent care to determine if I had thrombophlebitis. I went to two different urgent care centers. Neither had the ability to do an ultrasound exam. I ended up in an ER because that was the only way I could get an US exam.
9
For those who lived or trained in any developed country, such as in Western Europe, it is incomprehensible that in a rich and supposedly developed county like ours events described in this article are possible. Most of these cases would be resolved in a visit to family doctor if we had an universal health care. Will we ever join a civilized world?
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@Stefan As long as most American physicians vote Republican things will never get better.
8
@Dan Woodard MD This is stupid. The Democrats have had the power as much as the Republicans in the last 30 years, of not more, since they rule all the big cities, and they were no better.
1
Having worked in a Level One ED for 20 years I can attest to the uphill fight in bringing order to chaos that dedicated ED staff face 24/7. Unless and until human suffering and, therefore, patient care becomes the priority for the payers the slog will continue to be uphill and chaotic. And excellent medical personnel will continue to do their best while burning out because of the crazy non-system in which they serve. I for one applaud their tenacity despite the odds, and am grateful for those who follow their vocation so faithfully.
10
@James Sterling As long as the payers are insurance companies and not Medicare yu can be sure thier priority will be denying care.
3
Iam lying in a hospital bed I Burgundy while reading those lines and albeit the growing difficulties plaguing the French health system and public hospitals ( to the point many doctors are threatening to resign), I can't help thinking us working far better than others for less money. The few stents I 'll get as soon as tomorrow are paid for already. The fact the first economic power in the world can't afford something roughly similar is ,still today, totally astounding for a French citizen.
20
@Bruno Parfait We can afford it, we just choose to spend our riches on things, not people.
15
The other side, the primary care side, which is what I do, also has it’s pervasive problems, maybe not as acute and dramatic, but important nonetheless.
We have to struggle with more and more administrative burdens that burns us out and impair our ability to provide care.
It seems that the only ones doing good with how the system works, are the administrators, insurances, pharma etc, at the expense of patients and providers
Many of my patient’s go to the ED out of convenience BC of the after hours availability, and yet there is no real incentive for primary care provider to improve after hour access. We are burned out as it is now, many I know are selling or closing their offices and having personal problems BC of how taxing the job of providing medical care has become.
Daily, I have to struggle to find the silver lining of my daily routine. Will I have enough to pay my staff and run my office operations the way my patients deserve? or I will have to fold and become another employee for a big system, it would be much easier, but will not have much a say in how care will be provided to my patients.
Something has to happen soon.
24
@Daniel
We Americans should look at the UK system on this issue. Some NHS hospitals have signs directing the public to the reality that the ER is for emergencies, and there have been campaigns nationally for this same purpose. There was a catchy Youtube video titled "Why A&E" to the tune of YMCA as part of the program. The NHS is far from perfect, financially stressed, and has huge issues regarding physician satisfaction. Administrative burdens are notable there, too. However, they have ideas that merit consideration: Primary care practices that are open every day. Pharmacists who can prescribe meds for common ailments, such as diarrhea. Of course, the big benefit is that every citizen is covered by the NHS, so the consequences of uninsured status are less likely to occur.
6
@Daniel I agree totally. But the reason for all that paperwork is because the insurance companies can boost their already obscene profits simply by preventing you from providing care. Become a wage slave for a giant HMO and your employer will force you to see 80 patients a day. We have one chance, and that is Medicare for All. If the members of Congress have to use it for their relatives you can bet the care will be adequate.
9
Did anyone report Jean-Luc’s care home for neglect? A school teacher is required to report signs of abuse or neglect among students. A doctor in the ER should be similarly required to report.
As for, “... a few weeks ago, when she was last in the E.R. and we didn’t find a way to get her asthma inhalers to her at home,” that level of aftercare is not within the ER’s purview. That patient was, when released after the previous visit, able to walk and use public transportation. If she opted to not fill her prescription, that was her choice.
But kicking people to the keen is not acceptable, either.
A few years ago I was released from the ER with two broken legs and no wheelchair. I had to crawl into the car, and crawl (up and down stairs) into and around my house. It was three days before I could get a chair, and the ER knew it would be several days before it could see the surgeon they referred me to. No one from the ER checked on me. There was no asking whether I needed home care. I had to crawl to the bathroom. For my local ER it isn’t up or out. It’s just out.
10
That was supposed to say “kicking people to the kerb.” Darned autocorrect got me.
While I’m here, can anyone tell me why a nursing home would prefer to do a urinary catheter on a man instead of the condom-style urine collector the writer thought was a better choice? I assume that the latter device might need more monitoring (might be more likely to detach), but that possible problem should be balanced out by the decreased possibility of infection. Is it just a matter of cost?
I'm 85 with Parkinson's Disease. I have been in the emergency room of "one of the best hospitals" in the country.
On Friday night it is a madhouse--noisy, crowded. And if my wife
hadn't brought my PD meds, which I take four times a day, from home, I wouldn't have got them from the ER, since I hadn't yet been "admitted."
3
@84 Why would you go to an emergency room? You have a chronic illness. Be prepared not to get the best care. ER's should not be treating chronic illness.
1
@Mary Rivkatot : Why do you assume that 84 went to the ER for Parkinsons? They never mentioned *why* they went to ER, just that they had Parkinsons because it was relevant to the story.
3
@Mary Rivkatot
Oh my, how lucky to not be familiar with the term "co-morbidities"! My 85 year old mother had Alzheimer's, which like Parkinson's is a progressive, neurodegenerative disease. She also had congestive heart failure, osteoporosis with lumbar fracture, a clotting disorder and that was all while still able to live at home. But when one of those other conditions, or difficulty fighting off infections, strikes at night or requires an IV, she was at the ER. And treated with kindness and care.
8
Here in North Miami Beach, billboards promoting brief emergency room wait times seem to have become more common than those promoting popular restaurants and jewelry stores. Seems like quite a disconnect between marketing and doctors handling the rush.
4
@Seth Eisenberg Good point!!! Hospitals advertize to get insured people with minor problems into thier emergency rooms because the cost of seeing them is minimal and their insurance companies will pay a lot more than it costs to see them. When indigent patients cannot pay their highly inflated bills are used as tax writeoffs. What does an administrator call an overcrowded ER? A profit center.
1
I live in a medium size Midwestern city. I have about ten urgent care centers within as many miles from my apartment. Also the university hospital runs 24 hour (very clean and attractive) full service "emergency room centers."
There is no reason whatsoever to go to a full-service ET unless you are very seriously ill or the victim of major trauma.
I understand you have to accept everyone. I would just make it difficult for the not actual emergencies to be seen. Kind of like the walk ins to an expensive restaurant where everyone else has reservation weeks in advance.
3
@Mary Rivkatot Unfortunately, Urgent Care centers require payment up front while Emergency Rooms do not. For those who are uninsured or have outrageous co-pays, sadly the ER can be the least expensive option in the moment. They take payment plans.
8
@Susan However a patietn of mine was sued and nearly imprisoned by Deaconess Hospital in Evansville when he was attacked and could not pay the $20,000 bill for his (relatively minor) treatment.
1
So I am in psychiatric practice. But I did 15 years in a rural ER. What is said in the article is right on. I will go one step further. The current measure of success in corporate medicine is speed of service and volume of patients seen. Thus, no one, from the PCP on down is recognized or reinforced for solving problems, more than just treating bodies. We need to go back to a somewhat more relaxed visit where we establish relationship. The relationship begets trust, implies caring, and enhances compliance with the plan. Since I see clients more often than most docs, I inevitably notice new things, like obesity, hypertension, chest pain syndromes. I will refer or manage some of these issues because they also directly affect mental health. But also, what good is your mental health when you are dead? Too many “managers” who know dollars, but don’t know humans. And aren’t physicians. But who manage your care without your knowing it. Not sure if it can be fixed, but the path ahead is not faster and faster medicine. It is slow medicine. Medicine that LISTENS and doesn’t just prescribe.
33
@Idahodoc I had a doctor visit this morning at Ohio Health. They run an "ER" next door. Very clean, easy access 24 hour. No one there of course. It's supposed to be a step up from urgent care. Walking through, I was stunned at the giant wheelchairs and scales. Good grief, how can all of you complain about our poor healthcare system when any in our population is large enough to need that kind of equipment. You get what you get. You reap what you sow.
@Idahodoc I absolutely agree. I am certrified in ER but now treat drug addicts slowly. Often 30 minutes for even an established patient visit. Not much money but patients appreciate it.
2
@Idahodoc - Its really hard to establish relationship with a doctor you only see twice a year just for labs. And worse, when the doctors of the clinic keep moving. In the two years I have been with my clinic, I have seen four different people. When I met my new doctor recently, I smiled and told her that it was nice to meet her but that I would bet money it would be our last meeting.
Somewhere on file, I have a primary physician but I would have to call the hospital to get his name. We met once because another clinic demanded that I have a primary doctor. I remember that he is Jewish since we talked about not celebrating Christmas. But I could not pick him out of a lineup and my landlady knows more about my health than he does.
When a healthcare worker only sees me for 15 minutes once or twice a year, how on earth could they develop much relationship? Its the equivalent of speed dating. Even an hour isn't going to change this.
Once a month, I hit the coffee shop across the street from my pharmacist/doctor's office. The baristas there know me better. They don't even need to look at a chart, they just smile and say, "double tall mocha breve extra hot?".
2
Here is an idea (crazy or not, I don't know.). Have Urgent Care facilities that stay open all night. A lot of people come to the ER because there is something unusual, something frightening and it is the middle of the night. Where else are they going to go? Even if they have a doctor who says take two aspirin and call me in the morning, it doesn't allay their fear. Being awake during the early morning hours is disorienting for people and they imagine all sorts of things.
29
@Ex New Yorker We have 24 hour quasi ER facilities in Columbus. They are peaceful and quiet and run by the excellent university system. The problem is not just that so many people run to the big ERs but that they are too ignorant and lazy to figure out there are many other options. But then catch 22 if they had that much executive function, most would not need constant ER visits. Sorry -- I'm fed up with how disgustingly unhealthy Americans have become. Fat and sick.
1
@Mary Rivkatot : Wow. Judge much?
12
@Ex New Yorker Why not merge the urgent care and the ER, and just triage the minor patients to the "fast track" where they can be seen by a midlevel? There's no reason it should cost more to be seen at an ER if you get the same level of care.
5
Both sides of the problem can be helped: There can be a well trained (non quite MD) to free up the doctors for the small stuff-with both gate keeping and the simple treatment. If there is a wait they wait for this nurse or PA. If they have questions the MD is available for that.
For those not getting what is needed outside the ER, there can be a social worker and her BA level assistants. There are many of the latter out of work or making near min wage and these educated people, especially perhaps the mature ones with experience in the medical community could go a long ways.
Part of the problem is also for example people not eligible for the ACA or not having access to a doctor that both takes medicaid and is the specialist who would prescribe. On some insurance plans like Ambetter there is not a single psychiatrist where you can really get an appointment and even when you do they are now to afraid of liabilty to prescribe real anti-anxiety medicine. So advocacy can be helpful even for those not so disadvantaged.
4
@david Private insurance companies want to get customers, they don't want to provide care. Any plan that allows private insurance will find they provide decent care only for those who pay top dollar. With budget plans they have a financial incentive to deny care.
1
Initial cost for routine labs in the emergency department: $6500.00. Not including radiology. Physician, and facility charges.
Charges overwhelm patients and society.
Most ED physicians are not aware of charges and costs. This oversight should be corrected by hospitals and residency programs.
5
@H Striper But, of course, those charges are necessary to the hospital's fiscal survival. So nothing will be done, except more expensive tests to buck up the bottom line.
2
@WSB Fiscal survival for our loacl hospitals includes higher ER charges and grand pianos in the lobbies.
1
As a consumer of medical care in the USA and other countries during my six decades on earth I’ve noticed profound changes in the USA. Every single doctor I see in the past 5-7 years arrives with a computer in their hands. Their interaction with me consists of checking boxes to follow protocols listed in said computers. Protocols developed by google and other third party “protocol” developers. Very little face time, less conversation of why I’m there and the symptoms with which I’m presenting.
I’m rapidly coming to the conclusion that google and other third party creators of algorithms for healthcare are becoming the brains of the doctor in the room. AND I DO NOT LIKE IT ONE LITTLE BIT.
American consumers of medical care should expressly prohibit the transfer of their healthcare data to those entities by writing so on the privacy policy and any other paperwork presented to them. If we blindly keep signing away our rights we will find ourselves without any protected healthcare information. We’re one data breach away from having the intimate details of our health published online for all to see. And it going to happen.
8
@Michijim Be aware that that computer you dislike is an attempt to provide accessible and understandable patient records. In addition to improving the odds of a proper diagnosis, it is a safety tool as well since a patient history can prevent the administration of inappropriate, and sometimes lethal, treatments.
11
@Michijim
Electronic medical records are federally mandated unfortunately
2
@Michijim
A truly experienced physician will understand that the computer screen may never displace attention from the patient in conversation and in eye-to-eye contact. Despite numerous criticisms among doctors about computerization, the net benefits of the computer in the room are huge. Notes are timely and legible. There is the possibility for the physician and patient or family to fashion the note in real time, to be certain that instructions are understood, especially when the patient receives care from a therapist or in a skilled facility. I used voice recognition software that made me more efficient, not less. Prescriptions are not lost. Countless times I have used that computer to show the patient radiograph or lab results from testing performed only minutes before. In a comprehensive electronic record system, I could show the patient notes from other specialists she/he has seen. None of this was possible with a paper chart.
1
I am an emergency room Doctor an work primarily the overnights. I disagree with many of the comments made in re the ER. I don’t care whether someone is paying or not. Insured or insured. I am there to treat patients. Unfortunately the glut of my job is seeing patients that have no need for an emergency room. Is there no common sense left. How about taking a Tylenol for your headache and seeing a doctor tomorrow. Is a bad dream worth an ER visit. We have no ability to turn someone away for their non emergent matter. It would save the system blllions if we could. There is no reason that everything less than perfect needs to be fixed in an emergency room. As a Doctor I need time off do I don’t burn out. The burn out is not from seeing sick patients it is from dealing with the multitude who abuse the ER rendering the word emergency obsolete
35
@Solomon M Maybe push them so far back in the line that they leave on their own.
@Solomon M if we doctors got behind Medicare for All patients would at least be able to see a primary provider. Most people in our country no longer can afford one.
2
@Dan Woodard MD - I have Medicaid and while it is great, it does not provide me a doctor 24/7 to tell me that a headache is not indicative of a brain aneurism and that I do not require an M.R.I. at 2 in the morning. I do have a primary provider but it takes at least 2 weeks to get an appointment and its only mornings, no weekends/evenings. And if I told him I had a headache, I would bet good money he would tell me that I need an M.R.I. and I'm back at the same place, just 2 weeks later:))
1
My daughter broke her arm and we went to the ER. I couldn’t believe how many people with just coughs and colds or the flu were there. The doctors and staff seemed really pleased to see an actual emergency and treated us very well. The ER is really being used for the wrong things. We need a better system for actual emergencies vs. things that need to be taken care of by primary care physicians during office hours.
17
@Qui You were lucky. I was in a similar situation and in great pain but I was not rushed in before all the people waiting in line with no pain at all, and I was forced to wait until I passed out because of the pain.
8
@Alexgri, ditto.
Your placement depends a lot on what you tell the triage nurse. Over the years, I have learned what to say, to get myself or the person I brought in looked at in reasonable time. I never lie, and I don’t exaggerate the pain. But my wording is precise because, if it isn’t a bleeding injury, I take the time to do a little Googling before driving to the ER.
For example, my husband was suddenly taken with intense pain in his lower back and abdomen, convulsive vomiting, and some other symptoms. He was conscious and did not have a fever, and his color was okay. Not in need of an ambulance, I decided. When I entered the symptoms into a search engine, they brought up a potentially fatal condition involving a major artery in the abdomen. I rushed him to the ER and presented the symptoms — his real symptoms —I had Googled. He was taken in almost immediately. It was just kidney stones in the end (painful, not deadly), but I assume that the possibility of it being the other thing is what got him admitted quickly.
When I went to the ER with broken bones and a knock on the head and possible neck injury (it turned out that I had a concussion), it was the head injury I emphasized, even though it was the bone breaks that hurt, and it was the bones that sent me to the ER.
2
@Qui There is no reason it should cost a penny more to see a patient with minor problems in a "fast track" in the ER instead of in an urgent care. Except of course that you need good insurance or at least $150 cash to be seen at an urgent care. With medicare for All, everyone could do it. And if they were seen at the ER, the ER would have more income and could hire more staff.
2
I am an emergency physician. I feel for this jaded resident, very likely overworked, early in her career, drowning in the humanity of emergency medicine.
The reality of the work changes when you get a few years under your belt, hit your stride in terms of clinical confidence, and are able to re-focus on the humanity of the individual patient encounter. As an emergency physician, I do not feel like I am just plugging the gaps in our healthcare system, I know that on a daily basis I am saving lives, curing illness, and improving peoples’ health.
Naturally there are cases and patients where the emergency department is not suited to fix the problems or address all of their needs. Even in those cases, there’s always something you can do, someway you can help. They are countries without an equivalent of modern American emergency medicine, I would never want to live in a place that doesn’t have a safety net like our country has, even with all its flaws.
21
@Robert, it is great to know that the personal struggles of being an ER physician diminish with time. But it seems to me you missed the point of the essay entirely.
What I read is a riveting analysis of a glaring structural deficit in contextualizing and delivering ER care. The focus, the author makes abundantly clear, is on getting patients up and out (wrongly assuming that others will address issues pivotal to well-being) rather than on how to structure the system, its functions and incentives, in order to best serve the needs of patients.
There's a time and place for doing your best as an individual in the frustrating realities of institutions. But there is also a time and place to lift analysis and response above that of pure individual effort, to address systemic issues. Sometimes being too good at coping with what is becomes a form of enabling.
I would far rather have this young resident advising and designing the medical services provided to me and my community than someone who, however kindly, simply admonishes that "you'll feel better about this after a while" and "btw, it could be a whole lot worse".
20
@Ron Kraybill
I don't think he missed the point at all.
I think that you missed his point, which is that the system we have, even with its problems, is better than none at all or what is found in other places
3
@Laidback What other places have you been? I have been an ER and in-patient in India, UK and Germany ... and of course in the US. Your blanket statement indicates to me you haven't had to seek medical care in many "other places".
Or you have simply been blinded by the fact that American hospitals are usually "prettier" than hospitals elsewhere. However, "prettiness" doesn't mean the care is better.
The fact is that health care in the US is by far the most expensive in the world, but by far not the best.
6
Medical care in the united states is in shambles. Ithe ER physician who works a 12 hour shift at night time is usually alone no matter how many patients walk in through the door. I would not like my mother to be taken care of a physician who has worked 10 hours straight and is exahaused enough to think straight, at the 11th and 12 hour when a lot of critical care patient come in. Its ridiculous! In most of the smaller town hospitals the ER physician is the only physician available for people to go to in at least a 20-30 mile radius at night time. Its worse than third world countries. Its all due to greed of the insurance companies and nothing else.
11
You cannot attribute this just to a dysfunctional health payment system. It is a dysfunctional country.
In my ER half of the ridiculous visits are medicaid patients- "It's free" for them. 1/4 of the visits are illegal immigrants getting routine care when they should not be in the country. The ER gets backed up because the inpatient beds are filled with ridiculous cases- my ICU is jammed with nursing home patients with severe dementia getting "worked up" for a variety of maladies in attempt to prolong their lives "because medicare will pay."
We need a change of culture across the board- stop the illegals, stop the deadbeats who don't pay taxes and stop the fruitless care given because families demand that we "do everything."
Maybe then there will be money left over for legitimate care for everyone who should be here.
35
@Ny Surgeon My immediate family members who are nursing students have advised that the part about nursing home patients is true. Sad
6
@Ny Surgeon
That would be most seniors who don't actually pay taxes. They do have Medicare though which you feel is far to generous. Nice.
Include students and stay at home care givers in that group. Perhaps a quick on-line check of credit scores could thin the waiting room, eh?
For you, apparently, humanity is tied to immigration status. Such a caring health care professional. For those who can pay, that is.
If you are worried about how it is paid for, you can ask the RCC which is buying up hospitals or perhaps tax shy urban areas.
24
@Ny Surgeon Illegal immigrants pay taxes so there's no reason they wouldn't be able to access a universal healthcare system.
Medicaid patients pay taxes too. Plenty of Medicaid beneficiaries do have jobs, they just have low incomes which qualify them for Medicaid. Many others covered by Medicaid are children.
What we really need is a universal healthcare system that grants equal access to all.
21
I was an emergency room doctor once.... and this column was a painful reminder of how agonizing that role was, and why I had to give it up.
The emphasis was on clicking little boxes on a computer screen, not talking to patients. The emphasis was on how much I billed, not how much I cared. The emphasis was on how quickly I "treated and streeted" patients...not how well I took care of them..
The ER is the epicenter of our healthcare crisis. Uninsured, uneducated, helplessly dependent people who have nowhere else to go are dumped into an environment where government regulations and rapacious malpractice lawyers mandate ridiculous details in the care of simple problems.
Patients waiting 3 days for an open psych bed.... Patients held in the ER for 6 hours because "the ICU is full" or "the ward is short of nurses"... Medicines ordered that were out of stock, on back order, too expensive, or "not covered"...
We lacked nurses on every shift.. (oddly enough, there were always plenty of administrators and chart reviewers).
Reprimanded y my bosses because "if you had asked that ankle sprain patient if she had a vaginal discharge, we could have billed a level 5 instead of level 3 visit"
What a relief it was to take a 50% pay cut and work in an office where I can be a real doctor.. one who has time to listen to patients and treat THEM, not simply "their condition"
60
@rick Very true. When I was in ER, I was stunned to see that all doctors stood at their computers and barely spoke with their patients. Mine spoke 1 minute with me and send me home 10 hours later unable to find a diagnosis. When I complained, he brought it a psychiatrist, then another, as if I were mad for being sick. I was sober, drug-free, and very much in pain.
2
@rick We need more doctors of your caliber!
5
Even with good insurance we are instructed by specialists and PCPs to go to the emergency room if 'it' get worse.
American health care is a pathetic joke in the USA. Give ME Your Money! Look at the salaries of Hospital CEOs and corporate everybody in the medical industrial complex. Nothing is going to change anytime soon. But by all means let's keep whining for another generation. Thought s and prayers.
8
during an ER rotation I found the drug seekers and ODers and oddly, the attention seekers were a constant presence along with people who needed to b there. The other unexpected group were the Medicaid recipients. When they or they're kids came in for a sniffle and I explained to them that they could go to a less urgent option they acknowledged this, but said they didn't want to wait and all they had to do was show the card and they'd be seen. As they weren't paying for it, there was no reason not to just walk in and abuse the system. There was a time when ERs paid their way in medicine, but now with illegals and citizens with no insurance, Medicaid and a sea of Medicare pts overwhelming them, hospitals are trying to figure out how to redirect pts or close the ER altogether. Not a great sign for medical care when you actually need one.
11
@ Er guy from Idaho. I wonder if your rotation coincided with my daughter’s visit to an Idaho ER (with insurance) and a trimaleolar fracture. She was released at two in the morning in a snow storm with no one to care for her. She was lucky enough to have an employer who came with her husband to drive her home and assist her to climb 17 exterior steps to her second floor apartment. When she had surgery (delayed by the holidays) her doctor released her into the dark of night with no suggestions as to how she was supposed to manage the same set of steps (he was so callous as to say that it was not his problem). Fortunately, I was there by then and we managed. She is not a dead beat. Or on drugs. Or an attention seeker. The system is not able to work holistically with patients, whether poor or not poor. The author is obviously compassionate, but many the commenters should find other lines of work.
13
@JF
I'm not an ER guy. That experience soured me. Your experience is unfortunate and from my experience not typical. My ER time was in SLC, decades ago. Since then I've taken care of many people, including many ankle fractures many of whom never paid a cent for their care (although in our system they are still free to sue, for any reason), for me or anyone else that took care of them. They all got the best care I could give regardless of their ability to pay. The mix of people who should be seen in the ER and who shouldn't, and the devided attention and care that causes hasn't changed. Visit an ER for a few shifts if you doubt me.
2
@JF I am curious as to what you think the MD/ER should have done about her 17 steps? She did have assistance, both times, yes, she was fortunate. Did you think she should have been admitted to the hospital, just because it was snowing and there were steps? Your daughter's experience has nothing to do with the issue of ERs (and the inpatient wards) being over burdened with inappropriate visits.
6
Today's NPR headline "What Else Disappears If The ACA Is Overturned?"
"Any day now, the 5th U.S. Circuit Court of Appeals in New Orleans could rule that the entire Affordable Care Act is unconstitutional."
Put that in your ER and smoke it.
12
My shift is typically like this, but it’s a 31 hour shift, from 8am till 1pm the next day covering the ER.
4
For every doctor that is willing to work with the disadvantaged ( I’m lucky to have one) there’s the type that refuses to take even Medicare. I know of such a doctor, virtually every dime he makes goes to support his gold diving wife and her horses. I know this woman well, a ex flight attendant, she went through several airline pilots before finding a doctor just out of residency (that’s when the cash starts flowing) to support her.
It’s sad that such a educated person is able to be so stupid in their personal life.
5
@Paulie The wife doesn't sound stupid, just greedy. The husband, on the other hand...
3
Wow! I can't wait until the government runs all the ERs. That'll fix this.
2
@JND They already do. It’s all the government regulations that drive this chaotic process
3
@Elizabeth Anheier Government regulations are driven by the lobbyists of the insurance, drug, and hospital industries and the AMA. The CEO of one large insurance company makes $160 million a year. i don't see him complaining. The one group the government does not listen to are poor people with serious health problems.
3
There is absolutely no credible reason for this.
3
In my years working as a visiting nurse in NYC one of my duties was to make sure discharged patients actually obtained the meds and received the patient teaching they needed. Also I made sure patients were scheduled for that first community health care provider visit. All of my colleagues did the same for the patients on their respective case loads. Are there no visiting nurse services in Connecticut?
11
Most of these comments blame the for-profit health care system, which definitely has some serious flaws. But patients who have severe deadly diseases need to be responsible and get the care they need if they have the resources. There are free health providers in many areas too. Employers and family should be just as flexible with a doctor visit or a trip to the pharmacy as they are with a medical emergency. Everyone has to take an active role in maintaining their health.
6
@SBC : Many areas do not have free health providers. And even if they do, meds are often not covered; referrals are often not covered, etc. And funding for community clinics is completely under threat by the current administration. What you're saying is like anyone get can food stamps quickly and easily and adequately if they were responsible enough. That, too, is not the case.
7
@Anne I have patients calling all the time. I see some of them free because the local medicaid companies don't want more providers. But I cannot get them the medications, lab tests, imaging, and surgery they need free.
1
UCSF Geriatrics has a home healthcare option for their patients. I am forever grateful to my mother’s physician who agreed, that constant visits to the ER for falls, stomach aches and labs was detrimental to my mom’s happiness and the lights, bells and beeps of the ER only increased the agitation and disorientation that was part of her dementia. The physicians could run simple labs, take simple xrays and draw blood all from my mom’s apartment. It was a win/win: mom was not tying up a bed in the ER and she was much happier with the personal attention she received in her apartment.
16
Why would one adopt a program that reduces visits to the ER? Such actions reduce the inflow of money from ER visits, an anathema to profitable operations. Blackrock and pals would have fewer targets for surprise bills.
Having the biggest pile of toys built on the biggest pile of bones sadly seems like the American Way-- or at least, the Republican way.
5
@MH
Maybe because most of those visits don't pay anything or if they do, don't cover the cost of the visit.
2
@Al Hospital management always advertises to get more people to come to the ER, not fewer, because the cost to the hospital of actually seeing a patient with a minor condition is trivial and the ER can bill even Medicaid for enough to make the visit profitable. Hospital management can always cut costs by cutting the ER staff.
I am an ED MD in San Francisco and President of the SF Emergency Physicians Association. Across all the city's emergency departments our volume has grown 40 % in the past 10 years which is 5x our yearly compounded population growth. No net increase in medical surgical beds have been added to the grid. You don't need a Stanford MBA to figure out that this math leads to waiting room bottlenecks and the vulgarity of patient boarding. Ambulances being diverted away from their intended primary destinations are at an all time high. These trends are unsustainable and this is not a San Francisco problem but a national urban ED acute grid crisis.
48
Our priorities are upside down. Why are convenience stores open 24/7—as if it’s impossible to plan for the purchase of a bag of chips and a case of beer—but there are few places to get 24/7 healthcare?
A primary care doctor will offer an appointment in six weeks. An urgent care facility will only be open 8:00 am to 8:00 pm. So, if you slice your finger at 10:00 pm, where do you go? The ER. If your child is screaming with abdominal pain at 2:00 am, where do you go? The ER.
If our society were logical, every pharmacy chain (Rite-Aid, CVS, Walgreens, etc.) would be open 24/7. The pharmacy itself would be open 24/7 (not like it is now where you can buy gum but not asthma medication at 2:00 am) and there would be a 24/7 first aid station with a registered nurse to check vitals, bandage minor cuts, recommend over the counter drugs, and evaluate whether a problem warrants a higher level of treatment at either an urgent care or ER facility.
Every single urgent care would be open 24/7 and have physicians who could care for situations that aren’t life threatening, such as taking x-rays, setting bones, and writing prescriptions for minor ailments.
This would free up the ER for its primary purpose: providing care for life-threatening conditions like heart attacks, aneurysms, gunshot wounds, and major burns.
ERs are overwhelmed because we aren’t meeting the reality that human medical needs occur 24/7. What will it take for us to provide it?
79
@Heather
Right? Heaven forbid our health care system actually serve its patients' needs.
6
@Heather unfortunately, er docs are a bit more costly to employ than 7/11 cashiers.
8
@Heather If the patient was the one who paid, this would happen. Health care providers would compete for patient satisfaction and there are many efficiencies to operating 24/7 as is common among large grocery chains.
But, insurance prevents the open competition of normal markets. The patient can't control the amount paid to the health provider and it is difficult and expensive for an insurance company to evaluate service.
House calls were common before most people had insurance.
5
Thank you for this piece. I work in the ER, and love what I do.I love helping people, but the current state of affairs is untenable. The system is broken and everyone comes to the ER for everything ,at an astronomical cost to everyone. We need to fill in the gaps in healthcare. Everyone needs insurance and primary care. We need to work on prevention and promoting wellness, not just narrowly saving the lives of people when they are horribly sick. As an ER doc, I want to thank all the other hospital staff: Nurses, techs, paramedics, secretaries....everyone who goes into the trenches to fight for our patients. It aint easy.
58
A true depiction of ER's impossible task to satisfy all comers...in due time...and prevent too frequent a visit by establishing 'outside groups' to compensate for the lack of time to give instructions for healthier alternatives. Having worked in the ER in my better days, I realize that the constant delays in prompt medical attention may be due to too many unnecessary visits...by folks who can't wait to see their own doctor (if they have one) for garden variety afflictions, not the least being our societal ills (chronic unrelieved stress...escaping into drugs, attempted suicides, domestic violence, job insecurity and/or unhappiness, and, last though not least, the feeling of loneliness). A never-ending exercise in frustration. But, in the middle of this chaos, there is usually room to appreciate that the dedication of professional workers in the ER do make a difference in some lives, an appreciation of a job well done, however transient or misunderstood. As they say, no one offered us a rose garden...as we try to do our best.
10
My mother is 85 years old with congestive heart failure and a host of other minor ailments. She had stomach pain of approximately one week's duration off and on. She called her PCP on Monday and was told the first available morning appointment (that's when I can take her) was that THURSDAY morning. No other doctor was available (supposedly) to see her. The short story is she was told to go to the ER given her age, heart condition and complaints. We arrived at 8:30 pm. Left at 3:30 am. The upside: the ER doctor actually took her stomach complaints seriously (which she's had for over a year and was previously told a couple of times she had indigestion and to take Pepcid) and ordered a CT scan, which revealed the diverticulitis. Much different than "indigestion." She also had a UTI. This could have been managed so much more efficiently! Make appointment with PCP. Go into the office. Doctor actually listens. Orders CT scan (she has complained about the same pain multiple times). Orders urine and blood work. Does not take 7 hours at a cost of - I shudder to even think of it - but if I had to guess - $25,000 or more. Obviously the cost to actually see her in the office, lab work and CT scan would be considerably less cost and take so much less time. What an irritating and inexcusable debacle. And this is just one of the many serious problems with our for-profit health care system.
34
@graceunderfire Every patient, over 70 years of age should be able to be seen by their PCP, or at least an experienced NCP/PA on a same day basis. PCPs who see older patients should have blocked off time slots, for same day visits for this population. Almost all pediatricians have this sort of scheduling set up, because just like frail, elderly patients, children can go from "not-too-sick" to REALLY SICK in mere hours and everyone knows this. I recently had to find a new PCP and that "same-day" appointment availability was on my list of screening questions for the doctors recommended to me. I am 62, and while not frail, have some chronic conditions that will worsen over time, despite my food, exercise,and healthy living efforts; I want to not have to use the ER in near emergencies.
7
@graceunderfire
It likely could also have been managed more efficiently if you had gone in during the day, instead of at 830 at night for a problem that had been present for a week
3
@Laidback
So not the point.
3
Private Equity firms buying up ambulances, doctor's offices and hospitals, CEO's and other hospital administrators now calling the shots instead of the health care professionals who actually know the science behind health care.
This article is another example of the badly broken health care system in America whose only goal, through no fault of the doctors and nurses, is to make the most money possible from each case that walks through the door. It stopped being about healthcare a LONG time ago.
25
@Jacquie This is what is referred to as 'The Rape of Emergency Medicine" and is detailed in the same named book. When hedge funds are primary stake holders in health care, bottom lines matter more than patient wellness.
6
@James Too many hospital administrators hired with exorbitant salaries who get in the way of real health care are also a big problem in Big Medicine. Hospitals used to be about providing compassionate care, today they are about only the bottom line.
5
The Affordable Care Act has been gutted thus it's not much better than no insurance at all. People can't afford primary care thus they utilize the Emergency Department because they know that they don't have to pay even though something that can be taken care of easily may cost them far more in the long run. People with insurance are more likely to be underinsured thus they can't pay for their care. Even some people utilize the Emergency Department when they need to "park" an elderly or disabled person to get some much-needed caregiver relief. EMTALA which was passed to make sure people were not abandoned without care, has been the bane of some Emergency Departments because they are required by law to workup and stabilize all who come through their doors. Out healthcare is a nightmare with Emergency Departments being the "canary" in the mine. This is not sustainable but no solutions in sight. It's a terrible time to be sick (even mildly sick) in the United States.
14
Sorry, America, but your doctors and nurses are no longer calling the shots in hospitals. This is new.
I have been a critical care physician for 25 years now, and until recently administrators would defer to nursing directors and physicians if a change in staffing or scheduling would affect patient care. This is no longer the case. CEOs with MBAs and without medical training now make decisions that directly influence how patients are treated in both Emergency Rooms and ICUs. Communities, city councils, county commissioners, hospital board members, and even chambers of commerce must rise up and support their local health care providers before it is too late.
131
@Gustav And yet more and more administrators keep being hired to hide from the public what is actually happening in our hospitals.
8
Great article, and the conditions described are unfortunately all too common. President Obama's Affordable Care Act was a great move in the right direction, but needed some revisions to make it better. Now, in the current political climate, continued health care reform has been sidelined, with no solutions in sight.
We have, in one of the world's economic super powers, a still broken health care system. People are needlessly dying as a result. I think we ought to have a sustained, bi-partisan effort to complete the health care reforms Obama started. Sadly, I don't see this happening anytime soon.
America has the resources to make good health care possible, but we seem to lack the will to do the much needed work.
17
@Elliot
Having corrupt representatives in Congress doesn't help.
6
The sad and probably premature death of Mariah, so movingly described by Dr. Siddiqui, immediately made me think of the 1997 film “As Good As It Gets.” Although Jack Nicholson gives an unforgettable performance as a misanthropic writer with OCD in the film, what made the biggest impression on me when I saw it was the very credible sub-plot of the young boy suffering from chronic debilitating asthma, whose desperate mother (Helen Hunt) does not have the financial resources to get him adequately treated through her HMO, so he is constantly in and out of ER. Jack Nicholson pays to have him seen by a competent specialist who is finally able to give him the treatment and medicines he needs to break the cycle of ER visits.
Because I live in a country where all citizens receive healthcare, the suffering of this mother and her child due to inadequate and unaffordable healthcare really upset me when I watched the film in 1997, and knowing that in 2019 increasing numbers of Americans are either without healthcare or underinsured, tells me that things have gotten worse. America is failing its citizens.
61
It could be worse. And in 5 years it will be - MUCH worse. First - look at the root causes - who stands to profit from the status quo or from a worsening of the status quo? Second - look at the dynamics that govern the health status of an increasingly large fraction of the at-risk of unwell population - costs per unit of anything helpful or necessary go up, socio-economic health for the service recipient goes down, and as we have known for many years, downward socio-economic 'mobility' is associated with more or less everything bad when it comes to health. Third - the rich get richer and an increasingly large fraction of the population get poorer. Fourth - poisonous thinking on the part of significant fractions of the population, e.g., who believe that poverty and poor health is a 'just reward' for what they believe is a slack approach to life (just try being poor for a day or so and you will find out how much 'leisure time' that lifestyle affords). So why would the situation NOT deteriorate?? And if we look at the change in the system over time - why would we not anticipate an abrupt, dare I say catastrophic shift. Oh yes I forgot - more older people living more years with disability and requiring care. Sorry, I forgot, there are fewer not more older people in the US.
FYI - similar dynamic with respect to climate. Who profits from business practices that harm the environment? Same people who will profit from dealing with the consequences.
15
There is no perfect health care system. The overworked and amazing people written about here will always face tremendous challenges. With that said, everyone knows what it will take to make it better, universal health care. It won't cure all the problems anymore than you can save every sick patient, but it will save lives and make ERS far more manageable.
Of course profits could be down at several corporate headquarters, so I wouldn't hold your breath.... I'm sure they can prescribe something if you do though.
5
How about asking the administrators why this area of the hospital is historically understaffed, when it brings in so much business ? That seems a fair question.
7
@JaneK Most admins will argue that it is staffed to the 50% of arrivals, and thus staffed adequately. But EDs don't work by averages, they work by surges. Staffing models will fail to meet the needs unless you are staffing to the 85% of arrival rates.
5
@JaneK
probably because ER doesn't bring in substantial cash flow.
2
I remember when primary care physicians followed the patient through hospital admissions and emergency rooms in order to supply knowledge about the patient and cooperate with a care protocol upon discharge. I'm pretty old, but still not pleased with much that is new about the treatment of the sick among us. Something vital is missing that technology and hospitalists
have not replaced.
An RN
12
Among the many issues, a key question emerges: why has there been no incentives for continuity in out patient care? People with or without insurance seem to ignore the crucial role of a primary care physician, the value of being known (medically and psychosocially) as well as provided with early interventions & maintenance care.
Medical students are being trained to go fast and an assembly line mentality has invaded clinical systems. Longer term primary care relationships have been trivialized when they are the best way to save lives and save money.
Maybe all insurers should require a home base and pay primary care MDs (aided by Nurse practitioners & Physician assistants)a bonus for continuity of care - not just for acuity.
10
@Sara "the crucial role of a primary care physician"
My "primary care physician" doesn't have the time to see me. Ever. Three week wait for an urgent appointment years ago when I had bronchitis. I went to urgent care and was treated that day.
I schedule appointments, only to be left in the waiting room for more than an hour past my appointment time.
Since I'm a dependent on my husband's insurance, I can't even get a list of doctors so he can switch me to another one. Why waste my time with a doctor who can't be bothered with me? I'm not "sick" enough to be worth it to him/her.
An insurer requiring people to see a primary care physician before covering urgent or emergent care would lead to more dead people. Of course, dead people don't pay premiums, so maybe that's not the best plan.
2
@Sara With or without insurance? People without insurance aren't ignoring the crucial role, they can't afford to go. I have insurance but I don't go - why? Because the insurance I have, for which I pay $14,000 per year (50%), has a deductible of $3,500. My gyn used to spend 30-45 minutes, finding out what was going on in my life, getting a complete picture. She retired and now? 5 minutes maximum to get a pap smear.
2
I think we have to finally acknowledge, honestly as a society, that there are now a vast number of individuals among us that are not going to be able to be productive members of society, for any numbers of reason- medical or mental disabilities, whatever. They will not be able to complete education, won't be able to hold down jobs, have relationships, raise children, and so on. I know a few people like this. it is frustrating but when it is your family, friends, what do you do?
It's a question for all of us. do we choose a compassionate route at a great cost to the rest of us? are enough of us willing? or do we let them eventually die on their own?
I don't have answers, but we better face the questions at least.
7
@JA They don't just die on their own. They die from health conditions that bring them into contact with health service providers. And they do not necessarily die quietly, with no collateral impact on society. So by my way of thinking, there is no question. Unless we are going to arrange panels that will judge people to be deserving or productive vs non-productive/non-deserving - we are going to have to do something about the health needs of the entire population - right away. The clock is ticking for a society that is incapable of making workable choices around provision of health services.
3
@JA - Well, start by starving them by cutting off
SNAP (food stamps). Then they can move to
the underpass or bridge by the river...
3
@jahnay The underpass is already overcrowded.
Physician here. Thank you for the very moving article. And thanks for the work you do in ER's. Factors which play a major role in ER overload and are not mentioned are:-
1) Very abbreviated (20 min) visits at Primary care MD offices which are insufficient to address all the complex medical issues of present day patients (who are living long lives) esp geriatric patients; this is due to corporate culture in healthcare and assembly line approach and
2) Under-staffing at Nursing Homes and long term care facilities-and this includes MD back up. It is simplest and easiest to say call 911, get an ambulance and ship them to the ER. Lot of ER visits can be saved if resources can be allocated to the time when symptoms first start by providers who are FAMILIAR with their patients. This requires TIME and CARE and CONCERN-all of which are rapidly being depleted by the great corporate healthcare machine. Free markets in medicine is NOT the answer!
62
By simply summarizing a single night shift in a large, high volume ER, Dr. Siddiqui has produced an outstanding compendium of many of the failings of the current monstrosity that is the U.S. healthcare "system". This was extremely well-written, artfully done and poignantly conveyed the conflicts faced by compassionate caregivers every day.
Radical, transformative change is required to materially improve a system that produces mediocre quality (at best), poor service and high stakeholder dissatisfaction across the board and does so at astonishingly high cost. Rigorous and objective assessment of the current state, with brutal honesty about findings, is desperately needed. There are no silver bullet solutions, nor can the issues be attributed to a single villain.
The only certainty is that the healthcare industry itself will never drive the necessary changes. Players across the board, from insurance companies to drug manufacturers to hospitals to.... yes, even physicians...profit greatly from the present inefficiencies. Cutting costs that contribute to their bottom lines, regardless of how those reductions might help the U.S. Healthcare system, has no place in their business models.
11
@JS Unfortunately you are missing the point. 35-40% of the problems are social masquerading as medical. Societal problems are being hoisted on the backs of medical professional who are already over burdened with a multitude of other task. It's a complex rubric with multiple variables which starts with the patients responsibility for his or her own wellbeing. Parenthetically speaking, the fastest growing medical specialty is administration which don't participate in the clinical care of patients. If we are looking for a silver bullet let's start there!
4
I feel like I read about this solution to repeated ER visits and hospital admissions some years ago: it's less expensive to do home visits for people who can't or won't take care of themselves.
2
I work in an ER where we have an adjoining urgent care open from noon to 8 pm. The urgent care is staffed with LPN's, NP's and PA's, and it works well. The triage RN (me, yesterday evening) assesses patients and directs them to ER or UC depending on symptoms. Patients are grateful to be able to go the lesser costing UC. It would be ideal to have UC open longer hours.
16
ER doctor here, 22 years of straight 12 hour nights in a busy single coverage department. Thank you for bearing witness, a beautiful and heartfelt piece of writing. There is a subtext here that a lot of the commenters are missing -- you do not turn anybody away. Your patients have been repeatedly turned away by other parts of the healthcare system. You tell them "What can I do for you today?" God bless you for this.
125
I feel your pain as a retired ICU/ER nurse. WE do the best we can with what is available and it will never be enough.
7
I think the answer is to use preventive medicine ahead of time (for issues like gun violence this means regulation; for less drastic cases, good prophylactics and wrap around care). It also might mean making medical school less restrictive. Medical schools admit something like 5 percent of applicants, and the medical school debt people have to take on prohibits talented people from applying and finishing. Of the many pre-med students in the country, you can't tell me only 5 percent are good enough to be doctors.
12
@David
I think it's absolutely vital to maintain the highest standards possible.
Let's not blindly foster a new generation of second rate physicians simply out of desperation.
5
@Larry Chan
Recall the old saying-
What do you call the person who was last in the class at medical school? Answer - DOCTOR
Point being - Docs post their med school diploma on the wall of their office but not their rank on the class. One trusts that passing all the tests and licensing requirements you are seeing a reasonably competent doctor (but it helps to get recommendations anyway).
1
Spot on. I am a former ED RN. I worked trauma ED for 10+ years. I saw too many patients in the ED because they couldn't access routine care with an established healthcare provider. I saw too many patients with "stupid stuff"-either because they lacked basic education or "didn't want to wait" to see their doctor. Yes, sometimes the "stupid stuff" really was serious. You can't get judgmental or jaded. I saw too many patients who waited too long before coming to the ED because they were afraid of the cost. I saw too many patients who refused admission because they didn't have insurance. I saw too many patients with "no" medical history, because they hadn't seen a doctor in years, be admitted with myocardial infarctions, diabetes, and kidney failure. I saw too many immigrant parents terrified when their babies got diarrhea-in their home countries, that meant the baby would be dead in a day. I saw the mentally ill, the homeless, the drug addicted. I have seen blood and brain matter. I have helped save lives and I have helplessly watched people die. I have been an ED patient and the family member of a frail elder. I have been afraid to leave my mother alone. I have had to stop young, inexperienced nurses before they made a mistake during my care. Emergency rooms in the US are a snapshot of what is wrong with healthcare in this country. I loved what I did but it took its toll-physically, emotionally, mentally. I had to get out before I became one of "those" nurses.
586
I've been a hospital med-surg RN for over 12 years and while I've never worked in the ED nor had any desire to, your comment about being one of "those" nurses concerns me. Health care professionals are prone to burnout and need to recognize when to step back and find other places to work. Nurses are fortunate that their skills are needed in many different settings. Burned out from working in the ED? Explore opportunities in public health, home care, school nursing, doctors' offices, surgical centers, nursing homes, adult medical day care, occupational health, or just other nursing units in the hospital. I love working on my unit and having plenty of days off - paid time off, keeps me from feeling burned out. If you don't take care of yourself, you can't take care of anyone else properly. It's not our job to fix a broken system, but to provide the best care possible within that system. Nurses are often our patients' best advocates
x
50
I get it that ERs in large cities are overwhelmed. I used to live in huge cities, and I have seen that kind of ER traffic jam firsthand. But I have been that patient “languishing without attention for hours,” in my local ER in a city small enough that it’s really an overgrown town. I have been ignored on nights so quiet that I saw staff sitting around playing with their phones. I think part of the problem with the ER lies in the attitudes of the doctors. Emergency room physicians love the rush of a good emergency. The simple stuff — sprains, minor lacerations, broken bones, minor concussions — is boring by comparison. So that languishing patient often gets treated as an annoyance.
13
@Passion for Peaches
I’m sorry but I think that is a really unfair and deplorable assessment of the ER physicians.
ER doctors are NOT callous, they are overworked and woefully understaffed.
They are required to follow the rules of Triage:
Definition of triage. 1a : the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors. b : the sorting of patients (as in an emergency room) according to the urgency of their need for care.
Merriam-Webster Dictionary
5
@Larry Chan, I am speaking to my personal experience. Your reality does not alter my reality.
2
You are indeed correct. His reality does not alter your reality. But your experience, or your reality, does not necessarily equal truth.
1
Burnout is a very real thing and you probably don’t hear this often enough- thank you for all of the hard work that you and your ER colleagues do everyday. Thank you for this lovely article.
24
"If this is a medical emergency, please hang up and dial 911". This is what most people hear when they are on hold calling the doctor. In other words, ER. I wonder how much of an impact this recording has had in the patient overload of most Emergency Rooms?
12
@M S J Reading between the lines, they are saying: "We don't want the cost and liability for treating a serious condition, so we want to dump you on the ER, where they must treat you and our schedule won't be wrecked by fitting you in."
3
As an ER doc who now combines addiction treatment with primary care, I have patients who I see every month or even every week, and often they actually improve. I give them all my cell phone number and answer calls at all hours, even when seeing other patients, calling in medications they need without charging them for a "phone visit". Why bother, if my goal is to help them?
The biggest obstacle to improved ER care is abysmal primary care. The biggest obstacle to improved primary care is, frankly, greed. Pharma, the real "drug cartel" charges thousands for one syringe filled with a generic drug developed with tax dollars.
Here in Florida the Republican legislature blocked Medicaid expansion even though it results in suffering and death because it was more important to prove to wealthy donors how much they hate anything associate with President Obama.
Why is health care expensive and ineffective? Because that is our goal.
121
A voucher for taxi transportation from their home plus reduced cost are what will prompt people not on medicaid to go to the clinic or primary instead of using the ER for the nonurgent needs.
Or mobile clinics parked in the neighborhoods and at the schools.
4
Perhaps we are trying to do the impossible: stop death that is due. What kind of lives do Jean-Luc and Mariah lead? Is it worth the pain and depression when it is nature's way of saying, "time's up?"
12
The medical profession brought this problem on itself. When I formerly had a minor complaint I would go to see my doctor or perhaps somebody who was covering for him. Now I get a message to call 911 or to go directly to the emergency room.
9
Primary care physicians do not see patients after hours or on weekends. So people go to ER to get medical care when they think it's emergent. When anyone calls their doctor's line after hours it says"if you think this is is an emergency please call 911'. Now an ordinary person who is unwell always feels terrified and thus decides to go or get taken to ER. It's only after their evaluation there that it is deemed a non emergency. ER physicians are trained to make that distinction,a common man cannot do so. If the ER staff starts grumbling or venting anger then they should stay at home. Where is a sick person supposed to go ? In sickness,everything seems to be an "emergency".
14
At the same time, many things aren’t emergencies. I sometimes think people come to our ED because there’s nothing better on television. Some common sense would be helpful.
3
@HP
Agree about inability to see one's primary for urgent health issues. The ER could institute triage personnel at the front door of the department to help separate the true emergency v non emergent primary care issues. This could be in the form of an ER trained PA, or physician, or specialty trained nurse practitioner.
Such a change would mean that hospitals might "suffer" a slight loss in revenue by adding additional staff and exam rooms to attend to these primary care needs of these non emergent "emergencies". Should they require more urgent/intensive care, no issue; they are already "on-site".
Of course this might diminish the huge compensation to hospital system admin, but surely would result in less burn out of ER staff, and less expensive care. The ER physicians would be less hurried in caring for the true emergencies. The triage team side of the department could assist with the primary care side of visits.
People do not always get sick between 9-5 AM. They cannot wait 4-6 weeks until the next available appointment with their doctor, if they have one. Such is primary today in this country-good docs, just not enough of them, limited hours/availability. Thus the insanity of the ER. Sigh, another reminder of our fragmented and broken health care delivery. The money side of delivering health care makes us all less well.
3
I call it ping pong health care. Anyone you see -- ER, primary care provider, etc...their goal is to collect a fee and get rid of you as quickly as possible. If you persist you just land in someone else's office.
For the Jean Luc's of the world...find palliative care. They are your only hope.
4
My spouse is another night ER doc. This article is accurate, and points to how the ER represents the apex of the failures of the healthcare system. Many uninsured use the ER as their main point of care, and of course, because of this, do not show up until their problems are serious. And as many have mentioned in the comments, the article does not take into account the impact of mental illness and addiction on ER use - for example, my husband is required to verify the 'fitness' of arrested people for jail. Yeah, they are brought in by police in handcuffs and he assess them for jail.
One urgent fact the article elides though is that, not only are ER bills exorbitant, but at my spouse's ER, only two of ten patients pay their bills. That is, his hospital collect 20% of what they bill from patients! How does the ER function (and maintain the high malpractice insurance needed)? Us. All of us. The ER is socialized medicine performed in the most expensive way possible with, as the article shows, gaping holes in outcomes. As a business model its absurd
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@Jessica
As hospitals are required to treat everyone who comes in, I've always felt that those who don't want to pay for health insurance have made a decision and that when they get sick or have an accident, they shouldn't be able to freeload off the rest of us.
7
@Jessica I have to agree with the article and your comments as well. One thing not stressed enough is the lack of psych beds outside the ER. At least at my hospital where I work as a House Supervisor nearly every day there is a pt with psychological issues or substance abuse issues who needs a bed and has to wait 48-72 hrs or longer to be placed. These pts take up beds in the ED and hospital resources that do not get reimbursed, draining out little Rural Access Hospital's resources. That's not to mention the frequent flyers who come in weekly because they've bumped their heads or just don't feel good.
19
@Jessica With my insurance, the hospital accepted 20% of what they billed as full payment. The ambulance accepted a partial payment and billed me for $700 more, for a very short trip.
3
Two issues that are likely playing an outsize role here:
One, the forced adoption of electronic medical records which were designed more for billing than for clinical purposes has reduced, rather than facilitated efficient care.
Two, the culture of hospitals, and of health care has over the past 10+ years become one in which economic efficiency is prioritized over clinical outcomes. As the author points out, emergency departments are not supposed to be filled to capacity at all times if the goal is to be available for emergencies. However, just as any restaurant owner wants his tables filled, any non-medically trained hospital administrator wants to see his or her beds filled. This is an atrocious way to provide health care, and sadly, not one that is likely to be resolved by single payer.
8
Good article. I'm surprised at the increase in ER use. Most cities now have a significant number of urgent care offices. I use these for problems that don't require the more extensive facilities of the ER. I'm curious as to why people who could be treated at UC end up at the ER? One factor is certainly that UC facilities are not open all night, but I think there may be other factors. Ideas?
7
@ShenBowen
Most urgent care clinics will require payment or proof of insurance to deliver services. By law, ERs do not have that option. Additionally, ERs are open 24/7/365 and an ambulance can be summoned to transport door to door. Sticky area of policy. Societal good to provide needed care anytime, as heart attacks and car accidents (and gun shots) don’t schedule themselves. Hospitals can charge extraordinary $ to provide this 24/7 coverage (see the article last week on “trauma activation” and other hidden fees). Unfortunately given the incentive structure, hospitals (which are becoming the de facto Heath care delivery systems) have no economic incentive to create other options (pay would be less for a stand alone urgent care center than an ER for a given non emergent service). Sticky.
3
@Bill Thanks for your reply. This makes sense to me. Another poster had the additional comment that EMTs always take patients to the ER for liability reasons.
I was with my son recently when he used the (very crowded) UC at a Kaiser-Permanente hospital. They triage people, having them see a UC doctor where it's appropriate or send them to the ER, informing them about the additional cost. This didn't seem like a bad system.
I was treated at a public hospital in China (broken rib). There, people routinely go to the hospital for ALL medical treatment. That's where the doctors are. I don't believe there are significant extra charges for ER treatment. Prices for common treatments are listed. I paid about $10 US for a set of x-rays and two consults with the orthopedist. Had I been a Chinese citizen, it would have been free. It's no-frills. You don't put on a gown for your x-ray, and they have you in and out of the room in about 30 seconds. Since there was a line of about 30 people, this was great, as I only waited 15 minutes.
I'm a retired ER doc. After 30 years, I ended up sleeping in the closet. Unless you've been there, you will never know how it is to cover for every doctor, dentist, and psychiatrist in town.
I remember, Rush Limbaugh and George Bush both saying, "There's no lack of access to care in this country -- just go to the ER."
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@Wabi-Sabi
Apparently you don't know that psychiatrists are doctors. To be a psychiatrist, you have to have an M.D, degree the same as every other physician.
8
@Steve You're right. But he probably does know, and meant to say "primary care doctor", rather than insinuate that psychiatrists are not doctors (which they are). :)
19
@Aussie
Psychiatrists - yes they graduated medical school. I have always imagined they threw their stethoscopes into the air at graduation instead of their hats. I've never seen a psychiatrist do a physical exam in 33 years. All medical problems are sent to the real doctors.
69
The standard of care in civilized counties has long been care of the whole patient, to minimize additional suffering and maximize their potential and quality of life. Our system is based on money, not people. It is inhumane, and all of us, providers and patients, are suffering - and being ripped off on top of it! Doctors and nurses are much better equipped to understand this - how can we get the message through to the people in thrall with the GOP?
12
Part of the problem is that I must offer you transport to an ER when you call me (the paramedic). The problem needs to be nipped in the bud. There should be a way to refer people with a sore throat or the flu to a 24 hour clinic but my hands are tied. No paramedic wants to be sued three years later when you can't even remember the call. It is an abused system and the fault lays with the providers (EMS/Fire- we bill for transports- a case of a conflict of interest if there ever was one), the legal system/liability and the fact people are using the ERs for something they are not designed for and then they complain about it!
7
@Way better.... i fell on the bus a few weeks ago - no harm done but because i am on blood thinners, I needed a ct scan in case of a brain bleed. When the ambulance - which the bus driver called - arrived I told them to take me to urgent care very close to my home, where I knew I could get a ct scan. They were unable to do so and instead took me to the Kaiser Hospital ER 30 miles away after which I received a co-pay bill for $210.00. I took up room in the ER and Medicare was charged over $1500. AMR did fine of course. Yes, there is a better way.
2
@Way better.... So true! The ER has become a catchall for many of society's problems : homelessness, mental health crisis, alcoholism, etc.
The one take away I have whenever anyone close in in the Medical - Industrial complex is that you need an advocate...a relative, friend, etc who knows the situation and isn't afraid to make calls and be a presence. This goes doubly if the patient is incapacitated or chronic...
3
Thank you for this beautifully written article. If only the CEOs of insurance companies, Cabinet level management of CMS and for-profit hospital CEOs would become activists in healthcare-life, literally, would change for most Americans AND become more cost effective.
Professionally I have watched with amazement at the benefit of just 1 puzzle pieces in healthcare-RN and LCSW Case Management. Utilized after PCP/specialist appointments and pre hospital discharge (every patient, not just E.R.) the effect on reducing readmission is impressive.
But it’s $$ up front and wallets seize up which just proves how valueless lives really are to corporations and profit margins.
4
I was repeatedly brought to tears by the extraordinary power of Dr. Siddiqui's vignettes. I read this article after returning home from my own overnight shift as an emergency physician here in Boston. Perhaps I was overtired, or emotionally spent after caring for so many patients while fighting my own fatigue. But Dr. Siddiqui was able to crystallize my own experience in a powerful way.
I am frequently reminded that essentially no one outside of the ED understands what we do on a daily basis. Not our colleagues in the hospital, not our spouses or families, and not our patients. This piece speaks our truth.
149
@Ralph Thanks for what you do every day to try to help Americans deal with a broken health care system!
7
As a Firefighter / EMT in the Seattle area, this article definitely resonates. It is already challenging for the average person to navigate the health care system and be an advocate for their best interests. It can be nearly impossible for vulnerable populations and those struggling with mental illness to do so.
The programs the author describes (the OR reaching out to people at home to supervise their care) can be very effective. Fire Departments in King County have recently started similar programs that also appear to be very effective in reducing 911 calls and improving frequent-callers' health care and quality of life.
14
@P.H. resident of king county here just to say thank you for your work! and yes, KC residents are lucky to have many programs available for seniors and other vulnerable persons. We are lucky to be in a place that values the experiences and opinions of our medical community:)
4
So, so sad and depressing. I had a baby at Yale-New Haven hospital more than 30 years ago and thought the staff and the care were pretty bad compared to the hospital where my first child was born. It sounds like the hospital still fails dreadfully short.
Thank you for this essay. I work in an animal ER, and see a surprising number of similarities (with the added angst of clients needing to pay at the time of service).
While most commentators blame this on a broken system, I wonder how many of these visits and long term care issues could be helped by better medical education among the general public. Simple knowledge about how bodies, medications, and infection work could empower people to take better care of themselves and get off this merry-go-round. I wish they taught basic physiology and medicine in High School... Pipe dream, I know.
14
@Kris It does seem intuitive that better public awareness of common maladies, and how/where they should be treated, would help here. However, whenever I try to discuss mechanisms of disease and health with my doctor, he recoils into a fetal ball and hurries me out of the room. My wife and I have experienced this reaction from dozens of docs for 50 years.
Let's include the docs (and their employers), who are so protective of their turf, in the discussion of empowerment of patients who really do want to get off the merry-go-round.
This whole discussion also blows out the silly idea that single payer would leave thousands of insurance company employees out of jobs. Medical care is incredibly complex and there is clearly a large unmet demand for people who can help stitch it together, make sure communication is happening, call patients and check on them, connect the dots. And my bet is most of them would be happier doing that than denying insurance claims.
22
@Pangolin
I am on original Medicare and looking at my bills I see claims are processed and paid by subsidaries of insurance companies who are contracted by CMS (Center for Medicare Services) who are contracted to provide these services. I do not think many folks would lose jobs except the highly paid ececutives.
1
I work in a "walk-in" clinic which also offers primary care appointments. I mostly see urgent care patients but also some "primary care" patients who have slipped through the various cracks and haven't followed up with their so-called "primary care provider". What this article leaves out in the case of the young woman who died from asthma with respiratory failure is patient responsibility. The patient apparently knew she had asthma but did not follow up for treatment of her chronic problem. I am certain she was told to do so, probably many times. It is not ED's responsibility to make certain this happens. What about the patient's family, friends, partner and last but not least the patient?
I recently saw an older woman for an urgent care problem. She mentioned she had some disability from a stroke. She was frail and unsteady. I told her she needed a walker. She declined. I told her to make a primary care appointment. Don't know if she did. The majority do not. I cannot control other people's behavior. Patients are given advice and if they choose not to follow it, well, it's a "free" country.
14
@Old Hominid
"The patient apparently knew she had asthma but did not follow up for treatment of her chronic problem. I am certain she was told to do so, probably many times."
It's all too easy to blame the victim. What we don't know is why she "chose" not to get follow-up care (and died as a result) - did she have insurance? could she afford to buy prescribed medication? was she choosing infant formula or food over her own medical needs? was already mired in medical debt? is she homeless? mentally ill?
(And, it's possible that she DID follow-up with a primary care provider who failed to ask about and/or was unable to remediate her very real obstacles to care.)
17
She was afraid of the cost. I understand. I’m elderly. I too say “no” to everything.
1
Mariah was 23 and had bipolar disorder. You may not understand how sick and unable to care for herself she was.
3
It’s not just an ER problem.
Primary care providers are increasingly forced to see patients in less and less time. Years ago, when I started working as a PA, my appointments at an urban community health enter were 20 minutes long - barely enough time to take a history, do an exam, make a diagnosis, discuss treatment options, provide appropriate education/counseling and then document care. 20 years later, those same visits were scheduled at 15 minute intervals and, sometimes 10.
After many anxious days and sleepless nights, I realized that not matter how hard I tried, providing good (or even decent) comprehensive, preventative health care had become impossible. I made the agonizing decision to leave clinical work (as have so many of the best, most compassionate providers - doctors, nurses, social workers – I have known).
The U.S. health care “system” is broken beyond repair. Until we put people before profits, many more Mariahs will die unnecessarily and the Jean-Lucs will continue to suffer.
84
@D. Lieberson As a retired family doc for 40 years, I see the truth all too clearly. Putting profit before patients is just too simplistic. In the absolutely justifiable search for better treatments (from radiologic modalities, new surgical procedures including robotics, to immunologic biologicals, to gene therapy) are all in the name of better patient outcomes. All the technology is incomprehensibly expensive. And we have about 60 million boomers like myself who inexorably come down with expensive illnesses. For me, so far, it's a total knee,several shoulder surgeries, and four heart stents. The ONLY answer is some type of single payer, care-for-all plan, administered by the Federal Government. No insurance company can in the long run offer benefits like psoriasis treatments which cost $13000 PER MONTH. The discussion must begin at the highest levels, and we all must be ready to pony up the tax revenue to support it.
24
@DrDon
"The ONLY answer is some type of single payer, care-for-all plan, administered by the Federal Government."
I completely agree!
12
@DrDon I think the Feds can't pay under the current system. The poor are pressed to the wall already and the rich have good lawyers and can pay off the Congress critters.
So why aren't there 24 hour walk in clinics?
My adult son, who was in an auto accident, was told in the ER that his pain would last a week and that if it got worse or kept on, he should see a doctor. After a week, it was still there and getting worse. What doctor should he see at 1 am? He doesn't know whether his pain indicates something serious or not. Even had there been a 24 hour walk in clinic, he would still have gone to the ER because of the belief (true or not) that the hospital would have vetted the doctor and have the needed facilities to get him the right treatment.
This is the problem with a health care system that is organized around profit centers and not patient care.
7
There are -- in New York City. A couple of years ago, spouse fell and had to get stitches in head around eight o'clock at night at City MD. Much better than going to the ER.
The doctor did a good job of sewing, too.
Some City MDs close at eight or nine, but others are open until midnight. After that, I guess the ER is the only option in a true emergency.
1
This essay reflects that we don’t have a health care “ system “. We have a duct taped arrangement with too many special interest groups , for profits, overloaded with administrators rather than Physicians and Nurses influencing decisions and politicians ( especially Republicans) who attack rather than try to continue to improve health care changes. This is a complex issue that truly requires an independent, experienced medical task force to make recommendations to improve the Affordable Care Act, to regulate the disjointed special interests, to address healthcare workforce needs and move towards a real system of health care in our Country.
12
Gina Siddiqui sad account of a night in the ER underscores the fact that America needs universal health care. Every other "advanced" country in the world provides health care for all its citizens, but we are held back by the greed of the health insurance industry and the stinginess of Republicans.
Our country has retreated into third world status in the way we treat our poor and our elderly. What a far cry from the dream of our Founders, who came to this land with high hopes for a place that offered opportunities equally to all. With help from the Republicans--even though they are a minority--we are no longer the home of the free and the brave. We are a sorry lot, with complicated lives that hinder our ability to ensure opportunities and safety for the neediest in our country.
33
I have been to the ER countless times when my disabled wife had recurring UTI and bed sores. I am grateful for the work they did. It is very clear from my experience that the ER dysfunctions is directly related to the lack of available and affordable care at lower levels to avoid an ER visit in the first place. Our system is totally driven by money and liability.
For those people who cry out against a national health care system and "socialized medicine", do you not realize that you end up paying for all of these uninsured visits through your taxes and cost balancing which is is passed on to you through your health insurance and hospital bills? We are doing things in the most inefficient way possible.
75
As a Former ER Nurse, This essay sounds all too much like a typical night in any ER across america. ER's have become the new "Walk In Clinics" for many Americans and many Non Americans. Work and daily living have gotten in the way and is too inconvenient to simply make an appointment to see a physician, why take time out of the day when you can just go to the ER? Why wait 10 days for an appointment to see a GP? If it gets bad' I'll simply go to the ER. When I worked in the ER many patients were the same patient over and over. And many were driven by family, and even drove themselves. The repeat patients all had primary care physicians for the most part, but it was too much of a problem to be bothered with making and keeping an appointment.
There were the occasional "Emergencies" but most were not. So how do we keep the typical ER from being overused, and in many instances abused? I agree with the physicians assessment that Preemptive resources with high risk patients would go a long way to curbing the number of visits and reducing the over all costs to insurance and Federal and state systems (Medi-cal and Medicare) in California. But we are fighting an up hill battle in getting that system up and running.
11
@Agentmike Do you realize that when a patient calls a doctor's office with an urgent problem, very often it's the office staff who tells the patient to go to the ER! I totally agree that an urgent care walk-in clinic is a much better choice most of the time.
9
@Agentmike You seem to be blaming the patients for the shortcomings in the system. Someone in acute pain or fear of his life should not be dismissed as impatient for not wanting to wait ten days to do something about it.
I often wonder if doctors get to thinking that their social prestige will be lowered if just anyone can drop in off the street and see them, just as though the patient's time is just as important than the doctor's.
That said, probably the best doctor I met in my mother's medical merry-go-round at the end of her life was a young doctor at urgent care. She asked many, many more questions and took far more time checking her physical condition than either the ER staff the nursing home kept shipping her off to or her own GP. Seeing a good, caring doctor without having to beg - what a concept!
A lot of ERs are now pairing up with urgent care facilities, which is a good thing. One problem, though, is that the urgent care folks generally ask for insurance and credit card up front, which is a problem for a lot of people, whereas the ER is prohibited from refusing anyone.
4
I went to med school but never practiced medicine. But my knowledge allows me to act as an advocate for family members and friends. I despise our health care system but I'm aware I am one small person who can only do so much. So I advocate as much as I can. I go to ERs with friends/relatives and become the squeaky wheel. I see the vast number of folks who have no one to advocate for them, the incredibly overworked staff and the occasional (sorry but true) doctor/nurse who is trying so hard to practice good medicine in the face of all the challenges. Life in an ER is mind numbing.
8
I actually am a medical doctor and in my long experience it is not just an “occasional” nurse or doctor who is doing the best they can. Most of us work long and hard but yes we are constrained by time and charting and interruptions so if they sometimes seemed rushed and abrupt please don’t assume it’s due to lack of caring.
13
I did ER work for awhile after returning from a tour in Iraq. In combat there are busy days and, mercifully, slow days. In the ER, just busy days, where - as the author points out - demand exceeds supply. In combat the resources of the nation are deployed to help our injured soldiers and Marines. In the ER there is a relentless fight for resources.
Don't thank me for my service. Thank your local ER docs. They deserve it more than I do.
118
I'm reading this while the sister of a friend of mine is a patient in this cycle. A week ago, she went to the ER, and was immediately rushed into surgery. She's now hospitalized; when she is "stable," she'll be sent home. But at home she is unable to take care of her multiple medical issues, so she'll be back at the ER, probably within the month. Unless, of course, she dies.
16
@Blonde Guy
Never an easy decision but would palliative care be an option. So much of what ties up healthcare now is delivery of care that in many ways prolong dying rather than prolonging living. Eye of the beholder completely understood which is why in our country decision left to patient/family and not the “system”. But if a problem can’t be fixed and interventions only prolonging pain/suffering until the next emergency, palliative care can be a very loving and compassionate alternative. And avoids ERs and hospitals.
1
How much more cost effective, medically relevant and humane would be a health care system that was not profit and loss based, but centered on good outcomes for patients.
Why can the rest of the prosperous nations provide government supported health care, say like Canada, New Zealand, et cetera, without have the economic and government collapse predicted for us by our oh so moral and caring Republican officials. The health care provided to them by our government is among the best in the world, so they seem a tad hypocritical to me in condemning it for the rest of us.
15
An eloquent, heartfelt piece. And a clarion call: Medicare For ALL. When everyone can obtain care at a Physicians office or Clinic, the unnecessary ED visits will be greatly curtailed. It’s basic common sense.
24
@Phyliss Dalmatian
Actually, not. My former hospital employer ran an ER in an urban setting. Even in an environment with almost universal coverage and primary care "medical home" practices with late/extended hours, the vast majority of the ER visits were non-emergent. Using the ER as a health care entry point has become a habit that's very hard to change, even when options are there. Hospitals can't refuse treatment and some will not discourage non-emergent usage because they are still in fee for service markets and get reimbursed.
7
This excellent essay points out that Emergency rooms are the entry point of our health care system for an increasing number of people. And that initiatives have been taken to place social workers there in order to intercept the patients who require care that the ER is not set up to provide and direct them to it. I praise those efforts to address the problem. Would that the government follow suit.
5
Would be interesting to compare this physician's experience with one in a similar situation where there is national health insurance, such as the UK.
19
@hp In many of those systems if you feel bad, you go sit in your GP's waiting room until you are seen. Might be a long wait but it keeps the chronic sufferers out of the ER. And you don't have to schedule an appointment two weeks in advance.
Obviously there are often down sides like longer waits for certain kinds of non-urgent surgery (like joint replacements) but that's offset by the availability of decent nonspecialist care. And insurance companies currently act like gatekeepers and limit treatment, so it's somewhat of a wash. But if the above-market profits now accruing to the insurance company shareholders were plowed back into the system you could address a lot of those issues.
4
The American health care non-system has trained for too few primary care physicians and far too many specialists. Reimbursement for primary care is too low. There are too few urgent care facilities and those that are do not have electronic medical record systems that are linked to a patient's primary care provider.
Stronger primary care would reduce total health care costs.
24
Precisely. Rather than specialize in acute and specialty care, our efforts would be better served preventing the need for both as best we can.
Big Pharma and our insurance industry are most often blamed, but rarely do our leaders talk about just how unhealthy our population is as a whole. Obesity, cancer, and comorbidity drive up our healthcare expenditures big time.
We are largely a nation of poorly dieted and sedentary people and that perhaps is one of the largest reasons we are so costly to treat.
7
@Brad, I agree with this, and would add that high med school debt contributes to this imbalance, as med school students have little choice but to pursue specialties that pay more and can more quickly eliminate their debt. We should be subsidizing medical training and waiving debt for doctors going into primary care, geriatrics, and pediatrics, especially in rural and heavily populated areas. This should free up practitioners in those areas to spend more time with their patients, improving preventive care and reducing hospitalization risks and costs.
18
@Tempest Victim-blaming helps no-one except Republicans, who wish people to die instead of costing money -- which they appear to think is all "their money."
8
I worked as a doctor in the ER of a busy hospital for several long miserable years. Best thing I did was find myself another job and stop working in emergency medicine. My sincere advice to anyone considering a career in emergency medicine is 'don't do it, it is not worth it'.
14
I have insurance which costs $1,500 a month, has a $5k deductible, and almost no medical organizations accepts. I tried to get bloodwork recently because I am concerned about my heart - no one, not the insurance company, not the clinic which ordered the tests, not the place that would draw my blood, NO ONE could tell me how much it would cost. I wasted half a morning trying to figure it out.
In the end I just gave up and threw the order for blood work away.
Everyone may end up in the ER because we have a really highly dysfunctional and broken health care system.
202
@Night You are correct. As an ER RN, I know that most people coming in the door are coming because they cannot get care anywhere else. Their primary care, if they have one, is so busy that there are no sick appointments, or they will be fired if they take off from work to get medical care so they come after work and after urgent care is closed. Or they are mentally ill, and even when admitted, will be discharged so quickly they aren't really stable into a world with few supports. As Dr. Siddiqui illustrated, we are a terrible last resort.
41
@Linda
Untrue Linda. Some have no other option but many abuse the system, calling 911 for an ambulance ride for cold symptoms. Many of these patients could go to a freestanding urgent care facility but would rather not pay the copay or deductible.
4
@Night Just curious, why wouldn't you go ahead with the work anyway if you are concerned about your health? Worst case financial scenario the costs are high and you spend some money towards your deductible, worst case health scenario is you die or are severely ill.
Health insurance is supposed to protect against financial disaster (owing $100K), not cover every routine level of spending that is reasonably affordable.
4
I went to the emergency room last year after an auto accent to see if my ankle was broken. I also had seat belt and airbag injuries. Finally there was an open bleeding cut on my knee. I spent two hours there. The only service I received was a (negative) x-ray on my ankle. Neither the doctor nor anyone else examined me in any other way. I left with the cut on my knee still open and bleeding. Not even any of the nurses could be bothered with it. I am no kid either, I was 68. I can’t imagine how much was charged out for this travesty since my insurance company paid it. They dragged their feet also, but that is another story.
13
Having once worked in an ER (now called Emergency Departments ie ED) I can attest to what this physician is describing. One change that could make a large and dramatic difference would be the ability of an ER to redirect non-emergency, non-critical people to primary care providers/family medicine. I never understood why there wasn't a separate walk in facility adjoining the ER for non critical patients. The triage nurse would determine who only needed minor resources. And if it turns out a patient was more ill than initially thought, the ER is right next door.
44
Many hospitals and clinics have an Urgent Care department designed for exactly this kind of service. I don’t know whether they actually succeed in diverting non-emergency patients and freeing up EDs for real trauma, but that seems to be the purpose.
2
@Rebecca : The problem is that those urgent care facilities are often just open the same hours as a primary care doctor is.
16
@KF2 As someone who sadly is an ER 'frequent flyer,' I would dearly LOVE to be able to go to the Urgent Care centre that is literally directly behind my house. However, even my relatively minor needs - IV fluids for rehydration and electrolyte balancing - cannot be met at Urgent Care for some mysterious reason that is beyond me. Thus my options are the ER or having a port installed, which comes with surgery, serious risk of infections, limits on my daily life, etc.
9
Having worked as a firefighter and paramedic for the past 15 years, I have seen a dramatic increase in citizens calling 911 and being transported by ambulance to an ER for non-critical, minor injury and illness, and many, if not most are insured. As first responders, we need the ability to redirect these patients to other facilities, and in some cases out right refuse transport to an ER.
24
@Jeff There are too many lawyers waiting to pounce for your department to risk that. Primary care would be better but your employer can't afford to mandate that. In some cases the patients aren't taking enough responsibility for themselves in advance - or don't have insurance - or no doc-in-the-box "urgent care" service is available. Reform of the legal system is needed as well as of the health care system
7
I totally agree, legally it’s too much of a risk.
2
@Kim from Alaska If a paramedic decided to "refuse transport," I would hope he or she were qualified for a different line of work, because you better bet I'd be after their license. They are neither trained nor qualified to make that call.
6
This country doesn't want everyone to have health care. So that being the given the ER is going to be full with people who wait till they cant wait any longer to get care. We know how to fix the problem, but we want to make sure the Health Care Industry and the drug industry need to make money hand over hand.
This doctor with all of the handwringing knows what the true nature of health care is. Very few of us have good medical care but we pay a mint for it. We are sicker than the people in Europe and we are waiting for hours to get a doctor to even read the charts. The system needs to be blown up and the money people need to be out of the way of progress. The product that is being produced are wanting.
27
"The frantic pace leaves little time for deliberating over the diagnosis or for counseling patients. Up, out."
Unfortunately, this description of emergency room treatment is also a good description of the medical treatment received in our system during office visits with specialists and primary care doctors, unless you are wealthy enough to afford boutique care. The whole process seems a big Whoosh. A breathless arrival from seeing the last patient and a quick exit to see the next patient. Little focus or attention seems to take place between the entrance and exit.
25
@Art Sorry to hear your experiences are so bad. That's not universal.
I ve worked too many night shifts during my career as an ER doctor. Dr. Siddiqui accurately describes the experience with eloquence, sensitivity, and compassion.
78
A year ago I was discharged from the hospital after a pulmonary embolism, with the instructions, "call urgent care immediately if anything changes." After a few days I had a sharp increase in chest pain and called my primary health care network's urgent care line. They refused to have me come in, insisted that I go to the ER at their referral hospital. At the ER, I spent 7 hours on a gurney in the hallway. Other than confirming that I was not dying, the staff ignored me. Throughout the period, was offered pain relief once: two Tylenol. Finally I just left, glad I was not dying but otherwise utterly exhausted, depressed, and angry. I then simply bore the pain until it went away. This article helps me understand the clinicians' response to my non-critical condition, but it does not excuse the behavior of the urgent care clinic, which could have provided the same service in less than an hour an at a small fraction of the cost. I assume they feared liability in case something life-threatening had occurred, but what is the point of pretending to offer urgent care when you're not willing to deal with urgent needs? We won't solve the ER problem until we solve the liability problem.
49
@S You didn't need an urgent care clinic, you needed urgent care. NSAIDs would have been better than tylenol, and you probably needed (at least briefly) an increase in anticoagulaiton.
4
I also had a pulmonary embolism. I went to urgent care in a large for-profit chain prevalent in Wisconsin. I was extremely short of breath, which did not improve when they tried an asthma inhaler. They made me an appointment with a pulmonary specialist for 5 days later. in 3 days I began experiencing chest pain with each breath. I drove to a Catholic hospital ER. in the next town (the chain also has a hospital in that town). Within a little over an hour I was admitted and began treatment.
Hopefully most patients have access to not-for-profit hospitals, but they are becoming scarce in this state.
2
We expect, as a society, that our schoolteachers fix broken homes in six hours and that our EDs fix society's problems in ten hours. It is all reactive, not preventive. As a Social Worker in a Level One Trauma ED, I believe a lot of the fixes exist outside the hospital, but I believe the ED's are innovative and moving in the right direction but there needs to be greater collaboration. Unfortunately, many politicians do not seem to notice or care what happens here, or in prisons or in schools. Change needs to come bottom up. Top down management has worked as well as so-called trickle-down economics.
Thanks for publishing this piece.
34
@JaGuaR We as health care professionals need to press for Medicare for All. Most wealthy people, including most politicians, do not believe poor people have any right to essential care.
24
@Dan Woodard MD Medicare covers too much (I'm Medicare aged and I'm happy for the coverage but somewhat appalled as well). But the working poor and middle class and their children need free preventive care and basic care for easily curable diseases and injuries.
2
@Kim
You payed for your Medicare over your working life through your taxes. Don’t be appalled! Be proud that you worked hard, did your bit, and earned healthcare in your retirement that won’t bankrupt you.
I would rather pay in taxes what I pay in monthly fees and deductibles to ensure that everyone has access to primary and preventive care and health education. I wonder if that would drive down Medicare costs over the next few generations as general health might improve.
5
My family has ended up at the ER a few times this year - some emergencies, some not as it turned out. For both of the non-emergencies, we started at the prompt care but were sent on to the ER in an excess of caution when they couldn't find the source of the problem. As others have pointed out, a more robust non-emergency medical service with longer hours could help relieve overcrowding at the ER.
25
Possibly if this country offered basic healthcare coverage to a broader population there would be fewer of these scenarios. I can’t help but notice when I travel to Canada and Europe how healthy their general populations looks, ie more mobile and not as fat.
35
@ellie k. Not being fat has more to do with sugar subsidies than health care finances. We eat way too many carbs, which actually make us feel hungrier.
Get control of your insulin and you will have better health.
1
The whole systemic broken.
The ER should be a where patients are sent by their primary care providers or brought by ambulance.
Patients should be discharged with home health care aid and back to their primary care providers or their specialty physicians. Nursing homes should not be so disparate in the quality of their care.
Where is the system going to find the primary care providers when medical school is so expensive graduates migrate to the highest paid sub specialties. Specialty physicians shun the pittance that government insurance pays.
And why go into primary care when your clinic puts you on a treadmill to see as many patients as is humanely possible and the rest of your time is filling out electronic forms to garner the clinic as much income as is possible?
Health insurance companies if private are most concerned about their quarterly profits so their stock goes up. What is best for their customers or the system is never thought of.
Home health care has been a sink hole of fraud and abuse. Any attempts at regulation is met with unrelenting resistance. Attempts a regulating nursing homes is met with the same resistance.
Hospital administrators are also profit driven. What is best for their patients and staff are at best second level poriorities.
A recent study showed the average family now spends about 12% of their income on health care.
I can see the resistance to the unknown that Medicare for all causes but something needs to be done to disrupt and fix this system.
25
It would be helpful if there were urgent care facilities open 24 hours, or at least until midnight or so. In my community, we have nowhere to go except the ER if an emergency arises after regular hours. If the non-life threatened patients had a choice of where to go, it would lessen the burden on the ER. Urgent care facilities are missing an opportunity by not providing care late at night.
35
@Ms. Pea This is an extremely important point. A few months ago, I was experiencing scary breathing problems that turned out to be pneumonia. As an asthmatic, pneumonia can turn fatal very quickly. I needed urgent care at about 2:00 a.m. and to my absolute shock I discovered that urgent care facilities were not open 24/7/365. I truly had no idea. And I live in Chicago! This massive, sprawling urban area didn't have ONE place I could go in the middle of the night for an urgent health issue. I did not want to go to the emergency room, where I would be charged a $250 co-pay that I couldn't afford. I waited, terrified and gasping, for hours until the urgent care facility opened. This high co-pay was designed to keep unnecessary ER visits down, but it also discourages people from seeking care they desperately need. I frequently wonder how many people die every year trying to avoid those "punishment" co-pays. I have also been referred to the ER by an urgent-care facility and STILL been hit with the $250 fee, which baffles me--I'm trying to follow the hierarchical rules and I still get punished for it (and some insurances carry even higher fees for nonemergency ER visits). If these co-pays were intended to reduce ER visits, from where I sit, they are a failure and a detriment and need to be abolished. If someone needs the ER, they need the ER, and it should be their decision.
18
Aside from the florid dramatics and handwringing by this doctor, many of the problems recounted here are a direct result of policies created by hospital administrators which include physicians. I have been an ER nurse for close to thirty years and can tell you that the deliberate boarding of patients for days in ER's is part of these hospitals business model. Every year during the winter hospitals use the cover of "flu season" to save huge amounts of money by keeping patients waiting for days for beds in the ER. Its much cheaper than opening up floors that exist but are not utilized. As for those inappropriate visits for minor problems, likewise hospital administrators love them. Large reimbursements for very little work. And in New York the uninsured are usually covered by emergency Medicaid. So please lets get real here -
50
@Anne "hand-wringing" is a useless activity, this piece of writing is not useless, nor is it hand-wringing. I beg to differ.
13
Universal preventative health care would significantly decrease the need for patients to use the ER as their go-to medical care option. This is the major reason for overburdened ERs
50
@Steve Wrong. 1/3 of the state of NY is on Medicaid. Studies have shown that this specific population has not reduced the overuse of ERs for non emergencies since Medicaid was expanded years ago. As a primary care provider, I still have to urge patients not to go to the ER for xrays, etc for symptoms of common cold. They pay nothing for ER visits so there is no incentive to not go.
4
@CA In fact, Steve is even more wrong than covered in your explanation. The San Francisco based Kaiser Foundation analysis (they are a middle to middle-left policy organization) concludes that folks with insurance utilize the ER 55% more often than folks without insurance.
2
@CA I don't have the statistics on hand for my state, but anecdotally based on our charts, I'd say ER usage has increased in that population. It's free to them and it's 24/7 with little to no wait. We need some kind of mechanism to disincentivize such behavior.
3
A few years ago I read that the financial incentive in cancer research (perhaps medical research in general?) is focused not on cures but on the drugs that sustain patient care. In other words, pharmaceutical companies make more money from meds that keep people alive and paying than from the potentiality that any illness could someday be eliminated.
As long as we are chasing the money in healthcare, and not spending the dollars on brain-power that could figure out and institute new ways of dealing with the complexities of human health and sickness -- the whole system and its people will stay unhealthy, and only a precious few will get wealthy.
29
@SGK Treatment adherence is critically important. A potent cancer drug that is not taken provides no cure.
Maintenance medication is crucial. Read the Emperor of Maladies.
Look at it this way, in the 1950s cancer was generally deadly within 24 months. We have developed treatments that extended the lifespan significantly, but we also learned more and more about cancer. While some forms are largely "curable" (meaning no maintenance treatment necessary once disease is defeated, think breast cancer & childhood leukemia).
But by extending lives 2 years, we now see cancer's true nature, it changes in the body and can move from organ to organ. Maintenance medications are necessary to keep cancer from reestablishing its dominance in the body.
I saw my mother thrive for years despite a cancer treatment, but an infection required her to stop taking the low dose chemo for a few weeks. The cancer (multiple mylonoma) quickly reestablished and spread through her system, ultimately fatal.
Keeping a cancer patient healthy is critical to the success of therapies. The medicine coming to market now is extraordinary (genomic treatments). Cancer chemo is as useful in 10 years when the patent expires. I love the profit motive has played in keeping more and more people alive.
3
@SGK Without providing the source of your "reading," your conspiracy theory is ragingly irresponsible at best. If you truly believe the astonishing allegation that drug companies are simply trying to prolong treatment (and there are other theories that purport that cures for cancer exist but are not used because cancer patients are a huge source of revenue--if they stay sick), you are compelled to cite your sources and provide a more researched argument than "I read something somewhere at some time that made me think medical research is a huge conspiracy theory but I have no proof."
2
@SGK I don’t know whether that is true or not but if it is, the people responsible should be time-shifted to the Middle Ages to receive their punishment.
2
Thank you for what you do and thank you for writing this and spreading awareness of the problems in one area of our health care system. The balkanization of health care is obviously a major problem. Demonstrably effective follow-up care should not be dependent on grant money in this economically successful society. Patients that re-visit the ER within a certain time period for the same or closely related issues should be given at home follow up of some kind - maybe through a special unit established for this purpose at the hospital providing the ER care. Repeat visits for same or similar illnesses should be recorded in a specific database and be one of the measures of an ERs effectiveness (or ineffectiveness). This database should be open to the public (with appropriate privacy safeguards). Speed of treatment is not the only measure of success, given the myriad issues that are attended to in ERs. If hospitals get paid over and over for treating the same or closely related issues in the ER, what incentive do they have to change?
11
Thank you Dr. Siddiqui.I worked for 30 plus years in my Community Hospital as a RN.The majority of my career was as a Triage nurse in the Psych area of the psychiatric section of the ER,and on the inpatient psych. The majority of elderly patients had no previous psych diagnosis.So many of them were delirious.I usually suspected a UTI, pneumonia or side effects from prescribed medications,charted what I observed, and reported.The majority of the time I was over ruled by the NP or PA or the consulting psychiatrist.The reimbursement from Medicare was higher if they were admitted to the locked psych unit for a psych diagnosis.Medicare patients that had not used their yearly 60 days of hospital in patient benefit were especially likely to get admitted.Lots of stories about non medicare patients too, many who ended up in bankruptcy. I tried advocating for the patients and to identify the fraud.I was targeted for being a whistleblower,eventually resigned,as I was set up to be fired several times and saw the writing on the wall.Profit needs to be removed from healthcare.
159
This is a brilliant essay by Dr. Siddiqui. Dr. Siddiqui, you're a wonderful writer. I hope to read more essays by you in the future.
Having been in the emergency room recently, I know what Dr. Siddiqui is talking about. The waiting room was filled with patients who should have been seen by their primary care physician and not waiting in the ER.
I was very fortunate. My life was saved by my PCP, surgeon, and the doctors in the ER. To say I have a new appreciation for life is an understatement.
However, I couldn't help but notice the overtaxed nurses and doctors and feel compassion for them. Imagine that: I had a near-death experience, but I felt compassion for our over-burdened medical professionals.
When will we fix our extremely broken healthcare system? When will our health and longevity outweigh avarice?
40
@Pamela L. Think we are more likely to suffer consequences of climate change than see our healthcare system improved.
3
There are two separated categories of ER visits. The first is of legitimate emergency situations. The second group is of non emergent illnesses which could and should be managed by primary care providers. This crisis is unique to the US healthcare system where insurance or lack thereof determines who goes to the ER for care and who goes their provider. The failure of the ACA was the result of the inability to pass a full scale medical plan to cover everybody. We need more coverage, not less. I have sympathy for ER physicians who are burdened by a failing healthcare system, but do they really want to fix the problem or do they just want a bandaid to coverup the problem. We need some form of universal coverage for all, we don’t need to eliminate private insurance, just add a safety net for those who cannot afford insurance.
18
Our nearest ER is sub-contracted by the hospital...that is, it is not part of the hospital administration but is a separate entity. This allows the ER to set its own rates. My daughter's last visit in the middle of the night with unremitting nauseas resulted in her not even being touched by a doctor. I mean this literally They also ran no blood work whatsoever. Despite her extensive chronic autoimmune disease and concomitant complex medication regimen with its possible serious side effect, they told her she had a bug and sent her home without any examination whatsoever. She went to her rheumatologist the next morning and the blood work showed she was in liver failure. ER's in the US have become totally useless unless you have a major injury or are having a heart attack. There are plenty of serious illnesses that can require a trip to the ER even when patients are following protocols and seeing their physicians routinely. Access to 24 hour care is almost always through an ER. There is no other choice.
23
@jcs I took a friend to the ER suffering from prolonged constipation. In her mid 80’s she was an RN, had seen her regular doc, but wasn’t getting relief. The ER was not busy, staff chatting away, and it struck me the attendings (who I’m not even sure were docs) just wanted more tests done. She left the ER with no change in condition. They didn’t seem to want to touch her, when they might have manually been able to alleviate her misery. Won’t go to that ER given a choice.
7
Canada has many of the same problems with over-use of ER's, and doctors placed in impossible situations. My province began an educational campaign to assist people in better decision-making about when to use the ER (when life is threatened) vs. when to use a minute clinic or their regular doctor. A large part of the problem in the US has to do with lack of universal health coverage, thus a lack of options for people who don't have regular doctors because they lack health insurance. Many people use ER’s and minute clinics as their only forms of health care - the most expensive form of health care there is.
26
This physician describes the world of the big hospital center. Consider the other tracks of the more rural ER. You have a mental health crisis? Wait in one of the beds for a couple of days while your care is arranged in an appropriate facility. This might also involve an ambulance transfer to a city 100 miles away (and ambulances are not necessarily available). Your problem is trauma, or a heart attack, or your transplant is failing, or something else beyond the hospital's capability? Wait for your physician to work out a transfer to a larger facility by helicopter or ambulance over the next hour. All this is why emergency medicine is easier in the city and harder elsewhere, although all the rewards are exactly opposite.
8
Almost regardless of pain you wait for hours in the emergency room waiting to be seen. Not good
5
The Emergency Medical Treatment and Active Labor Act (EMTALA) needs refinement. It was well-intentioned in trying to eliminate the draconian practice of patient dumping for poor people but it hasn't evolved with more pro-social models, like the Yale E.R. program mentioned in this article. Each ER needs an affiliated urgent care center to treat the non-life threatening cases so as to free up the ER for the urgent and most life threatening cases. ER doctors shouldn't be the first line in treating what are essentially under-treated or poorly-treated patients. It's not a sustainable model and it hurts patients most.
Mariah, the bipolar asthmatic patient who died should've had access to an urgent care center that had a home nurse program to help her keep compliant. Patients with mental illness are notoriously hard to keep compliant on any medication regime and need the human touch.
This is why we should discuss universal health care models to address those individuals with such needs.
39
@Lmca
True, but when you come right down to it, what we need first is a society that values the poor, the disadvantaged, the elderly, the mentally ill. America's hypercapitalist society values none of those people. Our value is judged by how much money we can produce for our corporate masters; if we don't produce money for the powerful wealthy, our lives are pretty much considered worthless. The system is working exactly as intended. It patches up the still-serviceable cogs in the wheel (extracting whatever wealth they've got in the process), and tosses the no longer serviceable cogs aside.
7
This is both sad and aggravating - kind of like the gun violence in the USA.
We all know health care and gun violence are huge problems that are tied to money and political laziness/corruption.
We are all sorry when health emergencies or shootings happen, and they happen with increasing frequency.
We all wish something could be done.
Other countries do it.
We do not.
It seems we cannot.
Why not?
35
Because we have to spend all our tax money on the military. And if we shift military $$ to health care, there will be howls that we're gutting our security and military. Apparently, it's ok to run a trillion dollar debt to increase military spending but not ok to rack up debt for healthcare, which is actually an investment in people.
100
@Dee
Because money trumps all other concerns here, and the current system is working well for those in power
6
@ellen Because we have to spend all our tax money on the military. "
"
And do not forget the big fat tax break awarded to the super rich.
7
Yale -New Haven is my emergency room and I only have the finest things to say about it. But over the decades I have lived in the area I have used it infrequently. Why? Because we belong to an HMO run by the University and it has its own Urgent Visit Department open 24 hours a day. Why there are not more of these high quality, all in one HMO’s is beyond me. It can’t solve all problems with medicine today. One needs to live nearby. But we have coordinated care and I have had the same physicians for decades. Most of my care is in one facility and we have a central, excellent hospital when we need more. Obviously this model can’t work in every situation but why it is unique is beyond me.
82
Yes it can be fixed, if everyone has medical insurance for routine medical treatment, they will not become emergencies. If people could afford treatments for Chronic illnesses like Diabetes and Asthma, they will not land into emergency rooms. If workplaces and other institutions did not have rules in place that send people falling ill to emergency rooms via ambulance only, that would help. If Ambulance services were paid normal rates for a ride instead of the fortunes they charge, they will not hover around accident sites like vultures going after the wounded animals. If our Senators and Congressmen would do the real jobs they were elected to do and are being paid for instead of being focused only on their reelection campaigns then we would be good. But none of these is going to happen, we will just muddle along, if Trump is reelected or the Democrats put in one of their own. The system has roots which are too deep and vested interests which always take precedence to make any real change possible. Real change will come when the current system collapses. We will know the current system has collapsed when we all work for health care and the only economic activity left is giving billing surprises to each other, just like we became a nation of property flippers in 2007 in the tony parts of the country. Exponential growth always kills the host, we just don't know when!
24
A note to agree with Dr. Siddiqui's point re the need for better coordinated care to avoid repeated ER visits:
Due to a change in formulary by her insurance and delayed dispute, my sister ran out of her bp medication, she became dizzy and started vomiting, someone called 911, Her bp was 180 over something, she was taken to the ER
There she was given morphine for the headache and an anti-emetic, and a CT scan, but no blood pressure medicine. When I arrived and asked for her to be given that medication, I was told that hypertension was a "primary care" problem.
This incident repeated a few months later. This time, after spending the night in a different ER, plus the day at another ER across the street where she was transferred, we refused to leave the treatment room until she was given her losartan and her bp came down. We also refused to leave until she was given a prescription for her regular dose of anti-hypertensive that we could fill at a 24 hour pharmacy on the way home.
31
Urgent care practices in our area are only open 9 am to 6 pm. Where do you go at 8 pm when you have an accident with a kitchen knife? Sometimes I think all of these businesses collude to make money for hospital ERs which then kick it back down the line. As every one says, the System is broken.
23
As a retired doc, I’ve done my time in in a big city ERs. It’s a ballet in double time ... except when there’s just ppl trying to keep chaos at bay.
IMHO, it seemed to me that “bouncers” had clues in their admission vital signs that they were too ill to get the standard “meet and street.” I’d love to see a study on this. Assuming the numbers are right, they’re easy to study. They’re numbers! HR, RR, BP, T, O2 sat, blood sugar, GCS, etc.
Secondly, some docs are “walls.” They feel the need to keep ppl out of crowded hospitals. Perhaps we could look at whether this is a good mentality.
And please, for goodness sakes, dispense some compassion to the patient. And hope the admin ppl don’t find a way to charge it as an add on, like tissues.
34
@Dr. Dixie The first thing we need to dispense is universal Medicare. The medical profession is grandually coming to realize that the reason we don't have it is that we give knee jerk support to Republicans.
4
NO surprise at all at the increased demand. Those who don't have health insurance don't seek treatment until their condition becomes acute knowing that ERs are obligated to treat anyone who walks in. As others have pointed out, most medical offices are only open during regular business hours, so any emergent urgent medical needs also go to the ER. The original purpose of ER for life threatening conditions has been completely distorted. Add to that the fact that ER's carry very high malpractice insurance, and you get a very expensive way to provide medical care that comes at great stress to providers and patients, largely funded by the tax payers.
32
@Consultant It's not that they don't seek treatment. it's that physicians will not see them if they don't have hundreds of dollars in their pockets, which most Americans don't. The medical profession has consistently opposed universal health care for my entire 68 year lifetime, andsince the ascendency of the Republican party as the party that opposes access to health care, most physicians have been knee-jerk Republicans.
9
I don’t think this article, which captures the anguish of doctoring and visiting the Emergency Department mentions the epidemic of drug use. The intoxicated are one of the main visitors. Alcohol, cannabis, amphetamines, pills bring patients to the ED in altered mental status. Many homeless visit, are detoxed and discharge or admitted to a psychiatric facility but then reuse often due to access to SSI funds, in a revolving door. Unless the drug market changes, the emergency room will be very busy.
22
@Markham Kirsten
Drug market?
While it may be a contributor, the larger isdue is the almost total lack if mental health care in the US.
In my state alone, we haveost half of the mrntal health beds from even 6 years ago. 50 beds per 100,000 is considered tge bare minimum. My state has 7.9.
It isn't just addiction fueling the drug and alcohol abusers - it is also those with mental health issues like bipolar and depression that are self medicating.
The largest provider of mental health services is the US incarceration system.
Pretending that we have a functioning mental health system is an expensive proposition.
Those costs show up in the ER, as well as the courts.
57
You actually think there psychiatric facilities? There are, they’re called prisons.
2
I can not remember calling an advice nurse to ask what I should do about a medical problem I don't understand and being told I should not come to the emergency room. I can remember both not taking the advice to come, with no major consequences AND taking that advice and being scolded by the doctor. Better remote advice, possibly by Nurse Practitioners who can escalate to remote physicians rather than the emergency room would be better. This, together with a system that does not result in primary care physicians for EVERYONE seems to me to be the major problem.
19
I feel for ER doctors. My internist does not take after hour calls. My niece's pediatrician does not either, and either does my friend's son's psychiatrist who treats his bipolar disorder.
So...when stuff derails at 3 am, all these issues which might be handle by someone on call, gets punted to the ER.
Around here, that 13 month old with an 101 F fever shows up in the ER because the pediatrician office's phone message says take all after hours issues to the ER.
You have my sympathies.
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@Ford313 I took after hours call in Pediatrics and during the Influenza or RSV seasons would take up to thirty calls during the night. That was after working all day and having to work the next day. All of those hours spent were without a cent of compensation. And if a patient came to the ER I went there too.
There are reasons why some physicians do not take after hours calls.
Gradually the system changed with nurses to take the calls, a walkin after hours clinic and staffing with ER physicians.
It is a better system for patients and physicians.
Also even with insurance most ER visits today will cause a significant out of pocket charges.
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@Edward B. Blau
I’m a surgeon and my wife is a primary care physician. With our call schedules, between the two of us someone is generally up every hour overnight answering phone calls and giving out medical advice - for which we ARE legally responsible but which we DON’T get any payment for. This is a huge reason why many docs no longer take call nor will answer phone calls after hours.Getting compensated for these calls (as your friendly lawyer does) would help tremendously in decreasing unnecessary ER visits.
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@Barry
The cardiology group that husband and I deal with have one of their docs on call after office hours. They call back within 20-30 minutes.
They then bill Medicare (presumably they also bill other insurance that younger patients might have.) It probably takes a fairly large practice--this one has eight doctors in order to do this.
14
Thank you, NYT, for publishing this article. I want to thank my lucky stars for my relatively good health at almost 66 years of age. I have a couple of ER horror stories (one being sent home with “a virus” when, in actuality, my appendix had burst) but I lived to tell about it. Many, many thanks to the ER personnel everywhere. I don’t know how you do it.
147
Sobering article, one every person who cares about health care access and quality should read.
But I'm surprised there is no mention of the impact on ERs of our lack of resources and funding for mental and behavioral health care.
In Vermont at least, ER beds are too often filled by psychiatric patients who have nowhere to go, sometimes for stays of more than a week. Those beds are effectively offline and the needed psychiatric care is virtually non-existent.
We won't solve the problem of care outside the hospital until we stop using ERs as a holding tank for people who need psychiatric care.
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Actually, the psychiatric care is very existent but cannot be accessed properly if those in charge of funding in the state of Vermont refuse to acknowledge that it takes money to provide quality care!
It takes money to provide adequate psychiatric care let alone high quality care and mental health services are always lowest on the agenda regardless of how much emergent need there is!
11
You can thank the root of this on St. Ronald Reagan. I was in need of psychiatric care before and after Reagans rein. In the matter of a year the coverage for psychiatric care disappeared.
Thanks, GOP and all the fools that vote them in. Working class republican voters are like a suicidal person that decides to take 10 innocent people out with them.
15
One of the most visible symptoms of a broken health care system.
Spend a night in an ER and watch. (though I recommend NOT going in with a kidney stone).
You have an astounding number of people with alcoholism or drug addiction - often coupled with mental illness. Some of these people seem to be 'regulars' familiar to the staff and in on a regular basis. This stream of patients needs its own destination.
There are lots of people without regular medical care (or insurance) who show up with real medical problems that need attention. Some problems are minor, some are major. They would not be in an ER if we had a better health care system, they'd have gone to a regular doctor.
Then you have real emergencies - illnesses, accidents or criminal injuries - what ER's were set up for.
Without the first two categories ER's are probably sized right.
As is, ER's are understaffed and could use more nurses and doctors
37
@cynicalskeptic - What is the problem with going in with a kidney stone? Both my father and my husband ended up in emergency rooms (two different ones some years apart) with kidney stones and were well taken care of. Given their experiences, I should think that kidney stones would be a frequent cause of sending people to emergency rooms.
1
I'm a minister, and I've sat with quite a few people and families in ED waiting rooms. I've tried to buoy their spirits by saying, "the only thing worse than waiting a long time here is being hustled into one of those treatment rooms." Most everybody gets that. But the ones I see are the ones who already have biological and church families. (Chaplain departments don't like freelancers speaking to folks uninvited, and they, like other disciplines, are grossly understaffed. Or, I would talk to others too.)
The use of the ED for primary care is no new problem. It's been covered in newspapers like this one for the half-century I've been reading it. I've wondered why EDs don't set up simpler clinics a few steps away. The patient with the bloody nose, you can send there. The patient I sit with, I can go along to reassure them. Staff at a clinic like that might be able to spend more time with families and patients. Plus I imagine it would save a few bucks. And, you're not kicking people to the curb, which you cannot do. Rather, you're securing appropriate care.
How would you staff those clinics? The early attempts could be grant-supported, and staffed partially as teaching facilities for all kinds of pros, including public health people. For very short money or maybe even as volunteers, you might be able to get community clergy associations to provide people like me to sit shifts. After the concepts are proved, SURELY, the economic factors will defray these costs.
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@Oliver Jones
That's how my local Indian Health Service hospital is set up: urgent care on one side, emergency on the other. If you lack a primary care doc and need prescription refills, you are seen in urgent care.
We had a new IHS hospital/clinic/medical school open last week. It's the biggest IHS health care facility in the nation.
I haven't been there yet, so it will be interesting to see how that facility is set up. I know we now have a drive-through pharmacy.
This is considered a rural area, and yes, Indian Health Care takes Medicaid and Medicare.
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My large hospital in Texas functioned like this- urgent care for lower acuity patients and emergency department for the sicker patients. The urgent care has evolved to essentially become a second ER.
6
@Oliver Jones I live near a medical college, and this is how their ER is set up. Different areas for different levels, and they have an Urgent Care built in. Patients all go to the same triage, and then get divvied up. It works pretty well.
My last visit as a patient was for a migraine that would not let up with my standard home treatment. I had a definite reminder of the difference when someone came stumbling in with a gun-shot wound.
I still ended up on the ER side since the hardcore migraine meds are IV, and they don't do that in urgent care. I've wondered that, as for me, 3/4 of the times I've been to the ER as an adult are due to a need for IV medication (migraines, kidney stones). If my local urgent care had an infusion room, I'd definitely go there instead.
7
The medical care landscape in rural areas is especially dire. In Northern AZ, we desperately need primary care physicians who accept Medicaid. Nurse practitioner practices try to address the gap and are overwhelmed, many patients lack transportation to any provider. I imagine this is the same all over the U.S. in rural communities. At our ERs, psych care is non-existent. I came here a few years ago from a large city, never expected such a lack of services. The crisis is real.
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@InAZ - It should be noted that this crisis also exists in some countries that do have universal health care. Except in the UK, doctors are not employed by the government, so are free to choose where they'll set up practice. More rural areas everywhere offer a lot of problems that simply going to single payer will not solve. And, unfortunately, the money-oriented AMA has no interest in trying to solve this crisis in our country.
3
In my experience trips to the emergency room were necessary because doctors’ office were closed - on weekends and in the early evening. Since most family and internal medicine practices are now group practices, I don’t understand why there cannot be evening and weekend shifts. Public defenders do this kind of shift work for arraignments - every couple of weeks each one has evening and weekend shifts.
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This is a great idea and does exist-but in practices that are staffed well enough to accommodate this. But keep in mind that most primary care physicians have lots of patients to see during daytime hours and then have extraordinarily high paperwork and charting requirements on top of that. The doctors simply don’t have the time or resources to do this.
25
@L. West : The USA has one of the lowest physician per capital ratios of the developed world: 2.6, according to the World Bank Data.
Uruguay has a ratio of 5.0. Last time I checked, Uruguay is a developing country (I have friends from there, trust me).
You need MORE primary care physicians rather than specialists.
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@L. West
We spend our evenings writing clinic notes. We would love to not eat and not sleep, but then we'd probably be killing ourselves in even higher numbers. Most of my friends just want to GET OUT of this profession.
26
I was an ER director, a walk-in chain director, and most recently a solo practitioner of Internal Medicine for the last 35 years. I dislike the term primary care. I have always had an open door policy for patients, call us in the morning, if needed we’ll see you that day or the next, scheduled patients can wait a a little. This is possible because we take ownership of our patients and operate at the highest level of professionalism we can achieve. Our patients know us and we know them. I do not live in a small town, but one of my patients called me a country doctor, best compliment I’ve ever had.
But..... my practice has seen the loss of patients to ER’s and minute clinics because they are more convenient despite my availability. People are impatient, and marketing of these services is intense. In addition, large corporate practices of cardiology, hematology, etc are black holes that steal patients by churning them through multiple nurse practitioners visits when they could have seen me.
Oh yeah, I also make less money than I did 25 years ago! I’m board certified in 3 different so called primary care specialities, so what. Don't see much improvement coming down the road, but medicare for all might help a bit, and getting rid of big corporate medicine, insurance hegemons, pharma etc. A piece in the NyT said there are 10 administrators for every doctor, Gack! as Bill the Cat would say. Dinosaurs had a pretty good run too, but they lasted longer.
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@fotoave
I had a similar practice in the 80's and 90's in a classic group practice HMO. Saw people in the hospital early, then to the office. The way dollars flowed, it made sense to have late and weekend hours at several offices for urgent needs. Some sites had x-ray, lab, and pharmacy available, making it easier on patients. But patients did not like being restricted to certain doctors or tests.
In the present system, there are too few primary care doctors nationally, and there is little financial or legal downside for any practice to leave a recording to go to the ED. The system is getting exactly what it is designed for.
22
@fotoave Wow, your patients call in the morning and can get in to see you the same day! If you think this is the norm, you are sadly mistaken. I live in a urban area with a robust number of primary care providers, many associated with a large, university-affiliated health care organization. But if I call for an appointment with my primary care doctor, I'm lucky if I can get an appointment in under two weeks; often longer. If I say I can't wait that long, I'm told to go to urgent care or the emergency room. Pediatricians have figured out how to schedule in sick calls; there is no reason that adult primary care docs couldn't do the same if giving good care was a priority.
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@Judy you saw patients in the hospital early, and then patients in the office? I’m impressed but I think the era of PCPs visiting patients in hospital is long gone. During the last decade, when my parents and my husband have been hospitalized, their primary care doctors never set foot in the place or even called to check on them. Instead, hospitalists took over, typically seeing the patients before 7 am and being difficult for the family to reach - even when patients were dying. I grew to despise doctors serving as hospitalists for their arrogance, inattention, and inaccessibility. Maybe they are more efficient for hospitals, but they always left me with the impression that they probably could not have succeeded in private practice and hospitalist was an easy way out. I am sure there are exceptions, but not in my experience.
28
Good health insurance no longer prevents ED visits. Many primary care physicians do not have late office hours on weekday, and are rarely opened on weekends. Those offices that are open often do not take many “walk-ins”, because these patients take too much time, including follow up for labs and diagnostic studies. Simple treatments such as hydration are not offered. I have been told to go to the ED even during regular office hours for concerning symptoms that only required reassurance.
31
@horatio Every time I am sick and make use of my PCP's walk-in hours (available every weekday afternoon!) I thank my lucky stars. I can avoid seeing a stranger at the minute clinic (not known for great outcomes in my area) or taking up valuable ED space/time with a non-urgent matter.
3
I believe it was President Bush who said something to the effect that the uninsured could just go the the ER if they were sick. That ignorant statement reflects the general attitude towards the ER. Lack of access to insurance, preventative health care, and primary care physicians (it takes months here in Indianapolis for a new patient to see a pcp) have contributed to a large number of sick patients using the ED as their primary care provider. Profit driven healthcare systems are happy to take the payments. Insurance companies deny basic care on a regular basis hoping the patients will give up. They frequently do and then end up in the ED. It's a huge problem that the ACA was starting to chip aways at until the current administration came on board. Universal health care is the only answer.
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@Indulgent Nonsensene EMTALA was a political ploy. Politicians who did not want to grapple with our highly dysfunctional health care system or offend its lobbyists, but who didn't want to come right out and say it was ok for uninsured patients to just die. So they added an extra layer of dysfunction to the system so they could hide behind Bush's ignorant statement. It was purely performative.
EMTALA probably contributed to that weird subcontracting arrangement where hospitals use out-of-system ER doctors whose fees bankrupt patients. That way they don't carry the cost...
6
@Indulgent Nonsensene Give Obamacare a chance to work. If we go to M4A, we will bankrupt the Nation. Besides, I like my healthcare system just fine and don't want to see it disrupted because some people don't care enough about their health to schedule follow-up visits and listen to their PCP.
The Affordable Care Act wasn’t given a chance to be effective.
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@disgracedhousewife Perhaps, but the ACA's big flaw was the necessity of including insurance companies. Until the day this country has single payer care, with private insurance being an option, our health care system will continue on as the disaster it is.
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@H Silk - I'm in favor of getting rid of private insurance companies also, but in all fairness it should be noted that quite a few of the countries with universal health care operate with a system of private insurance companies rather than single payer. The big difference is that those companies are usually non-profit and are tightly controlled as to what coverage is included and what they can charge. They apparently compete on service and "extras" such as private rooms, etc. It's possible that the ACA could have evolved to a much better system without the obstructionism of the Republicans.
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Yes, it can be improved. Two basic ways will greatly help the problem.
Pass a national, quality, affordable health care system like just about all of our peer countries have instead of our current (pre ACA) de facto criminal system where the wealth of the billionaire medical exec. is put over the heath of the average citizen..
Cure our gun death/injury sickness epidemic, unique to the rest of our peer countries with a system of legality, regulation, responsibility, non promotion of the gun like we did with great success with cig. smoking and drunk driving.
Our gun sickness not only affects conservative gun owning states but also the culture of gun violence in our inner cities.
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Thank you for sharing your perspective! In college about 15 years ago, I contracted a rare form of Brucellosis from unpasteurized milk which complicated my hereditary hemolytic anemia and sent me into septic shock. Had it not been for the quick work of the talented ER physicians and resources at Johns Hopkins, who took my history and brought in an on call hematologist and infectious disease specialists, I would not be here today. After one week in the hospital with blood transfusions and multiple antibiotics treatments, I made a full recovery, even though I was thousands in debt afterwards (with insurance!!). Still, I appreciate the initial care I received in the ER and have done my best to stay healthy since then. Although not full proof, checkups with my hematologist and GP and preventative nutrition are significant. To this this day, I realize I was incredibly lucky to be at a top notch hospital, but this is not always the case for others around the country. This health emergency experience at such a young age was truly an eye opener for me.
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"An E.R.’s success is measured by how fast it sees these patients, not by whether it breaks these cycles."
BINGO - I am an ER nurse practitioner and whole-heartedly agree with this. The for-profit health system is obsessed with metrics, rather than really trying to fix the problems described here. Another point: living in Europe, I've seen what other systems offer. Show up at an ER without first checking with your PCP? Sure, they'll see you for your sore throat, but only once you cough up (pun intended) 100€; or, they'll boot you back into the primary care system....what happens? ERs are reserved for life-threatening emergencies, costs are held down, and patients actually develop relationships with their PCPs...the way it should be.
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@H : This is the heart of the problem. We have turned the ER into a catch-all/urgent care center for the low SES patients with little to no insurance coverage and we wonder why resources are strained.
16
@Lmca The problem is we make it impossible for poor people to get prompt care from primary providers because we as physicians do not support Medicare for All.
23
@H I think one of the better "inventions" of recent years is of the urgent care centers, sometimes associated with a hospital, often not. They're particularly useful--in my experience, at least--for relatively minor injuries that require something more than at home care but do not seem to be serious enough for the emergency room. Getting in to see a PCP on very short notice or during non-office hours is next to impossible, plus these centers offer more equipment than is typically available in a doctor's office. In our family, we had two instances of falls for which the urgent care center was the perfect solution. We also had an instance in which such a center would have been the answer, but since the injury took place late at night, the urgi-care was closed and the injured person went to the emergency room instead. The injury, while it needed treatment, was relatively minor; the bill for the emergency room was not.
There may be other problems I'm not aware of with these centers, but the ones I see are that they don't exist everywhere, they are not always open, and most importantly, while low-cost compared to an emergency room, they're not free and can certainly be beyond the reach of those without health insurance.
These kinds of centers keep people who don't need emergency room treatment out of the way so that hospitals can concentrate on those in more serious situations.
9
I am a primary care provider who works with the poor, the mentally ill, and the under- and uninsured. I also used to be an ED nurse. I know what these patients need—from both sides of medicine. But my efforts are often stymied by the sheer volume of patients and the barriers to care, the biggest of which is good, consistent insurance coverage. My uninsured patients have me choosing whether I can order certain blood and imaging tests due to the cost to the patients, and spending time on the phone with specialists to attempt to provide care for conditions for which patients either couldn’t afford to be referred out, or are just unlikely to go elsewhere. My underinsured patients have me scrambling to find solutions when a simple medication (insulin) isn’t covered in a form that will allow the patient to use it consistently and easily. For example, some insurances will cover insulin in a vial that needs to be drawn up in syringes, but will not cover an insulin pen device, where you dial in the prescribed units and simply inject. Trying to teach a 72 year old with diabetic retinopathy to draw up insulin using tiny syringes with minuscule markings is an exercise in futility—and which will result in noncompliance, and poorer health, and frequent ED visits. Add to this the cost of practicing medicine in New York, and clinic administrators are pushing providers to see more and more patients per hour in order to pay the bills, resulting in rushed care and burnout.
470
@Colette That's why we need a single system that covers both the aging poor and the decision makers. Medicare for all. As LBJ said in 1966, Congress won't fund Medicare because they are nice guys. They fund it only because their own parents are on it and they will be themselves. The _only_ way to keep the water from being poisoned is to insist that everyone drink from the same well.
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@Dan Woodard MD
Dan, the 72 year old patient she references would be on Medicare. Medicare is also not free, people pay for it when they are on it. If that patient is struggling with insulin coverage it is likely his supplemental coverage, which again he pays for. Not cheap!
Lastly, it would be simply impossible to keep our hospital structure afloat if we had a universal health care system with Medicare reimbursements. It would take several decades to unwind the cost structure - cost of buildings, admin, change over all these companies that handle processes. This is why Bernie and Warren are not being taken seriously.
10
@Kevin - So what you are saying is that a more sane system that covers everyone just cannot be done, right? In one of the richest countries in the world, it's just too, too difficult and too, too expensive, so let's not even try?
60
At the time I write this, if this letter gets published, there will be 2 letters of 3, from physicians who left the field burnt out. In m career I worked with wonderful people: pharmDs, nurses, nurse practitioners and PAs, and constantly dreamed of what they might be able to accomplish if properly resourced. But health care resources go to all the wrong places, including administrators who create measures of success as mentioned: how many did you see and how fast did you do this. I too often compared it to my job waiting tables: turn those tables over and make more money!
But here is an ugly fact. Primary care doctors make too little money, yes. But has anyone looked at the ridiculously high salaries of some? Radiation oncology, orthopedic surgery, etc....no reason they should make $1M and more. Needs attention.
214
Totally agree - specialists make very high incomes. Where I work now they start at 700k without a lot of experience, and could easily make double that in private practice. I believe physicians should be well compensated and that medical school loan costs are out of control. However, as both a patient and a medical professional, it is hard to listen to physicians talk about healthcare reforms (less testing, fewer procedures, etc) from one side of their mouths while also doing other things (upcoding, ordering unnecessary imaging tests, etc) to benefit their incomes. It feels morally disingenuous to me.
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@JS Not to mention salaries of the administrators...
83
@JS
There is "no reason" that they should make what they do except for the most important reason, which is that is what the market pays.
Exactly why there may be "no reason" that a hedge fund manager should make tens of millions of dollars, yet it's possible.
5
I was worked in a Boston trauma EU in 1978. Fast forward 41 years, the same problems still exist. The surgeon general needs to make gobs of grant money available to ease this complicated mismanagement of the sick and suffering. My expectations are low as he is silent on migrant family separation.
30
@AW Grants run out and help only a few. We need physicians to stop voting for Republicans and support Medicare for All.
12
@Dan Woodard MD Yes, I concur, Medicare for all!! My amazing medical team looks out for the voiceless and chronically ill. My spot on assessment skills tell me they didn’t vote for Trump.
4
@Dan Woodard MD - The medical establishment is why we don't have universal health care in this country. Look up the article, The Lie Factory, at the New Yorker. During Truman's administration, the American Medical Association spent millions--literally--to convince Americans that universal health care would lead to communism. Not only did that campaign stop efforts at a time when the practice of medicine was a lot less complex than it is today, it left a residue of fear that still affects much of our discussion. I fault the AMA, too, for not taking the lead over the years in modernizing not just treatments (which, of course, bring in money) but also the very structure of health care in this country.
5
I'm a physician and I don't envy physicians who went into Emergency Medicine one bit. I was miserable when I rotated through the ER when I was a medical student and an intern. Many of the cases that came through were not true emergencies or even remotely urgent. At the worst end of the spectrum: We had patients come through just to get sandwiches. Some women came through with "abdominal pain" to get pregnancy tests -- as soon as they test came back negative, they would leave without any further workup, AMA (against medical advice). And when I was in training, the adage of pain as a "vital sign" was so heavily pushed (at least where I did internship) that people were afraid to deny pain meds except to the most blatant of drug-seekers.
Add in the non-physician bean-counter administrators "at the top" who peruse spreadsheets to track turnaround times -- God forbid you spend an extra few minutes assessing the patient, allowing a consult team see the patient, or letting the lab and radiology get full reports back -- and it's an utter disaster.
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@BN
In medical school I thought I wanted to go into emergency medicine until I did 8 straight weeks of it during 4th year.
I changed my mind. That 8 weeks was enough ER work for me for life.
Not only for the medical reasons, but the lifestyle too. Working Tuesday and Wednesday during the day, then Thursday and Friday off, then Saturday overnight, etc etc is not for me.
I didn't know what day or time it ever was, and I realized that I wanted to be back in the Monday-Friday 9-5 work world.
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The health care industrial complex needs the fix. Until the profit motive is removed from health care nothing will change. I worked a “fast track” in the E.R. my job was to “treat em and street em.” Great if it’s a new patient each time, each night. Except it was the same people over and over. People who could not afford health care, who did not understand the complex rules of finding a health care provider(if you could find one) and on and on. Health care is a poorly run expensive business. I eventually left it burnt me out. It really was an impossible job.
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@Just human Profit orientation may contribute to some problems, but the bigger issue is a failure of our country to acknowledge the many social problems that contribute to poor health. We also treat everything with highly marketed drugs, and ignore the underlying problems of poverty, hunger, and ignorance.
I worked in an urban Chicago ER in college more than 40 years ago - the problems have not changed. One of comments suggests shifting money from the military to health care. It makes sense - then prevention and social support could significantly mitigate many of these problems. We need as a society to demonstrate compassion for our neighbors - then we can begin to fix the actual problems that inflate the cost of health care.
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@Just human Sounds like the ER needs a robust social worker department.
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@Laura it has one but all the social workers in the world won't change the cost of health care. People go there because they don't have insurance. Some state Medicaid plans in Oregon will only cover ER not primary care, that's enough to make your head explode. Patients also get sent home with big bills they can't possible pay It is endless how broken the health care system is. It's about $$$$$ not care. The health care providers care but it slowly breaks your heart day after day. I am back in primary care and take my time with my patients. I don't care about numbers I care about quality time with my patients. They keep coming back and we work on having good health and well being. Theirs and mine.
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