This article was originally posted on the American College of Emergency Physicians blog, The Central Line (centralline.org) on March 29th, 2013.
Observations from the Emergency Department.
The Emergency Department (ED) is a fascinating, wonderful thing. It is an area that has dominated the last decade of my life, since I first began my residency training in Philadelphia, to the hospitals in the Northeast where I now practice. Although I have migrated from one department to another, over time I began to realize that despite changes in names and faces, states and principalities, each ED is essentially the same. That is, there exists the same type of patients, personalities, efficiencies, dilemmas, doctors, nurses, techs, waiting rooms, food, drunkards—it is all the same, just dressed up and packaged differently.
This realization came gradually as my exposure to different EDs increased over time. I spent the first few months of my practice getting my feet wet, and acclimating myself towards my particular style of working independently as the attending physician (the top of the doctor pyramid). As a resident and intern (the respective second to last and bottom of the doctor pyramid) you are afforded the luxury of being supervised and working under someone who can guide you with their superior experience, knowledge and clinical know-how. Once your training is complete, there is no longer that crutch to lean on and the buck truly does stop with you. If there’s a problem, you solve it, and if you can’t handle it then too bad—you still have to deal with it. Working through these challenges and hurdles is what develops character, and gives each physician the confidence and experience necessary for the calm and purposeful delivery of appropriate medical care. These same challenges form within each physician the ubiquitous clinical “gestalt”, or “sixth sense” which ultimately serves as the powerful central command of each physician’s clinical decision making.
As time passed and I comfortably settled into my own style of practicing Emergency Medicine (EM), my thought processes evolved from the appropriate means of medically managing patients toward managing the people behind the patients: the psychology, social issues and heightened sense of apprehension that is associated with being acutely ill (or thinking yourself to be ill). It is this evolution in thinking that inspired me to start writing this essay. After all, when it’s 3AM in the middle of a blizzard, you begin to wonder what drives a person to brave the elements in order to seek an evaluation in their local ED. The reader would assume from the title of this essay that an exposé awaits that will unmask the mysteries of the ED. This is true but I also hope that the patients and non-medical personnel reading these pages will have gained some insight into how the mind of the ED operates, and how this relates to the delivery of medical care.
Now the most important lesson I have learned in my EM career is based on perspective and perception. These are two cardinal concepts that permeate any encounter in the ED. Perspective applies to any human being that is involved in emergency medical care—this can be a doctor, a patient, a nurse, or whomever—but can most easily be categorized into two groups: those involved in the provision of care (providers) and those who receive care (patients and their families). Perspective will certainly vary depending on which role you play, but also how much time you spend with the patient. Perspective also varies a few degrees within each group but differs the most between the two groups.
Amongst ED providers, I find that we are generally on the same page, since we all work in the same environment and have similar exposures. After all, a physician will never see a patient by herself, or will a nurse by himself and vice versa. We are familiar with the same acute pathologies and have experience in managing a host of diseases, so its almost like following a formula: if Patient X has Y, then we do A, B and C. Sometimes this is very straightforward, and treating patients can generally be boiled down to following an algorithm.
Nurses actually spend the most time with a patient, and often have the best insight into the patient’s condition. On more instances than I can count during my career, there was a nurse who was kind and diligent enough to share information and insights with me that I was unable, or neglected, to procure myself. Being asked the same questions by multiple people is how information is collected in medicine, and this is how the system should work; no one can be right (or at least think they’re right) all of the time, and patients almost always vary the information they give when asked the same question. Providers who have different perspectives can supplement each other’s knowledge to provide the best care possible.
This highlights an interesting point in what I call the “inverse pyramid.” I believe that medicine, unfortunately, is a culture of blame and not one of responsibility. I suppose this is a fact not intrinsic to the field per se, but is a commentary on human nature. When something goes wrong, no one rushes to say “I’m guilty,” but rather they look for someone on whom to place the blame so they can sleep comfortably.
The inverse pyramid comes into play because in medicine, blame tends to move upwards, to the top of the decision-making hierarchy—this is the burden of responsibility. This is “inverse” because in any other arena of life blame always tends to run downhill: the CEO blames the VP, the principal blames the teachers, and the senator blames his aide. It is standard in medicine that a legal arrangement exists where one provider works under another, or a provider practices based upon the consent of a superior. For example, in New York State a physician’s assistant (PA) works under a physician, so legally the PA cannot see and evaluate someone unless under the supervision of a doctor (the supervision need not be direct). Also, a registered nurse (RN) will care for a patient under the auspices of a doctor, who gives orders that are then fulfilled by the RN. In each case, if something were to go wrong the legal defense for the PA, for example, is that they were working “under the supervision” of the doctor, and thus legal responsibility shifts upwards. It is not a coincidence that PAs and RNs respectively, often hold small policies and are NOT required to have, malpractice insurance, whereas physicians are required to carry policies in the millions of dollars. Now given that setup, if you were a lawyer and wanted to sink your teeth into someone, whom would you go after?
Since the burden of responsibility is vastly different amongst providers from a strictly legal standpoint, doctors have less of an incentive to be more carefree and liberal about patient care. I wouldn’t therefore conclude that other providers have more of an incentive, but they certainly assume less risk, which can influence behavior. I invite the reader to ask any nurse about their experiences with a doctor, and I guarantee that every one has at least one story to tell about a physician who always “does too much” or “orders things unnecessarily.” Granted, each physician will always have their own style and nothing about medicine is absolute, but there are many doctors who will practice in defense of, or in case: a topic for alternate study into the downfalls of the current medical malpractice system, perhaps.
Perception, on the other hand, can also be segregated along the lines of the two groups (providers and patients), and herein lies the greatest discrepancy between the two. Each person’s perception is a lens through which they view the world, and can be tainted by prejudices, expectations, the Internet, their personal physician, past experiences, and comparison: “That’s not what they did the last time” or “That’s not what happened to my brother” or “My wife told me differently” or “That’s what Wikipedia said I have.” More often than not, if there is a conflict or an argument that arises in the ED, it oftentimes involves divergence in perception. When in doubt, I find one simple question can often harmonize any perceptive differences in the start of provider-patient relationship: What are your expectations for your ED stay?
The key point as a practicing EM physician is that I have been trained to view the ED and patients in a certain way: I must seek out and find any acute or life-threatening medical emergencies and then initiate the appropriate treatment. If an acute or life threatening emergency doesn’t exist, then my perception is that my job is done. I may not have found the root cause of a patient’s symptoms, but I can reassure them that they will not keel over and drop dead.
This is the first classic dilemma. Why? Patients, anytime and everywhere, will have a problem and want an answer. It need not be a good answer, but something that gives them clarity. They don’t know what’s wrong, so they go to the hospital with the expectation of seeing an oh-so-smart doctor who has spent countless years learning how to seek out and trample upon those bothersome diseases. If someone spends eight hours in the ED, has blood work done, X-rays, CAT Scans, and whatever else, and after everything is said and done is told, “Everything is fine, you can go home now and follow up with your doctor,” a large sense of dissatisfaction remains.
Sounds annoying, right? Of course it does, because the patient in question came to the ED with the expectation and perception that we would be able to diagnose, provide answers, and clarity. “We couldn’t find anything” is not an acceptable diagnosis to the patient, but at the same time brings relief and satisfaction to the ED physician. This, in reality, is how the system works—oftentimes something can’t be found to the best knowledge and ability of the medical team and the verdict of “ruled out” replaces a definitive answer.
The second classic dilemma involves patients’ expectations: they anticipate one outcome, and receive another. This is certainly my favorite to deal with because it often involves someone googling what they think they have on the Internet, and then coming into the ED expecting that X, Y, and Z will be done. Alternatively, it’s 3AM and the patient calls their doctor who tells them over the phone to “Go to the ER and get an MRI” or “Go to the hospital and have them get Dr. X to come in and see you right away.”
There are many obvious contributing factors to this problem. We live in the information age, when a plethora of data is available at anytime to anyone, anywhere. Our world is saturated with social media, where we are always encouraged to give our opinion and “like” or “dislike” something. Our judgements are aggressively sought after. The problem here is that without the appropriate medical background, it is very easy for the layperson to misinterpret common and banal symptoms as signs of life-threatening pathology. If an acute condition does exists then any ED would be more than happy to accommodate that patient, but, when people-en-mass are using the same erroneous logic to self-diagnose, and then demand treatment based on this logic, conflict will arise. Moreover, no provider would be quick to tell a patient, or a potential patient, that they shouldn’t worry, or advise them not to come in for an evaluation, because this puts the hospital and the advice giver at risk.
Don’t get me wrong—one of the most important tools any patient has is to educate themselves. Education is always a good thing, but education and information are distinct entities. The former involves rigorous preparation, proficiency in execution, real-life experience and recurrent exposure; the latter only requires a brief exposure and cursory understanding.
Another issue to keep in mind is that not all hospitals are created equal. Many patients think that if they walk into any ED, that hospital will be equipped to deal with their problem. Of course, the ED will be capable, but the problem may require a specialist that the hospital does not provide. Take, for instance a psychiatric problem (you want to hurt yourself). If the ED in question does not have a psychiatrist on staff, the ED will see and evaluate the patient, but they will eventually need to be transferred out of that hospital where a psychiatrist is available. Alternatively, let us say you bring your child to the ED and it is determined that the youngster needs to be admitted. If the hospital does not have a pediatric service, then the child will need to be transferred to another facility. In an ideal scenario, transfer would be instantaneous, but the reality is far from this. The process is complicated and legalistic, requires multiple steps, and includes securing space at the location to which the patient is going, as well as an accepting doctor at the receiving facility. As one can imagine, if the receiving facility is packed, waiting on a transfer can take several hours or even days before it’s finalized (And yes, that means the patient in question would be waiting in the ED for days).
Medicine is a lot like working on a movie set: oftentimes there’s a lot of waiting around, then the action happens, and then you’re left waiting for what seems like an eternity longer. In the ED, patients tend to perceive that because nothing is happening now, that nothing has happened or is going to happen, but that’s not the case. In many instances, medicine is very active (like open heart surgery), but it can also be very passive, like keeping your loved one on a heart monitor for 24 hours in order to make sure the heart is beating appropriately. In the latter case, it may seem that the patient is just lying in bed, which they are, but it amounts to more than that. We live in an instantaneous society where the public likes instant results. However, the body sometimes needs several days or weeks to heal itself. In any ED, one should not expect rapid and quick results; the medical providers are trying to rule out and treat acute emergencies, and from their end that is executed in the absence of time restriction (this rule applies in most cases, but there are instances where the minutes do count—if you’re having a stroke, for example, there is a window of time for action that opens when your symptoms start and then closes a few hours later). You can also never tell what incidental abnormalities may be found on simple screening. In the mind of the patient, a wait is a wait, and doing it in an ED is unfavorable.
Outside the ED, gauging how long to wait before coming in always boggles the mind. There are some people who will seek evaluation preemptively or at the slightest hint that something is going wrong. There are others, however, who will wait for an inordinate amount of time, and allow what was once a very small, minor issue to turn into a large and complicated one. The bottom line is that there is no golden rule for everyone and everything, but it would be prudent to neither jump the gun nor allow problems to snowball.
If you walk into an ED, all patients are screened through triage, which categorizes those who are very sick and those who are not-so-sick (in fact, within the first 60 seconds of meeting a new patient, all ED physicians answer four basic questions: Sick? Not sick? Stay? Go home?). The sickest patients are seen first. Thus, if an 80-year-old who has had a heart attack in the past is now having chest pain, he takes priority over the 21-year-old who has had a cough for two weeks. This is the only logical method to deliver care in order that the ED can fulfill its role to accommodate emergencies. As a side note, it’s vital to mention that in the life of any ED patient there are three key mental checkpoints: (1) When am I going to be called in? (2) When am I going to see the doctor? (3) When can I go home? Once the last two questions are answered, any angst about the hospital stay is largely resolved. Now some EDs are faster than others, but this is why in many scenarios the waiting times can become exceedingly long, because the newer, sicker patients must be seen before those that have been there longer.
Many patients think that medicine is a predictive science, but instead, at its best, it is a collective art. Doctors can assimilate a history, physical exam, labwork, x-rays, and things of the sort in order to make an informed decision, but despite their best efforts and knowledge, no doctor can predict the future. If I could do that, then I am in the wrong profession. So, patients and families often want to know if they will be OK, and the genuine short answer is: I can’t be 100% percent sure. Despite all the information that I have in front of me now, and regardless of my best judgment and intentions at this moment, the body may change its mind and alter its course in the future. I could also just be plain wrong.
I think possibly the largest separation in perspective is misinformation and trust. In working in both EDs and urgent care centers, the single biggest piece of misinformation I encounter is the thought that any fever or illness automatically warrants antibiotics. I still am unclear where this pervasive misconception was birthed (perhaps the pharmaceutical companies are that good in advertising) but many have assumed that when they are ill, then nothing will help them other than some sort of pill. Yes, in some instances this is true, but people have been getting the common cold (a virus) and the flu (another virus) for thousands of years. Even to this day, medicine has not developed medication that kills viruses; in many cases the cure is time and symptomatic treatment. Alas, try telling that to a concerned mother with a feverish 2-year-old at 4 AM, or to John Doe whose brother “had the same thing” and got a Z-Pack and was instantly better. In both instances, any intellectual argument or medical studies suggesting otherwise fight the larger opponent of the patient’s preconceptions.
There’s also a very large mental satisfaction when something is done to alleviate symptoms. If you walk into a doctor’s office and are told, “It’s a virus, do nothing and go home” or are given “only” reassurance, the patient is left with a void: the medical profession did not provide anything. In the same scenario, if the patient receives antibiotics, or even if they’re given a prescription for Tylenol, they leave with something, and now the void has been filled.
“Phone medicine” can also produce similar strife. If a patient describes symptoms on the phone, sometimes a diagnosis can be made, warranting a referral to the ED. Sometimes, however, describing something on the phone and then examining someone in person can yield two very different diagnoses. If the patient was told to go to the ED for a specific purpose and is then told something completely different on arrival, an uphill battle ensues.
Furthermore, the ED physician typically only sees a patient once—for the most part there is no legacy or relationship. The level of familiarity, and therefore trust, that a patient may have with their family doctor or pediatrician is thus lacking. The patient may figuratively ask the ED physician, Who are you anyway to tell me this? You’re not my doctor!
Another separation in perception involves the entire concept of emergency, defined by The New Oxford American Dictionary as “a serious, unexpected, and often dangerous situation requiring immediate action.” From the providers’ standpoint, we tend to think that if you are coming into an ED you must be acutely ill or on the verge of death. But, in reality the term emergency is relative to the individual or observer; the concept can be interpreted in a number of ways and is altered by personal, ethnic, economic, cultural, familial, and emotional reasons. Providers deal with emergencies all the time, so disease processes and worrisome symptoms become familiar. The general public does not have this exposure, and would therefore have a lower threshold for classification. What may be emergent for patient X is just another weekday for a provider. Hence, the logical conclusion follows that simply because something can be done in the ED doesn’t mean it will be done, given how emergent the problem is. Once any department begins to reroute resources toward non-emergent tests and procedures, this takes away from its ability to treat other, more acute patients, and the first step on a journey along a downward spiral begins. Many people have also assumed the ED replaces primary care, and unfortunately have abused the widespread availability of EDs to satisfy their own needs instead of establishing a relationship with a primary medical doctor (PMD—also known as General Practitioner, Family Doctor, Internist, or “My Doctor”). Having your own personal physician is always beneficial because they establish continuity, consistency, and act as the primary gatekeeper for all of the patient’s care; just as a mother knows her child best, an established PMD will be best suited to make decisions for the patient and coordinate medical decision-making. The goal of care in the ED is geared toward acute disease management, not long-term or wellness management; the inevitable discontinuity of care through multiple EDs, or within the same ED with different physicians, only acts against the best interests of the patient. Obviously, many societal and institutional barriers exist that prevent millions from following the ideal prescribed—lack of insurance, the increasing shortage of primary care physicians, and the lack of available office appointments after hours, just to name a few.
In the eyes of the world, the ED is there for any medical problem, whether you’re sick or not; this is the natural consequence of the way in which the system is set up. Hence, a person need not even think they have an emergency, but know that there’s something small that’s bothering them for a while, and—any ED will see them. Of course this is reality, because access to care is guaranteed (the law dictates that anyone who comes seeking care is entitled to a medical screening exam—a good idea), you never need to make an appointment, the doctor is always in, and the ED is always open 24/7/365. The only time an ED does close is after an act of God or some other extreme circumstance. This is a highly necessary and functional system to care for the acutely ill, but it also incentivizes people not to seek care elsewhere. After all, why should John Q. Public wait when he can be seen now in the place where all the resources are anyway?
Having a stroke? Go to the ER. Heart Attack? Go to the ER. Have you just lost feeling in your leg, which is turning blue? Go to the ER. Did you fall and can’t get up? Go to the ER. Is there a bone sticking out of our skin? Go to the ER. Did your water just break? Go to the ER. Have you been constipated for six years? Go to the ER. Don’t want grandma in the house for the holiday weekend? Go to the ER. You have 60 tablets left of narcotic pain medication but they’re just not cutting it and you need something stronger? Go to the ER. Is it cold and would you like a meal? Go to the ER. Is it past 11p.m. and did you just call your own doctor? Go to the ER.
The final perspective separation transcends the staff of the ED and involves the upper management of the hospital itself. It’s what I like to call the “corporatization” of emergency medicine—the same concept can be applied to medicine in general. I previously used the term “providers” to describe ED staff because we are nowadays being viewed as providing a service to a consumer. Hence, the “practice of medicine” is becoming the “business of medicine”. Many physicians have even gone back to school to obtain their MBAs, or enroll in combined MD/MBA programs in order to capitalize on this growing trend. In equating patients to consumers, not only is their medical care being evaluated, but their overall experience as well. It’s an evaluation that transcends how the patient is doing or how they’re feeling by (for example) inquiring if they were comfortable during their stay, if the staff was courteous, and if the amenities provided to them were adequate. This is taken seriously because reimbursement is partially tied to patient satisfaction, and many other reimbursement models use the individual physician’s satisfaction scores as a determinant of salary. As one can clearly see, anyone involved in hospital administration would have a vested interest in keeping satisfaction as high as possible, which entails beefing up services as well as medical care.
Making someone comfortable is not a bad thing, but patients are not consumers. The goal of a patient is to achieve wellness and health; the goal of a consumer is to obtain goods or services in exchange for monetary compensation. The danger of the consumer model is that when satisfaction and actual medical care are lumped together, the lines blur and the “patient experience” can overpower the delivery of sound medical care. Hospitals may actually start slacking in care, but if the stay is packaged in an attractive, clean, palatable way, the perception that good care was delivered becomes grossly positive. Additionally, in order to maximize happiness, the patients are the ones who will begin to choose and dictate care (because it’s what they want) against the sound medical decisions of the providers. This opens up the door to abuse and grants decision-making power to those who lack medical training. Unfortunately I have witnessed this growing trend first hand, and I regrettably foresee a future where it only gets worse, not better. Many physicians and administrative personnel have been seduced by the lure of money, as opposed to following the maxim “do no harm”. After all, if making the tough decisions was so easy why not grant every person a medical degree?
In addition, a ubiquitous philosophy exists amongst the public that more care equals better care, and more expensive care equals better care. The latter attitude has been validated in a recent study in the journal Health Affairs.[i] In this analysis, researchers utilized patient focus groups and asked the participants to imagine they had a disease, and then imagine they had a host of treatment options available to them—all options varied minimally in effectiveness but varied highly in cost. The researchers found that: the make-believe patients did not want cost to play a role in medical decision making; they acted in their own self-interest and ignored the added burden to the medical system as a whole, doubting their choices would have an impact; they felt entitled to the more expensive treatments; despite comprehensive medical discussions that suggested otherwise, the participants remained firm in the belief that the more expensive treatments were better. The clear danger in this perceptive difference is that it will drastically burden the medical system with excessive spending and waste with little or no resultant health benefits compared to less expensive options.
So you’ve been waiting for three hours for a CT scan? Perspective #1: this is horrible. Everyone is sitting around, doing nothing and I have to waste my day in this uncomfortable chair, in the hallway waiting, waiting, and waiting some more for nothing! I could be at home watching TV or taking a walk in the park. And, to top it all off, my cell phone has no reception. I can’t even text. I haven’t eaten in hours. I’m so hungry, why won’t they feed me. So what if I have abdominal pain. I want some fries and shake!
Perspective #2: I’ve been here for a while, but I’m thankful I’ve walked into the ED with my own two fully functional legs. There’s a man down in the hall, on a ventilator, in a medically induced coma. His family looks pretty upset. I guess I could complain about my circumstances, but then again, the fact that I’m well enough to complain speaks for itself. It could always be worse …
Perspective #3: I’m worried about that young guy in the hallway. He looks OK, but he has a fever and pain in the right lower part of his belly. He wants to eat, which is good sign, but if his appendix is inflamed, he will need emergent surgery and food is not a good idea. We had to move him into the hall and I know he’s peeved about that but we have to keep the elderly man on a heart monitor and give the other elderly woman with the low blood pressure a blood transfusion, something that can’t be done in the hallway. I realize I may have been short with him, but there are plenty more patients to see and I have to keep moving.
Perspective #4: I really don’t understand why that young kid is getting a CT scan. I mean look at him: he’s fiddling with his phone and is more concerned about texting his girlfriend than his so-called pain. I don’t know what they’re thinking, but they’re always ordering all these studies on people, and never find anything. I should be the one treating this guy so I can send him home.
Perspective #5: Where’s the bathroom?
Perspective #6: Can I go out and smoke?
Finally, I believe that medicine has been slow to adopt a team-centered approach to the delivery of care, a concept that is pervasive in mostly all other arenas of life. The business world, for example, focuses on the collaborative efforts of many, where decisions are made through brainstorming, groups, committees and boards. In patient care, medicine normally rests on the executive decision of a solitary physician, unless the patient has a highly complex set of issues requiring multiple collaborative opinions. Medicine also tends to be highly segregated, so the orthopedists only deal with bones, the cardiologists with hearts, the gastroenterologists with the stomach and so on and so on. As a result, everyone keeps their particular focus in mind and leaves other issues to be dealt with by the appropriate specialist. Accordingly, physicians can often be islands where they are the masters of their domain; it is difficult then, to switch from this method of thinking into a collaborative one. It would be far easier for rival factions within a company to come together for the “good of the corporation,” but that binding force does not have much strength in the medical world. Doctors can be separated along state lines, competing groups in the same area, and be credentialed at different hospitals to name a few examples. Moreover, collaboration need not only be a good thing—I have often said if you ask five different physicians the same question, you will receive twenty different answers. As a patient moves from doctor to doctor, she may receive differing opinions on management. This cannot only be frustrating but deleterious to the overall delivery of care. In the ED, for example, the patient bouncing back three days in a row may receive three separate diagnoses.
In the end, I have realized that the most effective way to manage an ED is not to deal with a patient but to deal with the person who happens to be the patient at the moment. I find people are much more open and understanding when a compassionate, clear and honest explanation is given whenever a discrepancy exists between perspectives and perceptions. When providers openly admit the ED’s inadequacies when things fall short, and tactfully explain when a service falls out of the realm of emergency medical care, everyone can enjoy peace of mind. As always, do no harm.
C.H.E. Sadaphal, MD, FACEP
© 2013 CHE Sadaphal
[i] Sommers, et al. Health Aff. February 2013 vol. 32 no. 2 338-346