What's the Big Emergency?Zachary F. Meisel and Jesse M. Pines take readers' questions about E.R. abuse and its culprits.
Posted Thursday, Sept. 18, 2008, at 4:59 PM ET
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StumbleUponHarrisburg, Pa.: How much is the shortage of health care professionals contributing to the increased use of emergency rooms?
Dr. Jesse M. Pines: While there are shortages across the board for healthcare professionals (nurses, doctors), the major shortage is in primary care physicians. This is because the economics of primary care does not allow them to be paid a large amount per patient they see. As a result, they have to book their clinics at 100% to pay their staff. When clinics are 100% booked, there is little room for urgent patients or extra time to spend with those who are more complex. Most people don't plan on getting sick. Therefore, clinic overflow and more complex patients are directed squarely to the ERs.
Dr. Zachary F. Meisel: There is some debate among economists about the physician supply. In Philadelphia, if you can pay or have coverage you can find good primary care. However, other communities do struggle with primary care shortages. In our Slate piece, we are particularly interested in why patients who are covered and have doctors still choose (or are sent) to come to the ED when they may not have to.
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Boston: One thing you story didn't mention is that people get sick at night, on weekends, on holidays. I was recently in the ER for bronchitis. It was Saturday night, and I was having trouble breathing. I got way too much treatment—IV, X-rays, etc, just in case. I often have taken my kids to an ER. They've got a bad earache, it's 9 p.m., and when I call the doctor's office and finally get to talk to a nurse, she always says go to the ER.
Dr. Zachary F. Meisel: Certainly very important to go to the ED if you can't breathe. Whether or not you got too much testing is probably debatable. One consequence of the ED usage for lower acuity issues is that ED docs and staff will treat your condition like an emergency, at least in the beginning (because by showing up in an ER you have declared that you think it is an emergency as well). Also they may not know you or have access to your outpatient records. This will probably lead to more testing.
Dr. Jesse M. Pines: I agree with Zack on this.
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Boston: Walk-in quick clinics are just starting to be allowed in the CVS pharmacies around here. Do you think that type of thing, or more general neighborhood clinics, could help to alleviate some of the strain on ERs?
Dr. Jesse M. Pines: Walk-in clinics like CVS can alleviate some of the strain on ERs. However, while the waits may be shorter, they have fewer resources than ERs do. If they need a more complex assessment (like a CT or an MRI), they will need to come to the ER anyway. Or alternatively, if it is not truly emergent, they can see their doctor (if the doctor will see them in a timely way).
The other issue with walk-in clinics is that people have to pay for services up-front at CVS, where many ERs don't require this. So those who have fewer resources may just choose ERs because they may perceive out-of-pocket costs to be lower, even though the bill they get in the mail will certainly be higher.
Dr. Zachary F. Meisel: Also many communities have tried to set up late night walk in clinics/urgent care centers and for many reasons, they have not been able to stay in business.
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Seattle: I have been to the ER three times in my adult life: Once for an ankle injury that may have been a break, but it was swollen to twice normal size and had turned purple, once for chest pains that turned out to be two months of un-treated GERD, and once for appendicitis. Were any of these abuses of the ER?
Dr. Jesse M. Pines: These all seem like reasonable reasons for using the ER.
Dr. Zachary F. Meisel: Agree.
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Gaithersburg, Md.: I work with a population with severe and persistent mental illnesses. Many of them have difficulty differentiating between acute symptoms of their illness and non-emergencies. At what point would you consider an ER visit appropriate versus abusing the service? (By the way, I work with Jesse Pines' Mother at CBH Health Life Skills.)
Dr. Jesse M. Pines: You take care of a challenging population of patients and I commend you for that. Regarding their ER use, whether it is appropriate depends on what the complaint is. If it is something that can be taken care of in a primary care office (like a sore throat or a cough), you should take them there. If it is something more serious, like a trauma or they are having chest or abdominal pain, they should come to the ER. Say hello to mom for me.
Dr. Zachary F. Meisel: We, as practicing emergency docs, also struggle with differentiating between serious and non-serious problems in patients with mental illness (despite having access to lots of tests and treatments in the ER). So this is not an easy question.
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Washington: Doctor availability is a big issue—even with good insurance, I have trouble finding a doctor who can see me today or tomorrow for something that's urgent. I have to wait days or sometimes weeks to get an appointment (and don't get me started on how long I have to sit in the waiting room once my appointment rolls around). In at least one case, during the wait my condition worsened, and I ended up in the emergency room. Insurance companies could save a lot of money by including urgent care centers in their plans.
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