I am an ER Physician and agree with what you say, but the reality is that it's so easy to say "Go to the ER."  If a patient's physician thinks that is the right solution, and if there is some information that he/she has that might help expedite the care, then I suggest they call the ER and talk to the ER Doc.  This will not only benefit the patient by having an informed care-giver when the patient arrives, it also will help expedite the care - get the patient back to a room more quickly because he/she was expected and as a courtesy to the calling physician.  We really do appreciate it when a referring physician calls and gives history.  It helps us provide the right care expeditiously and it also provides us with a contact for the calling physician for follow-up discussion.

 Paul Hildebrand, MD, Gig Harbor, WA

I find this to be an interesting question to ask.  I am a RN in a clinic that is 30 miles away from the nearest hospital in any direction.  Many times, we will have patients walk in to our clinic for emergency treatment because they do not want to "wait in the emergency room for hours before being seen". 

If we are sending someone to an ER for evaluation, we will call ahead of time and speak to either the ER provider or the charge nurse and give a report.  We do have ER "intake" forms from the hospitals that our patients use that we complete and fax, including any pertinent testing done, medication lists, medical history, etc.

Hi Seth,

Its a great point and question that you raise.  I frequently find patients with non-urgent sounds complaints (long-standing atypical CP, palpitations) getting sent to ERs.  I think a lot of this is "defensive" medicine, especially when the provider taking the call doesnt know the patient.  

 Some it is also expediting testing.  Often blood work, MRIs, CT's ordered from the ER get priority over outpatient testing.  Also when a series of tests are needed (i.e. lab work, THEN EKG, then CT scan), our systems are set to make that a slow process in most clinical locations other than the ER.

 Finally, expertise and comfort.  While you or I may feel comfortable managing patients with atypical sounding chest pain as outpatients, most PCP's that I hear from are not.  They either want them seen same day in my office (which we will try to do) or send them to the ER. 

Great thoughts and very much agreed.

Seth:  This trend has increased to the point that 80% of patients who get admitted to the hospital come through the ED.  I am an ED attending. It is often a matter of convenience. Getting a battery of tests can best be accomlished through the ED if they are desired to be done quickly.  As for internal medicine/ primary care MDs, they have a full or overbooked office schedule already.  They cannot possible deal with chest or abdominal pain of an urgent nature in one visit. Many E.D. patient explain that they do not get as far and an office RN or MD but are told by the office staff that if they can't wait for a regualr office visit or if they hear the words "chest pain" or "belly pain" thye are instructed to "Go to the ER." There is the fear of malpractice: what if I don't order a troponin and chest radiograph, d dimer, or doppler of the legs to r/o DVT/ PE? Even if it sounds like GERD or muscular pain.  Same for abdominal pain: what if I miss a AAA, appy, mesenteric ischemia, etc. As for admissions, hospitalists want all of the patients who are send in for admission to go throght the ED so all of the tests/ labs can be done for convenience because "what if the patient has ...." As fewer PMDs come to the hosptial to admit patients, the E.D. is becoming the default access point.  See any reason why the ED is crowded and slow?  Seth, you are atypical of practitioners.

Hurray for Dr. Bilazarian!  He evinces genuine concern for patients.  One thing he doesn't mention is that not only can ER care can miserable for patients with long waits and so forth, for some it can be very hard on their pocketbook.

My sister has expressed great irritation with the constant newspaper stories about people going unnecessarily to the ER when she has on several occasions been directed by various doctors to the ER for what she perfectly well realized was NOT an emergency (even much less so than the examples given by Dr. Bilazarian).  She absolutely did NOT want to be in the ER for these minor situations.

This commentary and the examples were absolutely terrific!!

Seth,

I used to work in a hospital in Atlanta and they had a place called the DTC, diagnostic treatment center. You  had  to have an appointment to be seen there.I  would  call the DTC and make the appointment for  today, order the tests I wanted, go in and see the patient and decide the proper  disposition. There was little wait since these patients were insured so there were fewer of them. and they were screened by phone by a "real" MD. However, I had a way of practice that considered a face to face visit useful. Of course I  would not send them there if they did not need to be seen that day.

Subsequently  I became a hospitalist out of state. Nowadays hospitalisits  are the default option  for the specialist who does not want to work nights or week-ends.  We would take care of them.They  would come in later unless I needed her sooner( and could convince her otherwise).The whole  idea of the hospitalist is to keep the specialists  happy  and productive/ (Going in to the ER is  NOT a great way for them to generate fees.)

It also became obvious that the hospitalists were   STRONGLY encouraged to admit. This was partly a result of the ER doc  knowing that they could do what amounted to a triage assessment  and call us.This saved them a lot of time and effort,thererby this increased ER turnover, volume and fees   and admissions which helps the hospital stay solvent . 

  "Go the the ER"  is the new standard of care. 

  I enjoy your thoughtful  posts. 

 Seth, thank you for a well recived, thoughtful input on a growing proble.

 I practiced cardiology from 1963 until June 1996. Our insrtuctions to patients was that if they had a problem , to come to the office right away. The problem would be quick screened by a nurse or physician, and if it appeared serious, was immediately seen by a physician, and if necessary, was admitted and cared for right then. The patients who were kept waiting accepted the delay, since they knew that they would get the same treatment when it was their emergency.

 One can understand the frustration I feel when calling my internist, getting the recorded menu of voice-mail messages, and the first of which is "If this is an emergency, call 911!". I know that responsibilities have changed, but in my book, this is malfeasance!

I guess Dr. Bilizarian you have not been burned by a patient who complained of minor things over the phone and turned out to have major issues when presenting to the ER. I have seen epigastric pains represent acute MI, including fatal ones. The reality is we need to practice defensive medicine. I look at it from a statistical perspective we need to be sensitive more than specific because the expected value of a miss is very high. Also from a non defensive medicine perspective, when patients call the doctor rather than make an appointment it is usually because something is wrong not because they want to disturb the doctor.

  I agree. Patients want attention when they are sick, in pain or worried. Our ,in my opinion,

over emphasis on preventing  confitions  that are pre conditions  for conditions   that may or may not result in clinical illness are a great way to generate income but I believe  the patients really

want to be taken  care of when they are "sick".. I believe this concept is now officially

an orphan out there searching for someone to adopt it. "Go to the ER" is medical speak for

"you are not really my problem  sir."

Everything you say is more than true. There are two issues that also impact the situation. I have worked on both sides of the equation - ER and community position.

The ER must adopt a posture that 'rules out' the most serious (causing increased and more sophisticated = costly testing) risks. So, what would have been a simple face-to-face visit that would possibly include some targeted testing and treatment now becomes a major (costly to the patient) production.

Calling a 'specialist' (or even a PCP occasionally) the answer 'go to the ER' also delays the care - the 'specialist' is deferring the initial assessment to the ER physician (they are good and specialist have a confident relationship with them; but that is disrespectful to me) and then (as they would have to anyway) the 'specialist arrives in the ER to 'finish' the care. So now the patient (or insurance) is blessed with the opportunity to not only pay for the ultimate care - but the ER physician and the ER use as well. Another issue is that the ER often must acquire or prepare the 'tools' for the 'specialist' - more delay / cost / disruption.

The answer - well I'm not sure this is perfect - scheduling. All of us who provide scheduled direct patient care should build into our day some 'space' to allow for the urgent care needs. Pediatricians usually do it best.

We're really going to love it when the insurance industry standard becomes paying for diagnosis rather than presenting complaint, as a few insurance companies are starting to do.

If the patient presents with chest tightness, shortness of breath, pallor, and dizziness, but is diagnosed after the million-dollar-workup with acute anxiety, guess what? The insurance company doesn't want to pay for the MI and PE workup.

The patient is then resposible for all but a paltry few hundred dollars of the bill.

Did anyine think of the patient when no acute disease entity is found and the patient is admitted, Insurance denies the admission and there is unnecessary expense on the patient and the hospital, and now the physicians won't get paid.