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Instant Gratification Society (Part I?)

Those of us who work in Emergency Medicine have all had these patients. They present with a complaint that started two years ago and for whatever reason now deem it an issue that needs immediate attention in the ER. I had a patient like this recently who not only had the issue for 2 years, but also had a primary care provider. Not only did the patient have a PCP, they saw their PCP a week before coming to the ER. Their provider also referred the patient for some outpatient studies. The studies were reasonable even though they would unlikely get to the root cause of the patient’s symptoms (an issue I’ve addressed in prior posts). Despite being reasonable, the patient decided to not follow through with the referrals and instead decided to come to the ER demanding the studies be done there because the patient “needed to know today”. I politely went through my normal boundary setting dialogue about how the patient should be getting her outpatient studies done as referred by her PCP and how coming to the ER in lieu of that is an inappropriate use of the ER but it fell on deaf ears as usual. Now none of this is new. We see patients with chronic symptoms all the time as well as patients who have doctors. But to read many of the articles you find out there, whether it be on a news site, “news” site, Facebook or a blog, I have yet to see articles pointing out the issue of middle class, insured patients with primary care providers misusing the ER.

By comparison, I’ve read numerous articles making pariahs out of the uninsured and even those who signed up for health insurance via the Affordable Care Act. Many of us have read that article where the ER physician laments about the patient he sees with asthma who says he can’t afford his inhaler but has money for cigarettes and a brand new smart phone. By itself, a legitimate question but narrow in its view not taking into account a broader picture. Likewise many of us have read about how those singing up for health insurance from the ACA will inundate Emergency Departments for their care and stress out the system. Articles written on this topic target the poor, those without insurance, or insurance via the ACA for using the ER while seemingly giving a pass to the many patients who have private health insurance and doctors and still use the ER for minor and/or chronic issues best served by their PCP. This is both backwards and inaccurate.

Working in an urban Emergency Department on the edge of city all but forgotten by government, we see both inner city and suburban patient populations. I can give somewhat of a pass to inner city patients with or without insurance for utilizing the ER because at the end of the day, access to primary care in the city is limited. Maybe not total absolution at times but one can certainly understand. I know many more people who have insurance through the ACA grateful for it and use their primary care providers appropriately rather than inundating the ER. What I can’t give a pass to are patients who have private insurance and doctors that try to use the ER as a surrogate. The reality is, this happens with great frequency. The examples are numerous. Patient’s with simple common colds who don’t even try to see their doctor or “couldn’t wait to the next day”. Patients who present to the ER expecting a routine MRI of their knee. I even had a patient with a referral from the orthopedic doctor for a follow up x-ray of a fracture written 2 months before coming to the ER. The patient needed to get the x-ray done that night because he had his follow up appointment with the orthopedic doctor the next day. They had two months to get their outpatient x-ray done. Not to mention, those who come to the ER to get their prescriptions for chronic medications refilled.

I’ve read the term “entitled” used when referring to certain patients. When they do, they are usually referring to those without insurance being entitled to not only using the ER for convenient health care but to get fed in the ER and a cab voucher home. ¬†They are not always wrong however they don’t seem to apply it equally. Entitlement is blind to socioeconomic status. We live in an instant gratification society where anyone from any walk of life can and does feel entitled to getting what they want, when they want it. It could be health care, food, shopping, anything.

The reality is, middle class, insured patients who have their own primary care provider misuse the ER just as much if not more than those without insurance yet they are less likely to be called out for it or labeled as “entitled”.

Not with me yet? Well, as vapid as the saying is, a picture is worth a thousand words…

I’m sure one could write an entire article on how wrong this is. This advertisement is certainly not targeting the uninsured, inner city patient populations. It is targeting the middle class person who wants to shop and not have to wait to be seen in the ER. It also sadly demonstrates that people do not understand the term “emergency”. I am certainly empathetic enough to understand that something simple may be perceived as an emergency to a person. However if that perception exists, if a patient truly thinks they have an emergency, they are not going to stop by the mall first to go shopping. Conversely, if you are able to go shopping, you do not have an emergency. This is the medical equivalent to getting the beeper from a restaurant so you don’t have to wait and do nothing while waiting or worse yet, talk to other people. It’s not an emergency, it’s convenience. It’s instant gratification. One could also argue that the advertisement resides at the corner of Instant Gratification Street and Patient Satisfaction Survey Road. That is another topic in and of itself. The demand is obviously there if the hospital is supplying it.

Now many of you (hopefully) are reading this and agreeing with me. Here’s the rub. You are just as guilty of all this as any patient. I am too. I stated earlier no one is immune to it and it applies to more than just medicine. Every time you hit the drive thru instead of cooking for yourself, every time I use my phone to check Facebook, every time you ask a colleague to right a script, or when I call to expedite a family member to an ER bed, there is some mixture of entitlement and instant gratification at work. What’s solution? As with anything it’s multifactorial and can’t be deduced to just one thing. It is even likely that the solution may be a little different for each of us. As with anything, the first step in resolving an issue is acknowledging it exists, for everyone, not just certain groups.

The downside to getting what you want

Many of you know from my blog or knowing me personally that I’m very much opposed to unnecessary medical testing and treatments. While at times unavoidable, I do my best to practice clinical medicine and use testing only when necessary. I try not order tests “just to be safe” or to “lets see what it may show”. I usually recommend against back and knee x-rays, especially when there is no blunt trauma, as they tend to reveal no valuable information for the diagnosis. Even when testing is necessary, there are ways to eliminate unnecessary tests such as ordering only a Lipase for suspected pancreatitis, avoiding unnecessary CT scans for abdominal pains clearly due to viral etiologies. Granted there are times when it is unavoidable such as when a patient’s exam is still concerning for an acute event like an appendicitis but their labs are normal. Despite those times, developing good clinical skills, one can still decrease the use unnecessary testing.

Why is that important. Again, while I have written to this notion prior, I think the author of this New Yorker article does a much better job of the reasons and sometimes dangers of inappropriate testing and treatments. He rightly notes that inappropriate testing can be both dangerous and delay/ignore the correct evaluation and treatment of a condition. My one critique of the article is that he mentions the concept of patient satisfaction but does not go into how it relates to unnecessary testing or it’s lack of correlation to patient outcomes. Overall though, this is a good read.

http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande

The balance of medicine

While the linked article centers around Emergency Medicine clinicians, the gist of the article is applicable to any field of medicine. Not every symptom / condition requires the most expensive test or any test at all for that matter. The point being, just as one should be weary of clinicians who prescribe a pill for every issue, one should be weary of clinicians who refer patients for tests with every issue. Tests are not always necessary and in the case of multiple radiological studies, they can be dangerous down the line. Multiple and frequent tests can certainly increase healthcare costs as well. In my own practice, I’m very conscious in trying to minimize the use Cat Scans and X-Rays when not necessary while not withholding them in cases where they are indicated. For instance, x-rays for fractures to the nose and tailbone are almost never needed. Likewise, back x-rays in the setting of most injuries almost never yield useful findings. Even Cat Scans, especially in children, need to be carefully considered. With a good history and use of an accepted screening tool like the Canadian Head CT Rule, many head injuries do not require a CT scan. And in cases of suspected appendicitis in children, an ultrasound can sometimes make the diagnosis and spare the radiation exposure (though it can’t rule out the diagnosis, so a CT scan may still be needed). Sometimes, even a period of observation or having a patient come back for a second examination is an acceptable alternative. So, if your primary care provider is alway ordering tests, remember you have the right to take an active part in your care. Ask why that particular test, what will it diagnose, what can it rule out, and are there any alternatives that can utilized. A confident and competent clinician should not object or take offense to such questions.

http://online.wsj.com/news/articles/SB10001424052702303519404579354813030233586?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702303519404579354813030233586.html

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