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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.

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Our Own Worst Enemy

I have been pondering for quite some time our use and reliance on medical terminology as medical providers and specifically, its pitfalls. Granted, what I’m about to get on my soapbox about is not exactly new, it is something I feel the need to express my own view on. As medical professionals, why do we use complex medical jargon? To communicate patient specific issues between colleagues / consultants? Yes. To advertise one’s medical prowess (or at least prowess at memorizing)? I’m sure that happens. To verbally castrate a clinician one feels is far inferior? Alas, that does still happen from time to time. However, even the best of us forget to turn off our internal medical dictionary when talking to patient’s and/or family members, often leaving them with that glazed over, uncertain look even though they nod their head in understanding. Being on the side recently with my grandmother as a patient and hearing physicians talk to my family (not knowing my profession), I can honestly say some never turn that dictionary off. Much has been done in the way of trying to teach health care providers to speak to patient’s and family in a way that’s easy for them to understand, with varying degrees of success. However, how can we expect any real progress in that respect when we don’t even get it right between ourselves as clinicians?

What do I mean??? Take the good old case of sinus arrhythmia. We all know what it means, the¬†naturally occurring variation in heart rate that occurs during a breathing cycle, yadda, yadda, yadda. And hopefully most of us know, or at least have heard, that the terminology is wrong or in the very least, very inaccurate. With any other medical terminology, putting “a” in front of a word basically means “without”. Afebrile means without fever, Asymptomatic means without symptoms. So basically arrhythmia means without a rhythm, which we all know is not the case. It would be much more accurate for the terminology to be changed to “sinus dysrhythmia”. And while I’m glad to say that I do hear some clinicians (cardiologists, internal medicine physicians, PA’s, NP’s) use that terminology, most stick to the old, very inaccurate terminology.

I’m sure there are many others that you as colleagues may have thought of on your own. Of late, I have been giving thought to receptive aphasia. I don’t argue the definition / underlying cause of the aphasia. However, even though it is rooted in the patient’s ability to understand what is being said or written to them and even though they can speak clearly, the end result is that the patient cannot properly express themselves. While I’m not suggesting we call this a type of expressive aphasia, calling it receptive is not all encompassing. For while pathophysiologically it’s an issue with the patient understanding incoming information, clinically, the patient still cannot express themselves. Since there are components of both, why not change the terminology to something that alludes to both sides of it, such as “translational aphasia” or “fluent aphasia” as I’ve sometimes read / heard it used.

The medical terminology we use (and love?) is necessary, perhaps a necessary evil at times. While we can’t just toss it away, we do need to be more conscious in the way we utilize it. We must take strides in improving misleading and accurate terminology that we use in communicating with each other in addition to improving the way we communicate with our patients.

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