The Final Answer is Always ‘Go to the ER’
2023; Lippincott Williams & Wilkins; Volume: 45; Issue: 10 Linguagem: Inglês
10.1097/01.eem.0000990096.62815.f9
ISSN1552-3624
Autores Tópico(s)Healthcare Systems and Technology
ResumoFigure: ED, PCP, referral, UTI, ultrasound, primary careFigure‘I called my doctor, and he said, ‘Go to the ER.’” I hear this from multiple patients every shift. I used to doubt the veracity of these reports. Why would any PCP make a patient think his fever or sore throat couldn't wait? Surely, I thought, patients were misinterpreting what they heard. After all, most patients who tell me they were told to come to the ED have concerns that any reasonable physician with a minute or two to troubleshoot could easily address over the phone. Usually all it takes is a few key screening questions to weed out who can be seen in follow-up. I know patients don't always take away from a conversation what we mean, so I was skeptical that “Go to the ER” was actually said ... until it happened to me. My son's testicular swelling shed new light for me on what happens when patients contact their doctor's office with medical concerns. The reality is that patients are indeed being told to go to the ED for nonemergencies, although it may not be coming from the physician. My son told me one night in the middle of dinner, “Mom, one of my balls has been huge for a while, and I'm really worried about it.” I hoped it was a hydrocele (thankfully, it was), but with the possibility of cancer I wanted it evaluated as soon as possible. I called his doctor's office first thing the next morning and left a message asking for an ultrasound referral. By that afternoon, I had left two more messages and heard nothing, so I drove to the office to speak with someone in person. The receptionist was quick to school me. “You can't just call in and get a referral.” I divulged that I'm an EP, asked to please speak to the doctor, and waited. Eventually, the office manager came out. “You can't have a referral without your son being seen first. We can give him an appointment later this week.” I asked again to speak to the doc and kept waiting. ‘Just Go to the ER’ I do not know whether she actually spoke with the doctor, what kind of interaction she had with him, or how she presented the situation, but she came back and said, “He will not do that without seeing the patient. Make an appointment and come back.” I tried to explain to her that a testicle changing size warranted an expeditious workup, and asked for the third time to speak to my son's doctor. Then she said it: “Just go to the ER.” What ensued was not my best moment. “This doesn't need an ED! I work nights and weekends in the ED to take care of all the other nonemergencies you refer in. I'm asking my son's doctor for help, so we don't have to go to the ED too. Now I understand why so many patients end up there.” She had no intention of letting me speak to the doctor and reiterated, “Sorry. Nothing can be done unless we see him.” It was part mama-bear instinct and part frustration with the system—and a little dose of pragmatism given that I was working the rest of the week—that made me dig in and hold my ground. I had already called my son—who fortunately has a driver's license—and told him to come straight to his pediatrician's office as soon as he got out of school. “He'll be here shortly,” I told her. “We'll wait until the end of the day”—which was fast approaching—“so after the doc finishes his other appointments he can quickly look and verify that my child needs an ultrasound.” Getting a Referral Lo and behold, when he got there and she realized we weren't leaving empty-handed without seeing or talking to the doctor first, we got his ultrasound referral. (We never did speak to the physician.) The obstructionist office staff that day taught me that when patients are inappropriately told “Go to the ED,” there's a good chance it wasn't by a physician. There are layers of receptionists and office managers and triage nurses between the patient who is calling and the actual physician. It's hard even for EPs to get a physician on the phone when we call from the ED. Imagine how hard it must be for patients to speak to their doctor. Most of the directives patients get are likely coming from a nurse or office staff instead. Many patients turn to insurance hotlines for direction. Nurses on the other end of these hotlines don't know the patients and therefore lack the context for interpreting their symptoms. They run down their list of screening questions and if they hear one “positive” response, that patient is going to the ED. I recently had a patient on antibiotics for a UTI who called an insurance hotline about her low back pain and, because of her dysuria, answered “yes” when asked if she was having problems urinating. She came walking into the ED scared that she was having a spinal cord problem. Even when nurses and physicians want patients to follow up with them rather than go to the ED, they are often thwarted in their attempts at expeditious outpatient care. PCPs are often so overscheduled that it's next to impossible to fit patients in. “See me in the morning” is unfortunately becoming a thing of the past. With separate lab and imaging centers, outpatient workups are more logistically complicated than ever, requiring multiple appointments and much coordination. The ED is simply easier. Everything is in one place; no appointments are required. Sending patients to the ED is usually the path of least resistance. No discussion of ED utilization would be complete without touching on the logistical hurdles that insurance companies create. PCP offices can do everything right when a patient calls and still not be able to get the patient the care he needs because insurance won't cover it. I wonder how often doctors' offices devote time and resources trying to manage the patient as an outpatient only to be foiled by insurance restrictions and then end up with same outcome as if they had said “Go to the ER” in the first place. I wouldn't be surprised if each battle they lose with insurance companies creates a lower threshold for them to say “Go to the ER” the next time. Remember my son and his hydrocele the next time a patient tells you she called her doctor before turning up in your ED. Don't assume your patient misinterpreted the interaction. As I learned, this “just go to the ER” phenomenon is not solely due to patients skipping past their PCP. More and more, the final answer when people call their PCP or specialist offices seems to be “Go to the ER.” It's one of the many, many ways EDs bear the brunt of our broken health care system. DR. SIMONS is a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns at http://bit.ly/EMN-ERGoddess. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].
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