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A friend of mine, an Emergency Medicine physician at an academic center, recommended an article in the New York Times entitled "E.R. Patients Often Left Confused After Visits."¹ The article discusses research that found "[a] vast majority of emergency room patients are discharged without understanding the treatment they received or how to care for themselves once they get home … [a]nd that can lead to medication errors and serious complications that can send them right back to the hospital." I discussed the article with him over Google Chat. It went like this:

me: Interesting article about ER patients. I don’t know that much about the big picture, but it seems this may be the result of ER overuse. People go to the ER for almost everything; it’s like the US’s universal healthcare system. Ideally, in my mind, people would have a relationship with a family physician and then only use the ER when there is an actual serious emergency and the family doc is unable to help. The chick with the STD, for example. If she was at a family doctor with whom she had a relationship, things probably would have worked out better.

Friend: ERs do serve as a medical "safety net," providing care of all types to patients of all types. Though it shares certain characteristics with universal coverage (i.e., a certain level of care is provided to all who come), it differs in key ways, namely the absence of both preventative and comprehensive care.

me: Right. Wouldn’t you think, in a way, the ability to effectively communicate how to "self-care" is a type of preventative care? In other words, something the ER is not setup to do…

Friend: When patients show up to ERs for "primary care," it’s often only after multiple failed attempts to obtain an outpatient primary care source. There’s a huge shortage, nationwide, of primary care providers. (I know a medical school dean who couldn’t get into a primary care office any sooner than four months from date of request.)

me: So, someone has something bothering them and they know it needs attention, they can’t get in to see a normal doctor, so they go to the ER. I can see that. That’s kind of what I meant by "ER overuse."

Friend: Patient education on disease process and healthy habits empowers patients to "self care." This is definitely a form of preventative medicine.

me: Taking it all together, then, stuff like what is discussed in the article should be expected. People are substituting ER care for primary care because they don’t want to wait (whether for a good reason or not) – and they get what they ask for: emergency (only) care. Would you say that’s accurate?

Friend: Most patients presenting to ERs with non-emergent complaints (e.g., strep throat) don’t have a primary care provider. In many parts of the country, waits to be seen can extend out to months, which, in the case of strep throat, is not helpful. In that case, many people end up coming to the ER. Their reasons for not "waiting it out" vary. In the strep throat case, they may include unbearable pain, unable to take off work and so wanting a fast-acting therapy, etc. ERs are able to provide a significant degree of primary care to patients. ERs provide patient education through printed materials as well as counseling and referrals. It’s [difficult], as you might imagine. The ER physician is juggling primary care cases, counseling and such, with gun shot wounds, stabbings, heart attacks, eviscerations.

me: Right. It seems natural to me that the not-immediately-life-threatening stuff (i.e., being extra-sure Nancy knows to discuss her STD with her partner) would have to take a backseat sometimes.

Friend: Within ERs, patient education is a redundant system, such that if the physician is unable to provide verbal education due to ER volume surges, the patient still may receive education through printed materials and written follow up plans prepared by the treating physician and then articulated by the discharging nurse.

me: So, would you consider the poor retention by patients a result of patient laziness? ERs not following the system? Something else?

Friend: Something else.

me: Any ideas/theories?

Friend: To address the last question, poor patient understanding with regards to discharge planning is multifactorial, and includes the patient’s ability to interpret verbal and visual information during periods of elevated stress (social psychologists tell us that, in general, the great majority of dialogue after a family member is told of a patient’s death is not remembered immediately after the dialogue occurs) and the patient’s degree of functional literacy (i.e., ability to both read, interpret and assimilate written information). There are other confounders, too. Cultural competency impacts patient understanding, as does rapport. and then there’s the issue of information occasionally not being provided in the first place. Follow up instructions can be very complex. I, myself, have been surprised to find, on multiple occasions, friends of mine having difficulty interpreting discharge instructions despite having advanced degrees.

I, like most everyone, have had Emergency Room experiences and also have some opinions about where an ER fits in the proper administration of healthcare. There are blogs aplenty with rants about wait times,²³ and the Times article isn’t the only one (seemingly) critical of the "system." It was interesting to get an ER physician’s view on things, for once.

¹ Tarkan, Laurie. "E.R. Patients Often Left Confused After Visits." New York Times, 15 September 2008. Accessed September 2008 from http://www.nytimes.com/2008/09/16/health/16emer.html.

² For example: "Man dies after 34-hour wait in ER." HealthZone.ca. 24 September 2008. Accessed September 2008 from http://www.healthzone.ca/health/article/504848.

³ Another example: "ER Death Points to Growing Wait-Time Problem – One more in Dallas." The Medical Quack. Accessed September 2008 from http://ducknetweb.blogspot.com/2008/09/er-death-points-to-growing-wait-time.html.