Nicely: “Get Out Of My ER!”
A call to all the ER docs out there: how do you tactfully, non-insultingly tell patients who come in with minor complaints, “You’re fine, go home, this is not an emergency, you should not come to an ER for a problem like this?” (For example, kid with a cold and low grade temp who is otherwise playful, active, eating and drinking well, with good sats, etc.)
“Hey, good news! I talked about your case with the attending, we reviewed your story and physical exam findings, and we both agree that you don’t need any blood tests drawn, or a trip down to the radiology department for some xrays. In fact, what you’ve got will almost certainly get better on its own, though here are the warning signs to watch out for…”
Then later (or earlier) you can mention, “You know, we triage patients so that complaints like yours today aren’t seen as fast as the life-or-death cases. You might save time, and get seen faster, in a primary care clinic. What? You don’t have insurance? You can still be seen in the resident clinic… And as you build up a relationship with these clinic doctors, they can give you more information on your condition, do routine testing to nip new problems in the bud… it really saves time and peace of mind, in the long run…”
This won’t please everyone (especially in Manhattan, where no patient likes to think they overestimated an “emergency.”) Some people feel entitled to testing because they waited forever. Some patients want a medical-sounding diagnosis for every ache or sniffle.
I tell them I see emergencies all the time, I love them, I go out of my way to look for them, but hey, it’s good news that I don’t think they’re crashing, they should be happy and reassured. And while it’d be great to pin a diagnosis on every little thing, I’m not a rheumo-neuro-psychiatrist… my job is to find emergencies, and yours isn’t one. Go celebrate.
Here’s what you say:
“You’re fine, go home, this is not an emergency, you should not come to an ER for a problem like this.”
That’s plenty tactful and non-insulting.
best,
Flea
I might add: “your kid has a cold, which will get better by itself. But by coming to the ER, you’ve exposed your kid to the people who are coming in with pneumonia. You can do more harm than good, bringing a kid in here with something that isn’t serious”
That’s why NSW (Australia) Emergency Departments changed their names a few years back. Used to be called Accident and Emergency.
Many many things can be classified as an accident.
It’s not so much of a problem here (although it does happen to some extent) because all citizens and permanent residents and people from countries that we have a reciprocal health care agreement with can have free consultations under Medicare.
Where this doesn’t work so well is areas with not many bulk billing doctors, areas with not many doctors full stop and after business hours.
Something that’s starting to be phased in is 24 hour GP (general practice) clinics attached to hospitals. “Your child’s runny nose is not an emergency. Go to the GP clinic next door and they will tell you that he doesn’t need antibiotics because it’s a virus”.
Who pays for ED consultations in the US? And who owns the hospitals? Do all hospitals with EDs have the same arrangements?
I’m a nervous parent, and though I’ve never taken my son to the ER for a minor cold, I’ve certainly thought about it a lot–especially if it’s the weekend and my pediatrician’s office is closed and there’s really no other way for me to get someone with actual medical training to see my son.
Food for thought: your average parent doesn’t know what a “good sat” is.
“Beat it, before I tro’ you a beatin’”
Influenza kills 36,000 Americans every year, mostly the very young and the very old. We have had half a dozen kids in Houston die this year from influenza already in the last month. Influenza is treatable, but the treatment is most effective if started within 12-24 hours of onset of the fever.
So at least this time of year, it’s inappropriate to tell nervous parents not to come to the ER for a fever. And other times of year, they don’t care anyway. Medicaid = no copay, so they will come any damn time they want, as often as they want.
“Sir/Madam, I regret to inform you that regrettably, your son/daughter’s case is beyond our ability to treat; the only thing we can do is wait and see. Check with the clinic down the street next week, they’re better equipped to handle this specific problem.”
There. You’ve made them think their kid is, indeed, a victim of some serious monkey business, AND you’ve given the sods down the street another nut. What’s not to like?
Start with a compliment of some sort to diminish anxiety and prepare the way for education.
“That was wise of you to notice that she still plays and eats well”. “Next time, You’ll be aware that those are signs of a simple virus that will run it’s course without treatment.”
“Do bring her in if she develops no saliva, dark circles under her eyes, or dry lips.”
You don’t. At least, you don’t if you want to avoid excessive complaints and keep your job. Every patient you tell this to is going to feel invalidated and humiliated. A certain fraction (relatively high) will call the hospital to complain. Your medical director will get a phone call from the hospital administrator, and will have to apologize for your behavior. Then he will call you and let him know how unhappy he is that he had to apologize on your behalf, and that you should just stop being a dick and knock it off. And the next time he gets the same complaint you are going to have to come in to his office to talk about it.
And that’s just not good for your career.
And every once in a while, you’re going to be wrong. and the patient will get worse, and maybe die. Then, my friend, you are fucked. Open wallet and start paying. Prepare your profound mea culpas for the hospital Quality committee. Clear your schedule for some mandatory re-education. Also not good.
HOWEVER, in certain highly selected cases, it is acceptable to say, in a tone dripping with contempt and scorn: “Uh-huh. And you came to the *Emergency room* for *this*?” It’s not tactful, but gets the point across. I’m reminded of the guy who called 911 for a stye…
Then there are the parents who send an angry letter to the editor of the local newspaper because their feverish child was not tested for influenza at the ED.
True story, although I have it on good authority that the paper declined to publish the letter.
I don’t know that there’s any good way of telling people they don’t need to be in the ED. Most people think it applies to everyone except themselves.
As a parent of a sick child (hypoplastic left heart syndrome) I will do all that I can to NOT take him to the ER. If we have to go and I mean have to then we are to inform them immediately on arriving that he is a heart patient and to contact cardiology. We then go sit in the main lobby – away from all the hacking and coughing.
We do get bumped up in line because of his condition, but other people with sick kids are waiting behind the “my child has a cold”. Are there not minor emergency clinics to take them to? I go there, but again my son can’t go there.