Finally, an interesting case!
There I sat in the physician enclave of our pediatric emergency room, signing up to see a patient with a history of SVT who had come to our ER with a chief complaint of a “racing heart.” Walking up to the door of her ER room, I could feel my anticipation peaking and that weird excitement we medical nerds get when faced with the prospect of diagnosing and treating a “cool medical case.”
Unfortunately, my joy was quickly stolen away when I learned that she actually has not had any issues for the past two weeks, including today. During our conversation, I learned that she had been experiencing some vague, benign symptoms off and on over the past several months, all of which were completely different from the palpitations she had experienced while in SVT a few years ago. She further detailed the issues she had been experiencing since moving over 1,000 miles away from home and starting a rigorous academic career, now being in the second half of her freshman year of college. She explained that her friend, who had accompanied her (and whose dad is an ER nurse at the hospital) advised her come to the ER to be evaluated.
After my patient interview and completing her exam, I took a seat and explained to the late adolescent what I felt was her most likely diagnosis: anxiety disorder. I counseled her that, given her history of SVT and prior history of anxiety, coupled with her difficulties adapting to a new world ripe with pressures every young adult struggles to successfully navigate, she should seek care and guidance with a therapist, cardiologist, and primary doctor. We went through the usual rigmarole to ensure we excluded any immediate, life threatening disorders, and sent her back to the dorm with scheduled outpatient follow-up at a local clinic in order to see a cardiologist and primary provider. And my deflated, unanimated self slinked back to roll my eyes as I relayed the melodrama about the ED misuser’s encounter with a co-resident.
We’ve all been there. I mean, I knew I made the right choice not to pursue a career in EM a long time ago, but there is nothing like being in the trenches of an adult or pediatric ER as a Med-Peds resident to help remind me of this. The shift work, the politics, the "alternative" approaches to work-ups and therapies … It is just not for me.
One day after a particularly soul-sucking shift in the pediatric emergency room, I found myself wondering if anyone in the community really knew what the word emergency meant! I felt like banging my head against the wall after a parent came in at 4:30 p.m. on a Tuesday because her doctor couldn’t see her child with URI symptoms in clinic that day, so she instead brought him to the ER for him to be evaluated. Meanwhile, her child, whose runny nose and cough could not deter him from playing with every toy on the wall in the patient overflow room, looked well enough to make it to their appointment that had been scheduled for the next day.
Most patients know that a cold, rash, back pain, loose tooth, and intermittent symptoms for the past two months are not reasons to go the ER. And yet, shift after shift on either the adult or pediatric side of an emergency room, I would evaluate people for these and other general complaints. I quickly learned to ask them “what did your Primary Care doctor say when you told them this?” as a way to plant the seed that this visit — with a $50, $100, or even $150 co-pay — was a total waste.
It wasn’t until I went to the literature to find statistics to help back up my outrage about the inappropriate use of the ED that I gained a different perspective to the ED misusers. Over 4 billion dollars are spent on non-emergent ER visits. A review article published a few years ago found a myriad of reasons for misuse of the ER: younger age, referral to the ED by a physician, convenience over a PCP appointment, and flexibility of payment (you don’t have to pay for service prior to being seen). But the most damning conclusion by the authors was that in order to truly make a dent in the inappropriate use of the ER, policymakers, physicians, and payers should individualize their interventions based on the populations they serve. Unnecessary ED visits, like the ones I’ve repeatedly experienced, are usually the result of socioeconomic issues, including patients without established outpatient care relationships and those who don’t have the financial means to seek routine care.
Unfortunately, some payers since the creation of the Deficit Reduction Act of 2005 have sought more disingenuous approaches to changing the way patients misuse the ER. The insurer Anthem, for example, had enacted a policy in Missouri, Kentucky, Georgia, Ohio, New Hampshire, and Indiana via their Medicaid products that denies payment of emergency room visits for diagnoses that are deemed “non-emergent.” And although not all non-emergent visits are denied payment, this and similar policies are a slippery slope for denying patients the ability to access care whenever they determine it to be necessary. It can also deter people with this policy (and similar insurance) not to seek care in a true emergency.
Interestingly, using a conservative definition of avoidable ER visits, a recent evaluation by the International Journal for Quality in Health Care of ER visits from 2005-2011 found that less than 4 percent of visits did not require any diagnostic tests, procedures, or medications and the patients were not observed, transferred, admitted, or deceased as a result/at the time of the visit. These patients were predominately female (52 percent), white (70 percent), and privately insured (33 percent).
Non-urgent, inappropriate, unnecessary. ED misusers are being told that there is no place for them in the ER care system, with anywhere from 10 to 70 percent of ER visits worldwide being retrospectively reviewed as being appropriate for outpatient management, it makes sense that we’d want to deter them. But in places like urban hospitals, smack-dab in the middle of the most at-risk and underserved communities, it seems ridiculous to develop methodologies to deter them from seeking care.
Ultimately, we need to develop a better alternative for triaging and directing patients that incorrectly seek care in the ER. Allowing the current model of care to continue means knowingly allowing patients to receive an inferior quality of care for their back pain, toothache, mental health disorder, etc. A better use of our health care dollars would be to provide targeted patient education, direct routing of these patients into Primary Care clinics, and increase availability to health care providers. The only issue with this solution, is the falling numbers of providers available to serve these communities. And so the downward spiral continues.
With the model for health care constantly evolving, it makes sense that the modes of caring for patients must too be ever changing. With the dawn of telehealth and the rise in mid-level providers, we have an opportunity to make a positive impact on this issue. Rather than penalizing patients for accessing care during avoidable ER visits, let’s find a way to provide them with a better, more appropriate avenue for receiving care. Let’s make patients hate going to the ER just as much as I do.
Dr. Chioma Udemgba is a third-year Med-Peds resident physician currently training at Tulane University in New Orleans, LA. She is passionate about creative writing, graduate medical education, and working with underserved populations.
Dr. Udemgba is a 2018–2019 Doximity Author.
Image by Yayar sentio BH / Shutterstock