The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Thursday, December 07, 2006


A model for change, or a dangerous precedent?

An Emergency Department in Florida has come up with an interesting way to curtail inappropriate use of the emergency: fees for non-emergent presentations. Remembering all of the times I had to bite my tongue to prevent myself from asking a patient "and what about your 3 month history of intermittent loose stools did you think constituted an EMERGENCY?", I have to applaud these kinds of initiatives. But I've also come to learn something important in practicing family medicine-- not everyone has the knowledge to differentiate the dangerous illnesses from the ones that are simply inconvenient.

Looking at it from the patient's point of view, it's a different story. Particularly things like abdominal pain, headache, bleeding of any kind... when all you can think of is the worst-case scenario, it's easy to get carried away. What if that headache is a brain aneurysm? And it bursts and kills me instantly because I didn't get it looked at immediately? What if my abdominal pain is a giant tumor, eating away at my insides? And a simple pill would have cured me completely, if only I had been seen in the emergency department?

Exaggerated, sure, but not by much. I've seen some crazy cases of ER abuse. Among my favorites: One frequent flier came in one afternoon with the chief complaint... "hungry". Apparently she became accustomed to the hospital meals that were passed around emerg to the patients. So when she got hungry, she came in. By ambulance, no less. Another favorite anecdote is the story of a healthy 32-year-old guy who came in with an interesting story-- apparently he had started a weightlifting program 2 months previous and wanted to see a doctor because his left tricep wasn't getting any bigger. I couldn't make this shit up if I tried.

But just when I had it bad, my husband started working shifts as a paramedic. Damn-- if I thought some of the stuff in the ER was an abuse of the system, I was shocked to hear about some of the calls that we don't see. The staff docs I've worked with assure me that you eventually become immune to it. We'll see.

Apparently, people are supposed to get charged for inappropriate use of an ambulance. In Ontario, people are charged for any use of an ambulance (I think it's about $100) but misuse of an ambulance is supposed to be charged about $350. I say 'supposed to' because it's just a rumour I've heard from a few paramedics. Apparently, there's some form that the emerg doc is supposed to fill out if the problem is clearly not emergent and they'll be charged the higher fee. Problem #1 with this situation is that no emerg doc I've ever spoken to has heard of this alleged form, let alone filled one out. Problem #2 is the fact that no one forces these people to cough up the money, whether it's $100 or $350. So more often than not, the bills go unpaid and the abuse of the system continues.

Although I think that this Florida hospital has the right idea, I fear that the fees charged would wind up in the same place that our 'ambulance fees' do... and nothing will ever change.

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8 Comments:

Blogger Flea said...

Let there be no mistake: EMTALA has been an unmitigated disaster - an object lesson in the law of unintended consequences.

Please go back and read and understand what these Florida hospitals are doing: they are not refusing to see anybody. They are performing triage, which is what ED's do.

If a patient isn't emergently ill, he is triaged elsewhere. Does anybody have a problem with this?

best,

Flea

5:29 AM

 
Blogger Couz said...

I did read the article-- if your triage category is non-emergent (we use different categories in Canada-- here, they'd be category 5) they're told to seek care elsewhere or pay and extra $100. That, at least here, is different from the way it works now. I don't know what EMTALA is, but if you're referring to this article... how has it been a disaster? It actually doesn't seem that it would have the power to change things all that much.

But as I said, more often than not patients have no idea if their problem is emergent. They don't have the knowledge doctors do to differentiate benign abdo pain from acute abdomen, or benign headache from something more sinister. So while I understand the intention, I don't think this would ultimately make a difference.

7:00 AM

 
Blogger Xavier Emmanuelle said...

Don't you ever worry though that people will come in and genuinely believe that their health problem is an emergency (i.e. they have severe indigestion and mistake this for the signs of an MI) and that they will still be charged the fee for misuse?

8:51 AM

 
Blogger Couz said...

Nah-- they're triaged based on their complaint, not their eventual diagnosis. So the case you bring up would be triaged as 'chest pain'. Even if it DOES end up being nothing, they wouldn't be charged.

A triage category of 5 is stuff like 'requesting prescription refill' or 'requires doctors note'.

9:15 AM

 
Blogger GUYK said...

Florida emergency rooms are crowded mostly because of people with minor illness who know they can go to an emergency room and get seen and never have to pay the bill..and of course thousands of illegal immigrants who use the emergency rooms as family doctors.

2:31 PM

 
Blogger Medstudentgod said...

This sounds like a rather smart step towards trending people AWAY from the ED unless they actually have, you know, an *emergency*. I saw nurses and doctors so disconnected that patients were treated as though they were faking and drug seeking during my ER rotation. I also saw people come in for stuffy noses, ear aches, and colds. The abuse is absurd and it needs to be stopped. I applaud this hospital's ingenuity.

6:25 PM

 
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4:21 PM

 
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6:05 PM

 

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