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'Inappropriate Use of the ER': An Emergency Physician's Flirtation With the ER

Policymakers should be aware that even well-informed patients with good access to primary care need the ER. Legislation should aim to increase availability of primary care, but not penalize for use of emergency services.
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How often do you hear stories about the "bad" reasons patients have for using E.R.? "Back pain for three months? Headache for a year? Why are they here now?" As an emergency physician, I've certainly heard these stories. Providers and patients alike voice their discontent. "Can't they see it's not a real emergency? This must be costing our health-care system a fortune!"

A couple of months ago, something happened that made me question this so-called "inappropriate use of the ER." Let me tell you about a generally healthy young woman who came back from her shift at the Brigham and Women's ER feeling a bit under the weather. She was a little nauseous, but was able to eat the Chinese takeout dinner that her husband brought back. Right after dinner, she went to bed, but couldn't sleep because she developed a gnawing abdominal pain. Then, she began throwing up, and kept vomiting at least 10 times in the next hour.

Being a physician, she came up with a "differential diagnosis" -- a list of the possible conditions that could explain her symptoms. This was most likely stomach flu: a simple viral illness. However, stomach flu generally involves diarrhea, which she didn't have, and she really didn't have other viral symptoms. It could be bad food, but her husband ate the same thing (and she, being Chinese, was sick of Chinese food always being blamed as the culprit). Any woman could be pregnant, and though the suddenness of her symptoms made that less likely, an ectopic pregnancy was theoretically possible.

So she set about to self-diagnose and self-treat. She sent her husband to the local 24-hour CVS to buy a pregnancy test and to pick up a nausea medication that she prescribed herself. The test was negative and the medication made her vomiting stop, but as the morning came, her abdominal pain was still there. In fact, it was now localized more to the right lower side, and it hurt her to walk.

By now you're probably thinking to yourself whether you would have bitten the bullet and gone to the ER to make sure you didn't have appendicitis. Well, this young woman was me, and I was trying to avoid checking in as a patient, getting the radiation from a CT scan, and burdening our overtaxed health-care system. Fortunately, I was able to call and find out the ER attending that day was an ultrasound specialist. She did me a favor to ultrasound me, and found that my appendix looked fine, but my intestines looked inflamed -- consistent with stomach flu. I got my diagnosis, and over the next few days, I recovered with no radiation and my appendix intact.

Had someone like me actually checked in as a patient, I could see how there might be grumbling from the providers. "A young woman with stomach flu who's actually getting better -- why is she here?" Or, "If she doesn't want a CT, why did she come to the ER?"

What I learned from this experience is that it's always easy to say in retrospect that the patient didn't have to come to the ER. In the moment, when the patient is scared and in pain, it's not so clear. Even as an emergency physician myself, I couldn't tell if what I had was something benign that would go away on its own (stomach flu), or a life-threatening process that required urgent intervention (appendicitis). How can we expect our patients to know whether their chest pain is the same angina as usual, or a heart attack, or whether their swollen ankle is a sprain or fracture?

My flirtation with the ER has made me more sympathetic to our patients who come in with seemingly "non-emergency" complaints. It also has me thinking on the larger scale about proposed policies that impose penalties to our patients for using the ER. Don't get me wrong; there is a need for more primary-care doctors, and our patients will benefit from increased access to primary care. However, patients can't always know whether they have primary-care versus emergency complaints. So I turned out to have stomach flu, something a primary care doctor can address. But had I been a "normal" patient, I wouldn't have been able to treat my own symptoms and then walk into get a favor from a specialist physician -- surely, I would have had to check into the ER to be seen. Would it have been fair to penalize me for that ER visit when it turned out that I had a less-than-emergent illness?

Policymakers should be aware that even well-informed patients with good access to primary care need the ER. Legislation should aim to increase availability of primary care, but not penalize for use of emergency services. For our part, we as emergency physicians should continue to embrace our duty at the front lines of medical care, diagnosing and treating every patient who comes to us in their time of need.

For more by Leana Wen, M.D., click here.

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