By: Camilo Mohar, DO
This opinion is of my own and not of my employer or the institution I work for.
What is the practice of emergency medicine? It depends on who you ask. In my opinion it is the practice of always being available to assess and treat any life or limb threatening illness needing immediate stabilization until definitive care can be provided. It was in this spirit that emergency medicine was born. Prior to the inception of emergency medicine, there was no hospital care late at night, or on holidays to see those with acute trauma, or those experiencing a heart attack.
Emergency medicine however has morphed into more than that, more than acute care. It has transformed into a safety net for patients to access healthcare when outpatient medicine falls short. It may fall short of convenience or it may fall short of providing care for those without means to acquire general care overall. The problem with this model of emergency medicine, whether intentional or not, comes down to two questions: Are EM providers ready to handle non-emergent conditions? What happens when our services are not enough to meet patient expectations?
The Costs of Convenience
Emergency medicine has provided millions of patients a convenient method to access care quickly regardless of the etiology of their illness. It may or may not be an emergent condition but when a patient is losing sleep due the symptoms that they have had for months, they can see a physician at 3am on Sunday morning if they choose to do so at their local ED. Convenience is a very attractive attribute to a service provided but when it comes to medicine, it often comes with a hefty price tag that many patients are often unaware of. Insurance companies are no fans of this price either but someone has to pay to keep the lights on.
People Expect an Answer
A patient presents to the ED at 3am with a several month history of neck swelling. Emergency providers are trained to evaluate patients for possible airway compromise. These exam tests include looking for stridor, tripoding, inability to handle secretions, or muffled speech. What happens when there are no clear-cut signs of an emergent condition? It would take some outside experience and knowledge to have differentials like thyroglossal duct cyst, branchial cleft cyst, thyroid nodule, etc for nonemergent neck masses.
The dilemma with the above given hypothetical patient is what happens when the emergency provider does not know the diagnosis and tries to give reassurances and follow up resources? Many patients feel little reassurance without the lack of diagnosis. Many patients and institutions also frown on the idea of forgoing imaging when there is no emergent condition. Hypothetical patient “Why can’t I get a CT? I know you have one” will often be a question. Not that this question is not a valid one, but again, what happens when emergency medicine does not meet the expectations of the patients we are serving?
Should we use the resources of the emergency department for non-emergent conditions? Many would argue we should as some patients would not have access otherwise. If that is the case, then are we truly practicing emergency medicine or perhaps primary care with emergency medicine characteristics. It is no wonder patients leave the emergency department – although alive and well – unhappy.
Emergency Departments are Abused for their Resources
Many patients lack adequate access to healthcare. This includes the basic primary care that provides preventative screening, vaccinations, and management of chronic conditions, This has clearly affected emergency departments everywhere. Patients know that due to EMTALA they will have access to a provider if they visit an ED. Those of us who choose emergency medicine are more than happy to help as many patients we can, but what happens when resources for those seeking primary care compete with resources for those that need acute care the most?
Let’s go back to the CT scanner example above. It would be unfortunate if a stroke patient had an emergent head CT delayed. This is magnified if it was because another patient with a non-emergent condition was occupying the CT scanner. I’m not being callous towards ED patients with chronic conditions. Emergency Departments are not designed for this purpose. Most of the time, our job as EM providers is to triage patients in the community and provide the most resources to those who need it the most regarding their acute life or limb threatening injury.
ED providers have licenses to order and prescribe. ED providers practice their own specialty, with their own standards and guidelines. We should not practice outside the scope of our practice. The nature of our practice does not prepare us for safe patient follow-up. Follow-up and referrals are a hallmark of good primary care medicine. Patients should not expect us to perform primary care.
The Future of Emergency Medicine?
If emergency medicine continues on this path, I am afraid it will not be very good at providing emergency care or primary care as most hybrid models fall short of either stance. I do not claim to have a solution. However, emergency providers need to stake their claim for the specialty they intended to practice. If we don’t, we will always be expected to give more non-emergent care with fewer resources to help us. These expectations are stemming from both institutions and the patient community at large. This is perhaps one of the many reasons why emergency providers lead in burnout rate, but that is perhaps a discussion for another day.
Maybe – just maybe – there should be a solution for those who do not have access to adequate care, and for those who choose to use the ED for an evaluation. Patients need a clear understanding of why emergency departments exist. They have lost touch with the purpose of their existance. I doubt that this will occur. There is an ever-growing hyperfocus on patient satisfaction, the economics of medical reimbursement, and metrics. Hospitals that support emergency departments are reimbursed based on these metrics. C-suite bonuses and insurance incentives also perpetuate market growth in the ED. These issues will also need to be discussed in a future article. So what is emergency medicine today? It is the ability to offer care at any time, for anybody with any condition, regardless of their ability to pay. Let’s hope they are satisfied when they don’t get the answer they want.
Dr. Mohar is an emergency physician and co-designer of the Provider Practice Essentials Ultrasound Course.