We’ll Get to You When We Can…

The word is that more patients are tired of waiting in increasingly crowded ER lobbies, and are leaving Against Medical Advice (AMA) in greater numbers.  Kaiser Health News is reporting a 57% increase in patients leaving AMA in the past 7 years from California ER’s.  One physician observed, “Most patients are sick but not critically ill,” which is an important point.  The article later explained that, “Compared with all ER patients, those leaving against medical advice were more likely to be men; people ages 20 to 39; and uninsured or on Medi-Cal, the government insurance program for the poor, state figures show. They were also more likely to complain primarily of non-specific symptoms such as chest pain or a cough.”  Which tells me they were less likely to be suffering an actual emergency, and were less likely to be concerned with the bill.   

Think that sounds harsh?  Wait-times in ER’s are increasing nationwide, with no stop in sight.  Per Kaiser, the waits are longest in the dense population states of California and the Atlantic Northeast.  In multiple, less populated small-town ER’s in Florida and Alabama, we have seen the same trends.  When a patient leaves AMA, the hospital corporations, administrators, and government auditors don’t care whether he was a frequent flier checking in for a sniffly nose or fishing for happy pills.  The general attitude is that the ED staff needs to prove that they were not negligent, while running between beds, dealing with demonstrative family members, or electronically charting inane mounds of pointless info mandated by those same corporations and government officials.  Quite a lot of patients who drive themselves to the ER are having serious, even life-threatening emergencies; and quite a lot how call EMS services also stretched thin, are having no emergency at all.  It is commonplace in ER’s everywhere for a mother and several children, all on Medicaid, to check themselves in for colds, simply because she didn’t feel like waiting an additional day to see their assigned PCP.  It takes a while for the triage nurse to fill out five different charts. When a family member wants a demented, chronically bedridden, elderly loved one “checked out” for weakness, they get the full workup because…among other reasons, lawyers.  I’m NOT saying they shouldn’t get evaluation or care, but the intensity and duration of that evaluation is often far greater than clinically necessary, which backs everyone else up.  And it is often the case that those who complain the loudest, and most often about waiting have the least emergent complaints, until they claim “shortness of breath” or “chest pain” to jump the line.  

Emergency department staffs are hamstrung by increasing numbers, tightening hospital budgets, punitive and stupid EMTALA requirements, unrealistic patient expectations, and the ever-present fear of malpractice lawsuits.  And throughout all of that, we actually want to do a great job and give the best care to those truly sick and hurt.  Beaten down as in other areas of medicine, ED physicians have a hard time standing up for themselves.  

“When someone requests to leave,” said one physician in the article, “it needs to be a priority that ranks just below a cardiac arrest.”

Wrong.  That patient is choosing to change their own status to non-emergent.  In a sane world that respected health care professionals, that choice would be respected, and no one else held accountable for the results.  But we don’t live in that world, and so will continue to get the blame for a situation over which we have no control.

Pat Conrad MD

Pat Conrad is a full-time rural ER doc on the Florida Gulf Coast. After serving as a carrier naval flight officer, he graduated from the University of Florida College of Medicine, and the Tallahassee Family Medicine residency program. His commentary has appeared in Medical Economics and at AuthenticMedicine.com . Conrad’s work stresses individual freedom and autonomy as the crucial foundation for medical excellence, is wary of all collective solutions, and recognizes that the vast majority of poisonous snakebites are concurrent with alcohol consumption. 

  4 comments for “We’ll Get to You When We Can…

  1. RSW
    June 4, 2019 at 8:28 am

    “When someone requests to leave,” said one physician in the article, “it needs to be a priority that ranks just below a cardiac arrest.”

    If a practicing physician actually said that, there is no hope for our profession.

  2. NN
    June 4, 2019 at 7:27 am

    Amen to this commentary. I absolutely love my specialty of emergency medicine. But I had to stop over a year ago after nearly 23 years. For many of the reasons you mentioned. I worked primarily rural my last 10-11 years of practice. Single coverage hospitals, in which the ED doc is responsible for covering all emergencies in the hospital overnight, should be illegal. We are still bound by EMTALA, patients leaving AMA, etc. and while managing patients in the ED, also be responsible for hospitalized patients. Too much liability without any support from our institutions. I was tired of being left to fend for myself and the patients. If I used a PA/NP, I was responsible for supervising while I could barely keep my head above water. RNs were overworked and woefully underpaid doing triage, bedside nursing and housekeeping duties. Add to that the dreaded EHR which allows the hospital and shareholders to continue to bill and make money but doesn’t do jack for quality of care…it just became too much. Can’t work in that type of toxic environment anymore.

    The next ED in which I work will be in another country which places value above volume.

  3. Dave
    June 3, 2019 at 5:41 pm

    We (emergency medicine as a collective) asked for EMTALA, with good intentions. However, it’s taken on a life of it’s own with consequences that were never intended. There are severe consequences for even incidental or unintentional violations. “Failure to provide an appropriate medical screening exam” as a launching point for an EMTALA charge has turned into yet another one of the malpractice scumbags tools, and unfortunately, that can be stretched out to include the person who signed in and then ELOPED from the ED. This is NOT, by the way AMA — AMA requires that there is INFORMED medical decision making, implying that a doctor has advised them of the risks of not remaining to evaluate their complaint. So even if a person who you were never aware of, never saw, never even looked at their chart shows up and leaves, and then has a bad outcome….look out EMTALA.
    Not to mention that ED docs are now defacto government employees (we HAVE TO see anyone who presents regardless, at pain of Federal prosecution), yet enjoy none of the benefits that are afforded to even postal workers.

  4. Thomas David Guastavino
    June 3, 2019 at 7:21 am

    The ER-The busiest place on a the planet where no one wants to be.

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