To Go to the Emergency Room—or Not

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I have never, ever seen an emergency room doc, myself included, try to gouge a patient or their family. While I have been fortunate to never personally made the tragic mistake of missing a fatal diagnosis, I know that many a doc has made an accidental, terrible mistake by trying to save money for a patient. The times that I have myself tried to save money for a patient by considering not doing a test, I have ended up with sleepless nights terrified that I made a bad decision that might have cost someone their life. I don't think people realize how very seriously we take our responsibility to save your life. The first thing we are taught to do as med students in emergency medicine, when we first walk into the exam room and see the patient for the first time, is to ask ourselves "what might be wrong with this patient that could kill them?" That is a very heavy responsibility! Only after I have made certain - or as certain as I reasonably can be - that you, my patient, isn't about to die - do I then ask the question: "OK, what's making them ill and how can I help?"
Now, if you are going to also require me to constantly also ask myself: "how can I save you money by not doing a test that is absolutely indicated?", then sooner or later you will die - or your daughter will die - because the right diagnosis, based on the right test, was not made in time. So, to the woman who accuses ER docs of gouging her, how much is the life of her daughter worth to her? Would she sell her daughter for $6,000? Would she refuse life-saving surgery if it cost $6,001? There is no doctor on earth who can be certain whether a teenage girl has an appendix about to burst just by feeling her belly. An x-ray won't tell you. An ultrasound will be wrong more than half the time. A CT-scan will be wrong occasionally, but they're pretty good at catching almost all of the appendixes that are close to bursting.
In the old days, before we had CT, there was a saying in surgery: "If a surgeon doesn't take out at least 20% of perfectly good appendixes, he's not doing his job"
I do wish people didn't have to pay for these expensive tests - I think medical care should be a basic human right, myself - but the way it is right now, procedures and tests have to be paid for, and there's no good way to try to cut the costs of testing without killing patients by missing life-threatening diagnoses.

DrK27 of OK 10:41PM April 02, 2010

I went to the er last year and they told me I had gallstones but couldnt do anything as of now because I have no insurance.They said to stick to a low fat diet .The only way they will take them out is if I come in the er and am in so much pain.It might be too late by then. I have alot of pain if I eat certain foods.I have lost about 40 lbs and not even on a diet.So meanwhile I just sit and wait to have and attack?? I am tired of feeling sick. So I guess I am stcuk with this situation and cant do anything about it. What a world we live in. Makes me sad...

kathi of NC 11:00PM March 04, 2009

In June our child complained of a pain in his lower right side. When it comes to children, parents don't take the same chances as they might with themselves and of course, it being a Saturday, we brought him into the emergency room.
There, doctors refused to answer the question: Is it his appendix until...sonogram, catscan, on and on to the tune of $6700.00. (Actually, he never saw an MD) Doctors can spew any version of homespun we care about you baloney, but this sort of overkill is obscene and exploitive. And what does it promote? Next time should we wait and see because every available test is going to be run before a doctor can determine it is an appendix or not? Maybe so but doctors should not have it both ways first supporting preventive steps eg checking out a pain before there is a life threatening event and then price-gouging for such preventive steps.
I even have a text message telling my husband to stop the defensive medicine but of course, no opinion would be given until the $6700.00 worth of tests were given. Doctors should take some responsibility in emergency rooms for doing what they're asked to do: Is this an emergency eg is it appendix? If the answer is no, tell people to have other things checked out, don't run the gamut of expensive tests just to gouge consumers because you can

conoutofconsumer of NC 10:38AM July 20, 2008

Having worked for over 21 years in a variety of emergency rooms it has become crystal clear that the CDC figures that 1 of 8 emergency room visits is not an emergency is probably accurate. BUT the statement that 50% of Emergency Room visits could be handled at urgent care centers is erroneous. m I hve personally diagnosed brain tumors that have presented as severe headaches, treated"a cold" that turned out to be congestive heart failure, had a patient say , "I'm here because my wife made me come in just because I had ingestion last night, I feel fine now." that last patient experienced a cardiac arrest five minutes later. It was gratifying to be able to shock him back to life and send him to the cath lab to open his coronary artery just 15 minutes later. You see, most ED's strive to have expert experienced emergency physicians, and despite a severe shortage, residency trained board certified emergency physicians available 24/7/365 to recognize , treat and when necessary guide a patient for further care. Emergency departments are a safety net for this country. We see all who need our services to relieve severe pain, efficiently diagnose a host of medical problems, expertly perform procedures that would cause an urgent care center to quiver: rapid sequence intubation, lumbar puncture, removal of foreign bodies, ultrasound at the bedside to find the aortic aneurysm and the gall bladder that is a sack of stones, reduction of dislocations, plastic repair of lacerations, unexpected delivery of babies, chest tubes for collapsed lungs, trauma care, direction of ambulances, and yes a little electricity for the heart that seems to have given up. we are the only resource for the psychiatric emergency 24/7, and yes they are true emergencies deserving of care that leads to a fruitful life. Urgent care centers and retail clinics can help to unburden a family practice for very specific injuries and illness of ery limited scope and can be very useful for those issues. The emergency room , for 120 million patients per year is the medical home away form home and the home where the light is always left on when acute pain, illness and injury strike us.

Alex Rosenau, DO FACEP, FACOEP of PA 10:02PM June 30, 2008

So far my colleagues have clearly explained why urgent care centers are not ED's, and while I agree that some patients may be able to be properly treated in an urgent care type clinic. the majority truly deserve to be there. According to the CDC Advance Data No. 386 June 29, 2007, less than 14% of cases presenting to emergency departments are truly non-urgent. So it seems to me that we are as much a part of the fabric of care that is truly concerned for the safety and well being of the American people as our dedicated Fire and Police services are, and as a Physician I would love to have everyone stay healthy and not need us, BUT the reality is, that when something does happen we are the only ones available 24/7/365 and the only ones that PROMISE to be there for everyone, no matter who they are or what their ailment is. So I guess I would invite Ms. Andrews to come work with me anytime and really see what goes on. We never turn off the lights and lock the doors, and for 115 million Americans per year, that truth is a little comforting.

Kathleen Cowling of MI 8:33PM June 30, 2008

Once again, it is unfortunate that people tend to confuse urgent care with inappropriate care that doesn't somehow belong in the ED. One third of my patients are children and I would argue that ANY parent who brings their child to the ED for evaluation is doing the right thing for their child. I have seen many a child with a cough have pnuemonia and a vomiting child become dehydrated. While most children are sent home from the ED, it is only after a thorough evaluation often with laceration repair, fracture treatment, or blood and urine testing. Even the best parents are unable to discern what constitutes a true emergency and with any child there is no room for error. Next time your child has a fever in the middle of the night, just pray that it's just an ear infection and not meningitis and choose wisely where you go for evaluation.

Ramon Johnson, M.D. of CA 5:58PM June 30, 2008

It has been shown by numerous studies that only 15% of ER visits are not urgent and do not need to be seen in the ER. This is a far cry from the statement that
" more than half" could be handled in an urgent care center. Most people cannot also differentiate between those that do need to be seen in an urgent care center and the ER except the most simple of complaints as noted in the article.

Bruce Bonanno, MD of 11:31AM June 30, 2008

As an emergency physician at a major trauma center I really appreciated the story "To go to the Emergency Room- or not," but need to correct one thing. According to government statistics, only 15% of ER visits are non-urgent and could be taken care of in another care setting, such as a clinic. There is no way that half of my patients, or the patients at any other hospital that I am aware of, could be taken care of in an urgent care clinic. People in the ER are way too sick for that.
Dallas emergency physician

Robert Suter, DO,MHA of TX 7:55PM June 29, 2008

Great article except for the statement about the % of cases that can be handled in urgent care centers. One of the toughest jobs in emergency care is figuring out who has a real emergency. Heart burn doesn't need to be treated in an ER, but a heart attack does. The only problem is that both can feel the same - until its too late. Urgent care centers (and better yet, timely primary care if you can get it) is fine for really minor stuff. But its a lot less than half of all vists to ERs today.
And by the way, the main problem that is causing ER crowding is not minor patients waiting to be seen. It is the sickest of the sick - patients the ER docs have already seen and stabilized, that aren't being moved upstairs to an inpatient bed in a timely way. When these patients backup in the ER, they delay care for everyone else, and cause dangerous ER crowding.

Art Kellermann MD of 4:11PM June 29, 2008

Until Congress and almost every state passed laws requiring insurers to pay for care when a patient came to an emergency department, many patients with life-threatening emergencies wouldn't come for fear of being stuck with a bill.
The supposedly non-emergent conditions outlined above, like a sore throat without fever, can indeed be life threatening emergencies as Dr. Bishop states. The question is, how can the average non-medical person tell? The answer is, they probably can't much of the time. And urgent care centers aren't open during nights/weekend/holidays and other inconvenient times when true emergency strikes.
Despite the fears of insurers when these laws passed that patients with nonurgent conditiions would flood emergency departments, it just didn't happen. That's why the unsubstatiated statement "it's estimated that more than half of visits to emergency rooms could be handled at an urgent care center" rings hollow. There have been multiple studies of this by many levels of the federal and state governments, and most conclude that only a small percentage of emergency department visits could be seen elsewhere.
Let's not have people with "indigestion" not go to the emergency department for fear the insurer won't pay. That "indigestion" might well be a heart attack.

Steve Epstein of MA 10:18AM June 29, 2008