American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, February 13, 2014

True emergencies

“Hi. This is doctor Rob, and you have reached my blog. If you are here to read my blog, then continue to do so. If this is an emergency, please call 911 or go immediately to emergiblog.”

That is one of my pet-peeves. Every single doctor’s office I call I am told the same thing: “If this is a true emergency, please hang up and dial 911.” I even got that message when I called the ER.

When I called the OR, though, the message was different: “If this is a true surgery, please hang up and call the operator.”

Not really.

Clearly, the message is put on every office phone system to cover their collective tuchuses (is the plural of “tuchus” tuchuses or tuchi?) They are protecting these sacred parts from when a patient having a stroke sits and listens to the 21 options (“as the options have changed”) and then listens to 20 minutes of 60s classics lovingly interpreted by Kenny G. Scientific evidence shows that after listening to muzak for long enough, even people without an emergency will eventually hang up and dial 911.

But I don’t put that warning on my phone system (and have opted for folk music instead of Kenny G). It’s not because my patients are smarter (although they clearly are), nor is it because I don’t value my tuchus. I wouldn’t mind getting rid of a little of it, but overall I value that part of my body. The reason I don’t put the “moron repellant” message on my service is because we answer the phone. If we cannot answer immediately we try to answer as quickly as possible. We are also available to our patients via messaging, email, or whatever other means they want to reach us.

When you think about it, a lot of patients aren’t really sure they have a true emergency and are calling to get advice about whether or not they should call 911, make an appointment, or just take some Tylenol. To make this decision, the patient has to run the gauntlet of the typical medical office’s “doctor protection plan:”
1. The patient calls, and listens to all 21 options (as the menu items have changed).
2. Listens to Kenny G (in the South, it’s sometimes Travis Tritt) for an indeterminate amount of time.
3. Speaks to a front desk person who is assigned to phones (usually a newer staff person who is not clinically trained).
4. Either is offered an appointment for some time in the next few weeks, get transferred to the nurse (or her voicemail), or be told to go to the ER (if it’s a true emergency).
5. If lucky enough to talk to a nurse, the nurse will give the same 3 options.
6. See the doctor when the next appointment is open (after 2 hours in the waiting room).

But what if it’s a “true emergency” and the patient takes option 6? Then the “moron repellant” message about 911 protects the doctor from the patient’s bad decision, a decision based on not knowing when something is worth worrying about and what is not.

The keys to good care are:
1. Care that is accessible
2. Care that is based on accurate information.

Our health care system puts a huge wall between doctor and patients, a wall made of inane messages, voicemail, Kenny G, front desk staff and clinical staff. Doctors are reluctant to speak to patients about their problems because they are too busy seeing people in the office, and because they are not interested in giving away care for free. We physicians force people to come to the office because it is the only business model that works. While the primary care physician has the most information about the patient, they are not accessible.

So people then go to the ER (or prompt care) because the incredible frustration they feel dealing with most doctors’ offices. Yet while the ER is more accessible, it is not based by good information about the patient. The doctor has to get to know the person’s medical history quickly, assess whether or not this constitutes a “true emergency” (requires hospitalization), take care of those with “true emergencies,” and giving a temporary solution to those who don’t qualify, with instructions to follow up with their primary care provider.

This obviously poisons people’s trust in the medical system, as nobody offers care that is accessible and informed. Nobody can answer the patient who wants to know if they have a “true emergency,” yet isn’t that one of the most critical questions to answer? Isn’t that the key to reducing unnecessary emergency visits? Isn’t that (as was the case twice this week in my office) the way to keep patients with “true emergencies” from sitting at home wondering and actually getting the care they need? Avoiding unnecessary treatment and getting necessary treatment promptly are 2 keys to reducing the cost of care.

We are far too quick to blame patients for their bad decisions. The system forces patients to assess themselves as to whether their conditions constitutes a “true emergency” before they get a chance to talk to anyone. Patients use the ER unnecessarily because it’s a pain in the tuchus to deal with their primary care provider, and when they actually sit in front of their actual doctor, that doctor is tired, getting their tuchus whipped by CPT codes, ICD codes, and meaningful use criteria.

Do I have to say it? There is a better way. Just ask my patients. Their tuchuses feel just fine. They don’t have to listen to the “moron repellant” message every time they call (or Kenny G), and actually get my help in deciding if they should call 911. I know them, they know me, and they have access to me when they need me.

It’s a novel concept that my patients have to adjust to: I want to talk to them. I want them to call me. My door is open.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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