I want to preface this comment by saying I believe that emergency care and emergency departments (EDs) are, in my mind, expected to deal with patients who treat both like an outpatient clinic. The definition of emergency medicine varies amongst people; my emergency might not be your emergency, and vice-versa. And maybe it is because I worked in a rural system, but I also believe that the access to healthcare – or maybe more so, the lack of access to healthcare – creates an environment where the EDs are clinic-ized simply because people either can’t get to a family doctor because of work or transportation issues or don’t have insurance, so they are unable to pay for a physician visit upfront before seeing a doc in his or her office. Either way, it’s really frustrating when people use EMS (emergency medical services) and EDs for routine or maintenance care.
Clichés are clichés for a reason – they are bound in some form of truth, no matter how trifling it is. A clichéd scenario for EMS is the patient who calls 911 and meets the ambulance in the driveway with a packed suitcase. If anyone spends any time in any capacity in which emergency care is the focus of their careers, this patient will surface. There have probably been a half dozen times in my life where this exact kind of patient – both sexes – have used me as a taxi service. Even more frustrating is when there is a patient who becomes a serial abuser. They’re the kind of people whose address never leaves your mind because you have gone there so often that it becomes a joke. But no matter how frustrating it becomes, you have to look beyond the surface of these patients because, hopefully, there is a reason that can be explained out to serial abusers as to why calling 911 isn’t the best option for them, nor is it the best option for the system.
I had a motto while I was in EMS: I don’t want something bad to happen to anyone, but, if it has to happen, it might as well be while I’m working so I have something interesting to do. Professionally, I used to cuss the serial abusers in my mind from the start if I ended up having to pick one of them up when another truck got to do something fun – like respond to a real emergency. Unfortunately, it happens more than some might think. And certainly EMS professionals are the last people to send on a run where the patient needs to get to the hospital because of a bunion or because they’ve ran out of furosemide. We are way too high-strung for that kind of thing. And I myself am completely guilty of lecturing patients about ED/EMS abuse. When emergency patients are pushed back because an ambulance that would be closer to their location is transporting someone who clearly doesn’t need an ambulance, or whom doesn’t need to be an ED walk in because their wrist has been hurting for six weeks and they decided that 10:00 PM on a Sunday was the best time to seek out treatment, those are the moments when I wanted to take these patients to the ED and show them a vent patient with CHF or someone packaged on a backboard whose best friend was killed in the same accident not more than an hour before. But I didn’t, because that is the nature of the beast, and it is one hell of a strong beast to have to contend with. This relationship is further complicated when patient’s fail to establish a primary care physician. There is no continuity of care when an emergency department physician is used for health maintenance. Because of this lack of continuity, the serial abusers might solicit EDs more often than those whom have a primary care doc because the role of the ED physician is grounded in the here and not, not in the idea that six months from now, the serial abuser’s care needs might shift dramatically.
Have we arrived at a time when patients who present to the ED for ailments that can be treated by primary care doctors should be turned away if they don’t meet a specific level of acuity? Primary care has having three foci, and this foci is what differentiates primary care from secondary or tertiary care: duration, frequency, and level of intensity. Primary care physicians may have the same patient pools for years and years. This is especially true of primary care physicians who set up office in a rural setting. It is possible that a primary care doc could see the same patient for upwards of thirty or forty years, specifically if neither the patient nor the doc ever plans on leaving the area both live and work. There is also the possibility that a primary doc can see multiple generations of the same family, again especially in a rural setting. And although specialty doctors can have long relationships with the patients – especially in fields like cardiology or pulmonology – where life-long maintenance is required for positive health outcomes, the frequency in which the specialty doctors and their patients see one another is a fraction of the time primary care physicians see their clientele. Primary doctors treat a host of condition within the spectrum of their practices, and the more care that can be executed by the primary care provider, the greater the frequency is going to be for when they see their patients. As for intensity, primary care providers are expected to provide patient education, maintenance of long-term health plans, the evolution of the patient through their lifespan and the trajectory of diseases over the course of as lifetime. This is unrivaled in any other arena of medicine.
And this is a testament of sorts as to the importance of primary care physicians as the “gatekeepers” or conduit of specialty care referrals. In a well-executed system, the primary care physician knows his or her patient like no one else. It’s this level of both intensity and intimacy that helps the primary care physician match their patients with the right kind of specialty care. Good primary care physicians know when the acuity and needs of their patients become too high for their level of practice. A good gatekeeping physician allows the patient to know when he is surpassing the scope of primary care practice. Once the scope of practiced has been reached, gatekeeping primary care docs help their patients make good decisions as to who and where the next step in the patient’s overall care needs to be focused.
uoflbioethics 