Tuesday, September 16, 2008

Fully Informed Patient

The New York Times has an article explaining how patients, once they've left the emergency department, are often confused about their conditions and recommended routine follow-ups. Patients' understanding of their illnesses and how to properly maintain and monitor their medications and health status are essential. However, I believe it is a mistake to insist that such knowledge derive from ER staff. In fact, the more we do to enhance this idea that a fully-informed patient should walk out the ED, the more we re-enforce misuse of the emergency department, which can have dangerous repercussions on overall patient morbidity and mortality.

The emergency room should be primarily used for emergencies, rather than health maintenance, and should NEVER serve as the patient's final stop in the body-fixin' assembly line. At an urgent setting, patients should be stabilized and cleared from any immediate threat to their health. Ideally, they should also know what to do when they return home. However, within the very same week, if not the next day, patients should follow up with a visit to the INTERNIST or FAMILY DOCTOR (there are many free clinics in L.A. where patients can see primary care physicians). There, patients can and should inquire more about their condition and general health, to achieve all of the information that they need to maintain control over their day-to-day well-being.

What people must understand is that there are trade-offs to everything. In medical wonderland of the future, people will leave from every medical situation fully informed. I, for one, subscribe to the old-school style of doctoring of partnering with the patient, in which it usually takes no less than an hour to discuss her medical conditions. Talking with patients is one of the reasons why I'm still committed to this messed-up profession.

However, it is impossible for an ER to provide the patient with the information he needs. Attempting to do so might give the patient a false sense that he requires no follow-up with a general practitioner. However the most serious consequence is that, If ER doctors, nurses, PAs, or even the cafeteria lady who happens to be standing by, spent more time fully explaining people's conditions, then the 8+ hour average wait time at my hospital's ED would inevitably be further extended. This could translate to addressing fewer time-sensitive emergencies.
While we may see the patient with the severe MVA or gun shot wounds first, the patient sitting quietly who had severe chest chest pain a few hours ago, and now seems fine, will have to sit around a bit longer. If such patient had an MI, every minute is more muscle tissue lost.

Life is about trade-offs. As we think about the additional enhancements we can theoretically implement in ER, let's be very careful about what our patients might have to give up in return.

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