The Once and Future ER
Believe it or not, emergency rooms are places of beauty. They offer relief to the suffering, comfort to the ill, and care for the needy round the clock. But they bear a near universal gripe: Waits are too darn long. As patients swarm entry halls and ambulances habitually bypass overwhelmed facilities, you don't need an economics degree to know it's a supply-demand crunch. In June, in fact, an Institute of Medicine study concluded that hospital emergency care is at the breaking point. With 114 million visits a year and growing--thanks to our older and sicker population--bursting point might be more apropos.
In fairness, ERs are victims of their own success. "They're problem-solving places," says Robert Shesser, chairman of the Department of Emergency Medicine at George Washington University. He sees today's emergency care as the interface between the public and its instant access to technology, which in an outpatient setting typically takes weeks of appointments. So much so that physicians with backed-up schedules increasingly send patients with urgent problems to the ER.
This challenges the myth that universal insurance will solve ER crowding by giving everyone a regular doctor. The vast majority of ER patients have medical insurance. Another myth claims that too many people use ERs for routine care. Government data show that only 13 percent of visits are nonurgent. Even then, most of them are driven by a patient's sense of urgency. On this, I'm with them: The golden rule of medicine is to listen to the patient. That chest or back discomfort, shortness of breath, or aching wrist after a fall may very well be serious.
Waiting times aside, patients will tell you they are pretty satisfied with ER care. As they should be. ERs are able descendants of the fabled family doctor making house calls--until specialized emergency talent and sophisticated diagnostic testing eclipsed the tools of the black bag. The modern ER, hospital-based with dedicated experts and accepting all comers, is an Anglo-American innovation also used in Canada and Britain. Most people come by choice and on foot, not by ambulance. This differs from the Franco-German approach practiced in most of Europe, where ambulances staffed with doctors and nurses provide emergency care in the field. Only those who need admission are transported to hospitals. Debates continue as to which model is better. But it's hard to deny that even the smartest of ambulance-riding physicians can't hold a candle to the wizardry of an ER and the in-house specialists who quickly treat the suddenly ill.
My aching back. Still, technology prolongs ER waits; so does its overuse by defensive docs. Failure to perform a CT scan or an MRI can mean failure to diagnose, three words that are lunchmeat for lawsuits. God help the doctor who doesn't jump on a battery of tests if someone comes in with even mild neck or back pain. Even worse, defense turns into retreat when specialists like neurosurgeons and orthopedists, fed up with excessive litigation and exorbitant malpractice premiums, just say no to ER duty. A few states have established Good Samaritan-like protections to keep ERs open, as the feds struggle on with tort reform.
Quite simply, the ER system is too vital to break down--and hospitals know this. Many are expanding their departments and have rolled out 24-hour observation units to counter bottlenecks in hospital admission. Some have created fast tracks to treat patients with less serious complaints promptly, often with nurse practitioners in the lead. Canada recently reported fast tracking as the most promising way to declog its own swamped ERs. And a new wave of nurse-practitioner clinics in places like pharmacies may become valuable decongesting agents.
Meanwhile, everyone needs an ER navigation plan. It starts with a doctor of your own, who is able and willing to communicate with the ER to facilitate your care should you or your family wind up there. Have on hand summaries of your medical history, including illnesses, medications, tests, and allergies. Learn all about urgent-care clinics in your neighborhood, and keep alert to which local ERs are best, even in waiting.
I'm reminded of what Yogi Berra reputedly said about the most popular watering hole in town: "No one goes there anymore; it's too crowded." Given the choice, people will go where they're cared for well, and efficiently. The best hospitals can do both, at least most of the time.
This story appears in the July 17, 2006 print edition of U.S. News & World Report.