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The Medical Professionalism Blog

Semper Paratus: How to Help Patients Make Better Decisions About Emergency Care

Unnecessary trips to the emergency department are expensive and disruptive for doctors and patients.  They are also fairly common.  Here is a patient’s perspective on the problem, courtesy of Jessie Gruman of the Center for Advancing Health.  In the spirit of “Show Me, Don’t Tell Me,” her post includes recommendations about how clinicians and others can help patients deal with this challenging issue.

Nora misjudged the height of the stair outside the restaurant, stepped down too hard, jammed her knee and tore her meniscus.  Not that we knew this at the time.  All we knew then was that she was howling from the pain.

There we were on a dark, empty, wet street in lower Manhattan, not a cab in sight, with a wailing, immobile woman.  What to do?  Call 911? Find a cab to take her home and contact her primary care doctor for advice?  Take her home, put ice on her knee, feed her Advil and call her doctor in the morning?

Sometimes it is clear that the only response to a health crisis is to call 911 and head for the emergency department (ED).  But in this case – and in so many others we encounter with our kids, our parents, our co-workers and on the street – the course of action is less obvious, while the demand for some action is urgent.

The question “which action?” has become more complicated of late because:

  • In some communities, there are alternatives to an ambulance or a drive to the nearest ED, such as Urgent Care centers.
  • Disincentives exist for going the route of the ED: in many cash-strapped municipalities we are charged for the cost of ambulance ride; we risk not having our ED visit covered by insurance if we make the wrong decision or fail to notify our health plan in a timely manner;  or, we don’t have insurance and ED care is expensive.
  • Some of us have a number of clinicians who could guide us about ED versus self-care on any urgent health matter, plus our health plan may have a nurse advice line that could do the same.  Which among them to call?  How long will it take to get an answer in the middle of a busy workday or a late night?
  • Many of us have no primary care clinician to call.

What hasn’t changed is that sense of panic.  We don’t know enough to judge how serious this is. We feel tremendous pressure to do something to resolve the pain and don’t know how to do it ourselves, but we don’t want to be responsible for underestimating the problem and causing additional harm.

Efforts to help us problem-solve quickly about urgent health events have been going on for a while.  For example, The HealthWise Handbook, distributed to more than 33 million people since 1975, walks readers efficiently through such decisions.  The Handbook information is available to everyone for free on WebMD and HolaDoctor. The American College of Emergency Physicians Foundation has a good list of general indicators for when to go to the ED available on their web site and elsewhere.  But finding the right guidance fast depends on our ability to know about a good source for relevant information, to locate that source – the book or the search term or nurse-line number – then to read and understand how it applies to the urgent situation at the moment.

Such efforts seem haphazard in light of two facts: First, that Americans made 123.8 million visits to the ED in 2008, and second, that a good number of these visits are not for urgent conditions.

It’s true that the ED is the only place that some of us can get health care and considerable attention is directed toward reducing visits by frequent usersBut none of us is immune to making the wrong call. Our decisions about where to seek care for a health crisis are made largely in the absence of knowledge or expert advice, wasting our time and money as well as that of professionals and institutions.

Health crises are common in the population, but rare among individuals.  Regardless of our experience, when one happens to us, to a family member or a co-worker or in front of us on the Little League field, we know we must act.  Right now, despite all the options and disincentives for doing so, the default action for most of us is calling 911 or getting ourselves to the ED.  We would benefit from a little help here.

So come on, those of you who have a stake in making health care more patient-centered! This is an easy win.

If you are a primary care clinician in a practice or a medical home, tell your patients how you and your staff handle emergencies both during the day and after hours.  Who should they call?  What can they expect?  Post this information, send it to them, remind them about it when you see them.

If you are an employer, make sure your employees know what services you have purchased for them as part of their insurance benefit to help them respond to an emergency.  Show them where this information is located on the premium information website or in the handbook; remind them about that nurse advice line.

If you work for a health plan, communicate directly, clearly and consistently with beneficiaries about their specific benefit: what must they do to ensure care is covered? Where on the plan website is there information that could help in making decisions about emergency care?

If you work on patient-centered care for the government, form a partnership across agencies and with private industry to gather the lessons from the 911 experience to inform the development and promotion of a self-triage emergency app for (web-enabled) smart phones. By the time you do this, smart phones should be in the hands of most Americans.

Ideally, “patient-centered” care would be organized to enable us to act and optimally benefit from the knowledge, services and technologies available to us.  Each of these strategies would help us do so.

So what happened to Nora?  She figured that since she wasn’t bleeding and probably didn’t break any bones, going home and getting advice from her primary care physician might save her a cold night on a hard chair in the local ED.  She’s hobbling but healing.


Jessie C. Gruman, PhD is president and founder of the Center for Advancing Health, a Washington-based research institute that works to ensure that everyone is prepared to live a healthy life and make good choices about health and health care. Dr. Gruman is a widely published author; her most recent book, AfterShock, What to Do When the Doctor Gives You — Or Someone You Love — A Devastating Diagnosis, helps patients navigate their way through the health care system in the weeks following a serious or life-threatening diagnosis. Her experiences as a patient — having been diagnosed with four life threatening illnesses — informs her perspective. Dr. Gruman is also a respected academic and scholar. She received her Ph.D. from Columbia University and is a Professorial Lecturer in the School of Public Health and Health Services at The George Washington University. She is the co-editor of the Journal of Participatory Medicine and serves on the board of trustees of the Center for Medical Technology Policy, the Advisory Panel on Medicare Education of DHHS, and the Technical Board of the Milbank Memorial Fund.

1 Comment to Semper Paratus: How to Help Patients Make Better Decisions About Emergency Care

  • June 18, 2011 at 11:20 pm | Permalink

    Thanks for this comprehensive overview, Dr. Jessie. My own concern, however, is exactly the opposite: how do we actually convince patients that they do need to call 911 and get immediate help! For many, especially women who don’t want to “make a fuss over nothing”, going to the E.R. may not be the “default” decision at all.

    This is a distressing – and deadly – reality for women heart attack patients. We know that women inexplicably wait longer before seeking help, even in mid-heart attack, and when they finally do, are under-diagnosed and under-treated compared to their male cardiac counterparts. Women’s outcomes are significantly poorer than men’s – could this treatment-seeking delay be one factor?

    An Oregon Health & Science University study published in The American Journal of Critical Care investigated women heart attack survivors and their acknowledged reluctance to seek help during a cardiac event, often despite exhibiting alarming symptoms. Researchers identified six common patterns of treatment-seeking delay behaviour in women who are experiencing heart attack symptoms. These include, for example:

    – “Knowing and Waiting” (women decided that they needed help but delayed seeking treatment because they “did not want to disturb others” )

    – “Managing an Alternative Hypothesis” (women decided symptoms were due to indigestion or other non-cardiac causes, and were reluctant to call 911 “in case there’s nothing wrong and I’d feel like a fool” – until their severe symptoms changed or became unbearable). Find out more about the other four patterns of treatment-seeking delay behaviour at: http://myheartsisters.org/2009/05/22/know-and-go-during-heart-attack/

    While “unnecessary trips to the E.R.” are indeed problematic, I’m concerned that medicine may be missing a more deadly potential problem: how to convince patients who are in dire need to pick up the phone and call 911 for immediate help.


  1. By on May 26, 2011 at 9:30 am

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