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The Medical Professionalism Blog

State of Emergency

During a recent talk at the Families USA conference, the Reverend Edward Livingston led an animated discussion regarding his groundbreaking work with the Camden Coalition of Healthcare Providers and Camden Churches Organized for People. (This work became well-known through Atul Gawande’s piece in The New Yorker, “The Hot Spotters.”)  In the course of his talk, he described a simple yet critical piece of their team’s work to design a functional primary care system for frequent Emergency Department users:  They asked these patients why they used the Emergency Department rather than seeing a primary care physician and used their responses to shape the intervention.

As a family doctor who is also the mother of three active boys, I am fascinated by the question of what drives people to use Emergency Departments, both for its cost implications and its effects on the lives of patients and caregivers. Through a combination of exuberant optimism, love of all sports and a certain lack of common sense, my sons have worked their way through a wide variety of orthopedic not-quite-emergencies including hairline fractures of the finger (six at last count), a mild shoulder separation, partial Achilles tears (2) and probably a few others I’ve managed to forget. Our primary care doctor is part of a Patient-Centered Medical Home and we are lucky enough to have good health insurance. Each of these conditions could and probably should have been handled without a visit to the Emergency Department, but we have struggled to figure out how to make that happen. Although our doctor has open access scheduling, this only applies if they have a slot when we call. Often by the time the child can be seen, it is too late for X-rays the same day and of course the doctor does not refer the child to an orthopedist until the X-ray results are in. All of this usually means that we are either faced with a choice between a three- or four-day sequence of medical appointments, all while the child is missing school and one of his parents is missing work or an evening visit to an Emergency Department, where exam, X-rays and splinting/casting can all be done in one place. Add to this our busy work and home schedules, and the choice to go to the Emergency Department becomes almost unavoidable.

While waiting in Emergency Department, I’ve seen countless babies and young children with head colds and other apparently minor illnesses. During my training, I cared for kids with similar minor illnesses in Emergency Department. I suspect that their parents brought them there for reasons similar to my own: jobs that don’t allow sick time for taking children to the doctor, difficulty seeing a primary care provider when a visit seems needed and, behind it all, a fear of leaving a child sick or in pain for longer than necessary because of a system that doesn’t serve our needs.

As we think about the urgency of cost containment and the potential of the Patient-Centered Medical Home, we will need to give real thought to the drivers of Emergency Department use and to finding real solutions that meet the needs of the patients who use them. We will have to ask the question that Reverend Livingston and his colleagues in Camden asked their patients: Why do you go to the Emergency Department? And we will need to begin building systems of care that respond to the answers we get.

bettigoleDr. Cheryl Bettigole is a family physician with the Philadelphia Department of Public Health where she sees patients at a city clinic and serves as the Clinical Consultant to the Office of Health Information and Improvement within the Health Commissioner’s Office. In her work for the health department, she has cared for diverse populations of patients at city clinics since completing her residency in 1999. As clinical director of a city clinic from 2006-2011, she worked to improve services for patients of limited English proficiency and to implement a chronic disease management program. Dr. Bettigole is a member of the Health Reform Task Force of the Association of Clinicians for the Underserved and is the President-Elect of the National Physicians Alliance as well as a member of the American Academy of Family Physicians. She is a magna cum laude graduate of Jefferson Medical College, completed her residency in Family Medicine at Thomas Jefferson University Hospital, and completed her Masters in Public Health at Johns Hopkins Bloomberg School of Public Health, where she received a Capstone award for her work on interpretation services in a public health clinic setting.

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