ER May Reveal Basic Problems in Hospitals

One brief — and, as it turned out, not too serious — visit to the emergency room in one of New York City’s biggest and best hospitals this summer proved to be very interesting because it revealed some systemic issues.

Perhaps if the problems seen and encountered there could be better understood and addressed, a trickle effect through the rest of the medical system could be magically launched.

Let’s start at the beginning.

Getting in was half hysterical and half amusing. A telephone call in advance of arrival directed the patient to ask for Joseph on arrival and he would immediately assist.

[The hysterical part] Checking in at the ER, the receptionist, a proud graduate of some school awarding degrees in “do not take no s&%t from nobody,” refused to call Joseph until AFTER she had “processed” the admission. As there were five people in line, that could not be quickly accomplished. The presence of an immediate and urgent problem simply eluded her or failed to impress her. She remained immovable until a medical professional observed what was going on and took charge.

[The amusing part] The receptionist was furious over this usurpation of her authority to insist on the domination of her role and her paperwork, and threatened the career of the registered nurse, as well as the patient, for being difficult.

Then began a series of identical examinations, many unrelated to why the patient was there, by three different categories of caring and competent pros. Despite inquiries, it was impossible to determine why three identical exams were necessary. The most rational explanation was that these procedures required repetition to catch errors. That explains, perhaps, two, but surely the third is either padding the bill or a preemptive defense to a malpractice suit. Or worse, that the staff does not trust each other. And if they do not, why should patients?

By the time this repetitive poking and prodding was finished, the issue that prompted the visit, which had followed an outpatient procedure in the same hospital that same day, had abated. Everyone, including the patient, was satisfied that there was no longer a problem. But no one was able or willing to “discharge” [until discharged a person can NOT leave] the patient until a physician associated with the doctor who had performed the procedure earlier that day signed off. After another hour of wrangling with the ER staff, that doctor showed up. She then she insisted on doing the same exam as the previous three!

Finally, after 3 and ½ hours, the patient was released.

What does this experience teach us?

First, big city emergency rooms are crowded, and it is said that about two out of three people who come in do not have a genuine medical problem. Yet the system requires the hospital to assume they do. Many are intoxicated on drugs or alcohol and need shelter and a place to rest. They have myriad and amazing “the dog ate my homework” reasons why they believe they need medical treatment, which consumes a lot of time and money and clogs the system.

Common sense says there must be some better way of filtering incoming people into appropriate categories and places. The staff mentioned triage but there was no visible sign of that process being applied quickly with judgment. Perhaps halfway houses could become a first (and if necessary very temporary) stop for such unfortunate folks, operating under contract with the hospital.

Next are those people who had recent treatment, in the hospital , and couldn’t reach their doctor for emergency help, who are invariably advised online and by phone to go to the ER. It should be a simple matter, in an age of electronic health records, to identify these cases and immediately direct them to the appropriate treatment. If such patients were able to have someone call or check-in before arrival, a “triage” process could be bypassed entirely for that type of case.

Signs of excessive defensive medicine were rampant, most obviously in the form of repeated tests and exams. I don’t have a solution to medical professional’s fear of being sued, but I am confident that the problem is exaggerated for purposes that don’t benefit front-line providers.

Like many large institutions, ERs have acquired an odd sort of lethargy. Despite the life-and-death environment, a shocking number of ER staff were simply standing around, texting, gossiping, and repeatedly getting in the way of those with something to do. Technology might play a role here, too, using data mining to better anticipate supply and demand and schedule employees accordingly. Time is, indeed, money, and the amount wasted in an era of spiraling costs is appalling.

One wonders what kinds of consultants are used. Smart problem solvers from outside of the health care field could bring fresh eyes and ideas to these obvious problems. But lawyers, insurance companies and doctors — as well as bean counters — have to be in the act too, with divergent motives and interests.

That, in fact, may be the very first problem that has to be addressed. The basic culture as well as the legal structure of our healthcare system needs to be reexamined.

Simple common sense, coupled with organized thinking, ought to be able to produce better medical benefits and patient care at substantially lower costs.

Consider this piece a cry for help. These issues must be looked at in a different way — simpler, with the doctor-patient relationship at the center, envisioning what a modern system could look like, and be, if it were being designed from scratch today.


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