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Where Should You Go When You Get Sick?

April 10, 2011

An article in Health Affairs documented well what all of us know in front-line medicine: patients who don’t feel well go the emergeny room. The study looked at data from a national survey and found that a minority of patients see their primary physicians (42%) for first-contact care, with visits to the ER coming in second (28%).

The reasons are multifactorial. ERs have to see everyone no matter if they can pay for the visit or not. Family physicians are mostly small business owners and aren’t required to see everyone who knocks at their door. Family physicians have been criticized for abrogating their whole person continuous care in the evenings and on weekends. They might respond by pointing out that insurance companies typically don’t allow any sort of extra payment for an out-of-hours visit, while they’ll pay without questioning an $800 bill to an ER for a patient with a cough (and $2,000 if the ER did a marginally necesssarily CT scan).

A similar phenomenon is happening in other countries as a change in the overall culture and attitudes of younger physicians who want more work-home life balance and aren’t willing to be on call 24/7 affect their healthcare systems. British GPs are no longer required to cover out-of-hours care individually, though the larger Primary Care Trusts were required to provide some sort of coverage, which I believe is commonly covered by doctors in training. We’ll see what happens in the new scheme where GPs have been given even more responsibility to manage the entire British¬†healthcare system.

The answer to the title question is you should see your family physician, or a call partner, whenever you get sick as much as possible (This statement assumes the reader has a critical amount of common sense). There are very few true emergencies in emergency rooms. By that, I mean patients where the diagnosis and treatment must happen in a matter of hours to save life and limb. About 50% of ER visits should be seen in a family physician’s office (these are my observations, not from the study). About 25% are urgent visits — they could be handled by a family physician if he or she had quick access to advanced imaging such as CT scans and sonograms. Only 25% are true emergencies.

By the way, working in an ER is easier than the TV shows lead you to believe. All the imaging and support staff are there, a huge list of doctors is available for immediate help, and there aren’t that many emergencies. What’s more nerve wracking is to see a patient in clinic with new symptoms of abdominal pain and nausea, not have any imaging immediately available, then sending them home without¬†ordering $4,000 worth of tests.

This overuse of the ER is another hidden cost of a healthcare system that doesn’t support family medicine. The payers need to pay family physicians much more for urgent visits (some number between an ER visit and a routine office visit). Family physicians must be ready to take up this mantle and cooperate with each other to provide excellent after-hours care. It’s just one more reform that must happen to lower the cost of healthcare for everyone.

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One Response to Where Should You Go When You Get Sick?

  1. pcp on April 14, 2011 at 9:33 am

    “By the way, working in an ER is easier than the TV shows lead you to believe. All the imaging and support staff are there”

    And no pre-auths are required for any of the tests ordered.

    The pre-auth process for a stat CT scan has become so cumbersome that I, reluctantly, send any patient needing one to the ER. I’ve explained to the insurers that this increases their costs 10x, and they tell me to drop dead.

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