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We’ll Keep a Light on for Ya


By Mark Lachs, M.D.

Mark Lachs, MDOver my twenty-five-year medical career, the route by which people are admitted to the hospital for an overnight stay has subtly evolved in ways that most patients (and even many doctors) may not realize. Specifically, the proportion of patients who walk (or wheel) themselves through the hospital's front door at their doctor's recommendation and are whisked directly to a bed upstairs has declined precipitously. Conversely, the percentage of patients who are admitted to the hospital via the emergency room has increased just as dramatically.

There are several reasons for these trends. First, when you're sick, you want and often need to address the problem as quickly as possible. If you can't find your regular doc to figure out how sick you are or what to do, the ER is the only reasonable alternative. There are very few incentives (in fact, there are a ton of disincentives) for your primary care doc to say, "Sure, bypass the ER and come on over right now." There's operational risk to his practice (he has patients scheduled every fifteen minutes for the next eight hours; treating you could result in the cancellation of many appointments), economic risk (tending to patients with complicated situations doesn't get him much more income than the five common colds you've just displaced), and legal risk (he's the guy who diverted you from the ER -- what if you have a heart attack on the way to his office?). Why would any primary care doc want to ruin his day with potential ulcers like this?

Another force driving this trend: Insurers simply won't pay for many of the elective tests and evaluations that "semisick" people used to get as part of a hospitalization; they believe that these can be done on an outpatient basis. Gone, for example, are the days when you could be admitted to the hospital for a leisurely evaluation of weight loss, wherein your doc brought you in for a few days of scans, X-rays, and blood tests. In my opinion, this is a mixed blessing; you already know about the many ways older people run into difficulty in the hospital and why most geriatricians will tell you to avoid going if you can. On the other hand, sometimes the complicated series of tests and consultant opinions I need to evaluate a spot on a chest X-ray, intermittent belly pain, or some other new symptom can be logistically overwhelming even to young patients with good mobility and access to transportation. I often find myself wishing I could bring my older patients into the hospital for less than twenty-four hours just so the four or five tests they need could be done efficiently and without taxing their bodies, memories, and travel budgets. On a positive note, a trip to the hospital is unnecessary for many of the things we used to do there (such as a simple hernia repair), which can now be handled in outpatient surgery centers or even some physicians' offices. That's a good thing.

So now more than ever, if you need to be admitted to the hospital, there is a high likelihood that it will be through the emergency room. Unless you're having a major scheduled surgery, it is increasingly difficult for your physician to call ahead to reserve a bed for you, as if it were a table for two in a restaurant. And anyway, if you've been to the ER recently, you know it's more like the department of motor vehicles or the supermarket deli counter than a fancy restaurant -- you'll probably be "taking a number" and waiting. (And what's worse, you can't tip the maître d' to cut the line; it's going to take a sucking chest wound to get immediate service.)

But as a geriatrician I can help you here. I've spent thousands of hours in emergency departments -- as an ER physician myself, as a geriatrician ministering to my patients there, as a family member hovering nervously over a loved one, and even as a patient from time to time.

Here, then, are my rules on how to emerge from the emergency room unscathed.

  1. Avoid it if you can. Call your doctor with your symptoms for the best assessment of whether you really need to go. A good doc can sometimes offer appropriate treatment without the need for the ER.
  2. Don't dawdle in calling your doctor if you're on the fence. If you're experiencing symptoms that you think you can "tough out” and soon discover they aren't improving, your doc needs to hear about it ASAP.
  3. Sometimes you just have to go. Trying to bypass the ER to go right to a hospital bed is appealing, but if there are no doctors on the floor or if it lacks the right resource, you might not get the care you need.
  4. Ask your physician to call ahead. In making such an overture, your physician not only can provide useful info to expedite decisions about the care you need, but also let the ER doc know that you are part of a system of care, and that your journey through the ER is being monitored.
  5. Squeaky wheels get the grease. Patients and families who advocate for themselves get better care, so long as that advocacy is not obnoxious.
  6. Understand the game plan. At every juncture during your ER stay, ask the physician for a brief update on how the latest information changes the list of diagnostic possibilities and what the next step is.


Copyright © 2010 Mark Lachs, MD, author of Treat Me, Not My Age: A Doctor's Guide to Getting the Best Care as You or a Loved One Gets Older