There are days, and they seem to come more frequently lately, that I wonder if I am really making a difference.
Explore This IssueACEP News: Vol 28 – No 04 – April 2009
At times, I feel like the character Zero in the movie “Holes.” In this splendid story, the diminutive Zero found himself on a juvenile work farm, where the warden forced the kids to dig deep holes. The corrupt warden hoped to find buried treasure under the dry lake bed. For Zero and his fellow inmates, it proved to be tiring, pointless, and boring work. In the end, things turned out well for Zero, and I suppose that it will for us as well.
Still, I wonder how much farther the safety net can be stretched by pointless and uncompensated work. As the economy circles the drain, and our elected representatives micturate away the futures of our grandchildren, we see more and more nonemergencies and receive less for our trouble.
How many of you enjoy being the drunk tank for the police, the dentist, the psychiatric clearinghouse, and the social worker?
No matter how one slices it, a large number of our patients should be seen in another setting or don’t need to be seen at all. Yes, I have read the study that shows it is not these patients who contribute to the delays and boarding that plague most of the nation’s emergency departments. There comes a point, however—and I believe we are already there in many places—that the number of nonurgent patients creates enough chaos to impair our ability to care for the people who truly need emergency care.
Twenty years ago, when reimbursement was better, the occasional uninsured patient did not stress the system, because compensation from the insured patients was reasonable. As reimbursements have declined, and the financial flexibility of the system has been lost, these patients now put an enormous stress on the system. Accompanying this has been the stress placed on staff and physical capacity.
In spite of great challenges posed by these stressors of the system, emergency physicians have been masters of adapting to change. We have found ways to become more productive and use patient care spaces more efficiently. We usurped surrounding office space from the nonproducers and cajoled administrators into building new emergency departments. It seems, however, that almost as soon as the new spaces are built, they are outgrown.
Many departments nearly crumble under the weight of patients who are sick and those who are not. The University of Chicago has recently implemented a plan to reduce unnecessary visits. They have been criticized for this and accused of possibly violating EMTALA. Clearly, the folks at the University of Chicago felt they were at the breaking point and needed to make tough choices in order to provide good care to the most ill. This is not a theoretical discussion.