Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Ishani Ganguli is a fourth-year Harvard medical student. E-mail her at email@example.com.
Somewhere among the suturing jobs, swine flu reassurances, and spinal taps that I added to my list of Key Experiences and Useful Skills during my month at Mass Generalís emergency department, there were lessons to be learned about the use, and misuse, of health care resources.
Since we were first-year students, weíve been taught to ask: what led you to come in today? The question, with emphasis on "today," is meant to elicit the patientís chief (or primary) complaint, a goal that is particularly relevant in a department dedicated to addressing problems that require immediate attention and shuttling patients to a less transient setting. Many of the answers that month fit my pre-med notions of emergencies -- chest pressure with trouble breathing, broken bones, stitch-worthy gashes. But often enough, they left me wondering why the patient had taken the trouble to come in.
For example, the anxious-looking, athletic 30-something woman who complained of leg pain that started in her buttock and shot down her leg.
How long has this been bothering you?, I asked with the tone of efficient empathy Iíd adopted for this setting.
Four, maybe five months? she told me.
Any numbness or tingling? Incontinence?
No, no. I know I shouldnít have run six miles this morning, she added. That always aggravates the pain.
What brings you here today? I asked.
I just couldnít deal with it anymore, and it takes too long to see my primary care doctor.
Itís not that her pain wasnít real, or that it didnít deserve attention. It was that the emergency department was not the best place to do it.
The uninsured are well-known users of the ED for primary care. What surprised me were the visitors who had access to primary care but came in anyway. Another told me that she had seen her primary care doctor earlier that morning and was there because she didnít want to wait for her ultrasound appointment the next day.
While patients will have different thresholds for what constitutes an emergency, such encounters seemed to me to be emblematic of bigger issues -- our shortage of primary care doctors, mangled allocation of resources, and a health care system designed to put out fires instead of prevent them. I came away more convinced than ever that we need better ways to leave the emergency room for the real emergencies and provide care more effectively: after-hours clinics, more primary care doctors, the kinds of solutions that are being discussed in some form in Washington and in hospitals around the country.
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