We are the “Real” Doctors Reply

Recently, I got a letter from a patient who had come into the ER with chest pain a few nights earlier. The care was great, she said. The $5,000 bill she received was not.  And the real kicker? We never figured out the cause of her pain.

That night, we did for her what ER doctors are trained to do: We “ruled out” lots of causes of chest pain: heart attack, blood clot in the lungs, a tear in the aorta. That involved a full workup and lots of expensive tests. What we didn’t do was provide her with a diagnosis.

“Follow up with your PCP,” we told her – as if it were perfectly OK for her to leave the ER without knowing what caused her symptoms, and as if her primary care doctor, two weeks later, would somehow have a better chance of figuring it all out. But it’s not just that we passed the buck, like people sometimes do when they’re in a rush. The implication was damning of our entire specialty: we’re just ER docs; leave it to the “real” doctors to make a diagnosis.

That paradigm has to change. Emergency physicians ARE real doctors. It’s time we started acting like them.

Truth be told, it’s not entirely our fault. As ER doctors, we’ve been trained this way for a generation – to do workups, to rule out life threats. This was all one could hope for when ERs were poorly staffed and could barely manage to triage the most acute patients. And at a time when most ER doctors were not specialty-trained or board certified, it’s no wonder many of them felt a certain inferiority complex. But these days, ER’s are staffed with fully trained emergency medicine specialists; we can do better, and our patients expect it.

That’s why the madness – the unnecessary testing, the unnecessary anxiety – has to stop. It’s expensive, it’s making our patients crazy and it’s not good medicine.

I saw a woman the other night with chronic headaches.  The ER doctors had ordered a CAT scan of her head “just to be sure.” Unfortunately, the scan showed an irregularity in a certain area of the brain – could it be a tumor? So they ordered a more sophisticated scan, this time an MRI, which showed that the area in question was actually perfectly fine. Good news!

But that’s not the end of the story, because the MRI turned up another finding – this time a blood vessel near the base of the skull that was probably just a normal variant, but the radiologist couldn’t rule out a small aneurysm.  So the ER called in a specialist who recommended more invasive testing with catheters and intravenous dye.

But ER doctors ARE specialists. We are meant to specialize in figuring out whether symptoms – like headache – represent an emergency or something else. So we went back and took the patient’s history.

She had been having headaches since her teenage years. They were worse during periods of stress or when she hadn’t been sleeping. They usually improved with over-the-counter medicine and a healthy does of rest. Once in a while, she’d end up in the ER (like on that night) where she’d get a shot and feel better.

She had migraine headaches. The tiny aneurysm on the MRI – if it was even real – was purely incidental. It was not causing her headaches and it was not likely to cause any problems down the road.

Sometimes ER doctors are so fixated on ruling things out, that we are prepared to do test upon test, leading patients down the garden path to more anxiety and more medical bills. Real doctors take a history and try to figure out what’s wrong with their patient. There’s no reason doctors in the ER can’t do that too.