A trip to the ER is seldom a planned or welcomed event. It’s usually reserved for the most serious of “oopsies” and, thus, we often arrive there with little knowledge of what to expect and what treatment we will receive. This leaves us vulnerable to the medical and financial unknowns that span a wide spectrum between life-saving or entirely superfluous. But by understanding the culture of the ER, the logistical realities of emergency medicine and the empowerment of patient choice, we can effectively protect ourselves from falling victim to a thorny system. My own medical mishap sets the context for these lessons.
On a recent spring ski trip, I suffered a minor neck injury after run-in with gravity. The stubborn Naturalist that I am, I tried to treat the pain with Arnica, until the swelling got so bad that my better judgment (read: Mother) brought me to the Emergency Department.
It was around 6PM. We sat in the waiting room for just under three hours, intermittently called over to different check-points to assess my vitals and verify my insurance. Once a room opened up, I was ushered in, slipped into a johnnie and prepped to endure another lengthy wait for the doctor.
She entered the room like a cold gust of wind, seemingly calloused by an overloaded schedule or maybe a bad run-in with a feisty patient. She scanned through my symptoms aloud and scolded me for waiting two days to seek care.
“Did you take any medication for the pain?” she demanded. I sheepishly replied that I was not a big fan of the stuff. “Well, there’s your problem,” she concluded. My mom (bless her) tried to come to my defense, explaining my preference for alternative methods. The doctor said nothing, just scratched some notes on her clipboard.
I’m obviously no stranger to the Allopathic/Naturopathic dichotomy. I’ve gone to Allopathic facilities all my life, largely for insurance reasons, so I’m all too familiar with the skeptical looks and awkward silence that can often follow mention of alternative medicine. Many physicians are not opposed, necessarily; they’re just programmed to treat patients through specific scientific methodologies. Furthermore, some still hold tight to the stigma that Naturalists are just earth-loving hippies intent on bucking the system in favor of herbal tinctures (okay, that’s not far off for me…). Whatever the reason for disagreement, this doctor was clearly in that camp.
I went in for a C-Scan, which didn’t reveal much of anything. No news is good news. They diagnosed a cervical strain and an edema, a buildup of excess serous fluid in the tissues where the neck muscles had stretched. Nothing a little ice and bed-rest won’t fix, right?
“So here’s what we’re going to do,” the Doctor began, “I’m going to give you a shot of pain medication and then write you up for a prescription-strength anti-inflammatory, oxycodone, a muscle relaxer, and we’ll start you on a steroid regimen. Also, have you been drinking enough during this whole thing? We should probably get you on some intravenous fluids.”
Wait a second, did I miss something? Or did she just miss that whole conversation about my aversion to medication?
I immediately rejected the IV. It didn’t make sense in the context of my injury and I wondered if it was just an extraneous, albeit harmless, measure that they pushed to bill the insurance companies.
Then I denied the pain medication. The discomfort was significant; but I knew if the swelling went down, the pain would go away on its own. And now that I knew the pain was not indicative of a more serious problem, I preferred to tough it out rather than dope it up.
The doctor grew increasingly irritated, and eventually left the nurse to coax me into the other prescriptions. The nurse was far more empathetic to my situation, and reasoned that she would give me some initial medications for pain, inflammation and muscle stiffness; and then I could decide whether or not I wanted to continue taking them after my release. She agreed that I could defer the steroid regimen and IV. I conceded reluctantly; these were medical professionals, after-all, and the trusting patient in me temporarily prevailed over the skeptical journalist.
After it was administered, I was sent on my way… strung out on muscle relaxers and vomiting from the pain medication. My neck, however, felt like a million bucks.
Ultimately, even after rejecting some treatments, my medical bill for the visit was $2,865.21 before insurance adjustment. The cervical spine scan did the most damage at $2,167.53. It was another $566.60 just to book a room in the Emergency Department… steeper than a night at the Hilton. The process of injecting the non-steroidal anti-inflammatory drug (not even the drug itself) was an additional $117 charge. Still, I considered it all an expensive learning experience in navigating a complex system of healthcare. But I’ll save you the money and just share those lessons with you.
Not every treatment recommended in the ER is necessary.
Under the stress of an emergency medical visit, you might feel pressured to concede to everything the doctor suggests; or you might be in so much pain that you happily oblige. In truth, the doc does know best; but keep in mind there are a few things dictating their suggestions.
The emergency physician is under the pretense that the patients coming in the door want instant relief, which means contemporary medications that will suppress the symptoms; but if, after assessing the severity of your pain, you decide medication is not necessary, you might be able to avoid potentially dangerous or expensive treatments that are just being pushed to put you at ease.
Also consider that hospitals are especially vulnerable to our society’s penchant for litigation. According to a report by the American Medical Association, around 50% of emergency medicine physicians are sued at least once in their careers. They are the target of malpractice lawsuits every year and have adjusted their practices in response, adopting a system of what many are calling “defensive medicine.”
Emergency medicine Physician Assistant Christopher Hanifin explains his take, “I view defensive medicine as the major driver of cost in an ER. There are significant reasons to be defensive, not least of which you are caring for someone generally unknown to you, and you view yourself as the last line of defense. Perhaps more than these issues, fear of litigation causes defensive medicine. The emergency department environment breeds angry, frustrated patients. They can be a very challenging population to care for.”
According to a Harris Interactive Poll, 79% of doctors reveal that they’ve ordered more tests than their professional judgment would suggest due to fears of litigation. 41% of physicians admit to prescribing more medications than they deem medically necessary, and 73% have noticed other doctors prescribing similarly excessive medications. And the cost of medical liability coverage and legal costs of meritless suits also fall on patient shoulders. Even the American Medical Association declares many states to be in a “medical liability crisis.” Under these circumstances, many doctors are operating under the umbrella of “better-safe-than-sorry.”
Our expert Insider Dr. Earle Mindell recently shared his top 5 of Unnecessary and Costly Treatments that Could Be Harmful to You. Among them are imaging for back pain within the first six weeks unless there are “red flags,” antibiotics for sinus infections unless symptoms last for seven days, or dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis if you are under 70 with no risk factors.
If it all seems Greek to you, don’t be afraid to ask questions. Even if an emergency physician seems short on time and patients, they are usually willing to field your concerns. And it never hurts to do a little research before you see the doctor; heaven knows you have enough time in the waiting room.
The hospital is a business.
And just like any business, it functions according to the same economic premise of supply and demand. The hospital or pharmaceutical company can bump up the cost or value of services because they know somebody is willing to pay them, whether that ends up being you or your insurance provider.
But it’s not corporate greed as much as it’s an attempt to contend with rising prices and compensate for those who cannot pay their bill. The Emergency Department is obligated to treat anyone who comes in their door, regardless of financial capability, so if some patients do not have insurance, the hospital (and, thus, other patients) absorb the cost.
Also keep in mind that their suggestions could be contingent on a professional obligation to push billable products or processes, as encouraged by the hospital administrators or pharmaceutical companies. Big Pharma has a vested interest in the Allopathic system and rely on these doctors to push various brands and encourage the “pill-for-every-ill” mentality. When this interest is backed by investment, physicians might be professionally inclined to take the pharmaceutical route, even if some options are more expensive.
Board-certified Emergency Medicine physician Christine Silvers reiterates that this was the case during her years in the ED. “Various medications were definitely influenced by pharmaceutical affiliations. For example, at one hospital, we'd use ‘Zofran’ for nausea/vomiting because it was on formulary there—even though it's an expensive medication.” A formulary is used to specify which medicines are approved to be prescribed under a particular contract.
“At another hospital, we couldn't use Zofran because it wasn't on formulary,” Dr. Silvers says. “Instead, there was a medication, Kytril, in the same class of meds as Zofran that was on formulary; so at that hospital alone, I wrote for that alternate medication to be administered in the ED. I didn't need to remember this because if I wrote for Zofran –which was my habit since I'd done so for 4 years during training—the nurse would let me know to change it to Kytril.”
Largely, the mentality is no harm, no foul. But unfortunately, the doctor did not take a Hippocratic Oath to your wallet.
Some non-life threatening injuries can be treated at home…or elsewhere.
Some of the most common injuries seen in the Emergency Department are strains and sprains (case in point). While they are no picnic to deal with, there is very little that the ED can do besides give you some pain relievers and a brace. If you are certain the issue is not a break or a fracture, ice and an NSAID could get you by until the swelling goes down and the body starts its natural healing process.
The same might go for other benign conditions. In an interview with renowned doctor of clinical psychology Leslie Seppinni, she warned that that those with a history of panic disorders, for example, should be wary of heading to the ED when they feel an attack coming on; all the physician will do is give the patient a very expensive Benadryl. She stresses that, while she doesn’t condone regular use of Benadryl for its ill effect on the liver, the patient could save a bundle if they just administer it themselves at the onset of symptoms.
You can also save yourself time and money if you wait it out until business hours. According to a report from the Center for Disease Control and Prevention, about 65% of hospital visits start on the weekends, or before 8am and after 5pm during the week. If you’re heading to the ED during these hours, you’ll likely have a longer wait and a lower quality of care. Opting for a local urgent care center instead of the Emergency Department may also prove more cost-effective.
Your doctor is an expert on medicine, but YOU are the expert on you.
Unlike your primary care doctor, an emergency physician does not know you, your extended medical history or your personal preferences. Under these circumstances, it is even more critical that you communicate and advocate your conditions and preferences. And it’s not just a matter of morality; if you’re not used to taking powerful medication, for example, you could suffer harsh side effects or aggravate pre-existing conditions.
This is also a consideration for individuals who are prone to addiction; dependence on prescription painkillers is becoming an epidemic in our culture and, based on my own experience, emergency staff does very little to curb it. Based on the 2007 National Survey on Drug Use and Health, in one month 6.9 million persons over the age of 12 abuse prescription-type psychotherapeutic drugs. Of these, 5.2 million abuse pain relievers. Yet, there are rarely screenings with patients to check for warning signs, and physicians liberally write prescriptions even if the patient does not request, or even denies, them. This could lead to a surplus of excess pain prescriptions that end up in the wrong hands.
Certainly, we cannot always expect the ED to be an environment of tender loving care; a busy emergency staff relies on a quick fix to expedite patient turnover and make room for incoming emergencies. But if they are not making you and your long-term health a priority, it’s your right and responsibility to ensure that they do. Money and convenience should never supersede patient wellness.
As for the waiting room, I suggest bringing a book.
Kane, Carol. "Medical Liability Claim Frequency: A 2007-2008 Snapshot of Physicians." Policy Research Perspectives. American Medical Association, August 2010. Web. 6 May 2012. <http://www.ama-assn.org/ama1/pub/upload/mm/363/prp-201001-claim-freq.pdf>.
"Fear of Litigation Study," Harris Interactive, Final Report, April 2002. 6 May 2012.
Mindell, Dr. Earl. "Unnecessary and Costly Tests and Treatments that May Be Harmful to You." Dr. Earl Mindell. N.p., 09 09 2012. Web. 6 May. 2012. <http://blog.drearlmindell.com/?p=434>.
Seppinni, Dr. Leslie. Telephone Interview. April 6, 2012.
"Results from the 2007 National Survey of Drug Use and Health: National Findings." Office of Applied Science. Substance Abuse and Mental Health Services Administration, 04 11 2008. Web. 6 May 2012. <http://www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm>.