[hundreddaysoff]

I'm an ER doc. I work 3 nights a week and see probably 5--10 patients a week who have waited over 3 hours.

The basic answer: most people don't go to the ER for emergencies. That is, they go for something like a rash, cough, or fatigue that they know is not an emergency. Many of them just want work notes, although some are convinced they have a legit emergency.

We scoop up the real emergencies from the waiting room ASAP. Eg, no one in the waiting room is wearing a tourniquet; if they are, it's my job to either fix the bleed or get them to a vascular surgeon ASAP if I can't.

The majority of people who spend hours in the ER waiting room have vastly higher time preference than your or I, and often lower socioeconomic status and higher anxiety as well. Often they can't afford phone service or even a car, so it's hard for them to get places quickly. Others are homeless and want a place to sleep or very anxious and just want to be somewhere with other people in the middle of the night.

[analog31]

Attach a regular urgent care clinic to the ER, and divert patients there. Medicine is anything if not statistical, and any ER should have a clear picture of what the care needs are for the incoming patients.

[hundreddaysoff]

Some hospitals do this and it works OK. But patients often believe that they should go to the ER rather than the urgent care part in this situation "just to make sure" or due to other myths. Also, during the day both our main ER and our urgent care are totally saturated at my hospital system.

"Well then your silly system just needs to build more facilities! It's obvious!!" You say.

One thing people need to realize is that it is not necessarily in hospital admins' best interest for all the ER patients to be seen. If it was, they would spend more money on more efficient triage systems so that we could just rake in the bucks. But, in reality they would often lose money on such a gamble in my understanding, due to how patients of different coding levels are reimbursed by payors (and whether a patient is even likely to have a payor).

[TaylorAlexander]

It is interesting to me that a system that had good social housing and guaranteed healthcare would not be affected by this specific problem, and would most likely (looking at places where this is true, like Austria) be cheaper than what we are currently doing.

[Sparkyte]

If you add a level of mandatory screening you can filter out ER to Urgent Care. The problem is still the connotation that ER is for everyone. Just put up posters in the ER lobby that make people uncomfortable things that say ER is for like car accidents. No one wants a reminder, but no one wants to be that asshole cutting in front of the guy who got a broken clavicle from a seatbelt or other various injuries.

[hundreddaysoff]

This has been suggested many, many times in my career. The problem in the US is that such posters would violate[0] a federal law called EMTALA, which prohibits an ER from turning away any patient for any reason until I or another provider has performed a Medical Screening Exam (MSE) to assess for A Real Emergency (TM).

EMTALA and confusion around it is another common reason why patients often stay in the waiting room for many hours when really it would be in their best interest to go home and go to a clinic during the daytime. It is the main reason I try to ~break all the soft rules at night and just go out into the waiting room and MSE anything that moves so I can send it home.

EMTALA was passed in the 1980s under Reagan I believe. Good luck repealing it or revising it to make sense in our current political environment!

[0] Or appear to violate the law in the optics of some administrator, insurer, healthcare bureaucracy maintenance organization visitor, etc. In this way, in large bureaucracies, magical thinking reigns, optics becomes objectivity, and 2 + 2 = 5 .

[Sparkyte]

It isn't about turning a person away, it is about enqueuing them into another emergency type care, urgent care is still a high priority but it is urgent and not deathly required.

This would allow prioritization of people needing immediate care.

[hundreddaysoff]

I happen to agree with you. I was writing not my opinion, but my experiences with the actual EMTALA law, or more accurately and importantly my healthcare administrators' perception of said law. I cannot change either of these things.

[PKop]

>but no one wants to be that asshole cutting in front of the guy who got a broken clavicle

Hang around an ER and I think you'll see this isn't remotely true.

>mandatory screening you can filter out

This would be great but is unfortunately illegal.

[Sparkyte]

Illegal if you don't have an urgent care facility attached.

[wolverine876]

> it is not necessarily in hospital admins' best interest for all the ER patients to be seen

It's still a systemic problem, where admins' interests are not aligned with the health and experiences of patients.

[hundreddaysoff]

No doubt.

I think that admins' interests not aligning with that of patients/consumers or with those of professionals/practitioners is making millions of people sad in a lot of other fields in addition to medicine.

Ben Hunt has written some great essays about this nebulous concept. His phrases "industrially necessary" and "raccoon" come to mind.

Is there a general solution? Dunno. But I suspect crafting even more regulation would be kinda like trying to make Wikipedia better by firing all the content experts and making all the admin-type people write all the words. It wouldn't result in a very good end product.

I seem do my best work when I am left to my own devices and my contact with admin is minimal.

[wolverine876]

I don't know much about it, but if hear one more person talk about how hopeless problem X is ... . It's a contagion.

[smugma]

A few years ago my wife had a very high fever (105°). I took her to urgent care and they determined she was too sick snd needed to go to the ER. So we shrugged and went to the ER,’where she had to wait for 3 hours before she was given some more Advil and a cold compress (and tested for a few other things).

[CoastalCoder]

> I'm an ER doc.

I don't know how you manage to do that job, but thank you.

[hundreddaysoff]

You're welcome! Basic answer: $250/h + benefits and 4 days/week "off". Plus, working in the ER at night is the most fun job I've ever had or probably ever will have. (Programming is second.)

Despite this, I plan to pivot to my telemedicine business full-time within the next year. I know I am not invincible and the older I get, the more mistakes I am likely to make and the more working nights will become a risk factor for heart disease, diabetes, and the like. Plus, working nights wreaks havoc on the family, but it's the only option to work stable days each week in the ER. (Ie, most ER docs either work all nights or work a random rotating schedule of first, second, and third shifts.)

[ibatindev]

Having worked as an MSI (Medical Specialized Interpreter) at $4/h, I've noticed that patients are still very reluctant to accept telemedicine for anything other than reviewing lab results.Do you possess a strategy to overcome this challenge?

LATAM Subcontractor for Teleperformance/LanguageLine Solutions/Pacific Interpreters.

[hundreddaysoff]

The strategy I possess is to use telemedicine in novel and directed ways when it suits the purpose.

Most telemedicine roles I have interest in start with a very directed patient population and a limited set of interventions. Patients at risk for HIV, obese patients, etc. In this context, these subsets of patients are happy to accept special-purpose telemedicine, in my experience.

I personally would not want to see a primary doctor or surgeon over the Internet, and if I needed follow-up testing in the lab right next door anyway, I would prefer to go in person to both places in one "quick" trip rather than dicking around with the Internet before going out to the lab anyway.

Patients are right to be reluctant. Telemedicine offers a lot of benefits, but it can never be as thorough as time in person with a primary doctor. (But this in-person time is just not possible to get for your average patient in my experience.)

[el_benhameen]

Completely understand if you don’t have the time or desire to answer questions, but I’m curious whether you went programming -> MD or the other way around, and how you made the transition.

[hundreddaysoff]

1. Grow up in the 90s and play too many video games and read the Extropians list too much.

2. Decide I want to be, like, the Hagbard Celine of pharmaceuticals and cure death, or something.

3. Learn programming because I still need a job if I fail at (2) and anyway programming is fun and people are scary.

4. Double major in CS and Bio, do bioinformatics research for minimum wage.

5. Move to Berkeley, learn more programming working at a random startup for minimum wage.

6. Get a job as a bioinformatics programmer at a lab; learn lots more programming and some bench biology and publish papers, under the theory that I need papers and a PhD to start a pharmaceutical company.

7. Look around and decide I don't want to be postdocking in SF for $40k/y when I'm in my 40s and have kid(s).

8. Enter an MD/PhD program (MSTP, ie combined and debt-free degrees) as a lowish-resistance hedge even though I dislike premeds and also the entire bloated medical system.

9. (8 years later) Do residency in Emergency Medicine because it's really fun and all the other specialties bore me. (Except radiology, but that's no fun with chronic sciatica.)

[p1esk]

Why do you say emergency medicine is fun? I imagine you often see people in pain, life degrading injuries, and all kinds of other sad things.

[hundreddaysoff]

Well, here's how an ideal night goes for me.

https://forums.studentdoctor.net/threads/patients-per-hour.1...

(Writing this in the middle of the night from that critical access ER I mention.)

I just don't think there's any other medical specialty that has a job as action-packed and gratifying as my job is for me. Surgery would be gratifying, for sure, but also I hate formal clinic and I have a weak bladder, so no.

Yeah, I guess I see lots of sad things. But (1) often patients are sad about things that could've happened but didn't actually happen, and I can cheer them up just by telling them the truth. (2) Often I can make patients happier if actual sad things happen to them, at least in the moment, and that makes me happy too. And (3) if I got sad every time I saw a sad thing, I'd be too sad to do my job and then I'd get fired. So, like, these things don't really make me sad because I'm here to do my job, not to get big feelings?

Does that make sense, or too facile?

[tomcam]

Wait you think ER is fun but also radiology? I feel like they are on opposite poles of the excitement spectrum. And are you saying you have sciatica?

[hundreddaysoff]

Yes, I think many things are fun or exciting, often for diverse reasons.

ER is fun because, eg, https://forums.studentdoctor.net/threads/patients-per-hour.1...

I do some radiology in the ER. I do find this fun. The core skill of radiology is to find stuff in pictures and then communicate these findings to others. Just like I did as a scientist, which I also found fun and exciting.

I also find it fun to do research in molecular imaging. I suspect I would further have fun researching AI techniques that may allow us to replace some or all of the human work of radiologists with computers. (I suspect "all" will never happen, for the same legal reasons that I suspect we'll never have real self-driving cars. Humans need, um, human scapegoats.)

However, yes, I also have chronic sciatica, or back pain. It gets worse the longer I sit. I don't like standing still enough to use stand desks and treadmills are distracting. Clearly being a radiologist and sitting in a dark room for hours at a time would not be good for this pain.

This is yet another reason I got out of full-time programming.

[Sparkyte]

250/h thats solid.

[leaferino]

What's your telemedicine business?

[hundreddaysoff]

Main telemedicine gig right now is diagnosing and managing HIV and other STDs. Patients love it as it's super private, and even testing can be done discreetly at home with a mailed kit.

Currently completing an online fellowship in obesity medicine and plan to start my own online practice or collaborate with midlevels who do so. Will probably get into tele-urgent care as well.

I've learned a little about all aspects of medicine as an ER doc, and it's exciting to apply that knowledge to telemedicine. Telemedicine is the Wild West right now. COVID-19 just opened it up a couple years back. We don't really know how to maximally benefit patients with it, but there are all kinds of new models being tried. When it works, it really works, without all the bloat and entrenched rentiers that can make brick & mortar medicine awful for both doctors and patients.

Reminds me of the state of the Internet around 2000. Wide open.

[kuchenbecker]

I was at ER today for an ear infection due to high pain, sudden onset, and urgent care wait of 6 hrs. Waited 20 min.

Sometimes it's the best option.

[_heimdall]

That tracks with what I have I assume the average wait times are. Given that its the average, I can only assume the ratio between actual emergencies and everything is worse than 10:1.

For that, I apologize. Maybe it comes down to fundamental problems in healthcare and most people not having a primary care physician, but I just can't imagine going to the ER with anything less than a very serious traumatic injury.

[musicale]

As I understand it, the ER cannot refuse patients without money or insurance?

Also people can get sick in the middle of the night or outside of regular clinic hours.

[_heimdall]

> As I understand it, the ER cannot refuse patients without money or insurance?

That's true, and a whole other discussion. If our ER wait times are 6+ hours primarily because they are full of people without a way to pay for treatment that's a much bigger problem.

> Also people can get sick in the middle of the night or outside of regular clinic hours.

For sure, that can absolutely happen. Though I'd argue the bar should still be high with regards to when a person should go to the ER. Unless its a true emergency one could still wait until clinics open for regular hours.

[jeffbee]

I once went to a large professional building attached to a hospital because I lost my voice and I wanted to see a doctor, any doctor, on any time frame. They said the only thing they could do is send me to the ER. These days, I would go to a walk-in clinic like Carbon Health or One Medical I guess, if I was in an American city away from home, without my own doctor. But I find it hard to blame anybody who goes to the ER for "just a cough" since I know the system won't do anything else for them.

NB when I was in the military they had the entire problem of suddenly ill people completely solved. Socialism.

[el_benhameen]

Yep. We’ve only ended up in the ER once for each kid (so far … knock on wood), but both times there were sudden onset symptoms that in my mind warranted urgent care but not the ER. Both times we called and were told that we could wait two weeks for an appointment or go to the ER, no in between.

[udkl]

It's so much better in India where you can walk in to any clinic or hospital for immediate attention without setting up appointments.

[neurotech1]

The irony that military healthcare, while far from perfect, has many advantages like it's part of the benefits to servicemembers and dependents, some retirees.

A surprising number of people, especially prior to the Affordable Care Act, would call expanding public healthcare "Socialism", even though many in Congress are veterans. The late Sen. John McCain (R-AZ), A Vietnam veteran A-4 pilot, and POW, cast the deciding vote against repealing the ACA. He earned his military healthcare, and then some.

[IG_Semmelweiss]

Thats certainly true, but not always so.

There's a strata of use cases that left in limbo in your argument.

Im a basketball player. I may have a microtear of a ligament from a 9pm game. The ortho guy, the pain doc, the sports med and my pcp are closed at 9pm.

I have no options but to go to the ER. I know because I've been there. Multiple times.

My kid is breathing and I can see his ribcage from forced breathing? If its past 5pm, its definitely an ER trip.

I pierced my hip with a chain link fence and need irrigation for the wound? ER trip

None of these injuries are life threatening. I'm not poor. My time is super valuable. i charge some clients $700/hour. Yet in each case, I spent > 4 hours in ER !

Now- I will literally wake up MD friends and ask them to write me a script to the 24hr pharmacy instead of waiting in ER for meds.

[hundreddaysoff]

There's nothing in my post that disagrees with anything that you're written.

Everything you've written is correct. I was not trying to argue anything and I think I hedged my words above quite carefully. I was mainly trying to answer OP's question and in passing explain a few things that make it look to patients like me that the ER is even more messed up than it actually is. (And it is actually pretty messed up!)

I love the people with microtears who can't get into the office. I love reassuring parents that they don't need to spend $10k for their viral toddler to be admitted and get treated with nothing all day and then get discharged, but slowly and passive-aggressively. I love helping people who are in the ER for legitimate reasons. I understand that the medical system is broken and most people who are in the ER should, in a halfway sane system, not be in the ER. I understand that way too many people wait for way too long in the ER and it makes me real sad, because as I've written elsewhere on this thread, I do think there are usually fixes that are possible and even easy, from my POV as both geek and JAFERD.

Telemedicine does offer some solutions to some of these problems, but not all of them by any means.

[_heimdall]

None of those sound like ER visits, except maybe the chain link fence if you're worried about infection if you wait?

It sure sounds like your justification here is that you have to take up time in the ER because you or your time is that important - I hope I'm just misreading that and your point was different.

[DanielHB]

In Sweden there are two types of ER, real ER and "närakut" which roughly translates to "near care". It works pretty well, the few times I had to go to närakut I waited less than an hour to talk to a doctor.

Just wondering, why does an ER doctor read hackernews?

[inemesitaffia]

He's a hacker and software is his backup plan

[wolverine876]

In the local ER - not your ER, probably - they only scoop up the dying. As I recall, one person near me had been in a car accident and was sitting there with very painful, unset broken bones for 9+ hours. They couldn't get painkillers until they were seen.

[ipaddr]

Everytime I've gone I see regular people spend 8 hours+. No one is looking for a roof over their head or a doctors note. The ability to pick and choose who requires care sooner is overrated.

[skyyler]

I can assure you that emergency room triage is not “overrated”.

[ipaddr]

I can assure you if you come via an ambulance you will get pushed to the front of the line over a walk in.

Easy to triage things gun shots are not so easy when the problems are internal. Easy to introduce bias. Parent poster thinks homeless and poor are only there because its warm or they have nothing better to do. It's okay to keep them waiting over someone who looks rich. They must have a serious problem, look at how well dressed they are.

Our medical system is still in the stone age.

[hundreddaysoff]

What is an alternate solution?

In hundreddaysoff fantasyland, the solution is to fire all the bureaucrats and triage everyone immediately. But, then nursing primaries and secondaries and all the other required paperwork wouldn't get done and CMS would come shut down our hospital.

[ipaddr]

Schedule more doctors. Hire people to do more paperwork.

[inemesitaffia]

There's a shortage

[hundreddaysoff]

There is no shortage of practitioners, ie ~medical middle managers such as myself and other MDs/DOs/NPs/PAs, willing to work in the ER.

(In the narrative of one faction, the suits have in fact created a surplus of us, including docs, that will only get bigger in the next 5 years, possibly hitting n=10,000+ surplus ER docs by 2030. If that happens, a major reason for that in this narrative would be that the suits have directly funded more Emergency Medicine residency slots opening in that time than there are interested American medical students applying to the specialty.)

There is no shortage of bureaucrats willing to shuffle paper and create more work for themselves in the name of Quality or whatever. See this doc's blog for a relatively balanced take on this growth, but I do think there is truth to his first graphic: https://investingdoc.com/the-growth-of-administrators-in-hea...

In my understanding, there is a critical shortage of RNs willing to provide the actual hands-on patient care, for pay that will still turn a profit for the hospital.

This includes skilled ER triage nurses.

But the other side of the coin from labor shortage in this problem is, again, that hospitals simply are not reimbursed sustainably to serve many ER patients, particularly self-pay patients, in the non-literally-emergent ways that those patients should be served, would like to be served, or deserve to be served medically.

Ie, in my understanding the ER is often a loss-leader for a hospital that serves to get patients into higher-total-reimbursement clinics such as GI, cardiology, and orthopedics.

Again, I'm not trying to argue for any faction here including doctors/midlevels, RNs, hospital admin, or even patients. I'm just trying to describe the system from my view down my periscope over 8+ years of doing this.