Could Lisa Rosenbaum, MD have ER doctors in mind when she wrote, if you want to fix the health care system, allow doctors to do what they set out to do?(N English J med. 2022;386:1850; https://bit.ly/3Rd0ekN.) After all, we are particularly adept in crisis situations at finding workarounds to what we set out to do.
This scenario is so common in emergency medicine that MacGyver has become the patron saint of the ER. For MacGyver, a crisis situation becomes a distinction of keen awareness, special skill, intuitive creativity, stubborn perseverance, and a fair amount of luck (and, of course, available nursing care). It’s honorable, even invigorating, for the immediate emerging medical crisis at the bedside.
We have learned that the disease environment is more predictive of disability than the disease itself. We recognize that the social determinants of disease and the political and social structures that reinforce them are at the heart of health, sometimes despite what we do. Nothing could illustrate this more clearly than the pandemic.
But it shouldn’t be up to us about MacGyver’s social determinants — all prescriptions, rides, security, housing, clothing, gun control, and timely tracking, all without breaking the law. Committing a lifetime of medical skill at the bedside deserves a medal of professional heroism, but it becomes an albatross hanging around doctors’ necks when they are forced to perform this duty at the curb. Emergency physicians must learn to draw clear boundaries between the bedside they are trained for and the sidewalk they are not.
Not really a solution
The most recent social diversion from the duties of emergency physicians is the pricing of pharmaceuticals and the electronic prescription of emergencies, especially after office hours. In the heat of a breathless shift, are we supposed to research what the pharmacy charges for ointment instead of cream? (The difference may be $100.) Or should we write for clindamycin in 300mg or 150mg tablets? Or if patients can afford Zofran ODT or Zofran tablets? What are the pricing breakpoints? How do I get a Xarelto or Eliquis patient when not covered by Medicare?
Should we add the AeroChamber essential to the inhaler for an extra $20, which might make it unobtainable? How do we treat someone for otitis media externa for less than $100 without writing two scenarios, one of them being a generic eye medication (for which you will later get a phone call from the pharmacist who will tell you “Doctor, are you sure you meant to write for an ophthalmological preparation?”)?
It’s common medicine, but if you don’t know the prices or get it wrong, it makes the difference between a patient getting the intended treatment and not, which is the essence of why it’s came to the emergency room, and all because the cost of bread and butter is not on the menu. Solving this problem by remembering to give each patient a discount card is not really a solution.
And at night, we are supposed to know which pharmacy the patient would prefer you send scripts to depending on whether it is always open and what other 24-hour pharmacy may be near them? As you hand him the discharge papers, which have been redone to reflect the other pharmacy he wants you to use, the nurse asks, “How is he going to get home?” Or “If you don’t deal with her pain better, she says she’ll walk in front of a car.” Or “She’s wondering if she can grab a sandwich before she leaves.”
Does the job
The well-being of emergency physicians is directly linked to these failures of emergent support of social determinants. Emergency physicians don’t have the time, expertise, or extra energy for the MacGyver emergency social determinants of pharmaceutical prescriptions, travel, housing, and security, to name a few. some. Not only does it go beyond what we should be doing, but it buries what we should be doing. It prevents us from doing what we have decided to do.
I have no problem being a lawyer, but I’m ill-equipped for social intervention. I’m certainly not suggesting that hospitals invest in large-scale social interventions, and I know the possibility of hiring multiple emergency medicine social workers in the current environment is a pipe dream.
The absence of a real public health system in the United States facilitates the amalgamation between emergency medical care and an emergency social assistance system. The most immediate cost of this confusion is the allopathic burden it places on the soul and endothelium of the emergency physician. It is healthier for everyone to say without malice: “I don’t know; it’s not a job I’m well trained for.
Instead of just another voice in pain saying, “It’s wrong. And I’m tired, morally hurt, exhausted and sick”, as are the people I work with, I would like to offer some small but potentially energy-saving advice to allow us to continue doing the work we are supposed to do. .
Don’t make MacGyver the social ills of your community or your emergency department. If someone asked you to repair a combine engine, you would rightly say, “I don’t know how to do it. I’d just spend hours tinkering around and it wouldn’t work any better. We should collectively say the same with emerging social determinants in our emergency department. Does the patient have no travel, money for a prescription, food, accommodation, clothing or a charger for their phone? You should definitely feel sorry for him, even offer him some good advice, but trying to deal with MacGyver’s social ills isn’t the job you set out to do.
Set limits on after-hours preferred pharmacies. Spend your shift fixing pharmacy errors from the last shift and trying to figure out e-prescribing failures at 2am when no one is open and people are changing residences and pharmacies, or ‘they have limits on which pharmacies honor their insurance, it quickly erodes the desire to do the job you know how to do. Send them all to one pharmacy, the one open 24 hours a day closest to the emergency department. It’s okay to set limits by saying, “We don’t honor after-hours preferred pharmacies.” Blame it on COVID-19; it’s not false.
Educate students, residents and staff on the value of prescribing, not on which drug is recommended by IDSA or on-call ophthalmologist EMTALA, but on which works at an affordable price. If you can display it throughout the emergency or manipulate your EHR to show the price on the electronic prescription, even better. I know there are regional variations, even among local pharmacies, but I don’t know why CAPE or a popular EM podcast hasn’t touched on the topic of the top 25 price savers for common prescriptions coming out of the box. ’emergency. These are emerging social determinants of health 101 over which we could exercise some control.
Avoid Party Prescriptions. Take the typical patient who comes to the emergency room, spends several hours and several thousand dollars at someone’s expense, uses advanced technology, considerable time and labor from dozens of highly skilled professionals, and receives sacrificial effort from empathy from housekeeping to X-ray techs and security (if you still have any). At the end of this massive, frenetic, complicated, costly and resource and time consuming effort, one must first ask oneself if he indeed got the right diagnosis (diagnoses?). (And that’s made easier by the fact that it’s most often if you’ve got it right and can allow the probably self-limiting disease to run its course.)
The next consideration is whether the patient really needs all of these scripts or are you trying to repay them emotionally (or pay yourself emotionally) by giving them something for the time, effort, and expense of diagnosing ” probably a virus”. “We know (or should know from our training) that Gabapentin, Flexeril, Tessalon Perles, PPIs, Bentyl, a Z-Pak, a steroid injection, and “trying an albuterol inhaler” are all part of it. of a rather worthless but very expensive therapeutic drama. which generally proves ineffective, especially for the substantial category of giving something we see every day.
Practice setting boundaries to try to please people for what they desire because they heard about it on TikTok or their aunt is a nurse. Instead, politely offer expert scientific medical advice that they don’t have to follow. It’s fair to say that this disease course has not been shown to benefit from CT scans, lab work, IV Dilaudid, antibiotics, or anything they can buy over the counter. It doesn’t matter if they paid a lot of money and time for the truth. And having a professional spine is also good for your health.
We are the fastest and most elite riders in our lane. We are committed to helping our patients’ medical conditions at the bedside. We should stay on this path. When we go out on the streets in territory and in conditions where we are not trained to drive, we are not really solving the patient’s problems and we are driving ourselves crazy. Doing our job well and being good at our job begins and ends with doing the job well that we set out to do.
Dr. Mosleyis an emergency physician in Wichita, KS.