Why ERs and PCPs aren't enemies
Bertha (not her real name) is a patient at the Cambridge Health Alliance, a safety net health system just outside of Boston, MA, where I work both in leadership and as a family doctor. She was put on my schedule by my team because her neck pain wasn't getting better and was beginning to affect her performance at work.
An emergency room physician and the physician assistant on her team at our clinic had already seen her and given the appropriate medications and recommendations, but the pain always came back. They had both asked Bertha about stress, but she demurred each time other than to say that her son had some billing problems with the hospital that she was worried about. At this point, all she wanted was a form filled out to take a leave of absence from work so she could heal.
“There weren't any medical red flags in Bertha's case, plus she had given up”
There weren't any medical red flags in Bertha's case, and I could have played with the medications she had been given and seen if a slightly different one would be more effective, but pills are infrequently the answer to something that has been going on for so long. Plus, she had given up – she was asking for time off work rather than another treatment.
I was the third medical professional to ask Bertha about stress that could be contributing to her pain, but again, she hesitated. Luckily, I can be stubborn; I sensed there was something more, so I asked the question from a different direction. When I asked about her family, she began to confide in me about private concerns about her family, bills piling up, walking to work to save on gas, and not being able to sleep — even with the prescribed muscle relaxants — because she was so worried.
By then, her visit had lasted 23 minutes, and I had to move on. I asked if she wanted therapy, someone to talk to about all these emotions which have gotten stuck in her neck, but she said she didn't have time and that she felt better just having talked about it. I gave her a note for a few days away from work and convinced her to let our community mental health partner call her before she went back to work. Another community health worker could review her finances with her and see if we could alleviate that stress.
Fast forward a few weeks, and Bertha let us know she no longer needed months off work to continue healing. She hadn't returned to the ER, and she was making some progress with the financial strain on her family, thanks to help from the team. This sort of collaborative effort is such improvement from a decade ago, but it still took more time than I normally have in a visit to figure all of this out. It was the trust established between us, her faith in the team I work with, and my knowing her well enough to sense there was more to the story that helped get to the bottom of her pain.
At CHA, every provider receives an email and a message through our electronic medical record system whenever a patient goes to the emergency room. We also have shared care plans for our more complex patients, allowing patients to hear the same plan in both places and helping them make the changes needed to avoid unnecessary care. It's entirely possible that if I hadn't received these messages about Bertha's visits to the ER that I would have missed the bigger picture; working with the information provided by the ER helped me figure out a plan to address Bertha's immediate pain and the bigger-picture problem.
“It's often seen as a failure of primary care when patients go to the ER, but it doesn't have to be”
It's often seen as a failure of primary care when patients go to the ER, both on the part of the doctors for not accommodating our patients and the patients for defaulting to an ER for relatively simple problems, but it doesn't have to be. PCPs in the United States are under cost-cutting pressure to reduce ER visits for our patients while also adding services like extended hours, same-day access, and telemedicine.
Health insurance that allows patients to choose their own PCPs is essential, but clearly this isn't enough. Even in countries where primary care is both financially and operationally accessible, ER visits remain high. The UK has hit upon a unique solution; there, the cost of an ER visit is little more than a visit to a clinic. This allows the patient to make the choice right for them in the moment and to get quick treatment for an immediate problem while taking pressure off the primary care site.
Bertha's case is just one example of how communication between the ER and a patient's doctor can help guide patients to get longer term interventions when needed. It's more than telling a patient to get checked out by their PCP following an ER visit; it involves shared care plans, communication, and coordination between the ER and primary care sites. Bertha's story in this context is actually an unqualified success. We can trust our patients more than we think, and we must also trust ourselves to set up systems that respect those choices and give health professionals enough time to listen to what is really needed.
Kirsten Meisinger, M.D. is Director of Provider Engagement and Regional Medical Director at Cambridge Health Alliance.