Emergency departments (ED) are open 24 hours a day, 365 days a year. Health conditions can develop or worsen at a moments’ notice, making the ED a necessary safety net for even the best healthcare systems. However, the very characteristic that makes the ED essential also leaves it open to abuse. When there is nowhere else to go it is an attractive location to bring the intoxicated, the homeless, the destitute – the people with nowhere else to go. Worse, occasionally it can seem like the ED is overwhelmed by seemingly healthy patients who are not patient at all.
These realities have led to the increasing prevalence of “patient-blaming.” A popular administrative response to ED overcrowding, especially in publicly funded healthcare systems, seems to be to tell patients to stay away unless they have a “true emergency.” Perhaps the best example is the Australian video “Keep Emergency for Emergencies” that recently went viral.
It implies that ED overcrowding is the result of low-acuity patients with “fake emergencies” – a conclusion that has been well-studied and found to be patently untrue [1,2,3] – rather than a systemic problem resulting from the health system’s inability to predict and meet demand. My own health region has not been immune from this line of thinking, having recently instructed patients on “proper use” of the ED.
The Canadian Association of Emergency Physicians (CAEP) frames ED overcrowding as a problem of ‘Access Block’:
“(Access block is) the inability of admitted patients to access in-patient beds from the ED.”
and asserts quite bluntly that:
“Contrary to popular perceptions, ED overcrowding is not caused by inappropriate use of ED’s, or by high numbers of lower acuity patients presenting to the ED”
While this does not make intuitive sense, it is true because low-acuity patients do not require a hospital bed and can generally be assessed and discharged quickly without contributing substantively to access block.
The problems with “fake” emergencies
It would be easy to conclude that having fewer patients in an overcrowded ED would be beneficial regardless of whether or not they created the problem. If that were the case this type of public service announcement would serve an important purpose. However, I think there are three problems with this conclusion.
First, sick patients often do not realize that they are sick. Over the past 6 months I can think of multiple stoic patients that I saw for general malaise (a condition that is not on any lists of “true emergencies”) that had serious pathology (e.g. myocardial infarction, hyperkalemia, diabetic ketoacidosis) requiring inpatient treatment. Our patients do not have the benefit of emergency health care training to help them determine what an emergency is and what it is not. In response to public campaigns inspired by the commercial above, these patients would have likely stayed at home because they “didn’t want to be a bother.” This decision would have been severely detrimental to both their health and the ultimate cost of their care.
Second, it puts the blame for overcrowding on our patients rather than our system. Beyond being unfair (and untrue!), this response has the potential to sour the attitude of already stressed healthcare providers towards low-acuity patients. Those that buy into this message could see patients as the problem, rather than our purpose, leading to dissatisfaction and poor care.
Third, it gets in the way of good care. In my (admittedly very short) emergency medicine career I have found that many of the patients who are perceived as abusing the system (and there certainly are some) do not think they are, do not want to be, or came in for another reason. Think of the patient with frostnip (who came in because he was worried that his ear was going to fall off), the recent immigrant with the flu (who did not know how to access primary healthcare), or the women with a headache (who was too scared to tell us that her spouse is beating her). In each case the assumption that these patients are “abusing the system” would result in worse outcomes due to missed opportunities for education and/or intervention.
New Concept: The Basic Assumption
Last year I attended the Comprehensive Instructor Workshop at the Institute for Medical Simulation, a course that puts substantial focus on the art of debriefing learners following simulation. One of the primary tenets of their course is instilling “The Basic Assumption” into attendees.
The Basic Assumption
“We believe that everyone participating in activities is intelligent, capable, cares about doing their best, and wants to improve.”
While at first glance this seems like a fairly standard motherhood statement, after conducting simulation debrief after debrief I have learned its value. Facilitators vary widely in their debrief style, but it is always clear that the best of them believe in the integrity of their learners. Their debriefs are more enlightening, honest, and educational as a result. Seeing this led me to make The Basic Assumption a central tenet of my educational philosophy.
Combining this with my observations of some of my most admired mentors led me to a striking realization: in the same way excellent facilitators assume the best about their learners, excellent emergency physicians assume the best about their patients. Noting this, I rewrote The Basic Assumption to change its focus from learners to emergency department patients.
The Basic Assumption about Emergency Department Patients
“We believe that every patient presenting to the ED is honest, cares about their health, and needs our assistance.”
In the same way that this leads to optimal educational interactions with learners, believing in the integrity of our ED patients will lead to better care for them and a longer and more satisfying career for me. Just as the Center for Medical Simulation embraces The Basic Assumption for their trainees, I would love to see ED’s embrace it for their patients.
Working in an emergency department is a difficult job. Even when the department is spilling into the nearby Tim Hortons we do not turn anyone away. After resuscitating a young trauma patient it can be difficult to have patience for a low-acuity patient requesting a prescription refill. However, a better understanding of the underlying causes of access block and ED overcrowding can help. I am encouraged to know that my health region will no longer ask the public to avoid the ED. Instead, we are working to find ways to connect patients with the resources they need – even if it means coming to the ED while we figure it out.
I hope backlash against the inaccurate and harmful “Keep Emergency for Emergencies” commercial and campaign will lead heath care leaders to a similar conclusion in Australia. After all, “these patients are honest, they care about their health and they need our assistance.” If we can find it in ourselves to greet each and every patient with this assumption, I believe we will be more satisfied with our jobs and provide better care to our patients.
Please share this post if you agree with its sentiments as BoringEM does not have the budget to make such a snazzy video in response!
Expert Peer Review: This post was reviewed by Drs. James Stempien (@docstemp) and Mark Wahba (@mywahbaMD).
- Affleck A, Parks P, Drummond D, Rowe BH & Ovens HJ. (2013). CAEP position statement: Emergency department overcrowding and access block. Canadian Journal of Emergency Medicine, 15(6), 359-370. DOI 10.2310/8000.CAEPPS [Link]
- Canadian Health Services Research Foundation. (2009). Myth: Emergency Room Overcrowding is caused by Non-urgent Cases. [Link]
- Picard A. (2015). What’s really to blame for ER congestion? The Globe and Mail. [Link]
- Lalani N (2012). LWBS – ER Inpatients – EMS Park – Overcapacity. ERMentor Blog. [Link]