A Young Emergency Physician Appreciates the History of U.S. Emergency Medicine Through the Lens of China’s ERs

I’m a young emergency physician, part of the “new breed” that’s always known emergency physicians to be residency-trained and emergency medicine (EM) as a well-respected field. Being a leader in the American Academy of Emergency Medicine, I often hear of our organization’s leaders speak about the struggles they had in establishing our specialty, but I didn’t have a sense of what they actually went through. Why is that they so dislike the term “emergency room” and cringe at the reference to “ER doctors”?

It took a visit to China for me to even begin to understand the reasons. In August-September 2012, I traveled back to the country of my birth to study the current state of medical education here. My trip traversed 9 provinces and involved visits to 14 medical schools and over 50 hospitals.

Being an emergency physician who is interested in healthcare systems, I was particularly curious to visit the Emergency Departments there (we prefer this term and the abbreviation “ED”s to ERs for reasons I’ll speak about later). What I found is quite far from the EDs I know. In fact, everywhere I visited, from rural provincial hospitals in Inner Mongolia to major inner-city teaching hospitals in Beijing, had an emergency ROOM. That’s because patients were literally seen in a giant room, with beds pushed against walls and (if they are lucky) a curtain to divide the rooms. Extra patients were lined up along hallways, often six-deep.

Many places had triage to service, meaning that patients were triaged to a specific area to be seen by specialists who came through the ER. So internists would see patients designated as having medical problems, surgeons would see patients thought to have surgical problems, etc. If the patient turned out to a different problem than was initially decided, a long discussion would take place before the patient was transferred to the correct part of the ER.

Since China is a densely populated country, many hospitals had serious issues with overcrowding. Not surprisingly, the biggest problem seems to be with patients waiting for a hospital bed—basically, boarding.

“Do you often see patients waiting for a bed for 24 hours?” I asked a doctor in a major Beijing hospital.

“24 hours? We are lucky if there’s a bed in 72 hours!” He went on to describe the difficulties he had with admitting an elderly woman with heart failure, diabetes, kidney problems, and liver cancer who came in with difficulty breathing. The cardiologists refused the patient, saying the problem was the kidney. The nephrologists declined, saying diabetes or cancer was the underlying problem. Oncology and endocrine stated the chief complaint was not mainly their issue. General internal medicine said the patient was too complicated. As a result, the patient stayed in the ED for the entirety of her care—a total of 30 days.

The emergency physicians I met attributed the problem of boarding to the lack of respect for the specialty. Though EM is a specialty in China, and there are EM residency programs in some cities, it is considered to be a specialty of last resort—for those physicians cannot make it in other fields. Most EDs are divisions that exist only under the auspices of “real” departments such as surgery and medicine. Attendings working in the ED are scorned by others, and fights over airway, chest tubes, and other procedures are frequent occurrences.

Hopefully, my fellow young American physicians are wondering what kind of backwards environment I’m describing, but many reading this column are probably thinking that this description is not too far from the reality they knew. Indeed, the road to becoming a specialty involves predictable stages. My generation takes it for granted that we are part of excellent training programs and will be specialists in a well-respected medical field. But it wasn’t long ago that our predecessors fought the same battles that China faces now, of specialty recognition, admission privileges, scope of practice, etc.

We young emergency physicians need to thank those who came before us for making our specialty what it is and paving the way for us. For creating the emergency DEPARTMENT (rather than the ER) staffed by emergency physicians (rather than ER docs). For ensuring safer and better care for our patients.

We must also recognize that while many problems have been resolved, many remain. Overcrowding and boarding continue to be problems in EDs across the U.S. There are continuing challenges to our scope of practice, and other specialties still question our abilities. Vocal groups still insist that there are other ways to become “certified” emergency physicians through alternative boards. The corporate practice of medicine remains a real issue for practicing physicians.

It’s imperative for young emergency physicians like myself to continue to find value for our specialty. China’s EM leaders have found creative solutions around their overcrowding and scope of practice by starting “E-ICUs” (emergency ICUs) and transitional care units (transition from E-ICU to home) and staffing “emergency inpatient” and observation units. As we look to the future of EM, we should be aware of our history, work to overcome ongoing problems, and continue to advance our specialty and improve healthcare, in the U.S. and internationally.

This article was initially published in AAEM’s Common Sense magazine. I welcome your comments!

6 Tips For Getting Your Doctor to Listen to You

Have you ever gone to the doctor and felt like he wasn't listening to you? Have you tried to tell your story, only to have him interrupt with a checklist of questions: do you have chest pain, shortness of breath, fevers, cough, and so forth? Have you ever felt ignored, and left thinking that your doctor never understood why came to him in the first place?

The New Year is the time to make changes in your health. If you feel dissatisfied or frustrated by your care, now is the time to figure out how to get better care.

Studies show that 80% of diagnoses can be made based on your history alone. Yet, doctors these days spend less and less time listening. “Cookbook medicine” is prevalent, with doctors resorting to checklists of yes/no questions rather than really listening to what’s going on with you. You have to make sure that your concerns are addressed—and even before that, to make sure your story is heard. Here are 6 tips for getting your doctor to listen to you:

Tip #1: Answer the doctor’s pressing questions first. Many doctors are so accustomed to relying on a checklist of questions that they have to get these answers before they move on. Help them out and answer these questions. If the doctor want you to describe the location of your chest pain, describe it (“it’s in the middle of my chest, right here”). If she want to know what you took to make it better, tell them (“I took an aspirin. It didn’t help”).

Tip #2: Attach a narrative response at the end of these close-ended questions. If your doctor persists on asking close-ended questions, add a narrative response at the end that may not so easily fit into a yes/no answer (“it’s in the middle of my chest, right here, and it started after I really pushed myself in swimming tonight”). Pretend that you are being asked “how” or “why” instead of “yes/no”, and add your own response. Look to make sure your doctor registers this answer—does he ask you more questions to follow-up on what you said, for example?

Tip #3: Ask your own questions. If you don’t understand why a particular question is relevant to your situation, ask about it. You may be surprised to find that the doctor herself isn’t sure and is only asking the question out of habit. On the other hand, you may find out that issues you wouldn’t have thought were related might actually be very important to discuss.

Tip #4: Interrupt when interrupted. If your doctor cuts you off when you try to explain your full answer, free to interrupt. Pretend you’re having a conversation, even when it feels like you’re being interrogated. For example, if you’re asked “when did headache start,” rather than responding “10am,” go ahead and tell your story of how the pain started: “I woke up this morning and I was fine, then I started walking to work and the pain came on suddenly like a lightening bolt striking me.” This is not a new tactic; lawyers will often coach clients in advance to answer yes/no questions with a narrative so that answers can’t be taken out of context. Interrupting is a way to ensure that your entire answer is heard, not just the part that the doctor thinks he wants to hear.

Tip #5: Focus on your concerns. If you get the sense that your concerns are being brushed over, interject, “Excuse me, doctor, I have tried to answer all your questions, but I am still not certain my concerns have been addressed. Can you please help me understand why it is that I have been feeling fatigued and short of breath for the last two weeks?” and so on. You can take charge of the conversation at that point. It’s your body and your duty to advocate for yourself if you don’t feel like your story has been understood and your concerns have been addressed.

Tip #6: Make sure you are courteous and respectful to your doctor. Your doctor is a professional, and is probably trying her best to help you. Your story has to be heard and your concerns addressed, but make sure you present your points in a respectful manner. This will ensure that a solid doctor-patient relationship is present, and is critical to the partnership you need to establish. 

You may be dissatisfied and frustrated by your medical care, but you can take control of your health care and transform your health today. I discuss more in my book, When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests. Try these tips on your next doctor’s visit, and build your partnership for better care.

Why Diagnosis is the Key to Your Health—And the Health of the Nation

May is a recent divorcee in her early sixties. She was working out at the gym when she began to feel queasy and lightheaded. She awoke in the back of an ambulance, and soon, she was in an E.R. getting blood drawn. “We need to make sure you don’t have a heart attack,” she was told.

As the day went on, May underwent test after test to “rule out” a heart attack, then a blood clot in her lungs, then a stroke. She was relieved when she found out that she didn’t have these grim problems, but she still had no idea why she felt terrible. By the next morning, she had developed a fever and was shaking with chills. It took until the end of the following day for doctors to figure out that the problem was a raging gallbladder infection. She had to undergo emergency surgery, where they found that her gallbladder had ruptured and was leaking infected fluid throughout her abdomen.

When you go to the doctor, you want to find out what’s wrong and how you can get better. In modern day America, though, what you will get are tests to “rule out” problems rather than figure out what you actually have. Patients go through x-rays and CT scans, get vials of blood drawn, and stay in hospital for days on end, then leave with a huge bill but little idea of why they feel sick or how they can get better. Not only does it leave them confused and feeling just as unwell, it often results in misdiagnosis because, as in May’s case, the focus was never on figuring out the problem to begin with.

Like the rest of America, our healthcare system has become morbidly obese. Costs are skyrocketing; we spend 18 cents of every dollar on health, a number that will rise to over a quarter by 2020. Millions of people are priced out of healthcare, with one in eight uninsured and far more underinsured. But our system is not just failing those who lack access to care. Those who have access are getting exposed to unnecessary tests with unnecessary side effects. People are going to their doctor and leaving without feeling any better.

In fact, they are getting misdiagnosed, and are suffering the consequences. Over 100,000 deaths due to medical error occur every year, and the majority of these errors are errors in diagnoses. There are growing movements to make medical care safer. I applaud these efforts to ensure surgical safety and reduce bloodstream infections, but the push for safety has to begin even earlier in the process, with getting to the right diagnosis.

Why is the diagnosis so important? First, it’s important for you to know what you have before you can treat it. You have to know what disease or process you have so you know what to expect, what to watch out for, and what you can do about it. Throwing medications at symptoms just masks them, but doesn’t get at the root of the problem. Second, not knowing what diagnoses are being considered is equivalent to searching for a needle in the haystack: it’s aimless and dangerous. Tests should be done to narrow down diagnoses, or else results are going to be obtained that don’t make sense, and you still won’t know what you have or what to do about it.

It took May a near-death experience and over a year of recovery to find out that the key to better to better healthcare hinges on getting the right diagnosis. In her case, all of the symptoms of a gallbladder infection had been there from the start. The problem was that the doctor was fixated on making sure she didn’t have other things—other problems that she didn’t even have symptoms for—and missed the boat altogether.

When you are next at your doctor, make sure you ask for your diagnosis. If the doctor is not sure, or wants to run some tests first before telling you, ask her for a list of possible diagnoses and the most likely diagnosis BEFORE you consent to the tests. Your doctor must have some thoughts on what you might have, and you should find out what that is (if she doesn’t have any clue, then that’s a problem too!).

Getting to the diagnosis is the first and most critical step to getting better, and you need to help your doctor help you. Only by ensuring that we get the best and most efficient care possible for ourselves and our loved ones can we achieve meaningful healthcare reform for the nation.