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Emergentology: Apples are to Oranges as the ED is to the Clinic

Walker, Graham MD

doi: 10.1097/01.EEM.0000513580.26789.08
Emergentology

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at http://bit.ly/EMN-Emergentology.

One of the many things I like about being a member of the Permanente Medical Group, the physician group that provides care for Kaiser Permanente patients, is that our leaders see EPs as adept members of the team. My colleagues in other specialties do, too (for the most part). They know we're pretty good at sorting things out if they need help diagnosing a patient or coming up with a management plan. We'll occasionally even get calls from urgent care: “Hey, you guys see this all the time. What should I do?” The constant barrage of patients, phone calls, and referrals is certainly high praise, but on some shifts I could do without all the compliments.

A few of us started working shifts in our minor injury center when we opened a new medical office across town because we're appreciated as the versatile, jack-of-all-trades physicians. We also provide consults to our colleagues in the building (“Does this guy need to go to the ED for his cellulitis?”), respond to syncope and other emergencies, and facilitate transport to the ED.

I've worked a fair number of these shifts, and the variety is certainly similar to the ED, but the patients themselves are vastly different. I'll see a clinic patient with a chief complaint similar to one we might see in the low-acuity section of the ED — back strain, rib contusion, or jammed finger rule-out fracture. It's a pretty good mix of work, but the similarities end there. I almost never see “hand on the doorknob” syndrome in the clinic. This is when you've wrapped up your history and physical exam for a patient with two weeks of eye pain, and just as you're about to leave, an obese diabetic patient with three stents says, “Oh, doctor? What about the crushing chest pain I have when I walk up the stairs?”

The patients in the clinic are typically straightforward, and have one extremely simple chief complaint. The injured clinic patients don't have chest pain and stomach pain and right foot tingling and a chronic cough and facial pain. Admittedly, there's bias at play here: I'm not seeing patients as a primary care physician; I'm seeing them for minor injury. It's right there in the name of the facility.

These patients are typically satisfied with my plan and diagnosis right off the bat. My typical ED spiel of “I'd recommend you take some ibuprofen for the next three days for your sprain, and ice and elevate your ankle” is often met with “I need something stronger for my pain, doc. Ibuprofen doesn't work on me.” I have had to strongly recommend ibuprofen to clinic patients because they “just don't like taking pills unless it's absolutely necessary.” Patients in the clinic also genuinely appreciate the care they've received. I typically hear multiple thank-yous by the end of a brief 10-minute visit. I can easily go hours in the ED without hearing a word of thanks.

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Venn Diagram

I have to say clinic patients just seem a little more normal. There are certainly less high highs and low lows in the clinic than in the ED. I thought this must be a fluke when I first started working in the clinic. “Why am I getting all the nice patients? Where are the unreasonable people? Where are the ones who won't give you a straightforward history or won't get off their cell phones?”

I've realized that clinic patients are not the same people who typically show up at the ED. If you tried to Venn diagram the two groups, there wouldn't even be as much overlap as there is in the Olympic rings! Remember in medical school or residency, you were reading some study about clinic patients and someone pointed out that “you can't apply this paper to ED patients because they're clinic patients, and clinic patients are different from ED patients?” I think that might be true.

Have you ever talked to an outpatient physician and told her a story about the patient who showed up to the ED for a pap smear, three years of tinnitus, and demanded their cholesterol be checked, and your friend almost didn't believe you? “Why would they go to the ED for that? It makes no sense!” It's because those behaviors are things only ED patients do. Your garden-variety clinic patients wouldn't go to the ED for a pap smear. ED patients are just different.

When I said clinic patients are more normal, I meant the day-to-day patients who come through the ED are usually sicker and frailer, older, less educated, poorer, less medically savvy, and more mentally ill, and their substance use is more common, they possess lower coping ability, and they are less medically compliant.

I'm painting with broad strokes here and have not done any research to back this up, but just the average ED patient with a back sprain seems markedly different from the average clinic patient with a back sprain. One can imagine that these ED patients are also much more challenging and expensive to treat, and, more importantly, lead to compassion fatigue (and burnout) faster.

Along with the many other challenges of our jobs (overwhelming decision-making, distraction, breadth, depth and scope of practice, weird hours, and a fluctuating schedule), could the patients themselves be contributing to our stress and burnout, compared with our outpatient colleagues? I worry the answer might be yes.

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