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Emergentology: Self-Sufficiency and Medical Helplessness

Walker, Graham MD

Emergency Medicine News: May 2016 - Volume 38 - Issue 5 - p 8
doi: 10.1097/01.EEM.0000483175.58350.ba
Emergentology

Dr. Walkeris 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://appstore.com/mdcalc/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him @grahamwalker, and read his past columns athttp://emn.online/EmergentologyEMN.

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I recently came across an interesting New York Times article reporting on a study that concluded that urgent care and drop-in retail clinics are largely unnecessary and not worth their cost to the health system. (http://nyti.ms/1QDz04K.)

The article cited executives in favor of the clinics, but did not interview the individuals who actually work there. The gist of the article was these places mostly just increase health care spending without really providing any quantifiable benefit to the average patient. The reason? Had these patients not gone to the retail clinic, their complaints were typically minor enough that they would have gotten better on their own.

Some health care economists talking about rationing actually report that a little bit of a waiting list is actually a good thing. (Emphasis on the little bit.) Round-the-clock, immediate access to every test a physician or patient wants leads to overtesting, and waiting a few weeks for an elective test (research often looks at access to MRI) is better for care overall. Why?

Many of the people on that waiting list for a nonurgent knee MRI will improve on their own and cancel their test. They got better, or they don't need or want it anymore. A waiting list selects patients who are more likely to have a significant disease that makes it difficult for their body to heal easily on its own and a higher likelihood that the patient is going to benefit from the test in the first place. Imagine if we did stat MRIs on all knee pain. We would find plenty of meniscal and ligamentous injuries, but surgically repairing every one we found would certainly lead to more medical harm than good.

We are familiar with this in emergency medicine, and urgent care centers and retail clinics see these complaints in spades: sprains, strains, contusions, minor head injuries, styes, conjunctivitis, URIs, bronchitis, otalgia/Eustachian tube dysfunction, otitis media, sore throats, post-viral coughs, and most rashes. Add illnesses that could be treated with over-the-counter medicines (GERD, constipation, many fevers, and viral illnesses, etc.), and you could probably generate a pretty huge list of diseases that really shouldn't be seen in an emergency department.

But let's not just stop there. These are often diagnoses that rarely need to be seen by a health care provider at all! I would guess if you watch those diseases for a week or so, the vast majority would improve on their own, some would have lingering symptoms, and some would get worse or progress and prompt a visit to their physician. (I know that patients don't know their diagnosis, just their symptoms. Don't worry; I'm getting there.)

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24/7 Wellness

Just like that Louis CK bit on Conan about how impatient our society has become with technology (an absolute must-watch if you haven't seen it: http://bit.ly/1mFLxbH), society has become impatient with their own bodies, too. We have been led to distrust our bodies and seek medical care for all symptoms. Even worse, we have built a society that teaches people to expect wellness 24 hours a day, seven days a week. (And, I might add, expect wellness while eating processed junk and fortified sugar from the comfort of our couch, barely exercising, and just popping a pill instead.)

We want our bodies to heal us faster than they can. We want colds to last no more than three days and ankle sprains to get us back to our half-marathon training by the weekend. We expect our bodies only to be vehicles for pleasure, enjoyment, and function, and we think any limitations or out-of-the-ordinary symptoms are a sign of medical dysfunction. It's a notion that aches and pains are pathologic, as opposed to the normal ups and downs of a human body living in today's society. We assume that we are all guaranteed a life free of pain, suffering, and disease until we die peacefully in our sleep when we are 100 years old.

We obsess that our bodies are secretly harboring disease, that all symptoms must have a clear cause, and that any symptom is cancer, a heart attack, or a stroke. We think we are above average and that we are that one percent with the super-uncommon presentation of badness. “My neighbor's sister's daughter went to the doctor for toe tingling, and it was actually a brain tumor!”

I think, unfortunately, we in medicine have failed (and are failing) to teach not just our own patients but our entire society what to expect from a life, how to manage common illnesses and complaints, and when to seek medical attention. And by ceding these educational necessities to Hollywood and making “edutainment” the standard way people learn about life, death, sickness, and health, we are not only giving them unreasonable expectations and learned helplessness, but we are shooting ourselves in the foot by not giving them tools to manage at home.

By letting Dr. Oz and “The Doctors,” and “House, MD” teach people health management and self-care — when their mission is actually to entertain and sell products through advertising and not provide clear and concise medical information — we are teaching our own families, neighbors, and populace to depend on the physician to tell them their runny nose will be better in about seven days and to get lots of rest and hydrate, as opposed to just knowing that information outright.

Minute clinics are just a response to the problem. Americans were never given basic, clear information about how to cope with being a good ol' normal human and they don't how to contrast that with suspecting something else might be going on and to seek proper, timely medical attention.

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