The U.S. rings the bell on health care spending, and some point fingers at patients themselves.

But why do patients choose the paths they choose? Just about every shift, I and my coworkers shake our heads, and wonder what may be driving our patients’ decisions. Parents who haven’t yet tried a drop of acetaminophen bring kids in at 2 a.m. with fevers. Patients show up with nose bleeds that have already stopped bleeding out in the car. Sprained ankles roll in by ambulance.

ER old timers (I guess me too now) can often be heard saying “when I was a kid there’s no way my parents would’ve taken me in for that.” It’s easy to blame patients. However, I suspect more forces are in play.

One big one is litigation anxiety. Patients call the ER all the time with simple questions, which are generally met with: “I’m sorry I can’t diagnose you by phone. If you would like to be seen, you will have to check in. Otherwise, you’ll need to see your primary.” Who can blame them for showing up with that kind of reply, especially when their PCPs are booked out for months?

Fear of litigation out in the field is another factor. During my residency, we helped to provide medical coverage during the New Mexico state fair each year. As you may expect, alcohol was quite popular. Anyone in the crowd who overshot the mark was planted each night in a small barn with hay. The next day they would essentially bloom, then stagger on home. More hay was added in prep for the next night’s seedlings. Unfortunately, not everyone woke up as planned. So the hay was eventually replaced by ambulance or police rides to ERs.

Today, you’d be lucky to get a peaceful drunken nap in your own bushes without a well-intentioned neighbor calling 911 that could potentially summon police, fire and an ambulance. If you awaken in time, and don’t particularly want the ride, you can’t just say no thanks. “Sign AMA here please.”

Then there is EMTALA. Say you’ve never been to an ER before and you just have a quick medical question. “Do you think this may need a stitch?” That’s not an option. You’ll need a medical screening exam. If do-gooder ER doc Sam steps into the waiting room to hand out some free advice, he risks being fined, maybe fired.

How about school clinics who won’t let kids back without a medical note? Or employers who require work slips? How about our drive to find an acronym for every malady, and a corresponding pill … along with all the nightly “ask your doctor” commercials? How is it that ibuprofen prescriptions through ERs cost less for some patients than over the counter prices at pharmacies? Why isn’t Zofran OTC yet? I wonder what kind of spending dent that alone could make.

Subconsciously, I wonder how much our language itself could be a factor. “You’d better go see your doctor for that.” You go to the clinic, the public health department, the lab, the imaging center, the urgent care, the ER, the rehab, etc. There’s just so much travel and expensive transport in modern medicine. “I think I’ll ring my doctor for a house call.” Sounds very 20th century, doesn’t it?

However, at the center of this immensely expensive flywheel, and the fuel that keeps it spinning, is the money itself. There are simply a lot of people making a lot of cash within our system. Every medical question activates thousands of micro-monetized gears. Instead, when patients stay home and call or text me to ask what’s best for a sore throat, and when I reply, “Ricola, ibuprofen, chicken soup, lots of rest, and have a nice day,” we are essentially short-circuiting a multi-trillion dollar enterprise.

Patient decision making is certainly a factor that has led to our remarkably expensive Rube Goldberg health care machine. But digging deeper behind our patients’ eyeballs, I suspect their decisions are often fairly rational within a remarkably wacky system.

Sam Slishman is an emergency physician.

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