I am an emergency physician in training. It’s a thrilling and rewarding job learning to treat the severely ill and injured. But it is also a rare clinical shift when I don’t treat patients with life-limiting alcohol and drug addiction, people struggling with homelessness, those whose behavior does not allow them to safely be in a shelter with others, undocumented immigrants with nowhere else to turn for aid, uninsured patients who cannot receive outpatient care or children and adults with acute psychiatric emergencies. Treating these types of patients in the emergency department results from our current health care “system,” driven by for-profit insurance companies, reimbursement disincentives, and current state and federal legislation.
After many years of ever-widening clinical practice, the term “emergency medicine” has become inadequate to describe our specialty. I propose changing the name to one that better reflects the daily reality in American emergency departments: safety net care & emergency medicine. Though in some sense still lacking, this name better encompasses the care we provide–to both those who are socially most vulnerable and those who emergently seek care on their most vulnerable day.
But what’s in a name? A change in nomenclature would help force our specialty and the health care system around us to address the failings that have led to our current state.
Pointing the finger at ourselves first, we are woefully underprepared to care for the ever-rising number of psychiatric complaints we deal with daily, particularly in the wake of the COVID-19 pandemic. We need additional training and infrastructure to care competently for these psychiatric patients. Some we can send home, but they have no realistic chance of seeing a psychiatrist with any immediacy. Most of these patients, though, will linger in our departments for days on end, waiting for a bed in a psychiatric hospital. We need to treat them, too, not just warehouse them. Similarly, we need to better manage medical patients who we can send home but don’t have the ability to promptly follow up with a primary care doctor.
Moreover, I hope this name change allows our colleagues from other specialties to understand better our role in the system and the pressures we face in the emergency department.
“Yes, Dr. Hospitalist, I understand that we can’t say this homeless patient’s cellulitis has technically failed outpatient treatment. But he couldn’t afford the antibiotics I prescribed him a week ago when he first sought care, so I believe admission is the best way to practically treat his progressively worsening infection.”
Additionally, I want this change to exert pressure on state and federal officials to address the societal and legislative failings that have made emergency departments the last hope for some patients to seek non-urgent care, be it medical, psychiatric, nutritional, environmental, or otherwise.
“Yes, Dr. Hospitalist, I know you don’t have a billable indication for hospitalization for this physically disabled patient whose house is being condemned. But I’m not able to send them home tonight under these circumstances.”
This should also signal to hospital administrators and contract management groups, who measure emergency physicians’ performance in productivity and profit, that the care we provide does not neatly fit into the metrics we are professionally evaluated on and compensated for. True recognition of our role as a safety net would prompt a restructuring of our current productivity and compensation schemes to include patient-centered metrics as a core measure of our care.
Practicing safety net care is an honor, but I wish it were unnecessary. We need the language to identify and address the failings within and outside of health care that have led to safety net care being a substantial portion of the emergency physician’s practice.
Jordan Hughes is an emergency medicine resident.
