Emergency Rooms
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The emergency room has become the “physician” for many patients. Patients who cannot find a physician at night, or who don’t know where else to go are coming to emergency rooms with increased frequency. The typical emergency room is now filled with nonemergency cases. Trivial illnesses which could have been treated with the aid of this book, routine problems more easily and economically handled in a physician’s office, specialized problems which should have been seen at a time when the hospital facilities were fully available, and true emergencies are all mixed together. Even though the emergency room is not designed for the purpose it now serves, it does a surprisingly good job of delivering adequate care.
However, there are major disadvantages to an emergency room as the sole medical contact. Emergency rooms make little or no provision for continued care. In the emergency room you will usually be seen by different physicians. The emergency room physician will attend to the chief problem reported by the patient but seldom has sufficient time to complete a full examination or to deal with underlying problems. While simple x-ray facilities are available, procedures such as gallbladder studies and upper G.I. series are arranged with difficulty. Thus, evaluation of a complicated problem is not well handled by the emergency room. When a true emergency occurs, patients with less urgent problems are shunted to the end of the line. You cannot estimate with any certainty how long it will take you to be seen in an emergency room. Emergency room fees, because they support equipment required to handle true emergencies, are higher than those of standard office visits. Emergency room services are not always covered by medical insurance, even when the policy states that the costs of emergency care are included. With many policies, the nature of the illness governs whether or not it is covered. You may end up paying a large bill if you go to the emergency room with a sore throat.
The smoothly functioning emergency room is a dramatic place and provides one of the finest examples of a service profession at work. Using the procedures outlined in this book, you can use this valuable resource appropriately
Know When To Use the Hospital
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The hospital is expensive. It is not home or hotel. It saves lives and it takes them. It must be used and it must be avoided. To manage these contradictions, the need for hospitalization for you or your family must be carefully considered in each instance. Don’t use the hospital if services can be performed outside the hospital. The acute general hospital does acute general medicine well; it does not do other functions well. Don’t use the hospital for a rest; it is not a good place to rest. It is busy, noisy, unfamiliar, and populated with strange roommates. Its nights are punctuated with interruptions, and it has an unusual time schedule. It has many employees, a few of whom are less thoughtful than others. Don’t use the hospital for the “convenience” of having a number of tests done in a few days. It does not provide tests in the most efficient manner; indeed, most laboratories and x-ray facilities are not open on the weekend, and special procedures may require several days just to be scheduled. Many have urged that we have a system of “hcptels,” which provide lodging at minimal cost, allow for efficient test performance, and are appropriate for periods of rest and minimal activity. A number of experiments along these lines are underway. Until more appropriate facilities are available, however, use the acute hospital with great reluctance. A century ago, the Hungarian physician, Inaz Philipp Semmelweiss (1818-1865J, noted that both infants and mothers delivering at home fared better than those in the hospital and that the existence of often fatal “childbed fever” was one of the risks of the hospital. This problem, due to poor hygiene in the delivery rooms, has long since been corrected. But in our
present age, new evidence suggests that for many conditions home treatment may work better than treatment in the hospital. For example, treatment for minor heart attacks at home has been reported as possibly better than treatment in a hospital. It is apparent to most hospital visitors that the crisis atmosphere of the acute hospital does not promote the calmest state of mind for the patient. Many therapeutic features of the home cannot be duplicated in the hospital.
Right Hospitals
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The private or community hospital is the most common hospital facility in the United States. These hospitals are usually nonprofit, and contain from 50 to 400 beds. Sometimes they have been financed with funds from doctors practicing in the area. More frequently, nonprofit organizations aided by government funds for hospital construction have financed the facility. The quality of care in these institutions is largely dependent upon the physician in charge of your case. Relatively few physician actions come under serious review. There is not always a physician in the hospital around the clock. Nevertheless, private hospitals usually give personalized care of high quality. The hospital is quiet and orderly. In the great majority of cases facilities are adequate for the care required.
Public hospitals include city, county, public health service, military, and Veterans Administration hospitals. These hospitals are generally large, with from 500 to 1000 beds. They have permanent full-time staff, and physicians are present in the hospital at all times. Usually, they have a “house staff,” with interns and resident physicians available around the clock. As befits their larger size, they offer more services, and frequently have associated rehabilitation units or nursing homes. Activities in the public hospital are more visible, and the efforts of each physician are scrutinized by others. The quality of care you receive depends upon the overall quality of the institution. The presence of interns and residents may pose some minor inconveniences to you as a patient, however, their presence is an excellent guarantee of good care. The physician-in-training has patient care as his or her primary responsibility, and is not greatly involved with office practice and administrative tasks.
Many public hospitals have the reputation for providing service to E poorer economic class. Within the community, they are often perceived as offering substandard service. Usually, these accusations are grossly unfair While not always quiet and orderly, and often not physically attractive these hospitals give dependable and excellent care. When available, they should be seriously considered by individuals in all economic classes. The teaching hospital is one associated with a medical school. Teachin~ hospitals are large, with a range of from 300 to 2000 beds. These hospitals always have interns and residents and additionally have medical students on the hospital wards. They have superb technical resources, and it is here that the most extraordinary events of medicine take place. Open-hearsurgery, transplantation of kidneys, elaborate nurseries for the newborn, support for management of rare blood diseases, and other marvels are all available here. Dozens of people may be concerned with the wellbeing of a particular patient. Crucial medical decisions are thoroughly discussed, presented at conferences, and reviewed by many personnel. On the other hand, the quality of personal relationships at teaching hospitals is variable. Many patients feel that they are treated in an impersonal way, and that their laboratory tests receive more attention than their human and social problems. Since these institutions are on the frontier of medicine, there is a tendency to emphasize the new and elaborate procedures, when older and more modest ones might have served as well. With the inexperience of some members of the care team, there is a tendency to order more laboratory tests than would have been ordered for the same condition in a private hospital. The sick patient is sometimes confused by having to relate to a large number of doctors and students. Medical educators are concerned with such criticisms, and have moved to correct some of the problems. However, some excesses of technological medicine still occur in these institutions.
Right Medical Facility
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A wide variety of medical facilities are available to prospective patientshospitals, emergency rooms, convalescent homes, and clinics. There are choices for most tastes and for the satisfaction of most individuals. It’s important to know the facilities in your area and to make your choices before you need the services. To select the best facilities, you will need to understand the terms “primary,” “secondary,” and “tertiary” care. Primary medical care is provided by a physician at the office or at an emergency room or clinic. It is care which may be obtained by a patient without the referral of another physician. It is often called “ambulatory care” or “out-patient care.” Secondary care is that afforded by the typical community hospital and the physicians involved may be specialists or subspecialists. As a rule, access to this care requires the referral of a physician. Much secondary care is “in-patient” or hospital care. Tertiary care includes special and extraordinary procedures such as kidney dialysis, open-heart surgery, and sophisticated treatment of rare diseases. This type of care is found at university affiliated hospitals and regional referral centers. When you select a medical facility, you want close primary care with good access to secondary care. Tertiary care is often a great distance from your home, and may never be needed during your entire lifetime.