Access to What?

Over the past decade, Americans are turning more and more to hospitals for care, continuing a trend seen over the last several years. For example, in 2003, hospitals saw more than 34.7 million inpatient admissions and nearly 111 million emergency visits - an increase in emergency visits of 11.6 percent in five years. This occurs in the context of reduced numbers of hospitals receiving emergency patients. Any ideas about why this is?

Diversion

This week, we're going to be wrestling with the difficult topic of access to care. There is a lot of attention on this issue that will only increase as the economy continues to sour. In emergency medicine, the conversation centers on diversion - or when it's appropriate to send patients to other hospitals. Please follow each of the links below to supplement your reading for next week.

Is it wrong for a university hospital to turn away a patient because he doesn't have insurance? What if it was a kid attacked by a pit bull? There's been a big splash in Chicago about a child with dog bites to the face being sent home to follow up at a different hospital. The situation has drawn criticism from the American College of Emergency Physicians, but the University of Chicago is defending its position to divert uninsured patients. This story's juiciness is enhanced by the direct connection between Michelle Obama and hospital’s Urban Health Initiative (UHI), which has as its goal to divert non-emergency patients away from EDs. It’s supposed to make the system more efficient by freeing up ED staff to treat the most urgent cases. But ACEP likens it to dumping unprofitable patients.

As the newspapers and ACEP present it, this policy clashes with one attraction for choosing a career in emergency medicine: being part of the urban health safety net. But shouldn't innovative solutions for improving access to medical care be implemented from within the ED? I didn't hear much about the UHI when I interviewed at the University of Chicago, but in a recent email to applicants, the U of C emergency medicine residency program director did say that resident training will actually not be very much different because of the University's policy. This makes a lot of sense, given that training occurs at four hospitals around the city and there are always patients in urban ED waiting rooms. As one of my friends (a student at U of C) points out, it is important to see both sides of this story. It sounds like the medical indications (not sewing up an animal bite wound because it had a high chance of infection) won out against the contextual features (it may look bad in the newspapers to send someone home with a loosely approximated animal bite wound).

Week Eight Online Challenge

"Nobody's Perfect!"

So goes the saying to console friends and colleagues when we fall short of goals or expectations. Personally, I have the feeling that in medicine, not being perfect isn't good enough. For this week's challenge, we're inviting you to do one of two things:

1. Write an account of a mistake you made or observed in a clinical setting. You may simply describe the mistake or reflect upon it by listing implications, detailing feelings or citing the ethical principles at stake.
2. Answer this question: What is different about mistakes made by health care providers that makes us uncomfortable to admit to them?

My contribution requires you to go to a different website. Last July, I made a mistake in the ED that was an amazing learning experience. Read it here then find your way back to post your own comment.

Week Seven Online Challenge

This week's online challenge is more of an assignment. We haven't assigned much reading this week in the hope that you'll be able to read a little bit on line.

Visit ethnomed.org and read about one of the four following ethnic groups: Karen, Hmong, Somali, and Oromo. Choose a group you're not familiar with. Think about how family structure or culture-specific health issues might influence your interaction with such a patient. What would be different about your ED interaction with a patient from one of these groups? What additional resources would you need? Would your approach to care differ? If you can't think of a reply that is specific to the ED, post an interesting fact from what you read to educate the rest of us about a new culture.

Also, if you are not familiar with The Spirit Catches You and You Fall Down, by Anne Fadiman, here is a case (set in the ER) from that book that you will benefit from reading. (Click HERE!)

Finally, if you have time for some additional reading, consider following links to two other articles I found interesting during my own preparation for this week.

Conceptions of Pain Among Somali Women. Finnström B, Söderhamn O. J Adv Nurs. 2006 May;54(4):418-25.

Principlism vs. Narrative Ethics. McCarthy J. Med Humanit. 2003 Dec;29(2):65-71.

Week Six Online Challenge

This week's topic is Sexuality and STDs in the ED. There is no way that we will be able to cover all of the potential topics in our first hour's case and discussion. This is a topic that should not be new; I suspect that everyone in the class has either witnessed or discussed dilemmas related to gender, sexual health, terminations of pregnancy or harassment. This week's challenge is for you to practice setting up a dilemma.

In about 100 words, write a case related to STDs or sexuality. Be sure that all personal identifications are obscured, and give us a title that identifies your case.

Don't analyze the case for us, but when you write a case, it's important to be aware of which principles, rules or laws are central to its analysis. The case need not be set in the ER, nor need it be based on a personal story. It could even be a few sentences. Consider writing about something you have experienced OR something inspired by any of the readings.

Do the Right Thing

Last week the New York Times' senior health reporter (Pauline Chen) wrote an article highlighting some of the tough situations doctors and nurses find themselves trapped by in the current health care system. It highlights some of the same issues we've been talking about to date. Does the article jog any of your thoughts? Could you see the moral confusion involved in the situations described? the moral sadness?

(This is the same article Dr. Cooper emailed a link to earlier this weekend.)

If you come across any ethics- or emergency medicine-related stories this week, we'd encourage you to post them here!

The Dilemma of Reporting

Last week's class discussed privacy and confidentiality in the emergency department and next week will address topics in sexual health. By coincidence, this month's issue of Virtual Mentor is written about Professional Responsibility in Preventing Violence and Abuse. In particular, the cases and articles about youth and partner violence are very good. If you're interested in keeping up reading about ethics, I'd encourage you to check each month's issue. I'll actually be putting together an issue about ethics in emergency medicine for June of 2010...

Octs???

Have you heard about the octuplets born in Northern California this week? It's not exactly an emergency medicine case, but it does raise a large number of issues in medical ethics. A report today in the Washington Post does a good job, I think, of outlining the criticisms and principles involved here. What do you think?

HIPAA

Privacy, HIPAA and confidentiality are pretty easy to understand, right? My response would be a resolute, "Yes and No!" If you are inclined to want to know more about this topic, here are some resources.

The Health and Human Services Department's HIPPA Information Page
A specific overview of HIPAA privacy issues (in .pdf)
The UW Bioethics page about confidentiality

Update: I added this late required reading from the Iserson Ethics in the ER text to help us all hit the ground running on Wednesday. It is temporarily viewable on my personal webpage until we can get it on the secure class page.

Week Five Online Challenge

Our next topic is confidentiality. Your first thought probably is of HIPAA - that is probably what should come to mind. This week's challenge asks you to write about your own experiences with confidential medical information - in the ED or elsewhere.

Write a personal vignette of a time when you or someone else on the care team breached or almost breached a patient's right to confidentiality. Some things to write about include: What was the situation? Did you or anyone else do anything about it? How might this be avoided in the future?

I'll start off with one of my own stories in the first comment.