Wednesday, February 25, 2009


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).


  1. In a way, we do this already.... we just do it in a more passive way.

    If someone comes in on a busy day and is not really EMERGENT... they end up in the waiting room. Maybe for 3 hours. Maybe they leave. They definately get some time to decide if it is worth the wait. This sort of self-selects against people who aren't really that sick. But clearly it is not the most efficient way to weed out non-emergencies.

    It is kind of refreshing that this hospital is actually trying to solve problems in an up-front way.

  2. I agree with what Cameron said about already doing this. My friend recently went to the ER here for abdominal pain. She waited in a room in the ER for 9 hours before she was finally admitted to the hospital. In the dog bite case, it seems like it is up to the ER doc about what to do. If the wound is irrigated and his pain is controlled then aren't some dog bites kept open (especially on the face) to avoid infection? If he has a major disfigurement that would be a different issue. The turning away because of no insurance seems a little cold-hearted but I don't know if that was improperly managed in terms of his medical care.