Patient Perceptions in the Emergency Department: Physicians, Physician Assistants, Nurse Practitioners

A recent survey in the American Journal of BioethicsPatient Willingness to Be Seen by Physician Assistants, Nurse Practitioners, and Residents in the Emergency Department: Does the Presumption of Assent Have an Empirical Basis?, indicates that 80 percent of patients expect to see a physician when they come to the emergency department. Parents were more insistent about their child see a physician or resident for even a minor condition such as a sprained ankle. Patients indicated a preference for seeing a resident alone for non-urgent conditions (60%) and compared to a physician assistant (42%). Interestingly, these numbers did not vary dramatically from a resident’s preference to see a resident alone (65%) over a physician assistant (38%). Patients willingness to see a nurse practitioner (NP) was less across the board, 32% of residents, 44% of non-medical patients, and 75% of physician assistants (PAs).

One of the greatest flaws of the study is a narrow patient population – English-speaking, educated, urban. Another point of interest would be to take a larger sample size and to stratify preferences based on age. The idea of NPs and PAs practicing in the emergency department is relatively new and has increased dramatically since the initiation of new duty hour regulations for residents in the 1990s. Their visibility may increase even more if the new ACGME duty hour rules pass this year (refer to a previous post, Resident Duty Hours: Loopholes in the New Regulations). The younger population of patients in the emergency department may be more willing to see PAs and NPs than the older population.

Another problem inherent in the study is that when you ask patients their preference for medical care in the hypothetical setting, it becomes difficult for them to answer the question honestly. In some ways, the act of posing the question itself – a question which relates directly to a patient’s expectations – biases people towards answering a certain way. It makes sense to prefer to see a practitioner with the most training – with physicians, followed by senior residents, at the top of the list – regardless of the medical problem. And the question which always lingers in the back of someone’s mind, especially in the hypothetical setting, is “what if the condition is a bad sprained ankle, or maybe a little worse – a break perhaps?” If, in a real situation, the patient is less concerned about this possibility, they may be more willing to see a nurse practitioner or PA.

One interesting question is whether these perceptions are changing over time – over the course of the last 5 years. My hypothesis is that they have, and that patients are becoming more comfortable being treated by practitioners without the MD behind their name. Another interesting question is whether years of experience matter – would a patient rather see a PA who has trained for 30 years, or an attending physician who has trained for 1 year? These questions further complicate matters.

Here is the bottom line, from my perspective as a health care provider: I think it is important for patients – and for residents, PAs, and NPs – to understand that the purpose of a hierarchy in medicine is to provide more support staff, not to compromise patient care. Our primary – and most important – job, as residents, PAs, and NPs, is to recognize our limitations and to ascertain whether one of our patients needs a higher level of care. Even patients who seem healthy may be sick. The common line in emergency medicine is, “Be humble or be humbled.” We need to keep this in mind with every patient we see and have a low threshold to ask for assistance.

The expectation that patients be seen by physicians is a longstanding one, but it is beginning to change. With ED volumes as high as they are, there are simply not enough emergency physicians to see every non-urgent patient . That expectation is not only unrealistic, but it is also not necessarily beneficial to patients. PAs are often very experienced at suturing simple lacerations or taking care of ankle sprains – and are often as good or better at it than physicians, depending on their experience level.

I think as times change, as PAs and NPs become more visible in the emergency department, and as long as we continue to remember our limitations as trainees (even attending physicians ask one other for help or advice from time to time, and emergency physicians call specialist consultants down to the ED if they are concerned about a patient), we will continue to provide good patient care in a health care system with a variety of trainees, all with different levels of experience and expertise.

A Year in the Hospital

Fireflies

Hand clasps hand
on the window sill,
he in a paper-thin gown,
she in her Sunday dress.

Snow falls.
He craves the sting of crystals
on his tongue,
a shovel to carve a meandering path
to the front door.

And she –
a spark from dying embers
that once flushed his cheeks,
now sunken and pale.

Lilacs blossom.
He dug the earth for their resting place,
pruned them religiously,
watered their roots.

She filled glasses with branches
pouring over the rim –
a breath of lavender anticipation.

Heat rises.
He remembers capturing fireflies in jars
with punctured holes to breathe
and watching them through the night
as their lights flickered
then faded away.

She remembers
laughing at the red juice stains
from freshly picked raspberries
on their chins.

Leaves fall.
The crisp sun is distant
from the blurred shadows of the hospital bed.
The hurried migration of the birds
is silenced by the glass.

From the window,
they imagine the rush of delicate wings
headed south
and the imminent scent of autumn –

Burnt orange peels, smoky maple,
roasting pumpkin seeds.
Their lights flicker,
then fade away.

On Medical Mistakes…

To err is human, to forgive divine.
Alexander Pope

A recent post, The Dangers of July in the Hospital, addressed medical errors during July, when residents and interns fill their new positions for the first time. A recent article written by Pauline Chen, Talking to Patients After a Medical Error, takes this issue to another level and poses the question: Should physicians admit their mistakes? A program started at the University of Michigan in 2001 which addressed medical errors by discussing them with patients and their families and by offering apologies with compensation. The end result was that the number of claims and lawsuits filed against the hospital decreased between 1995 and 2007. Should such systems be implemented elsewhere?

This is a controversial question. First, from a historical perspective, doctors have long been discouraged from admitting their mistakes. In doing so, they put themselves at risk for criticism and humiliation from their colleagues. The old-fashioned, paternalistic approach to medicine required that the physician maintain an image of professional, intelligent, and even faultless behavior. To admit openly to anything less than this would be considered failure. It would also cause anxiety, place blame, and put the individual and the hospital at risk for law suits. But these are not the only effects: there are benefits too, as demonstrated by the program in Michigan.

The morbidity and mortality conference, often used in surgery and anesthesia, provides a forum where medical errors can be discussed. But this forum is not open to the public and does not allow for internal investigations or discussions with patients and families. At the very least, it serves as a place where physicians can discuss their mistakes – and how to avoid them in the future – with their colleagues. It serves as a starting point for discussions about medical errors, which should be encouraged. It is only by examining our errors that we can work to reduce them.

But medical errors are a touchy subject and with good reason. Here is the harsh reality: doctors are human – and they will make mistakes. Unlike other professionals, however, whose mistakes may cost people’s jobs, money, or reputation, doctors’ mistakes can cost lives. The stakes are much higher (and they are similar to the military in this regard). Although we may be willing to accept the idea that doctors will make mistakes, we may not be so willing to accept doctors’ mistakes when they affect us directly. This becomes very personal.

Many medical errors happen not through the fault of one person but through a series of failures. For example, a patient is administered the incorrect dosage of a medication. This may be because the nurse is a little more tired than usual at the end of her shift and does not triple check the label on the bag that comes up from pharmacy; the physician is a new intern who may not know how to use the computer order system and inadvertently orders the wrong dosage; the computer system usually has an error message that pops up but somehow this error message does not go through; the pharmacist who normally checks these orders is out on sick leave. As a result of all these failures, the patient gets the wrong medication. In some situations, it is easier to place blame on a single person.

But in either case, a mistake is made. If there is an adverse outcome, how is this best handled? Families deserve to know about medical errors. And most physicians want to be up front with patients – even if only to free themselves of the heavy burden of guilt. Should fear of litigation prevent this process from occurring? Fortunately, the new research gives us a very encouraging answer: no. The success of the program at the University of Michigan should demonstrate to physicians and patients alike that not only do they deserve to be informed of medical errors, but they are also less likely to sue if they are informed. This information should not only encourage physicians to admit their mistakes but should also restore some of the faith we have in humanity – in spite of the easy access we have to lawyers, and in spite of the relatively large amount of lawsuits in this country, when our own and our families’ health are on the line – one of the most frightening, ground-shaking realities – and when, in the face of this, we are confronted with an honest confession and an apology, we are less inclined to sue – and more inclined to forgive. This new program should provide enough evidence that physicians should be honest with their patients and should be more open about medical errors, in the hopes of minimizing them.

Dawn to the Moon

Today began at the break of dawn and ended with the moon outside my window. I can hardly believe I am saying this – I miss the coronary care unit. The emergency department is a flurry. Placing too much emphasis on patient flow does not always mean providing the best care. I miss talking to my patients, listening to their stories, caring for them, and answering their questions. I can hardly estimate the number of patients whom I cared for today or remember them – 5 or 6 were flooding through the doors every hour.

A wonderful article was published today in The New York Times yesterday, Palliative Care Extends Life of Lung Cancer Patients, Study Finds. A study in the New England Journal of Medicine has demonstrated that patients with terminal lung cancer were happier, more mobile, in less pain – and they lived nearly three months longer. This study supports some of the thoughts I discussed from Gawande’s recent article in a previous post, The End of Life: Hope Without Cure. It offers proof that the purpose of palliative care is more than simply “to palliate” – it can also improve quality of life and can even extend life. Palliative care, along with alternative medical therapies including acupuncture and massage, can be important adjuncts to medical care. This needs to be further examined in the science-based health care system of the western world. More on this later.

For now, as the clouds begin to obscure the moonlight, I breathe – long and deep – to expel the chaos of the day. Working in the emergency department is draining in a different kind of way – fast-paced, high energy, elevated stress levels. It is not as much a marathon but a series of very long sprints.

The End of an Era

This marked the last day of my time in the coronary care unit. I leave with mixed feelings – mainly pure exhaustion and relief. At the end of a month in an intensive care unit, my emotional and physical strength are completely drained. I spend 28 days pouring every ounce of energy into these patients, their care – and suddenly, after what seems like an endless string of sleepless days and nights which blend together, the month is finished. I leave behind patients who will linger in my thoughts for some time.

Today my sentiments correlate well with a photograph I took on a foggy day along Pebble Beach Drive of the Lone Cypress. Solitude and a tinge of sadness, not for my departure but for my patients. It is nice to be in a quiet place after nights of beeping monitors, ear-piercing phone rings, and intrusive pager melodies. It is a relief to be removed from those circular intensive care units, with glass doors lining the circumference – all too stark a window into every breath, into every moment of my patients’ lives. Sometimes I feel as though I am in the center of a spinning merry-go-round, walking, running in one direction and then another. But the spinning sensation is all from my movement. The patients are still.

And this merry-go-round with its glass circumference is a precipice – surrounding us are the sheer cliffs which separate life from death and which plunge into the ocean’s depths. We build this structure, a well-functioning machine with its rhythm and noises, powered by our own incessant movement. But the structure is more fragile than it seems – the glass ready to shatter and the moving parts on the brink of halting. Even in the best intensive care units in the United States of America, we are not invincible.

R. Fitch made the first newspaper reference to the Monterey Cypress on January 19, 1889. “Rounding a short curve on the beach, we approach Cypress Point, the boldest headland on the peninsula of Monterey. Down almost to the water grows the cypress, and on the extreme point a solitary tree has sunk its roots in the crevices of the wave-washed rock, and defies the battle of the elements that rage about it during the storms of winter.”

The lone cypress tree, springing from rock, has withstood the test of time – it has withstood the barrage of the elements for over 200 years, including wind gusts up to sixty or seventy miles per hour. It has survived. But the tree has roots which date back even further. In Greek mythology, the cypress tree was named for Cyparissus, a youth from the island of Cea, son of Telephus who was loved by Apollo. He mistakenly killed his favorite stag. Overcome with grief, he metamorphosed into a cypress. As a result, the Cupressus sempervirens, or cypress tree, is the principal cemetery tree both in the Western and Muslim worlds. Below is an excerpt from Metamorphoses.

Ovid, Metamorphoses 10. 106 ff (trans. Melville) (Roman epic C1st B.C. to C1st A.D.) :

“In all the throng the cone-shaped cypress stood; a tree now, it was changed from a dear youth loved by the god who strings the lyre and bow [i.e. Apollon]. For there was at one time, a mighty stag held sacred by those nymphs who haunt the fields Carthaean [i.e. on the island of Keos]. His great antlers spread so wide, they gave an ample shade to his own head. Those antlers shone with gold: from his smooth throat a necklace, studded with a wealth of gems, hung down to his strong shoulders–beautiful. A silver boss, fastened with little thongs, played on his forehead, worn there from his birth; and pendants from both ears, of gleaming pearls, adorned his hollow temples. Free of fear, and now no longer shy, frequenting homes of men he knew, he offered his soft neck even to strangers for their petting hands. But more than by all others, he was loved by you, O Cyparissus, fairest youth of all the lads of Cea. It was you who led the pet stag to fresh pasturage, and to the waters of the clearest spring. Sometimes you wove bright garlands for his horns, and sometimes, like a horseman on his back, now here now there, you guided his soft mouth with purple reins.

It was upon a summer day, at high noon when the [summertime constellation] Crab, of spreading claws, loving the sea-shore, almost burnt beneath the sun’s hot burning rays; and the pet stag was then reclining on the grassy earth and, wearied of all action, found relief under the cool shade of the forest trees; that as he lay there Cyparissus pierced him with a javelin: and although it was quite accidental, when the shocked youth saw his loved stag dying from the cruel wound he could not bear it, and resolved on death. What did not Phoebus say to comfort him? He cautioned him to hold his grief in check, consistent with the cause. But still the lad lamented, and with groans implored the Gods that he might mourn forever. His life force exhausted by long weeping, now his limbs began to take a green tint, and his hair, which overhung his snow-white brow, turned up into a bristling crest; and he became a stiff tree with a slender top and pointed up to the starry heavens. And the God, groaning with sorrow, said; `You shall be mourned sincerely by me, surely as you mourn for others, and forever you shall stand in grief, where others grieve.”

And so the lone cypress withstands the elements for centuries. It survives. It prevails. But the tree itself is a symbol of death and mourning, associated with the story of a young boy overwhelmed by grief and loss. Fragility lies beneath its outward resilience. The line between life and death is finer than we imagine.

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