“The ER told me to follow up with you, but I didn’t see the point if they couldn’t figure it out”
-Judy*, 82 year old patient of mine, who had finally come in for her ER follow up visit.
To be honest, it was a proverbial slap in the face. It was said very matter of fact, I am sure she had no idea she had bruised my ego whatsoever. In all likelihood, there are a lot of people with this sentiment. “Why do I need to see my primary care doctor after and ER visit or a hospital stay?”. We get all kinds of reasons. Judy’s is just one of many. For some, it is because they just don’t feel good, and want to rest as home. For others, it’s financial, they don’t want another co-pay, and others just feel fine now and don’t see the point. Finally, there are the people like Judy, who just don’t think I will be able to figure it if the other doctors aren’t able to.
In Judy’s case, she had passed out at home two weeks prior. Her family (appropriately) brought her to the ED for evaluation. Fortunately for her, by the time she arrived, she felt fine, and the entire work up was negative. She only came to see me two weeks later because she was starting to get chest pains and shortness of breath. When I questioned her about what tests were done, she had no idea (which is also common).
So, why did I want her to come see me in follow up?
Not all patient conditions are obvious at the time of presentation.
Sometimes it takes time for the condition to progress for it to be able to be diagnosed. Timely follow up can ensure that we are able to accurately diagnose the problem.
EDs and hospitals run tests.
They certainly review those tests, but are really only searching for abnormalities that could be related to your presenting condition. If another blood test is incidentally out of range, they aren’t going to necessarily address that. (For an example, an elevated calcium in the blood may have nothing to do your chest pain, but could be a sign of hyperparathyroidism, which is more of a long term problem. (I.e. something that the ED doesn’t have time to address). Furthermore, when it comes to imaging studies, like X-rays and Cat Scans, the ED physician is only getting a preliminary report from the radiologist. For example, if they were to order a chest X-ray for someone with chest pain, the preliminary report would come back telling the ED doctor the basic yes or no, is there anything on there that would cause that chest pain. Later on, when the radiologist has more time, they will dictate out a much more detailed report. Sometimes that report has findings on it that are important to your health, but not an emergency. (I can’t tell you how many times there have been lung nodules on chest CTs that patients didn’t know about, that needed further follow up). I don’t always get copies of those results. But when you come in for your ED or hospital follow up appointment, we find out what you had done, and review it to make sure that there is nothing incidental noted on it, that could become a problem for you years down the road.
Emergency Departments are for emergencies.
In Judy’s case, I would definitely consider her condition an emergency at the time she went in, but (again, fortunately for her), by the time she arrived, she had recovered. The ED is not going to be able to do a full work up for a condition that had resolved. In Judy’s condition, there were a lot of further tests that we needed to do, that would never have been done in an emergency department. (Like a stress test, and echocardiogram, and a holter monitor). These are all indicated follow up tests that would have to be ordered by your primary care doctor.
ED doctors don’t have the kind of time that a primary care physician has to get to the bottom of the issue.
We just have more time to spend with you, and be able to ask the right questions, and hear your answers. We know you well, and have the benefit of that long term relationship. And that helps us tremendously in figuring out what is wrong.
The last reason she should have come to me sooner, or understood the importance of following up with me after her ED visit: I am pretty smart. I graduated from a top tier medical school, and could have chosen to go into any speciality I wanted, but I love primary care. Sometimes I can figure things out that others haven’t been able to. I’m pretty proud of that. I could have taken a job anywhere in the country, but I grew up here, and I love Northern New York. (Except the endless winters… spring, where are you?)
I think it can be helpful to think of EDs like doctors do. The ED doctor’s primary job is to stabilize you, then to determine your disposition. (Home, admission, or transfer). They specialize in the first one hour of care, (and they are fantastic at it), but then they pass the baton. Allow us to take that baton, and move forward in giving you the best care you could possibly deserve.