Canadian Medical Association Past President, Anne Doig, asked the physicians present to think about whether the healthcare system was giving good value for money, and what responsibility physicians and patients had toward the system. Several of my colleagues told about abuse of emergency services with patients arriving at 2 am with trivial problems that could have waited until the morning. The phrase that characterized these patients was "demanding".
Even though I think "demanding patients" is an unfortunate choice of words, I was glad to see that this was a forum where doctors felt able to express strong feelings about how the healthcare system is not working. It's tempting to tut-tut these docs and conclude that "they just don't get it". That would be a mistake.
My colleagues are expressing their frustration with the poor functioning of the healthcare system. However, rather than seeing it as a system problem, they've framed it as a behaviour problem with patients. There may be many reasons why someone turns up in the ER with a seemingly trivial medical problem in the middle of the night. Perhaps they tried to see the doctor during working hours, but appointment wait times are 2 weeks. They may have phoned the ER for advice on how to manage their earache and been told that the nurse couldn't give out advice over the phone. Whatever the reason may be, I think it's safe to conclude that no one wants to be in the ER at 2 am, so their presence could indicate an unmet need.
I sympathize with my family practice colleagues, however. I have the luxury of having my 2 am ER calls come from the ER doc, who has already assessed and treated the patient, and now is calling for specialist consultation. The rural family docs, in particular, face regular sleep disruptions which must be maddening.
In private discussion, several docs assured me that in fact there do exist truly demanding patients who aren't satisfied by the best efforts to provide timely and appropriate care. I don't doubt it. But, I think that, however we define inappropriately demanding patients, they make up a very small part of the larger group of people who are being tarred with the same brush. It seems to me to be too easy to label someone as being inappropriately demanding rather than exploring what their needs truly are, and how we have failed to meet them.
I can't be angry at either the patient who "demands" care at 2 am, or the physician who considers this behaviour inappropriate. Rather, I'm upset at the system that pits physician and patient against each other. It's a dysfunctional system that:
- doesn't offer timely clinic appointments to deal with minor problems at convenient hours
- doesn't allow non-physician care-givers to work at top of licence, and provide advice and care independently
- doesn't reward or encourage efforts to educate patients on self-management of common conditions
What can we do? Philosophically, we can try to convince docs that the problem is with the system, and not with patient behaviour. We could explain that the healthcare system's purpose is to provide appropriate care, where and when the patient needs it.
We could try that, but I think it would be cold comfort for the doc who's wakened from a sound sleep. Instead, measure the problem and, in doing so, identify the barriers that the system has thrown in our path. Rural ERs could survey patients arriving after midnight to find out their perceived problem, its duration and whether they had tried to access any other sources of care. Ask these questions with genuine interest in improving care delivery. Don't judge or disapprove. Aggregate data from several (all!) rural hospitals so as to get the big picture more quickly. Once the barriers to timely, appropriate care start to reveal themselves, so will potential solutions.
I welcome comments from my GP colleagues who struggle with this issue every night they are on call.
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