The Expect

Statistically, to avoid missing a case of appendicitis, one must send to the ER some patients with symptoms of appendicitis whose appendices turn out to be normal. This lesson from medical school is imprinted indelibly on my mind.

In my residency program, if a resident sent a patient to the ER, the resident was required to go the ER to evaluate them, to further their learning. However, this created a conflict of interest—if you had to meet a patient in the ER, you missed out on sleep. Hence I thought hard about the disposition of each patient.

Now, in clinic, I may decide a patient needs an ER evaluation and probably a hospital admission. Sometimes this choice is obvious, like a skin infection requiring IV antibiotics, but sometimes it is more subtle, like a gradual increase in leg swelling and shortness of breath. Regardless, the necessary paperwork, time, and phone calls disrupt the flow of the day.

When providers send someone to the ER, we phone the ER to provide a heads-up. This is called “The Expect.”

Even after 25 years of practice, I worry about The Expect. Telling a patient they need to go to the ER is huge. Perhaps they need to arrange care for a child or an older family member, or notify their employer. They may be scared by my acknowledgement that their symptoms are serious. Even worse, many of my patients have had traumatic experiences in the ER and may feel reluctant to return. Patients of color may have been condescended to or not taken seriously by ER staff. Or others may have had a loved one who experienced a missed diagnosis or who died at the ER.

Often patients negotiate: “Do I have to go? Can I go tomorrow?” Convincing them can be challenging. I may even question myself: Do they truly need the ER? Is the disruption worth the price?

I also harbor a secret fear—that the ER providers will roll their eyes or laugh at me. I envision them quipping to a colleague, “Can you believe that this provider sent this person to the ER? Couldn’t she have managed this at clinic?” My face burns with shame.

I troll my patients’ charts in the ER’s electronic medical record. When a patient doesn’t show up at the ER, my concern grows. If they are admitted, I eagerly await further news of their condition, hoping they are okay.

Pamela Adelstein
Newton, Massachusetts