The Right Level of Care for the Right Illness

By Jesse Hackell, MD

The phone call came in through the answering service around 7:00 pm. “She’s four years old, Dr. Hackell, and she has a fever of 102 since this afternoon. Should I rush her to the emergency room?” Aside from the fact that I was still in the office, seeing patients until 8 that evening, as we do routinely in our office, I began thinking about the difference between an emergency, an urgent matter, a worrisome problem and an ordinary medical illness or question.

This is not a trivial distinction to make when one considers the reasons that parents seek health care for their children, and it has a great impact as well on the burden that society faces in providing, and paying for, health care.

An Emergency

An emergency is a condition where there is an immediate threat to one’s life or limb, a situation where, in the absence of prompt medical attention, there is a risk of serious, permanent or even fatal injury resulting. Examples are many, and could include a heart attack, head trauma with loss of consciousness or skull damage, prolonged seizures or asthma with respiratory distress.

An Urgent Matter

An urgent matter is not so easily defined, but might be considered a medical condition which is not life-threatening but which requires medical care to avert progression to a more serious condition which could become life-threatening. One might think of pneumonia, less severe asthma attacks, hives, persistent vomiting, and other similar examples. A worrisome problem is something which is clearly an illness, which may be causing discomfort, and which could, in theory, represent the onset of a more serious matter, but which at the moment is clearly not affecting a patient’s ability to breathe or otherwise function and interact with others. This category might include fevers, coughs, pain in the extremities, pain on urination, headaches and so on.

Ordinary Medical Issues

And finally at the bottom of the list are the ordinary medical issues, best exemplified by the itchy rash of poison ivy, pinkeye, allergies and cold symptoms.

Why does this distinction matter?

It is inarguable that conditions should be treated at the facility best able to care for the patient in an efficient and cost-effective manner. Care in emergency rooms is many times more expensive than the same care delivered in a physician’s office, and in cases other than true emergencies, as defined previously, equally effective.

Consider the child with abdominal pain, fever, loss of appetite and vomiting.

When that child is seen in a pediatrician’s office, especially the child’s “medical home” where she is known to the doctor and staff, she will be seen and carefully examined, maybe have a urine sample and blood count done, and observed for the signs that her illness might represent a true emergency such as appendicitis, in which case she would be admitted to the hospital for either more testing or for surgery.

But more likely, the results of the evaluation will be normal or non-specific, and she will be felt to have a stomach virus or cramps, and be sent home with appropriate management instructions and an admonition to return or call if more worrisome symptoms develop.

Contrast that with the same child taken to the ER.

The hospital charges for ER use are high, as are those of the ER physician. In most ERs, the child is more likely to have a battery of blood tests done, as well as an expensive CT scan of the abdomen—again, seeking to determine the presence or absence of appendicitis. Even if the child turns out, in the end, to have a stomach virus, the costs incurred in getting to that diagnosis will be vastly higher than those for the child seen in her pediatrician’s office. In addition, the time expended in the ER is likely to stretch into hours; rare, indeed, is the office visit, even with a period of observation, which exceeds an hour in duration.

While no reasonable pediatrician would attempt to manage a life-threatening condition in the office, we do see urgent conditions every single day. We take care of kids with asthma who come in wheezing, we see children who have had seizures from fever, we evaluate injuries which might break bones and we manage vomiting and dehydration—these “urgent” conditions are often able to be managed quickly, efficiently and effectively in the same offices where children get their routine examinations and immunizations.

We insure that urgent matters are attended to promptly, compared to an ER where the asthmatic child might wait for hours until after the heart attack or multiple trauma patients are seen, especially on busy evenings.

Pediatrician’s office are often a more friendly environment.

Finally, the pediatrician’s office is a place known to the child, often more child-friendly than a large, noisy and busy emergency room, so the child is likely to avoid having an already scary situation be made even more frightening by the bustle of an unfamiliar place and unfamiliar faces.

Worrisome conditions are those which do not need to be seen in an ER, either, especially at night.

We all know how kids have a knack of getting sick at night, and on weekends and holidays. But it is important to decide whether the condition is a something that can and should wait until the next morning, to be seen in the child’s regular doctor’s office, as opposed to immediately running out to the nearest hospital, often giving everyone in the family from the child on up a long, miserable night in the ER.

With more and more pediatricians adding evening and weekend hours, it is rarely the case that a sick child will need to wait much more than twelve or so hours before being seen and evaluated. Life-threatening emergencies should always go to the ER, and I would encourage parents to be over-cautious in determining what they might be worried about as an emergency.

But at the same time, with a child with a simply worrisome condition, observing the child and thinking about how ill he or she appears is the first step to deciding whether or not to “rush” to the ER. A phone call to the pediatrician can also help a parent decide the degree of urgency represented by the child’s symptoms. Many times the child with a fever or an injury looks and acts good, and can be made comfortable at home until the doctor’s office opens in the morning. This actually will make the illness easier on the child, and enable him or her to be seen in the most familiar place, reducing the stress on all concerned.

It will also generally be more cost-efficient.

There is no doubt that the American health care system is in a financial crisis, given the large proportion of our national wealth consumed by health-care services. Pediatricians certainly do not advocate skimping on health care for financial reasons; in fact, the often-expensive preventive care which is our special interest may cost money upfront, but the payback over the years in dollars saved (and improved outcomes as well) is well documented.

What we do seek to encourage is the most efficient and cost-effective use of health care dollars, in order that we, as a nation, can get the biggest bang for our buck. Making sure that our children get the level of care appropriate for the degree of their illnesses is just one step in that direction.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.

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3 thoughts on “The Right Level of Care for the Right Illness

  1. Pingback: Anticipatory Silence: Florida Law Prohibits Freedom of Speech in the Physician’s Office | Survivor: Pediatrics

  2. Pingback: Are Pediatricians Different Than Other Physicians? | Survivor: Pediatrics

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