By Bruce St. Amour, DO, MMeD

Sometimes what happens in the emergency department (ED) is better left there. An incident goes down, but it's hard to say what exactly happened and even harder to say why. I know, from many conversations with physicians like yourself, that the last thing you want is to delve into that chaos. To help prevent that chaos, here is what we all really wish we could tell our patients.

Dear patient,

I can be truthful or nice. Ideally, I would like to be both, but the message is never really received the way it is intended. Emergency room (ER) doctors are, in fact, usually quite nice, even to people that are destructive, intoxicated, and smell of things not brought up in public. For now, however, I'm going to be truthful.

I want to talk about your expectations when you come to an ED. It's not that I don't want you to come. I would be incredibly bored if you didn't come, but I want to set expectations for when you get there.

First, let's talk about how you "rushed to the ER." Did you break traffic laws or ride in an ambulance using the siren? If not, then you didn't "rush" to the ER. You "came" to the ER. Just because you didn't stop at Chick-fil-A on the way doesn't mean you "rushed." Don't add the drama that most people crave to see while in the ED. While I'm at it, emergency room and emergency department are used interchangeably. It's not just one room.

I'm going to let you in on a secret, ED staff are really good at knowing if someone is sick or not. Now, when you say "sick," you mean that you don't feel as good as usual and wish to be made to feel better. This could be a fever or vomiting or pain somewhere. When I say "sick," I mean someone who will not get better. Without intervention, they will get worse until they die. We are really good at knowing who is sick and who is uncomfortable. We can live with uncomfortable. Sometimes you can be both. By talking with and looking at you, we can have a good idea as to what major malfunction is distressing you. We learn to think by pattern matching. It takes a few years to see enough patients to get really good at it, but most of us are. Be patient because this has bearing on you. Just because we are not in the room with you it doesn't mean we don't care. In fact, be glad we are not camped in your room. If we stay in your room for longer than about 20 minutes, be nervous. This means either we can't understand what you are trying to tell us, we have no idea what is killing you, or we know exactly what is killing you and we don't want it to succeed right now. (Usually, it is the last option.) If the ER doctor is taking a long time to come see you, you should think to yourself, "That poor guy over there...the doc has been in his room for a half hour already. I hope he doesn't die."

The best possible outcome in the ED is for us to tell you that we don't know what is wrong and send you home. Huh? Yeah, that's right. Here's why. In the ER, we look for things that are emergencies. Novel, right? If we don't find one, great! No emergency is a good emergency. I know you long for drama, but you can find something else to post about. The second reason you should be happy is that if we send you home, we have a very low suspicion that "Badness" is hiding nearby. Sometimes it likes to hide from us. It waits until we're not looking, and then, gotcha! We generally have a gut feeling when badness is nearby and will admit you to the hospital to make sure he goes away. If we didn't admit you, then you are clear from any emergency with a low suspicion of meeting Badness. Congratulations! See, I told you we're nice.

If you are a doctor, tell us. It generally won't change what we do, but it's nice to know. If you're not a doctor, don't pretend to be one. Tell us what symptoms you are having and if you've had them before. You know you, but we know medicine. Unless you have a flare up of a chronic disease, don't tell me what your diagnosis is or what tests to order. If you already know then you most likely don't need to be in the ED. People get all worked up because they read on some webpage that they could have some rare disease. Stop it! An uncommon presentation of a common disease is far more common than a common presentation of an uncommon disease. Please, don't make up stuff just to get a longer, more impressive list of complaints. The more complaints a patient has, the less likely they are to be really sick.

Lastly, why is care in the ED so expensive? Two reasons. First and foremost, convenience! There are no appointments, and we can't control the flow of patients. (Come the day after a holiday and you'll know exactly what I'm talking about.) We have to staff at high levels because other times the same staffing is not enough. This kind of thing is expensive. In addition, we have to be prepared for everything all the time. Lights, check; heat, check; CT scanner, tech to run it, radiologist to read the scan, check, check, check...24/7 is expensive. Most EDs lose money, but they provide a service and bring people into the hospital, so in the long run it helps.

The second reason it's so expensive is because we order tests. Sometimes we don't know what the tests will show, but usually we do. Why do we order so many tests? Because you get mad if we don't! We get complaints all the time that we didn't do anything. By "do something," people mean order tests they know nothing about and can't pronounce. The other reason we order so many tests is that we have to prove what is going on. People love to sue "rich" doctors. So, we have to have evidence of what was going on 3 years ago. Of all the information we use to make decisions about care, about 70% comes from talking to you, another 20% comes from physical examination, and about 10% comes from testing.

This is why, if you call the nurse line on the back of your insurance card, they almost always tell you to come to the ED. (Don't rush.) Why? They have no good way to evaluate you over the phone. They don't really want to pay for it, but they need to see you because people leave things out over the phone, like your chest hurts (because a pole is sticking out if it).

Is your bill expensive? Next time, consider whether you should just go to your primary care doctor instead. Most are really good doctors. And they're all nice.

Bruce St. Amour, DO, MMeD, is an emergency medicine physician in Salem, Virginia.