“Empathy for the Devil……”

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As Mick says: ““If you meet me, have some courtesy, have some sympathy, and some taste…”

Todays post is a guest one, eloquently  written by a colleague of mine @mattdoc1979. You have to follow him! The post is based on EDs in the UK but i think it could be applied to departments across the globe. So please spend 5 mins reading it and I hope it generates some discussion….

“Empathy for the Inappropriate Attender”

We are told “A+Es in Britain are worse than war zones”. That is a rather dramatic exaggeration but the situation has not been good. In the blame game of looking for culprits in this situation, the public are frequently cited as the cause of the problem. Many EDs have urged (or pleaded) the public to only use the service in the event of a genuine emergency. The President of the Royal College of Emergency Medicine has repeatedly stated “A&E doesn’t stand for Anything and Everything”. Surely the name on the door is self-explanatory? We read and scoff in disbelief at the reports of people attending the ED with a sore throat. Perhaps it is time to stand back and review the root causes of the situation before simplistic solutions are advanced.

Emergencies are a subjective and dynamic concept. What is an emergency for me is not an emergency for you. The medical profession has its view on what constitutes time a critical emergency but we have traditionally relied on the public to make that decision before enlisting our help.  It seems that, gradually, that bar may have been lowered.

As a doctor working in emergency medicine one might think I should be the most frustrated by this issue, and believe me, I am frequently frustrated. But I now see the problem differently. The crowded waiting room can be understood in terms of cultural motivators, expectations, heuristics (mental shortcuts) and bias. The behaviour of the person sitting in the waiting room or picking up the phone to call an ambulance ‘unnecessarily’ is understandable and, given the right circumstances, we are all likely to behave in the same way. I would therefore like to empathise with my fellow ‘inappropriate attenders’.

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How much of a problem is it? 

We are told there are ‘millions needlessly clogging up A&E’ and it certainly feels like it. But when studies have looked at this issue specifically in the past it hasn’t been as much of a burden as we thought. It may be different now but this is not data we formally collect. Emergency department staff used to believe that more patients with mental health issues presented on a full moon. But there is no correlation at all. On a full moon we just notice patients with mental health issues as being significant, confirming the belief. It may well be that we believe we are seeing huge numbers of ‘inappropriate attenders’ but are subject to the same mental bias. The problem may well be over-exaggerated.

Public Awareness Campaigns

There have been many initiatives to improve early detection and treatment of devastating diagnoses such as heart attacks, stroke and sepsis. People are now generally aware that chest pain should not be dismissed as just indigestion or a muscle sprain. Clearly the vast majority, while quite legitimately seeking help, won’t actually be having a heart attack. It is debatable whether these awareness campaigns have improved the outcome for heart attack patients. It is clear that the initiatives have increased attendances, investigations and hospital stays. Given that we have not targeted these campaigns at ‘at risk groups’, it is unfair to judge the increasing number of people calling 999 for every twinge in the vicinity of their chest when, in essence, we told them to.

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GP Availability

As Jeremy Hunt recently described, he was unable to get an urgent GP appointment and so went to the ED. This was probably intended as just another slam in his bitter campaign against my GP colleagues, but he knew he was using the service inappropriately. Reading the papers, you would be forgiven for thinking the demands for urgent health care have risen in isolation. The demands on GP services have escalated massively as well, from all directions. Even with this pressure and while there are local variations, if a patient genuinely needs an urgent appointment at their surgery most can get one that day. But not all and not always easily.

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It is a real problem that exists and demand is outstripping supply. I sympathise with frustrated patients who feel they have nowhere else to turn. But as the pressure continues to mount, there is an increasing likelihood that patients won’t be sent an ambulance or they will be redirected away from the ED. This is an area where other alternatives e.g. pharmacists and even private medicine can take over the reins for those who still feel they need to be seen. We can have a convenient service or a free one – the decision at that point should be up to the individual.

The more interesting question is – why do so many people believe they need emergency medical assessment in the first place?

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Information overload

It is good and it is right that we have access to all the medical information we want. The wealth of information on the internet should help us make rational informed considered decisions about our health. Unfortunately it frequently causes confusion, fear and demands for more investigations. The inexperienced user cannot quickly or effectively filter and analyse all the information they are presented with. That is not meant to be patronising, this applies to all of us. All of our brains’ computers are overwhelmed quickly by too much information and we end up making poor decisions. Hence why doctors increasingly deal with people clutching a pile of internet printouts. I frequently provide a reassurance service after Google has successfully terrified people.

Fear of the possible

From the dispassionate objective viewpoint, someone attending an ED with a sore throat makes no sense. It is extremely unlikely to be anything serious, it will very likely go away on its own and no treatment has been shown to effectively treat it better than a sugar pill. But that is not how our brains work.

Our brains mistake how easy it is to think of a terrible consequence with its actual likelihood. This effect is exaggerated if the occurrence is highly emotive or scary, for example, tragic cases of fussy toddlers becoming critically sick with meningitis. The media furnishes us with these stories and we change the way we live on the basis of incredibly unlucky tragic events.

Watch and wait versus early detection

There is also an uncomfortable dilemma in which we all want to detect serious disease in its earliest stages and instigate effective treatment. That seems entirely reasonable but watchful waiting is still the appropriate management plan for most vague symptoms. A patient will have to have headaches for quite some time before it is appropriate to scan their head, for example. We are all terrified by what it could be and it is that fear, rather than the symptom, that is the emergency. Waiting for symptoms to develop or resolve in time is not our expectation. 10 years ago I never heard the phrase ‘I thought I had better get it checked out’ in an Emergency Department, now I hear it every shift.

Fear influences Doctors as well

The medical profession frequently fuels these fears. Every doctor will have seen a sore throat that was a horrendous abscess, abdominal cramps that turned out to be bowel obstruction, a headache that was a brain bleed, a sprain that was a career-ending subtle fracture, a backpain that was a continence-threatening disc herniation, the list goes on. And each of these cases will change the way the doctor practices. We may lose the big picture, overshadowed by our recent unexpected experience, and over investigate every patient until the image fades. It is important to remember that healthcare professionals are just as susceptible to the same human factors as the patients, the clue is in the word ‘human’.

Expectations surrounding service provision are cultural and political.

It is undeniable that there is an expectation for immediacy and a 24 hour service. But this again is not a good reason to criticise the ‘inappropriate attender’ sitting in the waiting room. The patience and stoicism of older generations is really just a matter of different expectations. If the older generations had had a wealth of medical information at their fingertips, access to free effective healthcare, a maximum wait of four hours and a plethora of investigations, their demands would have stretched the service as well. They experienced the introduction of equitable healthcare for all but they were not brought up with it. It is now, legitimately, a right of the citizens of this country. But there have to be limits to a finite resource. Successive governments have assisted in driving expectations for choice, for waiting times, for social care as the costs and demand have risen. It is not politically prudent to tell people they cannot have something. But if we had been realistic and honest about what can be effectively provided by the NHS we wouldn’t be in this mess.

Expectations about healthcare are driven by the medical profession, not by patients.

It is not surprising that patients are confused about which management they require when the practice from one doctor to the next is extremely inconsistent. Every time we CT scan a child who has bumped his head, give antibiotics for a cold, x-ray a sprain or MRI back pain in the Emergency Department, we drive the very expectations by which we are exasperated. Doctors are frequently wrong about patients’ expectations anyway. Tests and prescriptions are quick and easy surrogates that replace the really effective interventions – good communication, examination and explanation. We need to realise that we can change expectations by being consistent and communicating effectively. If we ever doubt the power of a message we need look no further than the devastating effect anecdote has had on rates of childhood vaccination. Individual patients are parts of networks and networks spread information and ideas like contagions. This effect is now magnified exponentially with social media and we should be driving to get the right messages across.

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The 4 hour target – a victim of its own success

The 4 hour target has driven some significant improvements but it has, however, had some unforeseen consequences as all large scale reforms will. It has provided an expectation and got rid of the deterrent of an unpredictably long wait in an unpleasant waiting room.  While this situation was totally unacceptable it did mean people avoided the ED waiting room unless absolutely necessary. 10 years ago patients expected to wait. We then changed the goal posts, with good intentions, and we should not be surprised that the public’s expectations have followed suit. It has been suggested that the ‘4 hour wait’ target should only apply to those felt to need assessment in the ED. It would seem far fairer to me to simply assess and redirect the ‘inappropriate attender’ immediately at the door rather than ‘punish’ them with an indefinite wait.

Cultural fear of responsibility

Employers, schools, care homes and even our friends on the frontline, the police, contribute to our burden of ‘inappropriate attenders’. Far too frequently, their official policies will lead to an ambulance attendance. From my experience it is uncommon that the person making the call felt that an ambulance was needed. The reply is always the same ‘No, I thought they looked fine but I’m not a doctor.’ At every level from the office first aider to the nurse in the carehome there is an increasing fear of litigation and responsibility which inhibits reasonable decisions from being made. I have even met parents who will not give their child paracetamol without consulting a doctor. The decision making is creeping ever upwards with our culture of risk aversion. The only answer is to support, train and empower personnel to take the responsibility to make these decisions on behalf of others rather than defaulting to the ED.

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NHS 111

How can we expect people to use emergency services appropriately when we designed a system to help and it has made the situation worse? Given how simple it is to dial 999 for an ambulance, those who call 111 obviously don’t think they need one. They might be wrong, but not commonly. Even if an ambulance response is warranted from a 111 call, there is usually time to get a bit more information. NHS 111 should work with the baseline assumption that the patient is not suffering an emergency and reword the end of the overly risk-averse flow chart. It should no longer read ‘call the patient an ambulance’ but ‘call someone who knows what they are talking about’. I am tired of meeting frustrated and confused patients and paramedics who tell me ‘111 sent me’.

The easiest choice is taken, especially in times of stress

Patients are given multiple choices to help them choose how to deal with their health complaint. Urgent Care centres, Walk in centres, Minor injury units to name a few. There is good evidence to show that if we are presented with lots of options (which is essentially lots of information) we may fail to make a choice at all. But most commonly we default to the easiest or most familiar option.

Even though we didn’t know we were doing it, we have marketed A+E rather well. We never wanted to be competing with the local GP surgery for business but that is what has happened. For the same reason we pick familiar brands, we pick A+E. People have voted with their feet and only consistent, immediate redirection at the hospital front door will change the way people walk.

Individual drive trumps society’s needs every time

Our individual drives normally outweigh any considerations we might have for society’s welfare. It is an interesting balance of good-for-mine versus good-for-all and sometimes society has to step in to survive. But even knowing that, it is simplistic to describe the person sitting in the waiting room as selfish. We are generally unaware of how our individual behaviour can overburden a limited resource. It is not a strong motivator because we are but drops in the ocean. The mental and temporal distance from action and effect means we get no meaningful feedback to change our behaviour.

The inappropriate attender is not aware that they are attending inappropriately

We all think we are above average drivers when it is impossible for that to be true. For the same self-affirming bias we will look around at the others in the waiting room wondering why on earth they have come to the ED. Of course we don’t question our own decision to come. In general, unless we are clinically depressed, we tend to think our actions are justified and correct. It is predictable behaviour in all of us so it is another reason it is difficult to blame people for not having the insight to realise their problem isn’t really an emergency.

The hospital’s drive for satisfaction may reinforce entitlement behaviour

It is distressing to be confronted by indignant entitlement from patients on occasions. It is fortunately not all that common but it is an ugly emotion. It is normally just thinly veiled fear, powerlessness and insecurity. But we need to focus on what people need, rather than what they want. Patient satisfaction measures seem superficially to be a great idea. Of course I want my patients to be satisfied. But if their satisfaction depends on me fulfilling an expectation that is bad medicine for them and bad for society, then the duty is on me to explain why that expectation is misplaced. But I am an emergency physician, trained to deal with patients who need emergency care, and so those patients are my priority. What patients are entitled to, is effective, evidence-based, emergency management for genuine emergencies 24 hours a day. That is what I made a promise to provide. I cannot spend my time trying to satisfy people with their inappropriate visit, nor should I have to. We need to be kind but clear about that at the front door.

Inappropriate attenders do not realise the disproportionate time taken to see them

Doctors have all been taught that the ED waiting room is very different from the GP waiting room and the people there all have an emergency issue until proven otherwise. Doctors and nurses ‘frame’ these patients accordingly, so we are extremely uncomfortable sending patients home, and that is an even stronger effect if they called an ambulance. This leads to a disproportionate amount of documentation and discussion. Few will realise that the presenting complaint of ‘I just wanted to get it checked out’ which sounds very straightforward and quick, results in more time spent than ‘I just cut my hand off with a chainsaw’.

Inappropriate attenders don’t know they are getting a bad deal 

Another reason for sympathy is that attending an ED inappropriately might be bad for you, especially if you are expecting tests. Tests are more fallible than most people realise and doctors frequently fall into traps when interpreting them. Few realise how harmful over-diagnosis and over-treatment are. There is a ‘test threshold’ you cross when, in groups of patients who are low risk, the tests and their results may do more harm than good. The ‘inappropriate attender’ is at great risk here.

Payment per activity rewards doctors who orders tests rather than ‘wasting’ time to explain and reassure properly. The public and even the doctors seem to place more trust in tests than clinical acumen, not fully understanding that every test is only as good as the decision to use it.

Getting people to attend appropriately 

Influencing behaviour by studying our subconscious thought processes is seen by many as being manipulative and unethical, especially when applied to healthcare. The reason for our unease is that we do realise that our decisions are not often made by conscious deliberation. Advertisers and magicians have known this for far longer than scientists and economists. When we realise how easily manipulated we are, we don’t like it. But we may be able to ‘design’ the way we choose to engage with the NHS, in line with the concepts and findings from behavioural economics. Such designs may allow us to get what we need from the NHS without stripping it bare.

We have to be fastidious and research any interventions carefully. For example the posters saying ‘A+E won’t kiss it better” are trying to influence behaviour while maintaining the free choice to come anyway.  But some people are more influenced by them than others. If the message is interpreted as, ‘you are wasting our time if you come to the ED’ it is possibly more likely to influence the stoic older lady who is having a heart attack than the young executive with a sore throat. Playing with the psychology of groups can be extremely harmful and we need to study it properly. We know we can change behaviour. We can encourage patients and doctors to use the ED appropriately. But it is going to be more complicated than a few adverts making ill people feel guilty.

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Conclusion

“When the Service started and the demands for spectacles, dental attention and drugs rocketed upwards the pessimists said: ‘We told you so. The people cannot be trusted to use the Service prudently or intelligently. It is bad now but there is worse to come. Abuse will crowd on abuse until the whole scheme collapses.” ….  “The prophets of disaster have been proved false, as they so often are when new and ambitious ventures are projected.” Nye Bevan

The ‘inappropriate attender’ is not a bad person. They are not intentionally redirecting time and resources away from the people who genuinely need care. They are you or I in a society that has influenced our behaviour, terrified us, confused us, poorly advised us, perversely rewarded us, inconsistently punished us and given us unrealistic expectations. The inappropriate attender is in all of us and we may be able to use that insight to help people to make the right choices.

(ME- @mattdoc1979)

Well I hope this was a useful post. It’s a bit different to the ones i usually post on but it’s a topic that affects us all, especially those of us that work in the Urgent and Emergency Care.

KR

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