Liking the ER

Is a guilt-inducing feeling. I shouldn't like divorcing patients' immediate complaints from their psychosocial contexts. I am in training to be a primary care physician, after all. Primary care should be a lot more than making sure someone doesn't have a heart attack or doesn't have appendicitis (or a cervical-spine fracture, or a really bad pneumonia, or shaking-raving alcohol withdrawal). It should be about treating the whole person.

And that's what the patients think, too. As we know (and our president celebrates), many people come to the ER because they don't want to, or can't, find primary care anywhere else. Thus they step in the door expecting a holistic approach to their problems, while ER docs still cling to their theoretical model of Emergency as triage and immediate treatment.

I could wax abstract here about the difference between deep medical knowledge - holism - and goaltenders' medicine - blocking the bad stuff: each of these has its place. I could connect this to bekius vs. iyun: the long-standing Jewish yin-yang between knowing a lot of Torah and delving deep into it. But there's too much at stake here hour-in and hour-out to allow abstractions. Patients are to be triaged either upstairs or out the door, and few of them (at least in Bellevue) understand how they are to have their chronic problems addressed.

I liked my first day because I felt in charge and in control (though supervised and occasionally countermanded, of course). But, on second thought, I should have tried to grab on to whatever jagged outcroppings of social context I could find in every patient's primary complaint. I should have tried to act like a primary care doctor even while doing the ER triage dance.

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