Doctor sheds light on 'minor' E.R. visits

Later, as an attending physician and now director of pediatric emergency medicine at Strong Hospital, he heard the same question from new doctors.

"'Why are all these people coming to the E.R. with minor problems?' It's a question you hear over and over again," Goepp says.

Goepp recently organized a national conference on poverty and health care for children. Ideas from the conference will form the core of a new textbook that organizers hope will reveal the realities of poverty to new doctors, so they can treat children more effectively.

E.R. personnel are trained to handle life-threatening, urgent situations, but 40 percent of their patients have non-urgent problems that could have been handled in a doctor's office. Many of these patients are poor; most of the nation's more than 20 million children covered by Medicaid get their medical care in emergency departments.

Caregivers often wrongly view these patients as abusers of the health care system.

"Everyone is frustrated when people show up in the E.R. with illnesses that are not serious," Goepp says. "It's only with maturity and understanding that you begin to realize that there are good answers to why this happens."

A host of conditions can affect the health of poor children, he says, from the inability of their parents to afford a healthy diet to a lack of electricity to run medical instruments like nebulizers for asthma.

Consider, Goepp says, a mother who brings her six-year-old son into the emergency room at 3 a.m. because he has ringworm of the scalp, a minor infection that has persisted for several days. She wants her son treated immediately.

"Often this woman would be labeled by the triage nurse and the doctor as an abuser of the E.R., and they'd wonder why she roused her son out of bed at that hour for a routine exam," Goepp says.

But economic factors not readily evident could be at work, he explains. "She might work the late shift at a nursing home and doesn't get off work until 11:30 p.m. Then it takes her four bus rides to get home by 2 a.m., and waiting for her is a note from the child's teacher that her son can't get back into school until he is looked at by a doctor. If mom gets public assistance that is tied directly to her child's attendance at school, the situation now becomes an economic emergency.

"In her eyes, she is being a good mother by bringing him to the hospital immediately, yet she's met by people who castigate her for that decision. They think she is either inconsiderate or stupid--an abuser of the health care system.

"It's that attitude--that the poor act in an irrational fashion--that I hope to change. The poor act according to a set of rules that are very rational in the world in which they live. Those of us who take care of their health have an obligation to learn what those rules are."

Preparing doctors to deal with such patients would not only benefit the patients but also ease doctor burnout, Goepp says. A new curriculum being developed by the Ambulatory Pediatric Association for serving the poor will go a long way toward solving the problem, he says.

Held in Washington, D.C., the conference drew physicians, educators, law-enforcement officers, community organizers, clergy and others. It was sponsored by Georgetown's National Center for Education in Maternal and Child Health, which is associated with the Federal Bureau of Maternal and Child Health.