The patient’s dilemma: attending the emergency department with a minor illnessBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1941 (Published 27 April 2017) Cite this as: BMJ 2017;357:j1941
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Dr. Hill-Smith makes an excellent observation that reflects the different environments in which we work. Emergency physicians are trained to rule out the worst, before accepting a benign cause for the patient’s symptoms. This is at least in part because the pre-test probability of serious illness is higher in patients attending an ED than those choosing another avenue for care. However, we did not mean to imply that all patients get extensive testing to rule out a serious cause of disease. The patient with vomiting and abdominal pain does not undergo a CT scan for appendicitis if a more detailed history is one of diffuse crampy pain and multiple sick contacts, and the exam shows no focal tenderness. However, the patient’s initial complaint could have been due to appendicitis and only an experienced clinician can make the judgment that it is most likely just gastroenteritis.
Studies that look at the proportion of patients who are seen in the ED with “minor illness” use the discharge diagnosis to make a judgment about whether a patient’s visit was appropriate. Hence the classification is made in retrospect, after an experienced clinician uses either clinical judgment or tests to make a diagnosis. A recent study in JAMA, referenced in our editorial, looked at the chief complaints of patients whose visits were later classified as “primary care treatable” based on the discharge diagnosis. The chief complaints in this group were similar to those of patients who needed immediate treatment, were admitted or went directly to the operating room. The point of our statement was simply that determining something is minor often takes some form of expert evaluation, and it is not fair (or feasible) to expect patients to be able to make this determination on their own.
Competing interests: No competing interests
There is much wisdom in this editorial, together with its partner "Seven day access to routine care in general practice", but one view, from Ellen Weber, does appear biased and one perhaps too readily adopted by a professor of emergency medicine. Many years ago, immersed in hospital based medicine and pathology as a medical student, I recall a consultant psychiatrist taking me to one side and gently explaining why a psychiatric diagnosis can be made positively on the basis of a good history and examination, avoiding the inevitable delay and potentially harmful investigations needed to exclude all physical causes of the symptoms, especially when the mental health problem is common, and an alternative disease is very rare. So, the assertion made by Ellen Weber, that "Minor illness is a diagnosis made in retrospect" is from the perspective of someone accustomed to life-threatening emergencies. In contrast, over the past 20 years at the National Minor Illness Centre we have been teaching primary care clinicians the skills they need to accurately diagnose minor illness and to take appropriate action when the condition is more serious. So rather that assuming, as the published editorial claims, that "a problem isn't minor until you've proved it isn't major", we would say that what matters is making the right diagnosis, an aim that is common to all clinicians.
Competing interests: The National Minor Illness Centre runs educational courses for clinicians.