Emergency medicine - we can do better

When someone gets sick, what are their options?

They can try to make an urgent appointment that day, but how many of your doctors actually offer that? Most people will have to wait for weeks, if not months, for a regular appointment. Even if you go to a walk-in clinic, the wait will likely be hours, and you're not sure if clinics can take care of everything, so you head to the emergency room, thinking that you will get urgent care because of the word emergency in it.

And you will, after various amounts of wait time, but what do you give up in return?

To answer that question, let's see how the emergency room works.

When patients come in, they are triaged based on severity and afterwards shuffled to different parts of the ER accordingly. ER doctors then ask you just enough questions and draw just enough labs to make sure you do not have immediately life-threatening conditions. The ER does not necessarily address your chief complains or the main reason you come to the ER - it only makes sure you don't die in the immediate future. Everything else is left to be dealt with by the admitting doctors or your primary care doctors - if you have one. That means you will have to explain your medical problems at least a few times over, if not more, and the more times you tell it, the more interpretations of the story you will have, resulting in contradicting information and decreased quality of care. Moreover, that fact that there are more people involved in your care - admitting doctors, ER doctors - means that there are more hand-offs, resulting in more errors, disagreement on management, miscommunication, redundancy, waste of efforts and resources.

Why do we set ourselves up to do the same work twice? have patients repeat their stories over and over? And most importantly, why do we subject patients to risks and low quality of care?

There must be a better system, where we work together instead of separately at separate times, redoing each other's work. There must be a better triage mechanism that screens for better information that will allow doctors to collaborate as soon as patients enter the system and long after they leave the hospital. There must be a better system that allows health care personnel to get rid of their short-sightedness and view patients as a person, with identities other than medical conditions that immediately kill and worries that must be addressed other than their health. Instead of looking to finish just our responsibilities and deferring the rest to others, we should think about how to deliver complete care to patients as a group. Thinking about how to make lives easier for our colleagues will help patients and reduce work for ourselves, because we will reduce inefficiency and redundancy all around. The whole system will be more lean and happier for it.

There is no formula to a better system - we must find out through trial and error, but first we must recognize that separated we will fail. We cannot just save ourselves anymore - the world is too connected and too strained for resources for one person to make a fortune without making others poorer, and human beings by nature will not tolerate continued marginalization. It is the source of conflicts and violence in our world - war, terrorism, burglary, revolution - so let's save ourselves some agony and start giving instead of taking.

In the end, it's the individual who's not interested in fellow men who has the greatest difficulties in life and provides the greatest injury to others.

Rethinking Philanthropy

Recently I heard a 4th year medical student, a veteran of global health activities, chatting with excitement about her upcoming brief trip to the border between Thailand and Burma, in which she will develop an education program for the refugees during the 2-3 week duration of her trip.

My feeling as a Thai native was far from enthusiasm. The Northern border has become a revolving door of NGOs - the whole area has now thrived mostly on businesses catering to foreigners and sometimes I wonder if the town is inhabited by more "philanthropic tourists" than Thais and refugees. But the sheer invasion was not what irked me - it was the motives behind the influx of these philanthropic tourists.

Consider the individual level - exemplified by this medical student. Many foreigners visit without ties to NGOs in the area, hoping to do good during their time off. Most of these visits are brief - none of the visitors intend to stay permanently or even for a long period of time. They come at their convenience, not based on the timing of various needs of the refugees. They come with their preconceived ideas of what needs to be done, they come up with their own ideas of how things should be solved, and they marched into the sometimes unknowing, defenseless receptive arms of refugees, who, after their ordeal, would take any help they can get, even if that help is a bandage for the gushing cut wound that distracts away from stitches that would eventually save them from exsanguination. They somehow think that their ideas are different from others and that only they are suitable for the job - this usually results in fragmented, duplicate efforts competing for resources and creating confusion for refugees. These visitors leave, not when projects are finished or outcomes are improved, but when staying becomes inconvenienced by obligations back home. They leave and usually never turn back to look what exactly they left behind.

These issues are amplified by NGOs. Most NGOs are not so quick to enter or leave as individuals, as dinosaurs move at a slower pace than people, but the issues remain - egoism, lack of needs assessment, fragmentation/duplication, competition for resources, lack of continuity and distraction from long-term/meaningful changes, lack of accountability, and most disappointing of all, the focus on the agenda of foreigners instead of that of refugees.

We might be fooling ourselves to think that parachuting donated items or good-willed people into a needy area for a short period of time will create real change. The problem of parachuting pervades most NGO efforts, since help comes from outside and not from within. When was the last time a sanction on the Burmese government eradicated the corrupted generals? Do we expect to establish a peaceful nation by marching troops in, capturing the tyrant, then picking up our suitcases and leaving the newly-freed citizens to their own devices?

Look at China and Africa - the two are not so different. Both are plagued by human rights issues, bad health outcomes, pollution. But how come no one feels sorry for China? I don't see hoards of NGOs rushing to the aid of the Chinese people, and who do you think will emerge a victor in the next decade?

If we learned anything from our lesson in Iraq, it is that these are not our fights. The real victory springs from within the very people we are trying to help, not from us, and our only appropriate role as altruistic individuals is to empower people to fight their own battles. Empowerment is a lengthy and delicate process - one that will be damaged by parachuting, because failure and abandonment leave their marks on the faith of these fragile population.

So the next time you think about helping other countries in need, think about what you actually are doing. Think if your help is a quick fix that takes away from meaningful changes. Think if your good will might be disruptive to the real progress that needs to be made.

And most importantly, be honest and think to whom this altruistic act is really aiming for. It is not ok for you to feel better about yourselves at the expense of the disadvantaged. Remember, the road to hell is paved with good intentions.