Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative



When patients present frequently to the ED, clinicians must make an effort to validate them as individuals. It's also important to be aware of and work to change the underlying social determinants that may drive their visits.

“He’s here all the time. I bet you’ve seen him before. . .” In many EDs, there are patients we all know. Though acute, episodic care is the hallmark of emergency medicine, there are some patients who see us so often that they comprise an inadvertent continuity clinic. Their charts are populated with visit after visitthe individual represented in these notes nearly disappears under masses of words about their chronic foot pain and frequent visits, how they were just here last night, how they were at the other ED across the city this morning. Those with unstable housing, with substance use disorders, with untreated chronic illnessesthese are the people that often become familiar faces. And, too often, overworked and stretched thin by a healthcare system plagued by inequities in access and resources, many of us have been guilty of letting the glut of prior visits eclipse the individual present before us. They become a quick dispo, a frequent flier, a superutilizer”we find glib terms that mask the person, their individual discomfort, and our own discomfort at what their frequent visits represent about our healthcare system and society at large. We may record their words, palpate their bellies, hear the beats of their heartbut do we really see them? 


When we’ve seen someone a hundred times, how do we ensure we consistently see them each of those times? 

Some lessons I’ve learned from fellow faculty, residents, nursing colleagues, and, most importantly, from patients themselves, have stuck with me. I won’t get it right every time, and there are no pat solutions to the upstream causes of such ED visits, but surely seeing our patients is a step in the right direction.   


1. Remember that a patient is not their chart.

Remember that their chronic pain doesn’t define them. That each patient has lived, experienced and suffered just as I have. That they are someone’s sister, brother, parent, child, friend. That the reason they’re here in the EDhousing, a meal, access to recovery facilitiesmay not be triaged as “acute” or “severe” or as “urgent,” but that it’s completely valid because it’s a human need. 


2. Consider what it means when the ED is someone’s place of refuge.

For many patients, the ED is the last place they wish to be. It can be loud. It can be dehumanizing. It can be a place of pain and fear, visited only on the worst days of one’s life. 


But for some, EDs are a place of daily pilgrimage. We must stop to question, to consider, to sit with the implications of the fact that this place of last resort for so many is sought out by others. What does it mean to exist in a world where people who are vulnerable or socially isolated are obligated to learn to speak our language of chief complaints” and to couch their needs in terms that we will take seriously,” so that they may bargain with us for a place to sleep, for safety from violence, for another chance at recovery, for dignity and respect? What does it say about how our community functions and the resources available? What does it say about our streets and our shelters? 


3. What must this patient’s day have been like to choose to come to the ED?

Grappling with the cracks and failures of our system, the chronic nature of substance use disorders, the lack of freely available outpatient options for psychiatric treatment, the inequities that mar our societyit’s not easy. We often shield ourselves from harsh realities, avert our gaze, hide behind the layers of their chart.  


But when we choose not to see our patients, we’re also choosing not to see those realities. We must shake ourselves from this protective impassivity. The discomfort that we may feel in confronting these realities is nothing compared to the discomfort that brought someone to our door. And while some may argue that it’s not within our “scope of practice,” it’s certainly within the reality of our specialtythat some may come through that door for severe illness from a broken body, others will come for a warm space, a warm meal, a warm welcome, and respite from a broken world. 


As Virchow describes it: “Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution.” To point out such problems, to advocate for our patients, we must first see them. Some may argue that physicians cannot be all things to all people, yet, indelibly, our work is essentially human. This recognition of ourselves, our profession, and our patients as human is essential to truly seeing our patients, no matter how many times we see them.   








This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.