ER vs. Pre-R

With every ER shift, and every Pre-R call, I’m coming to realize these are pretty different universes. A couple med student friends have commented that they can picture themselves following the Pre-R career path. So this one is for them. Like a high school essay, I’ll compare and contrast.


1. Patients can sit in ER waiting rooms for quite a while sometimes, unless they have “true emergencies.” They’re often fairly nervous, tired and/or angry by the time I get to them during busy shifts.

Pre-R patients wait at home, and are generally calm and friendly when I get there.


2. When someone shows up in the ER with a cold, I have to take time to listen to their tale, and then their lungs. I dutifully look in their ears and their throats too. Eventually I break it to them: “It’s probably viral. Take some ibuprofen. Eat chicken soup. Ricola. Get rest.” They sometimes leave unhappy to have waited so long to then leave without antibiotics.

With Pre-R I can give some tips over the phone or Facetime, followed by: “… and if that doesn’t work, give me a holler in a day or so and I’ll come by for a visit.” I rarely make money from these calls, but I also catch far fewer colds. Much less pressure to treat viral problems with antibiotics, and patients appreciate the conversation.

3. EMTALA requires that every ER patient receive a medical screening exam. This also amounts to every minor scratch being triaged, “vital signed,” evaluated, and eventually sent a massive bill generated by an absurdly detailed medical record.

With Pre-R, friends or patients sometimes text me an image asking if their minor cut needs a stitch. No vital signs for these folk… because that’s craziness. Just a couple lines in our record: “Simple lac. No suture needed. Cleaned well at home. Tetanus UTD. Will call me if signs of infection.”

4. In the ER I meet patients who roll in by ambulance for nose bleeds, that have already stopped bleeding.

With Pre-R I meet patients who would rather die than call an ambulance. Some are elderly and frail. Some are bed ridden. Some refuse to leave their homes. Some are afraid of massive bills. Some fear hospitals more than death. They’re ecstatic for a house call. I get hugs sometimes just for showing up.

5. Patients in the ER who say they are suicidal trigger a cascade of labs. They’re often held for hours while we wait for lab results. Some are then evaluated by crisis management teams. Some are transferred to mental health hospitals, but only after becoming sufficiently sober. A few will have “sitters” posted by the door.

Occasionally a depressed or suicidal patient will call Pre-R. I provide the crisis hot line number, sometimes followed by conversation that can end with: “Hey thanks doc. That helped.”

6. I get paid by the hour in the ER. So a good shift is one with few patients or a small number of “interesting” and friendly patients.

With Pre-R, revenue comes from actually seeing patients. So I’m psyched for every call.

7. In the ER I sometimes save lives. I frequently help folks feel better. Because of EMTALA, I always monetize the worried well.

With Pre-R we mainly do the middle one – help folks feel better.

8. I rarely place IVs in the ER. Nurses are awesome. I click buttons for “orders” and magically things get done. Lots of laughs, camaraderie and learning too with nurses and other staff.

When I head to a patient’s house for Pre-R, the nursing care is all mine. I’m getting better at IVs and improvisation. Laughs mainly with patients and families. Lots more time to yibber yabber.

9. In the ER I’m a parallel processor tugged in many directions.

With Pre-R, I’m a serial processor, seeing one patient at a time with few competing forces, other than Vanessa and Max.

10. Supplies are a moving target in the ER and I use whatever is available. I use the hospitals’ chosen glue, gauze, splints and formulary. I have no clue about their costs for supplies and meds, and no major forces other than professionalism and sanity keeping me from wasting sterile gauze as toilet paper.

Through Pre-R, I purchase everything. I know that it costs $30 for one single Dermabond vial, and the same for a slab of 5″x30″ orthoglass. I know an EpiPen with 0.3mg of epinephrine costs ~$250, while a 1mg vial of epi plus syringe costs ~$6.

11. Rarely do I meet pets in the ER.

For some reason, almost every Pre-R patient has pets, and they like me more than the mailman.

12. When patients leave the ER, they’re gone. Sometimes I give them my phone number for reassurance, but the large majority just walk back into the woods. I get follow up mainly when my treatment fails or if a patient complains.

With Pre-R, virtually every patient gets a follow up text or call. Because of this, I’ve learned that three days of antibiotics for a UTI sometimes doesn’t suffice… despite the literature.

13. ER liability is notoriously high. As such we treat every patient like a ticking bomb. Every patient with chest pain is a heart attack, aortic dissection or pulmonary embolus until proven otherwise. We have one moment in time to get it right so we do the works.

With Pre-R I have conversations teaching patients about the implications of muttering “chest pain,” while touching on risk factors, and probabilities vs. possibilities. They can then make choices about which ways to proceed. They understand I don’t have every test at my fingertips, and they’re grateful for a bit of advice with some time to think.

14. While we bow deeply to HIPPA in the ER, we also know true privacy is unattainable. Doors are generally open and curtains do nothing for sound. Patients are paraded on gurneys past staff and other patients into their rooms. Sometimes workups happen in hallways.

Pre-R patients have home court advantage.

15. Because I generally don’t know whether or not my ER patients have insurance, and what may be their copays and deductibles, these don’t factor into my decisions. Maybe this sounds good. But I also have no idea what they will be billed, and what the financial implications of my testing and treatments may be weeks to months down the road.

Pre-R doesn’t bill insurance companies. We issue superbills to patients on request, which they may choose to send to their insurers. Most don’t, because it turns out their time isn’t worth the headaches either.

16. Whether or not your problem is solved in the ER, you will receive a bill. No such thing as a money back guarantee.

Pre-R has suggested fees. We request payment only after medical problems seem to be solved, or patients say they are satisfied.

16. Patients (few) can be as mean, drunk or nasty as they like when they stagger up to the ER, but they will still be seen. It’s their EMTALA-given right. They typically still receive excellent treatment, because emergency medicine is a service industry where we care about patient satisfaction too.

With Pre-R, we also care about patient satisfaction. But bad behavior meets rejection. “I’m sorry sir, you are seeking apples and we sell oranges. Have a nice day.” (This has yet to happen, but it’s an option.)

17. Narcotics are highly prevalent in ERs. The pain scale has become another vital sign, though distinct, being the only one that is subjective. For years we’ve been told to “treat the pain, treat the pain.” However, emergency medicine today is at an inflection point. Now we’re treating the addiction.

Pre-R prescribes no narcotics, sedatives, nor psychoactive medications. (True confession… We sometimes do. I doubt any challenging patients will be reading this far.)

18. In the ER we periodically intubate, do CPR and feel like we save lives. When things go well it can be a real high. These patients typically meet many other doctors, so thanks aren’t plentiful. But the “good saves” themselves are pretty uplifting.

Pre-R patients are profusely thankful for any help through problems they’d likely survive with or without me. Periodically, they bring fruit or eggs.

19. No way I’ll be able to do ER night shifts into my 60s, 70s, 80s.

Pre-R I can do long after I’m gumming my Cheerios.

20. If you have debt or dependents… ER.

If you’re a gambler, happy to live trim… Pre-R.

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