January 10, 2008

           San Francisco General Hospital’s Emergency Room:  Long Lines In Exchange for High-Quality Care

By Kerry Fleisher

            The line at San Francisco General Hospital’s (SFGH) Emergency Care waiting room can be so long that, not infrequently, lower priority patients watch the sun rise and then set.  It can be so long that patients like Nahid Brohead have watched entire seasons of “Who’s the Boss” on the 20-inch television stationed in the corner, from episode one to the finale.  But despite the excruciating wait, SFGH’s patients are usually pleased with the services they ultimately receive.
            “Very, very excellent services,” beams Brohead, who’s originally from Massachusetts and was waiting for a doctor to see a cyst.  “The services here are better really than any place I’ve been to before, better than any hospital I’ve been to in the West.” 
            The scratchy sound of the antiquated television in the sterile emergency room is pierced by occasional coughs and a few loud soliloquies from particularly restless patients.  Time passes without much evidence, except for occasional patient numbers broadcast over the loudspeakers, or the sound of ambulance sirens transporting someone to the trauma center.
            Tom, a man with a face full of white whiskers and the shakes, said that his spell in the waiting area this time is the longest he’s experienced at the hospital:  he arrived at 11 a.m., and it’s now 4:30 p.m., with no hint that he’ll be seen by a medical professional anytime soon.  Tom, who hails from New York and lives in the Tenderloin, is an emergency room regular.  The nurses always ask “very pertinent questions” during triage, he said, and “are friendly and efficient.”  The only thing he would change about the process, if he could, is “the wait. Definitely, the wait.”
            SFGH’s Director of Quality Improvement Eric Isaacs, M.D., points-out that the Emergency Department is strapped for resources, operating without the high-powered CAT scan and MRI machines typical of better-heeled hospitals.  However, one thing SFGH isn’t lacking is a committed faculty.  “The doctors are really passionate about what they do.  There are people destined to work at a public hospital.  You need to be willing to sacrifice a little bit,” said Isaacs.
SFGH boasts some of the nation’s most qualified doctors, drawing graduates from Harvard University, Stanford University, the University of California, San Francisco, and other elite medical programs.  And the hospital’s support staff keeps the quality bar high with one of the best translator programs “in San Francisco if not one of the best in the nation,” said Isaacs.
            Signs posted on the waiting room wall in Spanish and English proclaim that, “It is the POLICY of SFGH MC to Financially Assist Uninsured or Underinsured Low Income Patients: you may be eligible for low cost or free care.” “Patients run the gamut of socio-economic levels,” noted Isaacs.  Financial District executives, homeless people from the Mission, and under-employed workers from Excelsior all mingle together in the waiting room on a regular basis, he said.
            Mission resident Filemon is here for the second time, accompanying a friend to the waiting room.  He once came in with a banged up arm and waited four hours to speak to the nurses in triage, and then seven more hours to see a doctor.  The outcome: he was given a handful of pain killers, which he said wasn’t worth the wait.  Still, he recommended SFGH to his friend because it was close and “the nurses and doctors speak Spanish and seem to care.”
            “It’s not quite as sexy to give money to a public hospital, you may not get a placard,” acknowledged Isaacs, who would prefer to see all his patients much more rapidly.  The hospital is currently investigating how to handle the high percentage of repeat patients who regularly seek emergency care for non-emergency issues.  Isaacs is working with other researchers on a study examining how to encourage lower-priority patients to obtain services at a community free clinic instead of waiting for emergency care.  Lowering the number of patients with minor complaints could help reduce waiting times, and lower the stress on patients, doctors, and staff caused by the ever-present patient backlog.
            Research Director Robert Rodriguez, M.D. is also looking at what motivates homeless patients to seek emergency care.  He and his team are conducting surveys to assess how hunger, shelter, and safety factor into patients’ choice to seek emergency treatment, operating under the theory that roughly one-quarter of homeless people use SFGH as a de-facto shelter.  “Our goal is to define if this is the core issue,” he said.  By law, no one is ever turned away from emergency care; however, a long-term solution may be to establish a shuttle system to nearby shelters, or create an educational campaign to steer non-emergency cases away from much-needed patient beds, said Rodriguez.
            Edward, who’s nonchalantly sprawled across two waiting room seats, constitutes the target audience at the heart of Rodriguez’s study.  Edward, who lives near the ballpark, joked he’s been to the emergency room a hundred times.  “No, a lot,” he clarified, with a laugh.  Today he’s there helping a friend seek care, though usually “the most I have is a cold” when he comes in.
            “I’d rather be in San Francisco General than anywhere else,” he said.  “Anywhere else you might catch hell, you might even die.  They have a very professional staff, they make enough money that they can afford to pay for good doctors at a county hospital.  Here and Palo Alto, they can keep up with the private hospitals.”
            Edward pulls up his sleeve, and points to a huge scar covering his lower arm from wrist to elbow.  The stitches are a constant reminder of the high quality care offered at SFGH, where doctors tended to him after a car accident broke his arm in two.  “They put my arm back together, that’s for sure,” Edward laughed, a certain pride for his county hospital breaking across his features.