When waiting feels immoral: Fairness in the emergency department calls for empathy from all of us

Mr. Kane is using one hand to clutch the plastic basin into which he is vomiting and gesturing hello with the other hand when I introduce myself to him in the emergency department triage area.

He has suffered from headaches ever since he had surgery for a brain mass years before. Over-the-counter medications typically control the pain. But today it feels like a hot knife behind his eyes, and he had little choice but to come to the hospital. I examine him, start treatment, and tag him for an urgent bed in the main emergency department.

Only there aren’t any beds immediately available. He’ll be sent back into the waiting room in the company of the many other waiting patients, some possibly sicker than he is.

The specialty of emergency medicine is firmly grounded in social justice and providing access to expert care to everyone who comes in. That means treating anyone, with any condition, at any time. And yet, embedded into emergency department operations is a system that might be perceived as unjust: the concept of triage. The emergency queue isn’t “first come, first served.” It’s nonlinear by design, since triage prioritizes the severity of illness. The severely ill or injured receive immediate attention. Everyone else, to various degrees, must wait.

“This is wrong!” Mrs. Kane lashes out at me. She’s on her cellphone calling an ambulance to take him to another area emergency department.

There are situations when waiting feels immoral to me, not merely inconvenient. Being an emergency doctor means shouldering burdens for perceived injustices that we have little, if any, control over. Most of the beds were locked up with patients boarding in the ED, which means they are waiting for an inpatient bed to become available in the hospital.

This is what I tell her: “I won’t talk you out of your rage. You deserve it. It might not look like it, but we’re on your side.”

Hospitals have high expectations regarding how quickly patients are seen in the emergency department, and my colleagues and I share that goal. But there’s less urgency when it comes to discharging patients from the hospital, which would unclog the backup in the emergency department — and its waiting room. If the department’s techs and nurses could fold an origami bed out of paper, they would gladly do that for Mr. Kane and the others.

The perception of fairness shapes people’s impression of waiting. Those who are skipped over are rarely happy about it. It’s hard to bear the anger and frustration of patients and their families when you know you’d be complaining, too.

Waiting in the ED isn’t just a stressful test of endurance. It’s a first-order oxymoron. A waiting room in an emergency department? But that’s the warped and inescapable reality.

Many institutions and hospital systems have instituted changes to cut wait times for emergency care. Longer wait times can lead to worse health outcomes and drive up costs. But when we focus on the experience of waiting, I believe it’s more than a problem of time. It’s also a problem of empathy, recognizing that behind each blank stare is a churning imagination.

Waiting is a peculiar form of inactivity. It can push us to exhaustion — “I’m tired of waiting” — and compel us to impetuous behavior. Who hasn’t darted into the shorter supermarket line or nosed into the emptier lane on the highway only to be slowed down again? Waiting can distort the experience of time. Researchers in waiting, or queuing, say that our perception of waiting can feel as much as one-third longer than it actually is.

Pioneers in wait management, the folks who run the Disney parks, understand how to navigate expectations. Through distraction and constant entertainment, kids and parents are less aware of time’s passing. A 30-minute delay feels like a win when you are originally told to expect 45.

But distraction is difficult when your fears will still be there after the distraction is over. The wait for a thrilling amusement park ride is not the same as waiting while being tired, scared, hurt, anxious, and sick enough to warrant a detour from your daily routine for a trip to the emergency department.

The atmosphere in ED waiting rooms can feel like being lost in the Bermuda Triangle of might, should, and could. Patients bring with them more than symptoms and problems. Added to concerns about what might be the cause of their trouble are unmet desires and what should be happening — receiving medical attention— while life outside the hospital continues, spiking the wait with all the possible things patients could be doing: earning money for rent and food, caring for an ill parent, picking up kids from school, feeding the dog, even sleeping.

Mrs. Kane was apoplectic, but somewhere in her fury was the recognition that we were allies, that her fight was our fight. Paradoxically, waiting can serve as an occasion that unites patients, families, emergency physicians, and staff.

There were no immediate beds in the ED proper for Mr. Kane. But the techs and nurses found a space for him on a gurney in a part of the triage area. Mrs. Kane was satisfied that we were keeping him in our sights, and that he could wait and be cared for. Which makes you wonder if it still counts as waiting.

Mrs. Kane shook us up, but she also reminded us to check in with everyone else we’d seen in the triage area and sent back to the waiting room so they, too, understood they were in our sights.

Soon, Mr. Kane had stopped vomiting. In fact, as the medications we gave him took effect, he sank into sleep.

Mrs. Kane appeared so exhausted I thought she’d collapse and we’d be treating her, too. She told us about all they’d gone through. The surgeries, the onerous physical therapy, their kids in middle school, the long stretches when her husband was unable to work. Whenever he gets like this, she said, she can’t help but fear the worst: that the tumor is back.

Strategies to reduce waiting times must not ignore the fact that waiting demands empathy from the ED staff. They must design triage and communicate with patients who wait so they understand this process and their place in it. These conversations must include our recognition that waiting is complicated by anxiety and uncertainty, and we’re aware that patients might be traveling to some stressful and frightening places while they appear to be calmly sitting in a stiff chair.

The widening fractures in our social fabric lend urgency to this project, as the perception of injustice can push people to behaviors that shock their calmer selves. Violence in the emergency department is a worsening and pervasive problem that places the safety of patients and the ED staff at risk. It breaks my heart when a fearful grandmother is waiting next to a screaming, intoxicated man. Or when violence spills in from the streets.

Though time can be measured with remarkable accuracy, responses to waiting are as unique and unpredictable as the patients who do it. I remember trying to reason with a patient with chronic knee pain who watched the ED staff rush into a room where a patient was in cardiac arrest. She saw us talking with the tearful family, the priest providing comfort outside the doorway. And yet she gave me an earful about how long she had to wait. But more often than not, I’m astounded by how understanding patients and their family members can be.

Early in my emergency medicine training, a senior physician offered this bit of advice: When you enter a patient’s room for the first time, introduce yourself and apologize for the wait, even if they’ve waited only five minutes. I rolled my eyes. It felt scripted, a patient satisfaction gimmick. But I soon realized that by apologizing you are recognizing the breadth and complexity of a patient’s waiting experience.

The decision to come to the emergency department is a tough one, making it especially crazy that there’s a waiting room in an emergency department.

Jay Baruch, M.D., is associate professor of emergency medicine and director of the medical humanities and bioethics scholarly concentration at the Alpert Medical School of Brown University. The patient’s name and identifying details have been altered to protect the patient’s privacy.