As hospital boarding, increased emergency department (ED) volumes, and complexity of patients have increased, so have wait times. Some physicians now coin themselves “waiting room medicine specialists” as departments schedule a physician in triage or attempt to evaluate patients in whatever spaces might be available. After years of training to fully undress a patient for an exam at ABEM General Hospital, patients may now routinely be treated in street clothes sitting in a hallway chair. Although this practice attempts to deliver care in a more timely and efficient manner, core aspects of care may be lost. A tension between the necessity and the compromises of “waiting room medicine” thus creates an ethical conundrum.

Privacy

Dating back to the Hippocratic oath, privacy is a core tenant of the profession of medicine.¹ When space is limited, patients’ medical history is rarely protected from the vision or hearing of other patients and guests in the ED. The sensitivity of the details of an ankle sprain may seem minor. However, the history of a genitourinary complaint or the emotional impact of a miscarriage may be much more intimate. Attempting to obtain pertinent details and exams to allow appropriate and complete treatment may be compromised if care is conducted in the public space of a hallway or waiting room. A patient may not be willing to disclose a sensitive past medical history or events of an injury that they deem embarrassing and that could affect the differential diagnosis of a potentially otherwise benign complaint of pain or cough.

Waiting room medicine attempts to balance the ethical principles of beneficence and nonmaleficence. It is the response of an overwhelmed ED and health system attempting to provide the greatest good with inadequate resources, staffing, and space.² Focusing on the benefit of providing earlier testing and assessment, even under less-than-ideal conditions, will lead to more timely diagnosis, treatment, and disposition. However, this comes at the risk of potentially incomplete examination, missed details, and lack of privacy and sensitivity. Circumventing a traditional patient evaluation increases the risk for unnecessary testing or cost and risk for human error. There is also the recognized risk that a patient may undergo a partial evaluation and leave prior to full clinician assessment or results of tests initiated in triage. Struggling in the middle, emergency physicians balance what can be done versus doing nothing.

Harm to Physician Patient Relationship

Waiting room medicine is a component of ED crowding, which itself increases the length of stay for patients.³ This affects the physician-patient relationship by prolonging the duration of the ED visit without increasing time spent face to face with a physician. The majority of patients will underestimate their anticipated ED length of stay, and will provide lower satisfaction scores as a result.⁴ It also places a strain on the physician to provide optimal care for their patients while being constrained by space and time restrictions. Waiting room medicine results in significant strain on the physician-patient relationship and affects the ability for a patient to receive optimal care.