Questions with Answer

From a third party study aid for an examination that all American medical graduates have to pass comes the following question.

A 39-year-old disheveled homeless woman walks into the emergency department complaining of abdominal pain. The woman smells strongly of alcohol and seems disoriented. She describes the abdominal pain as "real bad" but cannot specify when the pain first started, where it started, where it is localized, or what factors exacerbate or relieve the pain. She then adds that she does not have health insurance and has no money to pay for her care. What is the next best step in handling this situation?

A) Inform patient that she cannot receive care unless she pays in advance
B) Ask patient's family members to either assume liability for her bill or take her home
C) Provide appropriate medical screening exam and stablize her condition
D) Transfer patient to the county hospital by ambulance immediately
E) Refer patient to a local free clinic for follow up next week

Two questions for readers:

1) What do you think the answer should be in an ideal world?
2) What do you think the correct answer is (i.e., what answer are the people who wrote the question looking for)?


The correct answer is C and the explanation given is as follows.

Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1996. This law was designed to prevent hospitals from inappropriately transferring, discharging, or refusing to treat indigent patients, and allows for strict fines to be levied on any hospital found in violation of the Act. EMTALA imposes three primary requirements on hospitals that provide emergency services. First, the hospital must provide an appropriate screen medical exam to anyone who comes to the ED seeking medical care. Second, if such an individual has an emergency medical condiditon, the hospital must treat and stabilize the emergency condition. Third, the hospital must not transfer an individual with an emergency medical condition that has not been stabilized unless several complex conditions are met.

I posted this because there is a common perception that people in the US are being turned away when requiring emergent medical care. The people holding this perception are often non-Americans I meet on the internet, though just as often, they are Americans. I find this odd because in all my years working in hospitals, I've never seen a patient turned away for emergent care. Insurance is simply not an issue.

One incident I remember from a few years ago is of a young male involved in a motorcycle accident who was taken to the emergency department, admitted to the surgical ICU, and remained there for a long time. Yet, nobody knew his identity till long into his hospital stay. He received expensive, top line intensive care without anyone demanding his insurance card.

I don't know the history of the EMTALA, but hospitals have been treating emergent situations without regard for ability to pay long before 1996.


As far as the "ideal" world question, yeah, a bit vague, so I'll withhold without comment for now.

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1) In an ideal world the woman, or somebody close to her who cares about her, would have the means to pay for her medical care.

2) C

All illegal except one

As far as my limited knowledge of the law tells me, A and B are illegal because of the legal obligation of hospitals to treat everyone. D and E strike me as probably illegal for the same reason, D being just possibly legal. So the only clearly legal answer I see here is C.

As for "ideal world", I don't know what you mean. There are different ways for the world to be "ideal". But maybe the answer you're fishing for is "C" here as well. In one kind of ideal world there are infinite drugs and infinite staff and everyone who comes in for treatment can be treated. As an occasional visitor to the emergency room, I know that in the real world there are some pretty severe limits on what I can get and on how timely a manner I c an get it in.

I'm reading your entry as saying, "the law makes unrealistic pie in the sky assumptions about the realities of medical care, so the law was obviously written by a bunch of morons." 

Taking "ideal" as in

Taking "ideal" as in "optimal under realistic expectations", the correct answer for 1) would take into account that:

- healthcare remains a scarce service

- demand would take into account this constraint on offer in a perfectly rational way

In my understanding, the ideal world is a maximum-trust world: there would always be an ultimate entity liable for costs which would have a mutually-agreeable contract with the woman, so you wouldn't even have to ask for liability as it would be assured to you already through voluntary contracting, insuring and re-insuring ; and the supply would be adequate (ideal world excluding irrational and accidental surges of demand) as well. In the end, the ideal world assumption is incompatible with all answers but C.

Of course, the answer for conditions 2) is C, too. Commie zombies walk among us, and all that.

Two answers for two questions

The good folks at offers a legal answer to the question.

(Answer number 2 first): I see the "correct" answer as being C.

Depending upon what you think of as 'ideal' the ideal answer could be any or all of the various choices listed although B seems a rather poor answer as the question doesn't posit that any family members are present (plus if her family had a home it makes the patient description as homeless rather odd although not impossible - unrepentant drunks may be refused a "home" even by family).

I don't know what an ideal world is.

1. In a just world it would simply be up to those providing the service to decide.
"In an ideal world should you choose chocolate or vanilla ice cream?" I don't see that the ideal-ness of the world has any bearing on the choice.
2. I assume C was the answer sought.