Fear, vulnerability and sacrifice: Drivers of emergency department use and implications for policy.

Patients' existential fears of unknowns associated with illness and unusual bodily signs and symptoms are common, but unexamined drivers to the emergency department (ED). This paper examines a May 2015 case study of a 51-year-old low-income, recently insured, African American man in Philadelphia (USA) who had two recent ED visits for evaluation of frequent headaches and described fear of being at risk for a stroke. Through ethnographic methods and anthropological analyses we find that fear of failing to fulfill social roles due to a potentially debilitating illness, and fear of burdening family members with medical bills resulting from doctor's visits affect this man's patterns of health-seeking behaviors. While current popular and policy discourses emphasize crowded EDs and ED "overuse," our analysis locates health-seeking behavior within a context of this man's social and medical history. We layer the impact of macrosocial forces with an analysis of his subjectivity to develop a robust understanding of how his patterns of seeking care reflect agency. In so doing, we reveal how this approach can inform policy interventions that could create entry points for patients to access the primary care they need in settings that are best suited to their condition, and leads researchers away from the unproductive binary of "appropriate" and "inappropriate" users that blames patients for seeking acute care. We suggest that institutions develop structural competency to address administrative "inattentional blindness" that erects barriers to care. Specifically, we recommend: increasing insurance coverage among individuals and across populations, and enacting place-based community-level care by employing community health workers.