Posts Tagged trust

Trust (Part Three)

courtesy wikimedia commons

courtesy wikimedia commons

Boy do patients trust their physicians. I write this, truly, without a drop of sarcasm. (And that last line without one, too. No, seriously.)

Despite the variation in the patients we see every day, it’s often easy to clump them together. “Oh, another cocaine chest pain,” or “Pregnant vag bleeder,” or “Fever, headache, rule-out meningitis.” But every so often there’s something special about the patient — perhaps their name, face, or mannerisms — that makes the patient encounter a little deeper, a little more personal.

Recently it was another one of those “Fever, headache, need-to-LP” patients for me. My “younger than her stated age”, stylish, yoga-enthusiast patient spoke with a cute slighty-European accent, and with her neck stiffness, I figured I had to stick a needle in her back. While I was consenting her, talking through the procedure, and how I avoid the spinal cord, it dawned on me that this was a pretty remarkable amount of trust she was giving me by signing on the line. This idea of trust was something I thought greatly about in pre-clinical medical school, where the patient is an abstract concept. A theory, an idea. A “doctor-patient relationship.” But as I go further down the rabbit hole of becoming a full-fledged, root’n toot’n attending, this trust is something you simply acknowledge and accept. Waxing philosophic does not a successful procedure make, and certainly does nothing to treat or diagnose meningoencephalitis.

Putting myself in her shoes for a minute, she’s meeting a young, ravishingly handsome, courageous and beneficent physician for the first time.* She’s never met this person — for all intents and purposes, a complete stranger — before. He says he’s going to get me feeling better (yes please), do some blood work (okay, I guess), give me some fluids (sure, fine), and also stick a long needle in my back in between my back bones to make sure I don’t have meningitis (wait, whaaat?).

*This is, of course, how I assume most people view me, not as the “dorky, way-too-young-to-be-sticking-a-needle-in-me, wow-you-have-a-lame-sense-of-humor YOU’RE my doctor? guy with slightly wrinkled scrubs” view of me with which I am sometimes confused.

I’ve gotta say, that’s a leap of faith, and an amazing level of trust in the medical profession that exists nowhere else. While we as physicians often struggle with trusting parts of a patient’s story, or what their body is telling us, it’s much more often than not that a patient gives up a lot of autonomy and lets us as physicians do whatever we think is right.

It’s often those patients that lack our trust that I find myself often labeling “difficult,” even though it’s usually a wrong diagnosis, poor treatment or bad outcome in a hospital or by a physician that made them skeptical to begin with.

With great trust comes great responsibility, and that’s the simple lesson that we all know yet can always use the reminder: we’re professionals. We try to do right by the patient, help more than hurt. We put their needs ahead of our own. Thanks, random patient, for bringing that reminder back into view. And I’m glad you don’t have meningitis.

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Trusting the Exam (Part Two)

via wikimedia commons

via wikimedia commons

Part two begins where part one left off: history complete, we move to the tried and true physical exam. Which is neither tried, nor true. Discuss.

There are two types of complaints: those that warrant a physical exam and those that don’t. (Controversy! Gasp!) I think the physical exam will always remain a part of medicine, as it should: I believe patients like — and perhaps even benefit from — the laying on of hands. The fact that the physical exam takes time, concentration, and attention to one single person, when often in the emergency department we are constantly having to interrupt patients with phone calls, EKGs to interpret, or pages overhead. The physical exam requires a physician’s presence. It makes patients feel that the physician is being thorough, even when it may not change your plan one bit. You’ve made up your mind a long time ago it’s a cold, but looking in the mouth and the ears, listening to the lungs, feeling the neck and patting the shoulder with comfort may be the difference between “this doctor doesn’t care and rushed through everything and I think I need antibiotics” to “Okay, I trust and believe this guy.” I especially find reporting what I find to patients helpful. “Great, lungs are clear, ears look normal as well!”

But really, often, the physical exam doesn’t matter. You’re a 70 year-old febrile smoker with a new productive cough? I don’t care how clear your lungs sound to auscultation bilaterally, you’re getting an x-ray. Now, some will argue that the physical exam has gone by the wayside because our physical exam skills have deteriorated as we’ve had to see more patients in a shorter period of time; this is especially true in the emergency department with patients in pain, crowded, less-than-private exam rooms and a noisy environment prone to missing 1/6 systolic ejection murmurs. Sure. Fine. I don’t percuss my patient’s lungs routinely, nor do I listen for egophony. Whip out your copy of Evidence-Based Physical Diagnosis and you’ll find the physical exam, in many circumstances, just ain’t that great. Take pneumonia. Crackles has a likelihood ratio of 1.5-2.5; decreased breath sounds about 2; egophany about 2 to a respectable 8, depending on the study. Orthostatics suck for evaluating hypovolemia (LR+ less than 2), and everyone knows palpating a AAA is rare. Whip out your trusty Fagan nomogram, and these likelihood ratios aren’t moving you anywhere, fast. Take something like temporal arteritis — something we’re even less familiar or comfortable with than pneumonia –and having or lacking temporal artery tenderness barely changes anything. (Note, the “Does This Patient Have” Rational Clinical Examination series in JAMA, which is often summarized in the Annals of EM often provides a great list of these.)

And then there’s the cases where the physical exam is going to move your workup in one way or another. The neuro exam, the abdominal exam, the pelvic exam, por ejemplo. Vomiting, abdominal pain, tender is a very different story from vomiting, abdominal pain, not tender. Or cervical motion tenderness versus not. Os open versus os closed. Left-sided weakness with pronator drift.

Scrap the physical exam entirely? But then what’s the alternative? We image everything, work everything up? And cause how many cancers and incidentalomas and further complications?

It seems to always come back to that one thing in medicine: the art of it all. That intangible bit that makes guidelines impossible to write or adhere to, that makes the individual patient in front of you the conundrum and challenge, but also the curiosity. Finding that sweet spot on medicine’s moving target.

The physical exam is flawed, just as we are (our patients’ bodies don’t read the textbooks, either). It’s not the end-all be-all if your clinical suspicion is high, but should be taken together with all the other information you’ve got to make your diagnosis, plain and simple.


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Trusting the Patient (Part 1)

Emergency medicine is an all-senses sport and then some. See, hear, smell, touch, (hopefully not) taste, body language, psychological clues, bullshit detector. We have to figure out which complaint is the chief, which are contributory, and which are noise that our patients use to make our jobs more difficult. Our patients were strangers to us only moments before we introduced ourselves; they often don’t speak our language (medical or otherwise), come from different cultures who interpret or experience pain or discomfort in other ways, or lack the education to understand what we’re asking or telling them. (But if it were easy, we probably wouldn’t have been drawn into the field in the first place, would we?)

We don’t always have much to go on. A history from the paramedic, from the home attendant, from the son: a medical game of telephone. Sometimes patients lie — for their own gain or from their own shame. Sometimes we miss the elephant in the room. Sometimes our patients are confused. Or aphasic. Or angry. Or drunk. (And sometimes all of the above.)

In medical school, we’re always told “listen to the patient,” that the patient and his or her history will very frequently lead to the diagnosis. And frequently it does. But get any number of patients we see every day with 4 or more complaints and a grossly positive review of systems, and you simply can’t address them all, or unify them all into one little nice diagnosis.

And with our handicap of not knowing the patient plus the patient often not knowing his or her own history, the patient often has magic words that force our hand. We lack the luxury of being the primary care physician who knows the patient, has evaluated the patient on multiple occasions for her “chest pain” or “abdominal pain” with negative workups. For us, however, say the magic words, and you’ve bought yourself an admission, if you want.

“Chest pain?” EKG, troponins, chest x-ray.
Intoxicated and “I hit my head?” CT brain.
“Weakness?” As big or little a workup as the physician wants.

Often we can’t tease out what made the patient decide to come in today, no matter how many times we ask, or how many ways we phrase it. Often the answer ends up being “I just got tired of it not going away,” like my patient last week told me for the reason he finally came in after being blind in both eyes for 6 days. Ugh.

On other occasions, we have to take the gist of what the patient is saying — the overlying theme, if you will — but ignore the context. Last month, a patient came in because, as he explained it, “The pain I always have whenever I get stressed just didn’t go away.” 3 hours and a CT scan later, voila, perforated appendicitis.

The history often leads us to our diagnosis, but sometimes through a very circuitous route. Sometimes hunches, guesses, or stabs in the dark lead to the answer. Often the textbooks are wrong and the patient is right.

A lot of this whole “becoming a doctor” thing is refining our filter — getting more comfortable with disease presentations, and teasing out the subtleties that lead to the answer. It’s why the “chief complaint” is supposed to be in the patient’s own words, but the rest of the history and physical is described by the physician. You take the patient’s history, and turn it into your own story to deduce what’s going on.


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