Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, April 10, 2008

An Open Request to Everyone Who Works in an Emergency Room

I hereby call upon all ER physicians, nurses, clerks, aids, receptionists, security and housekeeping staff, along with anyone else who talks to patients to BANISH the following words from your vocabulary:
Why didn't you come in sooner?
For starters, it isn't even really a question; it's a poorly disguised way of saying, "You should have come in sooner." Next, it doesn't matter. Science has yet to perfect a working prototype of a time machine, so whatever would have been different if the patient had presented at some time in the past is completely irrelevant. The patient is here now. Not two weeks ago; not two hours ago, but now. This is what you have to deal with, so deal with it.

It just so happens that a great many patients are in fact themselves wondering why they didn't come in sooner. At the same instant you are asking the (non-)question, they are feeling stupid/anxious/upset/other distressing emotions about that very issue. It does no good to intensify those negative feelings when the patient is already struggling with them.

For another thing, there may be a perfectly valid reason for the patient to come in when he or she did. I saw a woman today in follow up who had been to the ER for a pyelonephritis (and told, "Why didn't you come in sooner?") who'd had a respiratory infection preceding the UTI. She was achy; she didn't think anything of it until the pain changed and increased. Then she came in. Other people may have needed a ride (and felt that calling 911 was not appropriate.) Not only might patients have valid reasons for presenting when they did, it might even have been appropriate given the entire clinical picture -- which may not yet be clear to ER personnel.

The appropriate time and way to address the issue is at disposition. Under the guise of "education" it is permissible to say, "You know, if something like this happens again, it would be better to come in sooner."

So cut it out!


I guess I should have said something sooner.


At Thu Apr 10, 08:44:00 PM, Anonymous Anonymous said...

While I agree that "Why didn't you come in sooner?" is a poor way of phrasing the question, I often ask something similar of my patients, especially when they present initially with a chronic complaint -- "What made you come in now/today (vs. earlier)?"

I don't mean it as a veiled criticism, but an honest attempt to gain insight into their fears and motivations.

*shrug* Maybe I've just been at McMaster University too long. :)

At Thu Apr 10, 09:01:00 PM, Anonymous Anonymous said...

Speaking from my own very recent experience (as a patient - not a doctor) - sometimes it takes several visits to several different doctors to finally find a doctor who is interested enough to take the time to figure out why a patient feels so bad!

The problem I recently had was not that I did not get into the doctor "sooner" - it was that it took me 3 different doctors to finally discover one who took the time to figure out why I was having the symptoms I was having! :) In fact, today when I sat down with the lastest doctor - I absolutely burst into tears seeing the results of my cortisol/hormone tests - and was so relieved I was not told that I was going crazy!

I really enjoy reading your blog!

At Thu Apr 10, 09:06:00 PM, Blogger Ambulance Driver said...

LOL...actually, one of my most common questions is just the opposite: "Why didn't you see your PCP for this problem, instead of an ER?"

For the record, they're almost always patients of the local PCPs across the parking lot, and I rarely bother asking on weekends, holidays, etc, because their offices are not open then...

But when someone comes to the ER with the sniffles on a weekday, or has had minor symptoms for three weeks, I know they could have seen these particular PCPs.

Of course, they also get the de rigeur lecture about how continually using the ER as their primary care clinic only results in more inefficient, fragmented care which is unhelpful to them and potential harmful, because they'd be better off being followed by one physician who knows their history...

...and then I go beat my head quietly against the wall.

But I rarely lecture a patient about being in the ER when they really need to be there or that's their only avenue to healthcare. ;)

At Fri Apr 11, 08:06:00 AM, Blogger Dr. Deb said...

I think the statement of "blame" quickly moves to shame. So terrible to make someone feel those things. Let's just be glad that the person is there and get the healing started!!!

At Fri Apr 11, 09:03:00 AM, Blogger Nurse K said...

I dunno---I think it's a useful question to ask in limited circumstances, especially when someone's condition is severe and they report it being severe for a long time.

If the answer is "I am uninsured", I counter with something like "I understand it's hard to make the decision to go to an ER when you have no insurance, but we are a non-profit hospital, so we treat anyone and have charity programs available to help you with your bill. We don't, however, have programs to save you if you die at home." Usually, this is when the wife chimes in with "I've been telling him that!"

Sometimes the patient lacks total insight into severity of symptoms, and I take a couple of minutes to explain that severe chest pain with exertion unrelieved by rest could mean that there is something wrong with your heart or lungs and we'd always be happy to see you. "Oh, really?"

Some people (eg LOLs) just don't want to "bother" us. I counter with "it's not a bother to help someone with an emergency. You're the patient we WANT to see here. Don't worry about us, you'll always get a bed for chest pain no matter what time you come in. Don't wait, just come in for stuff like this."

To me, most people seem to like it if I take a couple of minutes to talk to them personally about their specific situation and validate that they are there for a legitimate reason, etc.

At Fri Apr 11, 04:28:00 PM, Blogger Allen said...

Deal, but you have to get your colleagues to stop saying..

..."they did a CT for this? It's obviously..."

..."of course I would have come in, if only they'd called me..."

..."dumb ER docs..."


At Fri Apr 11, 05:31:00 PM, Blogger The Happy Hospitalist said...

You've been Meme'd. Get over it.

At Sat Apr 12, 06:28:00 AM, Blogger Evil Transport Lady said...

Maybe it's the long wait, when feeling shitty sometimes the thought of the waiting keeps you at home. It did for me, or just thinking "it's not that bad " etc.

I feel like I have to be on death's door to go to the ER.

Maybe I'm just old school:)

At Sat Apr 12, 10:47:00 PM, Anonymous Anonymous said...

nurse K, I don't think my mom is ever going to believe the "we are a charity hospital" line again. She went to one of those who assured her that if they couldn't afford it, the hospital would help. What the hospital thinks a person can afford and what they can is sometimes two different things. And they charged her $10 for the box of kleenex they opened for her when she was talking to the social worker about being unable to afford treatment just before they bumped her to a different hospital.

You don't work at that hospital, but I'm just saying that sometimes these patients come in with histories that include things like that.

At Sun Apr 13, 07:21:00 PM, Anonymous Anonymous said...

To add to Nurse K's list, I am the patient who will wait (and wait and wait) to see if "it" goes away.

My own experience has shown me that in 90% of the cases it eventually does. The 9.99% can wait until my PCP office opens.
I guess if the 0.01% ever happens, I'll really be in bad shape when I show up at the ER.


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