Preaching tolerance

Recently, my department head forwarded me a letter sent in by a patient thanking me and my staff for their care. I looked up her case. I sort of remember her but honestly didn't feel I treated her any differently than the rest. I guess I was lucky she saw me in a good mood.

My department head said good job. My reply was much more melancholy. Thanks, I said. You win some, you lose some, I added.

For every patient who felt inclined to thank us, I'm sure there are many others who would much rather complaint about us.

In light of all the recent negative media portrayals of ER congestion and care in Fraser Health (many of which unfairly reported, I must say), frustrations and negative sediments against Emergency Rooms are at an all time high.

The down stream affect? Everyone is on edge, as if they are not on edge enough already simply by doing this job. In Abbortsford, where after an unfortunate outcome involving a pediatric patient early last month, a colleague told me the pediatric unit admission rates went sky high. That is hardly good medicine. Unnecessarily hospitalization lead to a whole host of potential adverse events and tremendous inconvenience for the families involved, not to mention a much higher financial burden on our already taxed medical system and draining of essential resources that would otherwise be serving patients who really need them. But that's what the situation is becoming. Medical practice not from sound judgement, but driven by fear or missing something.

This is a thankless job. We know this going in. We are happy to be doing it. We also know it's a field filled with landmines and it's all about mitigating and managing the risk we work with.

In fact, if there is one term that summarizes Emergency Medicine, it is essentially effective Risk Management.

Much of the Emergency Medicine scientific literature is about this. How to evaluate risk of a specific condition when a patient comes to the emergency room. How to calculate and perceive such risk. How to balance this risk with costly and sometimes invasive investigations that has its own downfalls. How to weight to risk of false positive or false negative results. What is an "acceptable" risk to miss a potentially dangerous condition? It can never be zero. Nothing in life is that definitely. In medicine, if your assessment tells you that the chance of missing something bad is down to about 1-2% or less, usually that is enough evidence to say stop.

But things are not always this easily calculated. And despite best sound judgement and evidence application, we don't work in a mathematical model, and things are just not that precise.

Clinical judgement, or gestalt, as we like to call it, counts a whole lot. Sometimes we do have to trust our gut.

But very often, I find that patients don't understand that. Patients like to (or hope to) think of medicine as black or white. Doc, do I have this? Will I get better if I do this? Are you certain this is not my heart? Is this cancer?

No, sir. I can't say anything like that. Our tests and technology cannot tell us that with absolute certainty. But I can say that having heard your story and after my examination and tests, I feel really good about you. I highly doubt this is this or that. But there's always a chance I can be wrong. Or perhaps this is too early in the illness and I'm not seeing all that I need to make a more informed decision. So, let's do this. But please, come back if things get worse.

Please, come back if things get worse.

That is perhaps the most important statement of all. And people need to realize that. Just because you are fine now, we cannot guarantee nothing bad can happen or develop. Of course, we don't want to send you home with doubts and uncertainty, and I think we can do our best to mitigate that fear. But, just in case, if things don't get better or get worse, please come back to us.

We live in a world of grey. Not back and white. Patients need to appreciate that. Emergency Medicine is MEANT to miss stuff. It is DESIGNED to miss a certain percentage of bad outcomes. That's just a fact of the limitation of the world we live in. We try our best, but you have to be your own advocate here.

I've certainly been humbled by a few cases when all my clinical judgement tells me there's nothing, but the patient asked one last question that made me change my mind, and added a test, and discovered something. These things do happen. And I'm humbled by them, and every time I told the patient thank you for advocating for themselves, and that working TOGETHER, we did something worthwhile.

But the key here is TOGETHER. Sometimes when I come across a difficult patient, I remind them. Hey, time out, let's work TOGETHER on this. We want the best for you, but you have to help me on this, so here's what I think, what do you think, let's reach a reasonable approach that we are both happy with, and go from there.

Advocating for yourself doesn't mean stomping the ground and demanding every single test to be done to "check everything", as many patients like to ask (I have no idea what that means to "check everything"). It doesn't mean demanding a CT head for every little head bump especially for your little ones. It doesn't mean antibiotics for every cold or flu. It doesn't mean admission for every elderly who is sick but can totally recover better at home. It does NOT mean projecting all your expectations and fears in an unreasonable fashion onto the medical staff until you get your way.

But it does mean you are entitled to speak up, politely, about your fears and let's work through them. And if your gut tells you something really isn't right, I usually trust that instinct, and I do promise to chase after it to the best of my ability.

We all need better tolerance and understanding at this time when our Emergency Rooms are in a perpetual state of crisis. (Having perspectives is important, however, and I do understand that wait times in a lot of departments across the country are far worse than what we have here in BC). We need patients to be aware of what we can and cannot do for them, and to look out for themselves, to advocate when it is appropriate, but most of all, to understand the importance of serial medical visits and examination. That is sound medical care, not negligence.

So please. Work with us. So that we can all do better for you. Which is why we go to work in the first place.