ED/EQ: A Matter of Perspective

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A 28-year-old man presented to the ED with an inability to move his right arm.  He was hastened to the back because he and his wife both thought he was having a stroke.  But a quick exam revealed that it was a peripheral neuropathy so the emergency physician started down the diagnostic tree.  There was some concern about a neck injury and pain making the question of a cervical etiology possible, but the exam pointed to a radial nerve palsy.  The EP returned to repeat the exam and clarify some history points to reach a final diagnosis and disposition.

Upon re-entering the room, the patient and his wife seemed unrelieved that the diagnosis was a peripheral nerve palsy rather than a stroke.  In fact, they seemed more agitated than at arrival.  While discussing prognosis and treatment his wife interrupted to ask “But how is he going to work?”


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There are many possible responses to this question, and none of them are medical because this is a cry for emotional help.  Do you recognize when the ED visit is not about the clinical concern but is about an emotional one?

Recognizing moments like these will make or break the ED visit, both for you and for the patient.  The right response will bond the patient to you and make both your experience and theirs feel good; the wrong response will do the opposite.  This can happen at any point in the ED visit—are you tuned in to know when this is happening, and what is the right response?

Train yourself to look for clues that the patient concerns have left the clinical realm so you know to step into empathy mode.  Stress is revealed in the patients’ tone of voice and speech patterns.  You will also notice key words like “but”, “why”, “are you sure”.  Look especially for the word “but” in your next patient encounters.  Is it ever used by patients in the encounters that feel good?  How close to 100% of patients say it during encounters that are going sideways?


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Here are some examples of times when the EP point of view differs from the pateint’s.

  1. EP point of view—what is the correct diagnosis and what is the best treatment?

Patient point of view–How is he going to go to work?

The question came out confrontationally, but the underlying emotion was fear.  Lost wages, uncertain future, poorly understood diagnosis. The best response is to recognize their plea. Instead of answering, try a question to find out what page they are on “Are you concerned that this may last a long time?” or “Are you worried that the symptoms may get worse?”  They may need explanations, comforting, or only to hear again that this is self-limited.   Sometimes there may be practical questions underlying that you can answer or solve: “Would it be helpful if I wrote a return to work note for limited duty?”

  1. EP point of view—what is your chief complaint and HPI?

Patient point of view—emergency provider is not to be trusted, a statement made by refusing to shake your hand, look at you, or be examined


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This patient is beginning their encounter with you by rejecting you, so it would be natural to react negatively.  This behavior is understandable when patients are brought involuntarily, but seems inexplicable when they come volitionally.   Almost without exception the explanation is that they already feel rejected and usually there is a history of previous interactions with the emergency department or the medical field in general that were unrewarding for the patient.

The goal of your interaction changes at this point.  The encounter will not be a simple back-and-forth about symptoms/diagnosis/treatment.  Your first goal is to connect with a patient who is challenging you.  Start simply with concrete statements.  “The nurse has said that you are here for trouble breathing.  Is that right?” and “Can you tell me more about your symptoms?”  Sometimes even open ended questions can result in a lack of response from the patient despite your best efforts. The critical mistake to avoid is sounding judgmental.  Consider a redirect “Why don’t I ask the nurse to (bring you some water/get you some nausea medicine/help you get undressed) and I’ll come back afterwards to find out more about what is going on today.”

  1. EP point of view—Find out what is different today, rule out worrisome causes of patient’s chronic pain

Patient point of view–How can the CT scan be negative?  I am suffering from terrible pain!

It can be baffling that some patients would prefer to be told that they have cancer than be told that their workup was negative, but remember that their world is often different from ours.  Cancer would validate their suffering, their requests for pain medicine, their coming to the ED at 2 am.  Some patients feel that a negative evaluation is humiliating.

When we suspect that a patient will not be receptive to good news, we can prepare them by explaining that even if the evaluation is negative, we will partner with them to help them.  As we all know, a negative workup does not mean that patients are making up their symptoms.   We can validate their reality without promising hospitalization, further treatment or narcotics.  Consider universalizing their experience by telling them that it is common to not be able to identify the cause of abdominal pain in ED patients and that for the vast majority of patients the pain simply goes away.  Reassure them that there is no emergency at that time and give guidance for when to return to the ED and what follow up would be appropriate.

We can feel vexed when a patient visits frequently for the same symptoms without apparent cause. An empathetic approach starts with something like “It must be hard to keep having these symptoms without knowing why.” and “Do you think we should repeat testing today?” “What would help you the most?”

For a certain population the request will be for narcotics.  “I believe that you have pain and I also believe that narcotics are not safe for you.”  Focus on their safety, not doing harm to them, and offer non narcotic analgesia.

Emergency providers need a wide range of tools in our toolbox because we need clear, effective, and concise communication with a broad range of people.  When your patients feel like you are on their side then they will trust you, follow your instructions, and rave about what a great clinician you are.  Listening for your patients’ points of view when you first meet them is the most important opportunities to change the outcome of that ED visit.

The easiest two cues to a visit that is going sideways are the tone and the word “but”.  When you hear these, redirect to immediately get on the patient’s page and earn their trust.  Doing this maximizes the chance of a good clinical outcome for your patient and of you having another great patient encounter in your day.  And from any point of view, those are great things to achieve.

ABOUT THE AUTHOR

Keri Gardner, MD, MPH, FACEP is an emergency physician and Chief Medical Officer of Alaska Regional Hospital.

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