A message to young clinicians

[u/imperfect9119]

We are dealing with very difficult populations in a lot of our EDs.

I got to a point in residency when the moral injury I was experiencing was so high that I became a bottle of rage down the path to self destruction.

One thing I have learned is to never let the patients transfer the responsibility of their emotions on to you.

First case For example: woman back for second visit after possible malignancy that was for scheduled outpatient work up that has been researching to come up with alternative deferentials. After asking me three times that: “ it might not be cancer right”. Flies off the handle. Her: “ you’re making me scared! You won’t tell me it’s not cancer”!

Me: you told me you spent hours researching reasons it might not be cancer. I told you your work up is at the beginning and this is the phase of no definite answers”. It’s okay to be anxious and scared when there are no answers.

Her: I am scared! Started to cry.

Me: it’s okay to cry and be scared when there are no answers.

I walk out and bring back tissues. Emotions have been transferred back to where they belong and I go see my next patient.

Second case

Wife is in pain but refused the specialist doing the procedure yesterday. Now back on a weekend day. We don’t even have the specialist on call at our hospital and it’s a non emergent situation.

As I ask questions. They know they are in the wrong even though they don’t admit it. You had the specialist ready to go and now you want it but yesterday is not today.

Husband: all you have is questions without solutions! I’m on the bed facing him and them in chairs. Me: I’m trying to figure out what your wife wants. She says she doesn’t want to do the procedure but would like to see the specialist again today. Wife refuses to speak: looks and defers to her husband so I can’t figure out what she wants. Husband: she is in pain! And all you want to do is ask questions. Me: you seem angry or frustrated. I’m going to leave and see other patients. Let the nurse know when you gather your thoughts and are ready to discuss.

I leave and in five minutes, the nurse comes and says he is ready. I give it another five and pre check charts on some peeps that I will see after I go back.

I go back: I examine the wife. She refuses all pain meds. She is the problem. His frustration is her. She doesn’t know exactly what she wants. She just wants “something else”. I discharge them. They will see specialist in office tomorrow. The husband smiles and thanks me. I’m not the enemy anymore.

Imagine if I had stayed spinning my wheels and getting agitated at the beginning of my shift?

I now leave people to think and come back more. It often results in them definitively leaving ama amicably or definitively accepting my plan.

The force of your intellect and way with words will not bridge the gap. Let them wallow. Let them swallow their own emotions. But be there to prevent them from drowning.

Good ama, with outpatient imaging, meds sent, epic notes to primary. Hand shake at the end to let them know you’re proud of them for sticking to their guns. Run the code when they code in the parking lot lol.

[u/One-Responsibility32]

This is very insightful thank you for this

[u/Praxician94]

I flat out ask people sometimes what they were hoping to have accomplished here today and explain, briefly, why that’s not going to be possible.

The most important thing I’ve found in my few years of experience and why I rarely have an unhappy discharge is to discuss the next steps. “Things look okay emergently here but I believe the next step will be ___ and I am placing a referral and prescribing these medications to help bridge the gap. Here’s what to look for if you’re getting worse.” Talking to people like they’re people instead of like you’re a robot hiding the big mysteries of how healthcare in America works does wonders.

[u/slypersimmon → u/Praxician94]

And I like to respond to their frustrations with empathy, eg: I know it can be hard to get these sorts of follow up’s scheduled, our health and insurance system can be really hard to navigate. I wish it was different. But the issue you’re facing isn’t one we can fix in the ER, where we focus on immediate interventions aimed at saving life and limb. Here’s my advice on how to get this addressed as soon as possible <give advice, share pre written resources on getting OP care>

[u/imperfect9119 → u/slypersimmon]

Love it. Once I switched to validating emotions and away from my LOGICAL doc mindset of explanation I have less conflicts, more of my patients cry with me, and I get more hugs now.

[u/slypersimmon → u/imperfect9119]

Word. I think: “I see your suffering. This is hard, and this isn’t fair. You do need help but unfortunately we can’t provide it here” goes a long, long way.

[u/imperfect9119 → u/slypersimmon]

Once I let go of my need to control everything, I have a better mental health. I cannot help, it is not in my capacity but I understand that you need help. I wish you didn’t have to sleep outside but the state needs to build more shelters and have chosen not to.

[u/penicilling]

The patient is the one with the disease.

[u/imperfect9119 → u/penicilling]

I had the disease of a false sense of responsibility and control. I couldn’t fix the ills of society but was carrying the weight. I put it down and now my life is better.

When they said, “ you don’t give an eff if I die”!!! Or you’re racist ( I’m black and apparently racist towards black people!) when I wasn’t going to admit, I would walk back to my desk indignant. I DO CARE. But distributive JUSTICE. I have to protect our beds! They are a limited resource. But I lie on the principles of medicine and the patients don’t have to agree with me for me to know that I weigh all four every shift. And I stay late often to coordinate care and tie things up with a bow.

[u/3EZpaymnts → u/penicilling]

…Gomers go to ground?

[u/Ananvil → u/penicilling]

IV

[u/PerrinAyybara]

I love this, absolutely love this.

Now to apply it to my practice... I'm gonna ride up front till you are ready to talk. 😂

But seriously, I think this is an extremely mature method and commend you.

[u/imperfect9119 → u/PerrinAyybara]

It came from years of spinning my wheels trying to have a meeting of the minds. I was always getting frustrated or angry. Now I’m rarely either.

I switched to a meeting of the hearts. And that works MUCH better!

People having rage fits will burn themselves out. RAGE is such a big emotion it needs an outlet or will burn out.

They will either start destroying stuff, threatening you or self harming or BURN OUT. The first three we know how to handle 👀😂.

[u/Loud-Bee6673]

I think it helps to ask people up front what they want to get out of the visit. Sometimes it is isn’t what you expect, and is actually easy to accomplish. That also helps you manage their expectations from the front end.

[u/imperfect9119 → u/Loud-Bee6673]

I used to do this. But after a couple of crazy encounters I have played with my wording over and over to find optimal wording that isn’t a trigger.

Sometimes I still say, “ what would be the best outcome for you at the end of the visit today?”.

I’m a woman. I had several men fly off the handle at me with versions of asking them what they are looking for.

They said you’re the doctor! Why are you asking me what I want! You should be able to figure out what’s wrong.

I saw a post in the primary care Reddit about older men being condescending and power tripping with younger women clinicians and then I knew I wasn’t alone.

Pulling my name tag towards them to read my name and peering up at me!

[u/Loud-Bee6673 → u/imperfect9119]

Huh. I haven’t had that experience (am also female) and sorry you have. Definitely something to keep in mind.

[u/Praxician94 → u/Loud-Bee6673]

Is it appropriate to ask every encounter if they’re here for help with their problem or just to get a work note? Asking for a friend.

[u/imperfect9119 → u/Praxician94]

I ask them hey you seem like you’re in pain or uncomfortable. Do you want a couple of days from work? They usually beam and say yes. It’s not my business if they get fired from their job. I offer the work note, who gives a crap! We should fight capitalism not reinforce it.

I basically open the work note convo myself with a lot of people. It also saves me time because in epic I could do it as I’m ordering the work up. So the nurse isn’t coming to ask for it after the papers are printed.

Here’s one possibility.

• I hope we can get you feeling a bit better today but when is your next work day? Oh! That’s so soon! Do you need a day or two to rest? Now you’ve opened the negotiation. Most don’t ask for more than three days. Then they don’t feel like snakes trying to manipulate me. Buys me a lot of goodwill.

Multiple patients have asked me to be their pcp lol.

I’ve only had one crazy request. Results may vary by region. They wanted me to write days till their out of country vacation and then days after. I said you get three days, she made no fuss. Just because they try to push the boundary doesn’t mean they’ll go apeshit if you hold the line. You also have to be careful with tone and body language.

• decompensated bipolar, borderline, anti social, narcissistic, chronic pain and addict patients are always sensitive to tone and body language. You should be as relaxed, and neutral or cheerful as possible. Neutrality may trigger them but if they start raging we got meds for them.

Most people are narcissists/low empathy these days. A lot of us now have main character syndrome all the time. We are privileged doctors and they are the victims. In their heads.

[u/InSkyLimitEra]

Thanks for this. I’ll keep in mind that leaving them to think about options is an option for me.

[u/Negative_Way8350]

Also need to be quicker on the draw with medicating patients who assault and abuse, especially nursing staff.

Patients will be nice to your face and horrific to nurses because they think they can. Don't take that shit lying down. Make it clear that we're a team and you don't exist to be manipulated and split. You are cruel to other staff, you are cruel to the physician. That means consequences.

[u/Dr-Discharge → u/Negative_Way8350]

Don’t medicate — discharge these patients.

[u/imperfect9119 → u/Dr-Discharge]

Also a great option. I run and review the chart and then discharge if I can.

For one being delusional is not a reason for crisis consult.

A patient with stable delusions and not psychosis and the delusions are not a danger to self or others should go! Not everyone needs crisis. If they ain’t stalking, get them out walking.

I also call family to pick people up who are asymptomatic high or drunk if they consent. Parents love picking up their drunk kids!

[u/Praxician94 → u/Dr-Discharge]

How do you usually document that? A few times per week I have to work at the shitty hospital on the other side of town with high instances of drug abuse and assholery. I’m certain most of the time these people have no emergency going on but you never know with populations like that.

[u/imperfect9119 → u/Praxician94]

If drunk. I document protecting airway. I document stable ambulating without risk of fall. I document if they ate some without vomiting. I give zofran if needed and send prescription to the pharmacy for the morning hangover.

I document consent to calling their parent or their roommate. These are people who would have left the bar and gone to bed if not for shenanigans like trying to drive. The police usually tow the car anyway. If they seem like terrible people, fill out the impaired driver form if your state has own. This will keep them off the road.

The parents LOVE picking them up. If the patient says NO, then stay till sober. They get real sad when they realize their car is towed.

I document discharge into care of safe adult and type return precautions.

Common intox to discharge is cocaine without symptoms. Not every PCP person is a raving lunatic. I had one that was pulled over on the side of the road. Police stopped and she was acting strange so brought her in. She didn’t need to be driving but she def was just chilling in the ED causing no problems at all.

[u/imperfect9119 → u/Praxician94]

Depends on your state but some of these drunks, get picked up sleeping on a park bench and then sent to the ED. We are not a hotel. Sleeping at the train station or park is none of our business.

If they weren’t drunk they would still need a place to sleep. If we have beds I’ll let them sleep. I tried that the other day and my nurses shut me down. I had to discharge because they said nope, we need the bed. Back to the underpass he went.

I also now respect my nurses decision on these things unless there is a safety risk. I literally will not see that patient until the am. But they may be walking them to the bathroom and feeding two to three meals.

I do ask them to give multiple sandwiches and drinks in a bag if we have stock.

[u/imperfect9119 → u/Negative_Way8350]

Girl I put it in as a prn now when I anticipate them failing verbal redirection!

Once of the patients was stepping to the nurses two weeks ago! I’m fairly tall. I put him down myself back in bed prior to security arriving.

I have a song I sing called zyprexa, zyprexa. Some of those old people are mean as hell and are suffering from Vitamin Z deficiency.

[u/PepperLeigh → u/imperfect9119]

Hypohaldolemia

[u/glasshaustrum]

Jedi, mind like water.

[u/nateisnotadoctor]

This is great. When patients are disrespectful i routinely will say “I’ll be back in an hour and when you’re ready to have a reasonable conversation” and explain myself with my feet walking away from their bedside. I ain’t got time for all that

[u/imperfect9119 → u/nateisnotadoctor]

Yes! You get work done, your emotions don’t get agitated for the next patient and they basically know that the requirement for conversation is THEM being calm. If you come back and it isn’t fulfilled then you can give them more time.

They become the limiting factor in their care and I LOVE that for them.

For the basic ass chest pain or abdominal pain you can also still shotgun the work up while they calm down so they don’t tie up the room.

This may be mean. But if they don’t need telemetry I’ll basically take the room away from them and give it to “someone who needs monitoring”. This is for the ones that have a history of destructive behavior. Preemptive action.

I also don’t let them tell me secrets they won’t tell the nurse. I’m not a freaking priest. It’s never been a quality secret like sex trafficking. It’s ALWAYS trauma dumping shit from like 20 years ago that doesn’t change management.

[u/highGABA_dealer]

Thank you for this.

This is where my frustration lies and I often say "well we can't do that here" which gets me in trouble.

I do often ask "what are you hoping we could do?" When I tell them that's not possible, that's when I have an issue.

I'll refrain and just step out and come back after telling them I'll give them time to think about it.

[u/Chir0nex → u/highGABA_dealer]

Setting expectations is definitely important but I think part that gets lostis even if we can't accomplish definitive treatment/diagnosis there are things we can do to temporize. Offering help with establishing follow-up, a dose of IV meds or rx for symptom management at home all can help lead to more satisfying interaction for everyone involved. For example for someone with chronic abd pain I'll explain they are not going to get an emergent GI or surgery consult but if they like I can place referrals for our specialties, give them a dose of IV zofran and toradol and set them up with some rx meds (or offer to change up whatever meds they have at home). Especially for someone who just spent hours waiting to be seen it helps alleviate frustration not feel dismissed.

[u/imperfect9119 → u/Chir0nex]

I agree with this. I really do a lot of continuity of care work and it’s extra work on my back but I get the gratitude as they leave. I made a pcp appt for you tomorrow. Me and your pcp decided to start you on amlodipine.

What I’ve found with the front desk calling the primary is that the patients are underestimating the time since they saw the primary! They say one year it’s two. Two it’s three. And some of the patients are basically of the primary’s panel without knowing it.

[u/imperfect9119 → u/highGABA_dealer]

YES.

You can also write down options on a piece of paper. Tell them just to help you remember, be self deprecating and say I know it’s a lot being thrown at you. Let them contemplate. Say if any of these need more explanation let me know when I come back or if you have a decision that’s good too.

That way you don’t waste your precious breath up front.

[u/Special-Box-1400 → u/highGABA_dealer]

I feel like there is a way to make that work, but you have to be willing to go with what they say? What are you hoping we could do? Two Percocet a bag of hot Cheetos and a couple hours out of the sun would work for me?

[u/highGABA_dealer → u/Special-Box-1400]

Lol.

I think it's my language.

I'm a straight shooter who "well we can't do that here but let me get you to where you can"

They don't like the "we can't do that here part"

[u/imperfect9119 → u/highGABA_dealer]

I was a straight shooter. Now I lay the empathy heavy up front.

Flu patients: “ OH poor baby, you look like you are so uncomfortable”.

I also start with symptom directed care now.

Nausea: I can help. pain: I can help Cold: we got blankets Anxiety: hydroxyzine or hand holding

Then I actually get the story. Then after it’s easy to get out the room. I don’t tell them I already ordered the full work up including zofran, toradol and fluids.

I go: let me get your orders and meds started. I want you to feel better as soon as possible.

Gets me out the room easier than when I would get trapped at the beginning of residency.

[u/DadBods96]

Good insights but what can I do about the patient who says “If you don’t give me Demerol for my pain I’m just gonna buy Heroin and I might die, and that’s your fault” or the patient who says they’d been a nurse for over two decades who is amicable to doing some reading on the AHA asymptomatic hypertension guidelines, which you pull up on their phone for them, and when you come back a half hour later to ask what they think they say “Well these people are just wrong, I sent it to my coworkers and they disagree as well”.

[u/imperfect9119 → u/DadBods96]

I set a boundary.

I am not giving Demerol today, these are your options of what I am giving. Do you have any desire to kill yourself or any one else?

No! But if I take heroine I might overdose and die!

Would you like to be evaluated for detox services?

No!

Well if you want some time to think about whether any of the options I mentioned will work for you. I’ll be back. Do you want a sandwich, something to drink in the meantime?

No! I’m leaving. I’ll go somewhere else! OR yes I’ll take a sandwich.

For the Nurse.

I’m glad you have people in your life that you can trust and discuss with. It’s important to have a support system.

I am comfortable with my practice style. Your blood pressure is over 200 today so I will start you on a low dose of meds which will need titration by your primary.

OR

Your blood pressure is 180 today. Please keep a notebook to show your primary care. I’m happy you are a nurse so I know you will know how to take accurate blood pressures. Your primary is a doctor that follows you longitudinally and may have a different opinion than me. I’m reassured by your work up today. I’ll go prep your discharge.

[u/Hour-Palpitation-581]

Simplification, but I try to explain to my patients that the ERs job is to keep them alive, not to figure out what exactly is wrong.

That's usually met with "Oh!... Makes sense."

[u/imperfect9119 → u/Hour-Palpitation-581]

I’m with you 100%. I say this multiple times a day myself👏🏾.

Why am I dizzy?

“ I don’t know, sometimes answers take a while to manifest, but I do know what you’re feeling is REAL. But your sodium, potassium, magnesium, and thyroid levels are normal. Your ekg shows a normal rhythm. And your head imaging showed no critical abnormalities in your vessels. It’s really important that you continue to have a close relationship with your outside doctor so you can troubleshoot this together. Let me go prepare your paperwork so you can make use of the rest of your day.

[u/RegalEagle_]

Moral of the story: do not under any circumstances enter the medical profession because people are irrational, stupid, and make all of their decisions based on emotions which will drive you crazy if you can't disassociate and suppress emotions. But once you are desensitized and dissociative, you will be desensitized to everything else and extremely jaded. Source: me, an EM and urgent care provider.

[u/imperfect9119 → u/RegalEagle_]

I moved past my jaded stage and now I find human nature funny a lot more than frustrating and angry! I’m hoping we can truncate or eliminate that stage for the people coming underneath us.

You saw cards yesterday and your EF was 15% but all you can tell me is you have a “heart thing”, and “dunno, something with my heart”! And you didn’t tell me you told him you want think about AICD but are here for dyspnea. And you didn’t tell me any of this and this was yesterday!😂

[u/Skekkil]

I wish people could be in a space for me to do any of this. Our admin and nurses want us to do everything out of the waiting room which would add tons of headache going back and forth taking them somewhere to try and talk to them etc.

It is good advice though and a good approach

[u/imperfect9119 → u/Skekkil]

Yeah. It’s so important to adapt to your situation and population. I pull patients from the waiting room, examine them and send them back at one of my sites. Each site has its own unique challenges. From being single coverage, to pull till full and staffing with multiple PAs.

My nurses and techs are pretty great and will get them back for me if i need. So I can send them out to think if needed.

But in residency my nurses wouldn’t even set up procedures for us. And there was a confrontational attitude and passive aggressiveness towards residents. I’m glad when I talk to other attendings and they had the same experience.

I saw a post asking why the young docs are getting so burn out quickly.

I hope we can talk for solutions rather than just vents all the time!

[u/newaccount1253467]

Moral injury wasn't a phrase when I was in training and I'm not really sure what it means.

[u/imperfect9119 → u/newaccount1253467]

It’s the emotional toll that constantly working in a system that is not supportive takes on you. As you carry the weight and responsibility and backlash of things that are out of your control you develop the wounds associated with it.

Waiting room times Addiction Homelessness

It is the new term meant to replace burnout. Because you didn’t burn out. The system’s inadequacies took you out.

[u/newaccount1253467 → u/imperfect9119]

Just keep paying me and I'm good. It's not my job to worry about system issues, and I don't!

[u/imperfect9119 → u/newaccount1253467]

I don’t anymore ( like 95% better) but I used to experience a lot of turmoil for not having answers for patients that weren’t plugged in.

[u/builtnasty]

Big sad 😢