I mentioned to another program director that my residents were often reluctant to ask about their patient's employment status, and that I lectured them on how important this information is to understanding their patient's lifestyle and to managing their care. My colleague said she did not like her residents doing this because she felt it was often embarrassing to the patient. I found this odd given that we think nothing of asking a patient if he has blood in his stool or if her vaginal discharge smells foul. How much more personal did you want to get with someone you did not know a few minutes ago?
What would give you the most information if I asked you to describe me in a word or two? Possible answers: brash, arrogant, tall (6’6”), balding, Southern, and the list goes on. But the word that gives you the most information is simple: doctor.
If you are an EP taking caring of me, these two syllables will greatly improve your ability to manage my care efficiently and avoid potential hazards to my health (and also your career). You now know I am educated, and that I very likely have money, family, friends, and a home (and that I can find someone to take me there). You know I will probably fill my prescriptions, and make my follow-up appointments. In short, it would seem I am a “good” patient. You also know I can write letters to influential people, and that your performance is going to be under a powerful microscope. Any mistake will be easily noticed.
Now take the case of a construction worker with new onset low back pain. He has pain shooting down the back of his leg, and cannot find a comfortable position. Sleep is nearly impossible. I worked in construction during college and graduate school to make money for school and frivolous things (like food). Most of my colleagues at that time had unstable lifestyles. Drinking beer in the truck on the way home from a hard day of work was the rule, and we all lived hand-to-mouth.
If the laborer has a herniated disc and cannot work, he is facing disaster. He will imbibe any concoction of chemicals to keep slinging a hammer to make his car payment. And that follow-up with the neurosurgeon you arrange for him? It is never going to happen. Mind you, it's not that he is a “bad” patient, but you better understand that his social infrastructure is a house of cards.
How about a 40-something man with a headache? He is in flip-flops, his flannel shirt is not tucked in, his jeans have a hole over one knee, his hair is a little unkempt, and he has a thick mustache and beard. How will you change your approach to him when you find out he is a math professor at the University of South Carolina?
Here is an interesting one I had a few years ago. An elderly man with dizziness presented in pajamas and hadn't shaved for days. He looked like a lot of older patients who come into the ED via EMS. He told me he had just retired from the military. What's your next question? Mine was, “What was your rank when left the service?” He told me in a very modest manner that he was a lieutenant general (that's three stars). There are only around 40 lieutenant generals in the entire U.S. Army. Trust me, it's a good thing to know if you are taking care of one of them. If you disappoint him, I guarantee you will hear about it.
Do I even need to bring up how your patient interaction will change if a female patient tells you she is a plaintiff attorney or a member of state congress? You will really watch your step. Without overthinking, look at the following words and think about what each of them mean to you: farmer, server at McDonalds, congressman, soldier, homeless, disabled, cop, attorney, teacher, professor, waitress, bartender, stay-at-home mom, mayor, Pearl Harbor veteran, college student, plumber, sculptor, and stock broker.
Each of these words comes with baggage. We consciously and subconsciously change the way we approach people based on this information. The idea of profiling people is referred to in a less-than-complimentary way in our current vernacular. It seems unfair to judge a book by its cover rather than consider individuals by the content of their character. We want to give each patient the benefit of the doubt about the negative aspects we conjure up when presented with these roles. It is really difficult to shake the negativity and just do your job after years of patient encounters.
I have taken care of all of the people on the list, some more than others, and I would argue that these so-called labels are extremely important to the practice of emergency medicine. One of the most precious commodities of our specialty is time. We use this metric to analyze everything we do including wait times, number of patients we see per hour, length of time we care for the critically ill, door-to-balloon, and the newest one, door-to-CT-to-tPA.
I will be the first one to say that you cannot take anything for granted based on a patient's profession. I have met death-row inmates who were pleasant and many highly educated, well-off folks who were flat-out jerks. Finding the fastest way to consolidate crucial information is part of our survival training. Just as important as finding out which consultants are nice and which ones need to be shot, it's imperative to learn the social infrastructure of our patients to do our best for them and to protect our flanks from the bullet we did not see coming. It's really easy to do. Repeat after me: “Are you employed?”
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