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Emergentology: Why You Should Counsel Your ED Patients (Stop Rolling Your Eyes)

Walker, Graham MD

doi: 10.1097/01.EEM.0000440689.21270.a9

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT, a number-needed-to-treat tool to communicate benefit and harm.





The summer after my freshman year of college, I had my first experience with emergency medicine. I was able to shadow a physician in the emergency department at St. Luke's Hospital in Kansas City where my father worked. I'm sure I was annoying as hell, and I know that emergency physician had way more patience with a college kid cling-on than I do today. So thank you. I miraculously still remember some of our conversations. One that stood out was her take on the social history:

Me: “Man, it must really bug you when people do drugs.”

Her: “A little. But overall, not really. Actually, you realize in this job that everybody has his bad thing that he does and knows he shouldn't. Some are just worse for you than others, but we all have our problems, habits, and addictions.”

I often think of her perspective when I'm frustrated with a patient who seems to be doing it to himself. Like the very nice woman I've seen several times for alcoholic pancreatitis. She doesn't drink often, but she has her bad days, and you can understand why after having lost her partner and mother in the past year. She's not particularly dramatic, attention-seeking, or flamboyant; in fact, she's frequently quite ashamed. She asks for a few rounds of pain meds and then goes home.

I think we emergency physicians can all be a bit fatalistic when it comes to patients' behaviors and life choices. “It's his fifth visit for COPD, and he's still smoking,” or “Oh, Steven's back? Let me guess; he's been smoking meth for the past three days and having unprotected sex, and now he feels anxious and is requesting Ativan?” We see a lot of frequent flyers, frequently flying in their usual patterns, and we think, “I'm never going to change them.”

We often forget about the patients who successfully stay sober or stop making bad choices because we don't see them in the ED anymore. Out of sight, out of mind. Psychologists call this the availability heuristic, one type of cognitive bias. It's easier for us to recall patients we've seen recently and more difficult for us to remember patients we haven't seen in a long time, so we think the latter is less common.

I certainly sometimes feel that counseling and shaking my finger at a patient for smoking is not my job or responsibility: “I do emergency care” or “That's what primary care is for.” Even if I did counsel every single patient, it doesn't feel like it's effective; I'm never going to see him again, they don't know me from anyone else, and I'm mostly just a stranger to them. Part of our job includes gaining the patient's trust within minutes, and nagging or judging them is only going to harm that.

For all of these reasons, we probably don't counsel patients as much as we should. But we speak from firsthand experience about why people need to take better care of themselves. The emergency physician doesn't counsel a patient because he is worried about the effects of someone's drinking on public health statistics; I think we counsel people for a selfish reason and a selfless one.

The selfish reason: “Oh, dear lord, I do not want you coming back and having to get intubated because that is going to be so much extra work for me.”

The selfless: “I've seen what it looks like to die of a GI bleed from alcoholic cirrhosis or be constantly dyspneic from years of smoking and COPD or to die a slow, painful death from lung cancer or to care for someone hit by a drunk driver or to treat a teenager with uncontrolled diabetes who's now miserably ill with chronic gastroparesis.”

When I counsel people about their smoking, their weight, or their unprotected sex, it's because I've seen the ugly, horrible results. We all have. It's the stuff of nightmares, the stuff we don't wish upon our worst enemies. The worst lives and the worst deaths. We're not generically saying, “You're going to die!” We're saying, “Last week, I saw an alcoholic pour blood out of his mouth while his family wept, and there was nothing I could do to save him. I don't want that to happen to you, and I don't ever want to see that ever again.”

Maybe we should be more explicit. Tell more stories. Maybe then patients would listen. (The idealist in me says it just might work. The realist — cynic? — is rolling his eyes.)

I'm certainly willing to give counseling and disease prevention another shot. Sure, I'm not their primary doctor or their pulmonologist, but I'm still a physician. I'm still supposed to remind patients of the healthy choice, right? That's what we're supposed to stand for? I'd be a little upset if my dentist didn't constantly counsel me to floss more or clench my teeth less, right?

One particular specialty certainly is setting a good example, and they're even less likely than we are to see a patient again: anesthesia. They've launched a campaign to try to counsel patients to stop smoking prior to (and after) surgery — complete with reminders about healing and lung function after stopping smoking. If anesthesia can get on board as a specialty, can't we?

I like their approach of tying the counseling to a better outcome for the patient. Certainly the smoker with pneumonia is an easy one, but how about the smoker with a forehead laceration, and mentioning that they may have a better scar result if they quit? Or the obese man with a chief complaint of “no energy;” how about starting an exercise routine and changing your diet?

We may think we have no impact, but how long did it take us as a specialty to change our practices? We certainly weren't all doing ultrasound-guided central lines after the first demonstration, but slowly, with lots of patience and encouragement, we've changed to a better and healthier standard of care. It just took us some time, just like our patients.

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