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Emergentology: The Doctor of a Thousand Faces

Walker, Graham MD

doi: 10.1097/01.EEM.0000441175.27124.4a

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.





I precept preclinical medical students at the University of California-San Francisco every year, and it's fun to watch their clinical skills and knowledge base swell throughout the year. Last week, I was talking with a newly minted, first-year student about interacting with patients, and I mentioned that one of the things I (usually) love about emergency medicine is the challenge of gaining a stranger's trust within minutes by showing him your social, cultural, and medical competence. I had him shadow me on a routine patient encounter; I frequently seem to have better patient interactions when I have an audience, and this case was no exception.

A very pleasant family was at the bedside; the father recently had a near-syncopal episode. I started talking with the patient, but noticed out of the corner of my eye his wife watching me closely. (I'm fairly used to this; as any other young-looking physicians can attest, patients are frequently waiting for the real doctor to arrive even after I've handed them their discharge instructions.) I motioned to the wife to give me her input, and she stated that her husband “became diaphoretic all of a sudden,” and ah, ha, there it was: she was medical. I let her finish, asked a few more questions, and grinned at her. “You're in medicine, aren't you?” I asked.

“I used to be a nurse,” she admitted.

“I was trying to guess because you said your husband was diaphoretic instead of sweaty.”

She laughed, and then asked, “Did you do an EKG?”

Now knowing exactly what was on her mind, I let her know I'd looked at her husband's cardiogram and that it was completely normal: normal sinus without any ST depressions or elevations. After that, I told her and her husband the rest of the plan: a little blood work, but probably being able to go home afterward. I could tell I'd won them over by winning her over and proving myself to her medically. What she needed was proof that I knew what I was talking about. And with a little medical lingo, I proved it to her, Doogie Howser-look be damned.

As I was talking about this strategy with my medical student — reading the patient and adapting your behavior and language to him — I recalled more and more examples of this technique, and realized they were often some of the most satisfying encounters I have had. I don't mean to sound paternalistic, but it certainly seems that sometimes my “inform the patient with good data and evidence” approach leaves neither of us particularly satisfied with the interaction, regardless of chief complaint, disposition, or outcome. Instead, maybe I should just give ’em what they want.

If anything, I think we're pretty good judges of character and are some of the fastest professionals at reading people because that's more or less our job: meet a stranger, make some snap judgments and snap decisions with limited data and information, and go from there. We use this information to determine workup and treatment so should we also use it to frame our interactions with patients? You wouldn't go into the finer details of AV nodal blockade with a medically illiterate patient, just as you wouldn't tell a physician that he's short of breath because he has “water in his lungs.” We certainly adapt our speech to our patients' education level, so why not our behavior as well?

Take the anxious 22-year-old with palpitations. I typically find these cases go much smoother and the discharges much faster when I acknowledge their symptoms: “That feeling of palpitations can be really scary. I've had it before, too!” Then I state very clearly what I found on physical exam, no matter how banal: “Wow, your lungs sound so clear. I don't hear any wheezing or signs of pneumonia at all! And your heart sounds totally normal to me. No murmurs or irregular beats!”

Or the 19-year-old with an upper respiratory infection. “I'm so sorry that you've been feeling sick; I had the same thing last week” is my usual line, along with a few extra minutes looking in his throat and ears and auscultating his lungs. Is any of this going to change the fact that he has a URI that requires absolutely no treatment besides the tincture of time? Probably not. But is it what he wants — confirmation that he was thoroughly checked out and that it really is just a cold? Probably.

Or finally, my most recent patient, a young woman with a history of depression and anxiety who had been recently diagnosed with HPV. After some terrifying Googling, she was unable to sleep because she was now “dying of cancer and rotting from the inside” (a little dramatic, to say the least). My typical routine would be to give her some data points and statistics about HPV. But this time, I tried something different. I was quite authoritarian with her, perhaps even paternalistic. Instead of saying, “Ma'am, it is very unlikely that your newly diagnosed HPV is cancer,” I simply told her, “You don't have cancer. HPV is not cancer. You are not dying from the inside. You are not dying at all. In fact, to me you look very healthy, and have a very loving husband next to you, but you look quite scared. And I have a treatment for you: you are no longer allowed to read Internet forums.”

She did one of those little “I'm so embarrassed” stuttering laughs, and five seconds later, wiping a tear from her eye, the fear and exhaustion melted from her face, and she finally smiled, probably for the first time in three days. Just by giving her what I thought she probably needed: not data and numbers, not information, but an authority figure telling her she was going to be all right.

Is this approach acceptable? Ethical? Morally repugnant? Is it unprofessional to tell a patient she doesn't have cancer when you don't know that for sure? Or to tell a patient his chest pain isn't cardiac without having done a cath? Next month, I'll provide some even murkier examples with an interactive poll so that I can hear what you think, along with some caveats to this tactic. Obviously it's not right for many patients, but it is for some. Which ones?

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