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Emergentology: Thumper's Rule

Walker, Graham MD

doi: 10.1097/01.EEM.0000451957.01175.36

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. Follow him @grahamwalker, and read his past columns at





Every summer during middle and high school I'd go on these service trips with my church. We'd caravan a dozen of those 12-seater passenger vans out to a particular locale, and give 10 days' worth of work to an organization that needed it.

Imagine 15 parents supervising 80-plus teenagers at a Habitat for Humanity in Texas or reroofing a summer camp in rural Michigan, and you probably can't fathom why any parent would sign up for such a thing. (Thanks, Mom!) We'd sleep in sleeping bags on the floor of a church, and make all our meals together. It taught us the value of physical labor, sweat, teamwork, and helping others. We didn't do a whole lot of “churchy” stuff on these trips — I rarely recall a Bible being present, and I still remember some of the dirty jokes that were told — but we did discuss and reflect on general themes of being a good person: Do unto others, love thy neighbor, and of course, Thumper's Rule: “If you can't say something nice, don't say nothing at all.”

I'm reminded of these trips after reviewing the poll I put forth a few months ago. You may recall the hypothetical ethical conundrum I discussed: Implying that you're a practicing Christian when you're not to calm an anxious religious patient prior to draining her abscess. I wanted to share some of the great comments I received. More than half of the respondents didn't think it was unethical, and a third thought it was “maybe a little bit.” Half the respondents identified as religious, and there was a pretty good bell-shaped curve of respondents age.

The most common theme from the comments was that the focus shouldn't even be on the religion; it should be on whether the action was appropriate in the emergency department, which most thought it was. One commenter wrote, “You're doing what's in the patient's best interest. There is no hidden selfish gain for you as the provider, and the patient is benefiting.”

She continued: “Being ill, even the sniffles, can be a vulnerable place to be. Patient satisfaction is really about being willing to connect with your patients. And the malingerers, sometimes the kindest thing you can do is tell them the truth. It can even save you time. ‘Look, I see a pattern here that is consistent with addiction. Addiction is a real problem. We as a medical community have let you down in helping you get here. You need help. I will give you a list of resources. (Have one ready.) I am going to document this conversation in the chart. I care too much to not tell you the truth. I can write for five tablets to prevent withdrawal. But you need to get help.”

That's when I was reminded of Thumper's Rule, when the commenter summarized a good rule for appropriate behavior in the ED: “You will truly never go wrong if you treat them like your mom is watching.”

I think that's a pretty good summary of appropriate behavior in the emergency department for any professional there. Would your mom be proud of how you are interacting with patients? (I'm lucky that my mom is a former psych and emergency nurse, so I might get a little more leeway than you.)

I know I come back to this point again and again in this column, but I think it's critical to our interactions with patients and to our ability to negotiate the patient-physician relationship within minutes of meeting: Intent matters, sometimes even more than content does. Often the way we deliver our words matters more than the words themselves. We are great “BS detectors,” but so are patients: They can smell insincerity from five gurneys over.

Finally, one commenter cautioned about misleading or overusing these tactics, however: “But remember we hold most of the cards/power so [we] should be gentle with our patients.”

This is a great point that we often forget in the emergency department: The patient to us may be “just another chest pain,” but the patient is at his most vulnerable, worried or scared he may be having a heart attack or that his life is ending. The normal EKG and underwhelming story to us may make us at best reassured and at worst annoyed. But the patient often has no idea what an EKG even tells us, let alone whether a troponin or chest x-ray is indicated.

We are faced with ethical issues on every shift, from paternalism and autonomy in the kinda demented patient or the kinda intoxicated one to confidentiality when dealing with sensitive diagnoses and demanding family members. There are always some right ways to handle these situations and plenty of wrong ones, so having some criteria by which to judge them, like asking yourself if your mother would approve, is probably a good guide when the choices are murky.

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