Patients and emergency physicians differ drastically in their expectations for emergency department care. An EP may pat himself on the back for ruling out appendicitis, but his patient may still leave frustrated, angry, and in pain, thinking, “The doc ran a bunch of tests, kept me in the ED for six hours, and still couldn't find out what is wrong with me?” The million-dollar question is: How can we titrate our patient's expectations to a more reasonable level?
The “Missed” Diagnosis
Let's take, for example, an average shift. We meet our EMTALA obligations, conduct comprehensive medical screening examinations, rule in or out emergency medical conditions, get a hospitalist or subspecialist to admit the patient, or we discharge the patient to outpatient follow-up after stabilization in the ED. We do everything right. Heck, we even find a stool most of the time to sit at eye-level when communicating with our patients. On top of that we smiled, spent extra time with family members asking the same questions, introduced key members of the ancillary team, and at the end of the shift, left feeling pretty darn awesome. We delivered top-notch ED care! We smile and go home tired but satisfied that we tried as hard as we could to connect and gain our trust from each of our patients.
Now think of the same visit through the eyes of our patients. Move back to the beginning of this same shift, and ask yourself, “What did my patients really expect from their ED visit?” They drove by the hospital billboard quoting an ED wait time of five minutes, and yet are surprised when it takes two hours to perform the CT they demanded. They know not of EMTALA or numerous other federal and state statutes that govern our professional practice. They expect their primary physician to meet them in the ED, which rarely happens anymore. Despite your smiles, time spent, and appropriately provided emergency care, some of your patients will leave the ED feeling slighted and unimportant.
Let's look at one patient who had a sore throat and post-nasal drip for two weeks. You are the first physician she is seeing in years. She expects a definitive diagnosis and treatment guaranteed to make her problems go away. You rule out a variety of possible emergency medical conditions, and she says she feels better after a comprehensive medical screening exam and some basic nursing care. You share your findings and impressions, give her a prescription, and provide after-care instructions that include strict return precautions and follow-up instructions. You covered all the bases, did it with a smile, and she seemed satisfied and understanding of the care plan. Her physician, however, diagnoses her with sinusitis two weeks later at the follow-up. She blames you for not making that diagnosis, saying you misdiagnosed her. She writes a grievance letter to you with copies to the Joint Commission, the state medical board, and the hospital CEO, and demands a refund for the substandard care she received in your emergency department. And did we mention the negative review on Yelp?
Patients' top two complaints and grievances about physicians, according to our talks with several community hospital risk managers who reviewed hundreds of complaints and grievances from ED patients about physicians, were that physicians did not spend enough time with them and physicians misdiagnosed them. A deeper dive into the allegation of misdiagnosis showed that none of the quality-of-care reviews ever identified a true misdiagnosis. The cause of so many complaints, it turns out, is the gap between the ED patients' expectations of an ED visit and a doctor's office visit.
Emergency physicians can utilize several simple techniques to ratchet down such expectations to a more realistic level. Identifying the patient's fears and expectations and explaining clinical goals early in the ED visit puts the patient and clinician on the same page. A frank discussion about what can be accomplished in the ED visit, coupled with a pledge to do all you can reasonably do to help your patient, is a supportive offering of reassurance.
We should work on developing standardized patient education materials that articulate the scope of emergency medicine. Perhaps ED waiting rooms can have a video loop, an Internet link, or a brochure that explains what the realistic expectations of ED care should be. The public should have a reasonable understanding of EMTALA, which defines the hospital's federal responsibilities in caring for patients. Hospitals should work with marketing teams to develop facility based-materials and organization-wide standardized materials. Hopefully our patients' and our communities' great expectations will become better aligned with our own when we educate them about emergency medicine.
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