#106 Insider Insight: 10 Guidelines for Excelling as a Patient from an ER Doctor
Get the most benefit from your emergency department experience.
No one wants to come to the ER, but if you need to be there, you may as well try to have the best experience possible. As a board-certified and veteran emergency physician, perhaps I can help future emergency department patients (AKA: EVERY SINGLE ONE OF YOU) by offering similar common-sense rules regarding how one could be a good ER patient.
In a book that I wrote for healthcare professionals, Changing How We Think About Difficult Patients: A Guide for Physicians and Healthcare Professionals, I discuss how one in five interactions between doctors, nurses, and patients or their families go badly. Much of the problem starts with how doctors and nurses define who is a “good” patient and what good behavior is.
We have written an instruction manual in our minds that we assume our patients and their families know. In an effort to increase transparency, I have printed and explained my understanding of them here for you.
Many of us have no choice regarding where or when we are brought to the Emergency Department (ED). Someone on the scene of an illness or injury calls 9–1–1, your local paramedics start medical care, and you are brought to the nearest or the most appropriate emergency department for your problem.
Here are ten rules for becoming a good patient and for getting the most benefit from your emergency department experience.
Rule #1: Please try to be a “patient” patient.
The first person one sees as a walk-in is the triage nurse. Triage is from the French meaning “to sort,” and we need to obtain important information so that we know who needs to come back now and who can safely wait their turn. This is just the first time you will have to tell your story.
The entire staff is monitored for the wait and through put times, so it goes to the mutual advantage of both parties to move a sick or injured person through the system as rapidly as possible. You will have to repeat your story once or twice more when asked by the nurse, physician, or physician’s assistant taking care of you. We want to hear your words and not a summary on a triage note. We want to help you feel better as soon as we can.
If the triage nurse thinks you can wait to be seen, this is GOOD NEWS. Many sick and injured patients enter the emergency department through ambulance doors that the waiting room cannot see. Even some of those people who arrive by ambulance and are stable with minor problems are triaged to the lobby.
Some people think that calling an ambulance for transport will help them jump the line. This may or may not be true. A good patient will allow the paramedics and EMTs to be available for critically ill people at nursing facilities and motor vehicle accidents. Someday, each of us will want the nearest paramedic unit to be available and not be off-traveling someone with a minor problem that is not critical.
Patient evaluation and workups take a lot of time. Getting X-rays and laboratory studies adds to the time it takes. During many times of the year, particularly during the influenza season, the ED beds may be filled with admitted patients waiting to transfer to another hospital unit or another hospital unit. This factor and decreased nurse and physician staffing (many reasons for this) contribute to very long wait times at your local emergency departments.
A good patient will bring extra tolerance and understanding for the delays.
Rule #2: Try to go to the correct place.
Know where your doctor has admitting privileges. If you were operated on by a surgeon at the County General, you should go back to the County General for any issues relating to the surgery.
Surgeons dislike taking care of people with complications who were operated on by someone else. It is a little bit like adopting someone else’s troubled child. The new person does not feel the same attachment or obligation to you. In an emergency, they will do the right thing, but they would much rather take care of their own cases.
If you have an obstetrical or gynecologic problem, and you are able to, you should go to a hospital that provides those services. With specialization of services and hospitals, some smaller hospitals may not have pediatric, obstetric, or gynecologic inpatient services.
Many urgent care centers are not equipped to diagnose or handle more complex emergencies. One may be evaluated for emergencies in an urgent care center or basic emergency department, but transfer will be needed for any person needing surgery or admission. When in doubt or in need, go to the nearest facility, but if you have time to choose, choose wisely.
Dovetailing into the notion that you will probably have to wait your turn to be seen, you may certainly take a pain reliever or fever-reducing medication for you or your child before you leave home. One caveat is those people with belly pain. Those people with abdominal pain should not eat or drink before going to the ED.
A good patient will take care of the basic needs of themselves or their children before, during, and after they arrive in the ED. Bring your child enough diapers and nutrition to get through a few hours. Adults should take any medications they need to safely get through the time frame of their ED evaluation (four hours or more.) True, the hospital carries a lot of the basic medicines in its pharmacy, but not all medications are available, and it might take a while for a doctor to order them.
Rule #3: Anticipate that the physician might want to admit you and plan ahead.
Make sure a friend or neighbor has a key to your home or apartment and has that person’s phone number with you. Arrange for someone to pick up your child or look after your dog. (The cats seem to figure it out on their own.) Some people want to power through life on their own, but there will come a time when one needs to turn to a family member, friend, or neighbor for help.
Please don’t be that grumpy person who can’t ask anyone for a favor.
Rule #4: Please be honest with the nurses and physicians.
They cannot diagnose or treat the correct issue if you have not been honest about reporting your symptoms when they began, how much you drank, or what substances you actually took. I want to say that you will face no judgment for the truth, but that would be a lie.
The nurses and doctors are also humans who can be quite judgmental. One reason we doctors and nurses get so cynical is that so many patients lie to us either because they are ashamed of what they did, feel guilty about some behavior, or want us to prescribe medications that may not be indicated or are controlled substances.
Reporting your symptoms, when they started, their duration, what makes them better, and what makes them worse are extremely important in formulating an evaluation and list of differential diagnoses. Lies and half-truths throw us off the trail of finding and treating an accurate diagnosis.
If you lie or report false symptoms, you may be given treatment for a condition that you do not have. All medicines, tests, and treatments may have side effects or unintended consequences. We want to minimize the risks and maximize the benefits to our patients. We do this by obtaining an accurate history and performing a thorough physical exam. (bonus rule: please allow your physician to examine you), and ordering the tests that we think will provide us with useful information.
Having a lab test or X-ray has no benefit to you if you do not actually need it.
Rule #5: Be open to accepting the judgment, diagnosis, and plan of the physician or provider who evaluates you.
The clinician brings a wealth of knowledge based on years of study, apprenticeship, and experience. Many of the approaches to illness and injury are conducted based on evidence-based approaches that have been studied extensively. The information you overheard at the gym or read on a medical website may not apply to your situation.
It is certainly appropriate for a person to mention to their physician that they are concerned about some specific diagnosis that their father had or that they read about online. It helps your physician understand what concerns you have and address them directly. Sometimes, a particular test or lab value will exclude a diagnosis that is worrying you.
one view of a wrist fracture Cara Shelton@socalcaral
Understanding some of the bad diagnoses that appear unlikely or you do not have right now is a useful understanding to have. If you don’t currently have the really bad, needs immediate intervention now, type of illness, then you have a little more time to see your primary care provider and search for a definitive diagnosis. (Or you will get better.)
If you are unwilling or unable to accept the diagnosis or plan provided by your treating physician, perhaps you and she can come up with another plan. Patients should raise concerns and disagreements in a civil and respectful manner.
If you are unable to obtain the medication or follow-up appointment suggested, the physician may be able to substitute a generic medication or bring you back to the ED to be seen for follow-up. It is not common, but emergency physicians know that arranging follow-ups on weekends or within 48 hours is so difficult that some patients are told to return to the ED to have an abscess re-packed or an infection re-checked.
The physician should work to come up with a do-able plan that a good patient and his family can agree to.
Rule #6: Communication
If you do not speak English or are unable to speak, please bring a family member who speaks English and can help represent you. Most hospitals have language interpreters for Spanish and other language interpreter phones available, but these systems are not perfect or constant. Effective communication challenges physicians, nurses, and their patients even when everyone speaks the same language.
Without a common language, the medical evaluation takes on the shotgun approach and usually fails to address the real issues. Someone must know what medical conditions they have, what allergies they have, and what medications they take. A lot of expensive testing gets done just to cover all the bases and not to miss anything serious.
Rule #7: Do not ask the doctor to lie for you or compromise her own integrity.
I can’t write you a note because you decided to take the last week off from work. I can only say that you were seen today. If I don’t think you need medication, say antibiotics for a viral illness, do not ask me to write a prescription for them anyway.
Any medication can hurt you, and I have taken an oath to do you no harm. I want to take away your pain, but I don’t want to enable you to become dependent on opioid pain relievers. I can’t write a prescription for your boyfriend, who is not my patient. I want to keep my license.
Rule #8: Have a way to get home.
This correlates to rule three, where you are prepared for possible admission. The benchmarks for hospital admission are high, and most sick or injured people must be discharged, even in the middle of the night.
A good patient will have some friends or family to help him navigate with crutches, a cast, or a packed nosebleed. For those people without a home, the staff in the ED will work very hard to find you a spot in a shelter or other facility.
It also helps to have some way to get the medicines that are prescribed for you. Frequently, one gets the first dose of some medication in the ED, and the rest must be obtained through a pharmacy. If you have no means to get your medicine or supplies, tell the nurses and doctors.
There are some programs through the hospital or social services that can assist. The staff cannot solve the problems of inadequate resources or access if they do not know about the problem.
Emergency physicians would like to admit more people but beds are chronically unavailable and in the current winter influenza/Covid season, bed availability is even worse.
Rule #9: If you get worse or you don’t feel better in two days, return to the same emergency department.
After a reasonable interval (generally 1–2 days,) one should see some relief or improvement if one has taken the medications prescribed and followed the instructions given. If you do not get better or start to get worse, the physicians in the emergency department want you to return to the same emergency department.
Studies show that one in four patients who return to the ED have been given the wrong diagnosis. Good doctors and nurses want a second chance to get it right. Also, in many cases, certain illnesses take a while to declare themselves and become more obvious. Making the correct diagnosis will lead to effective treatment.
Going to a different emergency department or health system will likely lead to repeat testing, imaging, and treatments. The second set of doctors and nurses may NOT have access to the first set of notes and test results. Presenting to a new hospital may not be as helpful as you might think. The second set of doctors and nurses may harshly judge the patient to be shopping around.
One difficult concept for some patients to understand is that some rather serious illnesses are more appropriately evaluated as an outpatient and not in the ED or hospital. That means that a person gets some bad news and then is given a phone number to make a follow-up appointment with a specialist.
It feels rather uncaring of the ED staff because the responsibility for further work-up and treatment gets placed squarely on the shoulders of the patient or the family.
Most people cannot be admitted while awaiting a work-up.
Rule #10: Maintain civility.
Physicians and nurses understand that one common response to illness or injury is regression to a more childlike state of development. We know that our patients look to us the way a child looks to a father or mother to take care of them. We want to take care of you, too.
We need you to behave in a reasonable and mature manner.
When you, as a patient or family member, disagree or get frustrated, aggressiveness and anger will not have the desired effect. Yelling and violence against the staff and the department will quickly get you removed from the premises. You may get arrested. We expect civility, and you should receive civil treatment in return.
Conclusions
Like it or not, this is our current healthcare system. It helps to have skilled and compassionate physicians and nurses working in well-equipped and well-staffed emergency departments. It also helps to have patients who are familiar with the “rules” of how to be a good patient.
Perhaps we haven’t been quite as clear about explaining these parameters to our patients. We thought the rules were obvious, but clearly, they are not. Some patients will use anger and intimidation to try to get what they want.
Physicians and nurses will consider those people who are unwilling or unable to observe the rules laid out here to be “difficult.” Patients labeled as difficult tend to get less attention, less care, and quick discharges. The staff wants to minimize their exposure to them.
I have written a little book to help physicians and healthcare professionals understand these people, ask better questions, and accept their patients’ most challenging behaviors. I teach that we know a fraction of what goes on in the lives of our patients, and we must extend kindness and empathy when they break every “rule.”
If both the sick and injured patients work with their healthcare professionals and understand the rules laid out here, our interactions will be far better and more healing.
