Social Engineering in the ED?

I’ve been having the same interaction in the ED, day in and night out, since I began:

 

me: Hello, I’m GruntDoc, what is the problem today?

patient: umm….

(pause)

I feel bad.

me: okay, what does that mean to you?  Do you have pain?

pt: uh, well, I uh, it started a while ago, and now it’s not better…

What follows is usually a long question and answer session to clarify the problems, timing, etc.  (I keep reading that if we just let patients talk they’ll tell us what’s wrong with them.  I tried that one day, I really did, and I either got very long, strange silences or a literally 5 minute long monologue that went nowhere.  Maybe that works in office-based practice, but it doesn’t often work in the ED).

 

Please understand I’m not making fun of patients, what I’m trying to point out is that patients present without actually thinking about how to describe their problem(s).  (There’s the exception, and they’re rare, and usually complicated).  So, I wonder if a little social engineering might be in order (and that may be the wrong term).

What I’d like to try (has it been tried?) is putting up a sign that says ‘you may be asked the following questions’ in each room, the waiting room, etc.  In that way the patient could be assembling their thoughts into a more usable and understandable fashion.  This would have (I hope) the following happy outcomes:

  • a quicker, more usable history
  • more inclusion of patient history, pertient facts
  • not missing important history because they didn’t remember for 2 hours, etc.

I think having better histories would do more for patient safety than all the medication reconciliation forms in the world.  Has this been tried?  I think it’d work, but maybe I’m kidding myself. 


Comments

  1. I think that’s a capitol idea. Just a simple sign on the wall to help nervous patients get their ideas together. You MD types are so busy, you just want to help, and we are stuck going ahhh….ummmm….what would be even better? I pencil and paper to write things down on: “Here’s a paper to write down your symptoms, anything you might feel is wrong with you today”

    I always make a list when I visit the doctor…makes everything a little easier.

  2. It strikes me as ridiculous at times that the patient has to give their history four times: to the greeter, triage nurse, the ed nurse, and then finally me their er doc.

    On the other hand, I think these “pre-histories” give the patient a preview of what I’ll be asking, so that they are more concise and remember stuff they wouldn’t have otherwise (remember as a resident when the attending walks in the room and the patient suddenly remembers some vital information like yes you might want to bring up your Marfan’s when I ask about medical problems.)

    Of course, some patients/people just don’t have the intelligence or social skills to express themselves in any sort of meaningful way. Can’t hurt to put up a sign, but somehow I doubt it will make much difference.

  3. “What can I do for you today?”
    “Fix me.”

    “Tell me what’s the matter.”
    “You tell me.”

    “What made you come to the ER today?”
    “My momma made me come.”

    “What’s bothering you today?”
    “Didn’t you read my chart?”

  4. Goatwhacker says:

    Agggh, lists are OK but often my patients have a list something like:

    1. Dizzy
    2. Toe hurts
    3. Cleaning lady says I shouldn’t be on my medicine
    4. Ears ringing
    5. Back hurts
    6. Cold feet my whole life
    7. Crushing substernal exertional chest pain radiating to the left shoulder and jaw associated with nausea and shortness of breath.

    Of course by the time you get to number 7 the appointment is almost over. A common variation on this is with middle aged men where the last question is ALWAYS about Viagra despite it being the main reason they made the appointment to begin with.

  5. alot of patients are scared and that makes them behave differently and speak with less clarity. and alot and whole lot of patients have ‘Doctor-worship-syndrome’ its like they are in the presence of a supreme being or something.
    When the doctor walks in, all of the sudden they seem to forget everything that was on their mind. This happens in the doctor’s office as well as the ER. I agree there is no time for games in the ER, and not much more time in the office.

  6. I wish they’d just say “I’m just here for some Vicodin” instead of coming up with all this ridiculousness that causes us to have to do a workup of some sort wasting everybodies time and energy.

  7. It’s like getting information out of reluctant or uninterested people anywhere. They won’t *tell* you anything, but they’ll be happy to correct you if you say something that’s wrong.

    “So, I understand that you’re here because your left big toe hurts?” “What? No, I’m here because I my chest hurts from here up towards my left shoulder.”

    Providing information to a doctor is a distant second to getting the opportunity to correct a doctor.

  8. While in the waiting room, patients could be given a handout with body outlines. They would be instructed to x the spot(s) that are problematic. Given that health literacy rates are abysmally low, keep the written instructions and word choices minimal and simple. Include the happy/sad face pain scale. Voila! Multicuturally sensitive, illiterate-friendly, and non-threatening. Most school-age children could also make it a go. And when your drug-seeking patient has colored in the entire body with red crayon, you’ll have a clue what’s up.

  9. So what do you want today?

    1) vicodin
    2) work excuse
    3) unnecessary antibiotic prescription
    4) someone to talk to
    5) I can’t remember what it’s called, but it’s a shot that starts with a D
    6) Habla Espanol?

  10. Jim in Texas says:

    “Please understand I’m not making fun of patients”

    LIAR!!!!!!!

    Military docs are genetically programed to make fun of patients especially senior NCOs, it’s in their DNA.

    heh

    Jim in Texas

  11. How many times has the story changed since the triage nurse did the first assessment?

    Triaged a patient last week that complained of chest pain, substernal with radiation down the left arm. Second story to primary nurse was chest pain with cough for two days. Third story to the doctor was chest pain 10/10. After a full cardiac work up, patient was sent home with prescription for Vicodin. Oh, I forgot to mention she was 23 years old, no cardiac history and on her 20th visit.

    Yes, it would have saved time and money for all of us to have the patient fill out a note with the actual reason they were there. But that still requires the patient to be honest. Good luck with that happening any time soon.

  12. sultan of swage says:

    Sultan: Hello, I am the sultan, what brings you in today?

    Patient with incredulous look on their face: I’m sick! Why do you think I am here?

    Sultan: Well, sick means a lot of things to a lot of people. What can the sultan do for you today?

    Patient with exasperated look on their face: Uhh, you tell me, sultan. You’re the doctor.

    Sultan, in his final attempt to initiate the HPI process with an open-ended question as was decreed holy writ so many years ago in our cheekily ignorant med school days: Perhaps you could tell me what exactly brought you to the conclusion that you needed to visit the emergency room straight away, what necessarily had to be rectified tonight. I see you told the triage nurse that you are having chest pain. Perhaps we could start with that.

    Patient, with frown firmly etched into his brow and eyes fixed on the television above his bed: Yeah, I got that too. But I told you already, I’m sick. I want you to fix me. Man, you’re not a very good doctor.

  13. I like your idea. One of the things that frustrated me when working with my grandma through her recent back/neuro problems was how she would just forget very important things – or just decide for herself what was/was not important. I had to tell her to quit downplaying everything because she’s of the generation where you should never complain about anything. And then she’s a major stickler for everything but yet when it comes to what pills she’s taken for her back pain, she won’t write them down…too impatient for that….so I’ll say, “Are you taking this med?” and she’ll respond with, “Oh….no I always forget that one.” or “I think I took that one yesterday.” or something else. I love her dearly but her impatience and nonchalant-ness (now I’m making up words!) was making obtaining medical care very difficult.

    So when I knew she had an appt with the neurologist and also the back specialist, I did something for her that she later thanked me for…this was before she lost what I had done, that is! I went through her drawers and pulled out all the pill bottles and asked her which ones she actually took, how many, how often, etc. I then typed those up, included her med allergies, and also a list of her medical history – just a brief thing with some dates where applicable. I then typed up a list of questions that she was likely to be asked by the physician – including when the pain started, what is the quality (stabbing, burning, aching..etc) , severity 1-10, is there numbness and tingling, what makes it better, what makes it worse – a whole bunch of questions along those lines. Of course I cannot possibly guess all of the questions that the physician would ask her, but I know the basic ones that she would certainly be asked, so I tried to get down as many of them as possible. And I typed each question and allowed for a big space for her to write in the answer. I then typed up a list of questions that she should have for the doctor. (Which of these pain meds should I actually be taking? Should I be going to physical therapy? other really basic stuff…) I told her that the doc may cover a lot of these things without her even having to ask them, but the list would be a reminder of other important things. I then made a little calendar for the month and for each day, I included a place to put her pain level 0-10, pain location, what medication she took and the time (and even made up a key so she didn’t have to write out the name of each med for each day) and what non-medical things she tried to relieve her pain, etc.

    She really thanked me a lot for this. She even wrote me a thank you letter. And she called my mom and told her how helpful I had been with this.

    So often, I think people just have no idea of what to expect when going to the doctor, so they don’t prepare because they don’t even know where to start.

    I’ve had a lot of practice (unfortunately) with going to docs, and I’m also a nurse. Now when I go to a new doctor, I have a typed history with current meds, med allergies, conditions or major events of medical history, and a supplemental list of all the things I’ve tried in the past for whatever condition. I can scale this down or up depending on what type of doctor I am going to. I originally designed it to take to my new primary care doc, so I felt that it was best to be thorough. I always go back and alter the list of questions I have at the end. When I met with the new primary care doc last year, I apologized for my typed medical history because I was worried she’d think I was a freak or a hypochondriac. She told me not to apologize and said that it was all extremely helpful. As we went through the appt, she continued to jot down her notes on my papers. When she sent me off to a rheumatologist, she actually sent an intro letter ahead to the doctor, all my recent lab results for rheumy stuff, and then called me on the phone and told me to bring my typed history. She was the first doctor who made me feel like my own neurotic planning tendencies were actually helpful.

    If I have to go to the ER (it happens), then if I’m able, I try to at least scribble down a list of meds I’m currently on, my med allergies, and then my current medical conditions. If I’m having a really hard time, then I jot down some things about the reason I’m going so that I remember and it’s easier to say it quickly and concisely. Even after all the times I have had to spit out my medical history, I still forget about the DVTs I had if I don’t write them down. I also sometimes forget to mention a history of hypertension because it’s not a problem right now. Sometimes when a problem improves, patients forget to mention it – irregardless of the fact that I’d been given beta blockers while in the tele ICU because of how high my blood pressure has gotten in the past. When a patient has a complicated medical history, I find that it is all that much more important to be prepared so that you can give your history in a quick, concise manner. So I think your idea is great!

    Take care,
    Carrie :)

  14. NoAcuteDistress says:

    So what’s the problem?
    -I got sinus.
    Hmmmmm…..what do you mean?
    – I got a sinus infection.
    Hmmmmm….what do you mean?
    -You know. A SINUS infection.
    Well, that could mean different things to different people. What symptoms are YOU having?
    -Sinus pain
    Meaning??
    -Pain up here (the temples) and on the back of my neck.
    That doesn’t sound like pain related to your sinus cavities.
    -I want to see another doctor.

  15. “I find that it is all that much more important to be prepared so that you can give your history in a quick, concise manner.

    Keep practicing, LOL ;p

  16. LOL Scalpel…I know, I know. I can give the history quickly – everything else…take me or leave me! lol ;)

  17. the syntax of the uneducated and ignorant is humorous at first but after about 35 in a night it is frustrating. it is fun to contrast it’s polar opposite arch nemesis. litigious lawyer guy….

    DR: how long have you had stomach problems
    PT: long time
    DR:how long, using units of time to describe the length.
    PT: well…since i had my baby
    DR: when did you have your baby
    PT: when i was 15
    DR: noting in your chart that you are currently 20, i calculate that you have had this pain for the past 5 years. is that correct?
    PT: just ask my momma more questions… i hurt too bad.

    contrast this with a lawyer who came in after a car hit him.

    DR: sir describe how the car hit you.
    PT: well Dr. i was walking west bound on 5th street and main. a blue 2004 honda accord was traveling south on 5th street. the driver was looking east and his front left bumper struck my lower left leg 4 inches below my knee. (I pushed my client whom i was escorting on the way to the courthouse out of the way and saved his life. i was knocked to the ground and scraped my elbow. he then goes on to give a complete review of systems and past medical history.)

    DR: i have no more questions…… defense rests…….I’ll call the insurance company and my lawyer right away…..

  18. oh yes they both came in the same day.