Expectations, or Letting People Down

One of the big joys of Emergency Medicine is helping patients. It’s truly enjoyable to suture a laceration, to reduce the dislocation, to give solace to the suffering (usually pain medicine, but not always, sometimes it’s a hand to hold). These are almost always patients who present with a sudden-onset problem, be it trauma or bowel-obstruction, and that’s why I’m there (and why my colleagues are there, as well). Patient faces begin with apprehension, and are often back to normal when they leave (and some leave with a satisfied look I take as the reflection of a job well done).

Then there are those patients I cannot help but let down. They come to me with vague complaints that have gone on for years, a pain they cannot describe or can describe too well, a discomfort that nags, a rash that won’t wane, a twitch that won’t stop or a balance that won’t start. They have seen specialists too numerous to mention, have tried medicines/potions and remedies that run the gamut of medical experience, they’ve done their exercises and, still, they want for a remedy.

I have finally learned that there are some patients I probably won’t be able to help medically and that it’s actually cruel to let them think otherwise. For instance, the patient with the low back pain that’s been to seven neurosurgeons (had three operations), been to the Mayo Clinic and to innumerable chiropractors, who looks at me and says “I need to get better”, what’s causing the back pain? Realistically, what can I offer that a myriad of specialists couldn’t? Oh, I’ll do the entire LBP exam, do a history looking for zebras and other horrible causes of back pain, and occasionally I’ll want to do some tests to rule out an emergency.

I used to leave the room with the generic “We’ll get you some pain medication and do some tests”, and then return to the room after some time, when the tests are back, and go through a prolonged ‘isn’t there anything you can do’ session with the patient and their family. They know there’s not, really, but I left that door open, and it’s at least partly my fault.

So now I let them down early. Yes it’s disappointing but I think it’s healthier for them (and me), in the long run. “You’ve had this for x years, you’ve seen about a dozen specialists; as a general rule, if a bunch of specialists cannot figure it out in their offices with all the studies, tests, etc. we’re unlikely to in the ER” is now my general start-of-the-letdown, and even the least reasonable from an expectations standpoint seem to get it: I’ll try, but it’s unlikely. Now the patient doesn’t spend the next hour-plus building up hopes to be dashed-yet-again. As memory serves I’ve never made the terrific diagnosis for the unfixable complaint, and it’s not for lack of trying. Some things I cannot change.

It’s disappointing for me, too. I’d much rather say ‘here’s the diagnosis, and the cure’, but it doesn’t work that way in real life. Maybe some of the letdown is for me. Okay, no maybe about it.

We’re pretty good in the ED with acute problems, less so with the chronic ones, and dismal with the ones nobody can solve. Sometimes expectation management is the best we can do, for everyone.

(General disclaimer: I do a real history, a real physical exam, and listen to my patients. I don’t prejudge anyone, and the above applies only at the very very end of the patient interaction, and not before.)