GruntDoc’s post about dealing with patients presenting to the ED with their chronic illnesses highlights the challenges Emergency Physicians face when caring for patients with chronic illnesses. Such attendances can be difficult because the Emergency Physician is unable to offer an instant cure where other specialists have previously failed.

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.

Source: Expectations, or Letting People Down

Often with these patients, what they want is not purely “medical” (i.e. a diagnosis or cure). There is a hidden agenda - fear, isolation, stress, strained coping mechanisms, breakthrough pain, grief, being at the end of one’s tether, etc. Sometimes the patients themselves haven’t thought about exactly what led them to present to the ED that day!

Sometimes I start the consultation by summarising their entire previous medical history in front of the patient. This shows that I am aware of their case, and really builds a trust and rapport. Patients appreciate the impression that you have already taken the time, care and effort to find out everything about them.

Then I cut to the chase by directly asking what exactly they want from me today.

This sort of direct questionning certainly helps to crystalise in both the patient’s and the doctor’s minds what their expectations for the consultation are.

With a better understanding of the patient’s expectations, both doctor and patient are in a better position to negotiate a realistic end-point for the consultation. By identifying hidden agendas early in the consultation the Emergency Physician can focus the consultation on delivering precisely what the patient needs at that crisis point in their chronic illness, rather than offering what he assumes is needed.