“You’re the doctor !!!”

[CoolDoc1729]

I am sick of having different versions of the following at dispo

Me: Ok, all your tests look ok, and

Patient: DONT BLOW ME OFF IM NOT LEAVING HERE TIL I KNOW WHATS GOING ON!!

Me: ok, well, you have a sore throat, we checked for covid, flu, mono, rsv and strep, so we will have you go home with some

Patient: HOW CAN I LEAVE WHEN I DONT KNOW WHATS WRONG?

Me: ok, but there are many viruses that can cause sore throat and we can’t test for them.

Patient: I need more tests

Me: what other tests would you be looking for? What other conditions are you worried about?

Patient: I DONT KNOW YOURE THE DOCTOR

I don’t even know how to respond to this. This was a 19yoF, but I’ve gotten it from any demographic. I can reassure someone easily who thinks they will have a stroke because their bp is 160/90, or someone worried that their hematuria clots will travel to their lungs (?!) but I don’t know how to reassure someone who is just angry and worried about nothing in particular ?

Anyone who has cracked this one, any tips?

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[WhatJobDoIPick]

I am sick of having different versions of the following at dispo

Me: Ok, all your tests look ok, and

Patient: DONT BLOW ME OFF IM NOT LEAVING HERE TIL I KNOW WHATS GOING ON!!

Me: ok, well, you have a sore throat, we checked for covid, flu, mono, rsv and strep, so we will have you go home with some

Patient: HOW CAN I LEAVE WHEN I DONT KNOW WHATS WRONG?

Me: ok, but there are many viruses that can cause sore throat and we can’t test for them.

Patient: I need more tests

Me: what other tests would you be looking for? What other conditions are you worried about?

Patient: I DONT KNOW YOURE THE DOCTOR

I don’t even know how to respond to this. This was a 19yoF, but I’ve gotten it from any demographic. I can reassure someone easily who thinks they will have a stroke because their bp is 160/90, or someone worried that their hematuria clots will travel to their lungs (?!) but I don’t know how to reassure someone who is just angry and worried about nothing in particular ?

Anyone who has cracked this one, any tips?

Depends.

If work in non SDG or place where PG doesn't matter, walk out of the room. Don't spend a second more.

If not, discharge with amoxicillin, Prednisone, naproxen after holding their hand and validating every twinge in their body that they feel.

Also who cares what a 19 yo thinks?

Setting expectations early helps.

"There's a good chance we won't find out exactly what is going on, but we'll be able to test for XYZ, and make sure you are safe. I also want to try to make you feel a little better along the way. If we don't find anything on these tests it's not because I don't believe you or that your symptoms don't matter. It's just that in the ER we are good at certain things and if we don't find anything initially, we then lass the ball to your primary care doctor for more testing."

 

[CoolDoc1729]

Depends.

If work in non SDG or place where PG doesn't matter, walk out of the room. Don't spend a second more.

If not, discharge with amoxicillin, Prednisone, naproxen after holding their hand and validating every twinge in their body that they feel.

Also who cares what a 19 yo thinks?

Setting expectations early helps.

"There's a good chance we won't find out exactly what is going on, but we'll be able to test for XYZ, and make sure you are safe. I also want to try to make you feel a little better along the way. If we don't find anything on these tests it's not because I don't believe you or that your symptoms don't matter. It's just that in the ER we are good at certain things and if we don't find anything initially, we then lass the ball to your primary care doctor for more testing."

I have that conversation many times a shift. But when they are being unreasonable and then come up with YOURE THE DOCTOR it’s really hard not to say THEN MAYBE YOU SHOULD LISTEN TO ME then I will end up in my directors office lol

 

[WhatJobDoIPick]

I have that conversation many times a shift. But when they are being unreasonable and then come up with YOURE THE DOCTOR it’s really hard not to say THEN MAYBE YOU SHOULD LISTEN TO ME then I will end up in my directors office lol

"There's nothing more I can do for you."

Walk out.

There's some PG scores that can't be saved.

You can't reason yourself out of a position you didn't reason yourself into.

Some people want to play the sick role.

Maybe refer to ID? Lol.

In all honesty unless it's an SDG and you're working towards partnership, you've already spent too much mental energy on this.

 

[BoardingDoc]

I am sick of having different versions of the following at dispo

Me: Ok, all your tests look ok, and

Patient: DONT BLOW ME OFF IM NOT LEAVING HERE TIL I KNOW WHATS GOING ON!!

Me: ok, well, you have a sore throat, we checked for covid, flu, mono, rsv and strep, so we will have you go home with some

Patient: HOW CAN I LEAVE WHEN I DONT KNOW WHATS WRONG?

Me: ok, but there are many viruses that can cause sore throat and we can’t test for them.

Patient: I need more tests

Me: what other tests would you be looking for? What other conditions are you worried about?

Patient: I DONT KNOW YOURE THE DOCTOR

I don’t even know how to respond to this. This was a 19yoF, but I’ve gotten it from any demographic. I can reassure someone easily who thinks they will have a stroke because their bp is 160/90, or someone worried that their hematuria clots will travel to their lungs (?!) but I don’t know how to reassure someone who is just angry and worried about nothing in particular ?

Anyone who has cracked this one, any tips?

When people tell me they "won't leave until you figure out what's wrong" I give some variation of: "Unfortunately, yes you will. At the end of the day, my job is to make sure there isn't anything emergently wrong with you. We've done that and thankfully you don't appear to be acutely dying. There are a million medical problems that you might have that I can't diagnose in the ER and for which you need to followup with <PCP/whoever I referred them to>. You should call them first thing in the morning to schedule a followup visit." <walk out of room>.

If they actually refuse to leave, have security escort them out. Their personality disorder is not a medical emergency. I probably have to do this 2 or 3 times a year.

 

[Mount Asclepius]

There is a skill in rapidly figuring out what personality traits/disorder someone potentially has, what fear they have, or what their primary objective is for the visit.

Some really want a diagnosis. If unknown, all documentation must still reflect caution and ambiguity for medicolegal protection, but verbally some of these patients benefit from giving a firm answer with authority even if still quasi-ambiguous. Throwing out one or two unknown medical terms helps.

“It’s likely an inflamed and pinched nerve from the brachial plexus.”

“You have viral pharyngitis. A lot of Adenovirus has been going around. I think it’s very likely that.”

“Your pain is likely intestinal spasm and dysmotility from increased stool burden also leading to gastritis.”

You don’t straight lie and patients should clearly understand return precautions. Unfortunately the only way for both yourself and people with certain personality disorders to leave an encounter satisfied is to convey expertise that a physician can provide when the testing is ambiguous. Uncertainty even if absolutely right leads to distrust on the part of some patients with everyone ending up unhappy.

You are trying to do the right thing every time. Unfortunately, the right thing has to fluctuate for reach patient depending multiple factors including but not limited to their age, intellect, and actual symptoms or disease process.

 

[JacobMcCandles]

You don't reassure these people once it's at that point. Any kind of satisfaction they will have from that encounter is gone no matter what all tests you did. You accept defeat and leave the room.

 

[Mount Asclepius]

Nah. A lot of it isn’t about the medicine. It’s a game. It’s worth trying to figure out how to win.

 

[bky3c]

1. If I don't know what it is, as an emergency specialist, that's a good thing... and although we're really good at finding and treating life-threatening things, we're not always good at the rest. Some people respond to humility, especially from a doctor.

2. Come back for any of these scary-and-possible-but-unlikely symptoms. Sometimes that helps put their cold in perspective. Some people truly don't realize that things could be worse... like the people who just can't believe that you were trying to resuscitate someone while they were impatiently waiting for you to look at their ingrown toenail. An emergency... in the emergency department... who would have thought?!

3. Sometimes it's just too early to tell what's going on, even with the best evaluation. Sometimes you can feel something before our tests show it. (This one is tricky and only works in the right situations but is helpful for the "but I know my body" or the "but why isn't there a diagnosis because I've never felt like this before".)

4. Yes, it sucks to have a bad cold, I hope it goes away quickly, etc. If they don't have anyone to tell them that in their personal life, it can go a long way toward making them feel seen, which is really what some people came in for.

5. Here's a work note. You know you're not legally required to tell your employer what you're sick with, right? (In other words, you don't need a specific diagnosis to parade around.)

 

[deleted1140701]

You tell them they have viral pharyngitis and it's impossible to know which virus however it is treated supportively and prescribe them viscous lidocaine and pain meds and give them a shot of Dex in the ER. A lot of it is just how you phrase it.

 

[southerndoc]

"Would you rather me tell you that you have cancer?"

 

[Rendar5]

I am sick of having different versions of the following at dispo

Me: Ok, all your tests look ok, and

Patient: DONT BLOW ME OFF IM NOT LEAVING HERE TIL I KNOW WHATS GOING ON!!

Me: ok, well, you have a sore throat, we checked for covid, flu, mono, rsv and strep, so we will have you go home with some

Patient: HOW CAN I LEAVE WHEN I DONT KNOW WHATS WRONG?

Me: ok, but there are many viruses that can cause sore throat and we can’t test for them.

Patient: I need more tests

Me: what other tests would you be looking for? What other conditions are you worried about?

Patient: I DONT KNOW YOURE THE DOCTOR

I don’t even know how to respond to this. This was a 19yoF, but I’ve gotten it from any demographic. I can reassure someone easily who thinks they will have a stroke because their bp is 160/90, or someone worried that their hematuria clots will travel to their lungs (?!) but I don’t know how to reassure someone who is just angry and worried about nothing in particular ?

Anyone who has cracked this one, any tips?

Tell them a diagnosis if possible. Acute pharyngitis works for the above. Acute bronchitis for colds (even if the actual written dx is uri or cough). Some people can’t handle uncertainty.

 

[Apollyon]

To echo others, I was fond of "I don't know what it is, but I know what it ain't". Then, how treatment all runs together.

 

[Groove]

I'm pretty good at the whole validate sx, apologize for ED limitations, here's what I can do while you wait to see X,Y,Z. For the personality syndrome, psychosomatic, agitated, histrionic crowd...droperidol has all but obliterated any confrontational dispos. I don't mind the confrontation when it's needed but that always alerts me for a potential complaint, risk managements query, suit, etc.. and you spend twice as much time on documentation. 75% of those situations can be avoided with appropriate patience, getting buy in with family members, redirection and social IQ IMO. Honestly, many times during that results/dispo discussion, I feel like a politician more than a doctor.

 

[WhatJobDoIPick]

Med students take heed:

This thread is another reason why EM sucks.

 

[JacobMcCandles]

I don't mind the confrontation when it's needed but that always alerts me for a potential complaint, risk managements query, suit, etc.. and you spend twice as much time on documentation.

The loudest complainers and the ones telling you they’re going to sue are typically not the ones who actually sue.

 

[Groove]

The loudest complainers and the ones telling you they’re going to sue are typically not the ones who actually sue.

You know people say that but my experience has been the opposite. Even if you don't get sued, patient confrontations are bad optics, you may or may not to your knowledge be recorded in this day and age of social media. Many times they generate formal patient complaint investigations, risk management query, which results in FMD query, which results in multiple meetings where great scrutiny is being placed on you as a physician much to the frustration of hospital admin and/or CMG brass (along with your FMD). In general, this is not good for job security. Drug seekers and malcontents are one thing but everyone needs to think long and hard before crossing that line into full on confrontation mode with a patient because it's generally anything but productive. I used to lose my **** in the first half of my career. Nowadays, I get it. I never get upset or allow the pt to see me upset. I'm 100% non ego. It's never personal for me any more. Anything they say slides off my back. My retirement is in sight. Absolutely no patient encounter will ruin that or is worth that to me. Even if the pt is completely unreasonable, I'll apologize for their bad experience (not mean it in the slightest) and offer all the usual hospital approved mea culpas. Quite honestly, I can talk and reason through the craziest situations without blinking. I can't remember the last time my heart rate got above 60 in the ED. I just rarely find myself in those types of situations anymore with pts but that wasn't always the case.

 

[Groove]

Unless they are an alcoholic cirrhotic demanding a paracentesis…then I lose my ****.

 

[WhatJobDoIPick]

You know people say that but my experience has been the opposite. Even if you don't get sued, patient confrontations are bad optics, you may or may not to your knowledge be recorded in this day and age of social media. Many times they generate formal patient complaint investigations, risk management query, which results in FMD query, which results in multiple meetings where great scrutiny is being placed on you as a physician much to the frustration of hospital admin and/or CMG brass (along with your FMD). In general, this is not good for job security. Drug seekers and malcontents are one thing but everyone needs to think long and hard before crossing that line into full on confrontation mode with a patient because it's generally anything but productive. I used to lose my **** in the first half of my career. Nowadays, I get it. I never get upset or allow the pt to see me upset. I'm 100% non ego. It's never personal for me any more. Anything they say slides off my back. My retirement is in sight. Absolutely no patient encounter will ruin that or is worth that to me. Even if the pt is completely unreasonable, I'll apologize for their bad experience (not mean it in the slightest) and offer all the usual hospital approved mea culpas. Quite honestly, I can talk and reason through the craziest situations without blinking. I can't remember the last time my heart rate got above 60 in the ED. I just rarely find myself in those types of situations anymore with pts but that wasn't always the case.

Therein lies the rub right?

As a Dermatologist or Plastic Surgeon, you get to say "**** off" but in EM or any other hospital reliant specialty, you need to train your hypothalamic axis to Vulcan level abilities over 20 years just to please a patient with a cold

 

[Groove]

Therein lies the rub right?

As a Dermatologist or Plastic Surgeon, you get to say "**** off" but in EM or any other hospital reliant specialty, you need to train your hypothalamic axis to Vulcan level abilities over 20 years just to please a patient with a cold

Exactly! Yet med students are deciding to apply in droves.

 

[JacobMcCandles]

You know people say that but my experience has been the opposite. Even if you don't get sued, patient confrontations are bad optics, you may or may not to your knowledge be recorded in this day and age of social media. Many times they generate formal patient complaint investigations, risk management query, which results in FMD query, which results in multiple meetings where great scrutiny is being placed on you as a physician much to the frustration of hospital admin and/or CMG brass (along with your FMD). In general, this is not good for job security. Drug seekers and malcontents are one thing but everyone needs to think long and hard before crossing that line into full on confrontation mode with a patient because it's generally anything but productive. I used to lose my **** in the first half of my career. Nowadays, I get it. I never get upset or allow the pt to see me upset. I'm 100% non ego. It's never personal for me any more. Anything they say slides off my back. My retirement is in sight. Absolutely no patient encounter will ruin that or is worth that to me. Even if the pt is completely unreasonable, I'll apologize for their bad experience (not mean it in the slightest) and offer all the usual hospital approved mea culpas. Quite honestly, I can talk and reason through the craziest situations without blinking. I can't remember the last time my heart rate got above 60 in the ED. I just rarely find myself in those types of situations anymore with pts but that wasn't always the case.

Some patients will get confrontational no matter what if they don’t get what they want. As you mentioned, losing your **** is not a good look and not recommended. The trick is to keep your composure when this happens. I also don’t spend a bunch of time trying to reason with a confrontational patient. I calmly tell them what I need to tell them and I move on.

 

[VA Hopeful Dr]

Therein lies the rub right?

As a Dermatologist or Plastic Surgeon, you get to say "**** off" but in EM or any other hospital reliant specialty, you need to train your hypothalamic axis to Vulcan level abilities over 20 years just to please a patient with a cold

Just give them an antibiotic. Saves 10 minutes of <insert whatever you do to placate people with viral infections>.

 

[Groove]

Some patients will get confrontational no matter what if they don’t get what they want. As you mentioned, losing your **** is not a good look and not recommended. The trick is to keep your composure when this happens. I also don’t spend a bunch of time trying to reason with a confrontational patient. I calmly tell them what I need to tell them and I move on.

Yeah I’m most definitely not talking about the angry, hostile, combative alcoholics. Those I just paralyze, tube and admit to the ICU. HR maybe 64.

 

[NYEMMED]

I had one demand a “full body MRI”

Patient: you haven’t even done any tests

Me: we ran blood work and you had a CT scan, this has been going on for years, I can’t…

Patient: but I ain’t leaving till you do a full body MRI, I know you can do it here

Me: uh no, we can’t, I can’t even order one unless there is a bad spine trauma etc from the ED.

Patient: I ain’t leaving till you do it

Me: here’s your discharge papers, door out is down this hallway, feel better

 

[thegenius]

Patient: I DONT KNOW YOURE THE DOCTOR

I don’t even know how to respond to this. This was a 19yoF, but I’ve gotten it from any demographic. I can reassure someone easily who thinks they will have a stroke because their bp is 160/90, or someone worried that their hematuria clots will travel to their lungs (?!) but I don’t know how to reassure someone who is just angry and worried about nothing in particular ?

Anyone who has cracked this one, any tips?

These are the same people you see on TikTok or Twitter who yell and scream at the McDonalds register workers because the order was wrong, then trash the entire place to oblivion prior to leaving.

The respect we get from a 19F?

 

[thegenius]

"There's a good chance we won't find out exactly what is going on, but we'll be able to test for XYZ, and make sure you are safe. I also want to try to make you feel a little better along the way. If we don't find anything on these tests it's not because I don't believe you or that your symptoms don't matter. It's just that in the ER we are good at certain things and if we don't find anything initially, we then lass the ball to your primary care doctor for more testing."

This works 3/4 of the time. I do this all the time. 2/3 of the pt's I see I let them know that my workup will likely not show anything at all.
for the remaining 1/4, nothing helps.

 

[thegenius]

There is a skill in rapidly figuring out what personality traits/disorder someone potentially has, what fear they have, or what their primary objective is for the visit.

Some really want a diagnosis. If unknown, all documentation must still reflect caution and ambiguity for medicolegal protection, but verbally some of these patients benefit from giving a firm answer with authority even if still quasi-ambiguous. Throwing out one or two unknown medical terms helps.

“It’s likely an inflamed and pinched nerve from the brachial plexus.”

“You have viral pharyngitis. A lot of Adenovirus has been going around. I think it’s very likely that.”

“Your pain is likely intestinal spasm and dysmotility from increased stool burden also leading to gastritis.”

You don’t straight lie and patients should clearly understand return precautions. Unfortunately the only way for both yourself and people with certain personality disorders to leave an encounter satisfied is to convey expertise that a physician can provide when the testing is ambiguous. Uncertainty even if absolutely right leads to distrust on the part of some patients with everyone ending up unhappy.

You are trying to do the right thing every time. Unfortunately, the right thing has to fluctuate for reach patient depending multiple factors including but not limited to their age, intellect, and actual symptoms or disease process.

Why do you tell patients with intestinal spasm, viral pharyingitis, a pinched nerve, or about a thousand other nonsense, catchall diagnoses to come back to the ER?

Tell them to see other doctors.

 

[thegenius]

"Would you rather me tell you that you have cancer?"

Oh I've said this a number of times. Almost always works but it's also figuratively saying "fuuck you, your an idiot." So I don't say it all the time, only to the dinguses.

 

[Janders]

There are two possibilities-->
(1) The patient is medically illiterate, entitled, and wants more/answers. The vast majority of the time, you can handle this. It involves empathy, phrasing, and offering them something. "Thankfully, we found you don't have a bacterial infection in your throat that requires strong antibiotics. Also, you don't have COVID! There are a couple nasty viruses going around that give patients a few days of severe sore throat. Its very horrible. Thankfully your body will fight this off. I want to give you a dose of a long-acting prescription anti-inflammatory steroid that you can't just buy at the pharmacy to help your pain. I'm going to get you a work note for a few days so you can rest and take care of yourself. Do you want an Rx for prescription ibuprofen as well?"

Give them something. Give them a Dx and a benign (hopefully helpful) medication. Give them 2 days off work.

Honestly these are pretty easy once you find your approach.

The chronic belly pain NOS are a higher degree of difficulty. Still reassurance and referral to specialty care is the order of the day.

(2) The less common true personality d/o who will literally fight back with anything you say, and demand increasingly impossible or potentially harmful tests / medications that absolutely aren't indicated. They might have been to 5 other ERs this week. They may have had 100 CT scans in the past year. These are much more rare. You need to remove your emotions, review the chart carefully, and be 100% sure there isn't something going on. Check yourself. Then feel free to discharge and absorb any hate mail you get.

You should find that (1) outnumbers (2) by an order of magnitude or two...

 

[RustedFox]

There are two possibilities-->
(1) The patient is medically illiterate, entitled, and wants more/answers. The vast majority of the time, you can handle this. It involves empathy, phrasing, and offering them something. "Thankfully, we found you don't have a bacterial infection in your throat that requires strong antibiotics. Also, you don't have COVID! There are a couple nasty viruses going around that give patients a few days of severe sore throat. Its very horrible. Thankfully your body will fight this off. I want to give you a dose of a long-acting prescription anti-inflammatory steroid that you can't just buy at the pharmacy to help your pain. I'm going to get you a work note for a few days so you can rest and take care of yourself. Do you want an Rx for prescription ibuprofen as well?"

Give them something. Give them a Dx and a benign (hopefully helpful) medication. Give them 2 days off work.

Honestly these are pretty easy once you find your approach.

The chronic belly pain NOS are a higher degree of difficulty. Still reassurance and referral to specialty care is the order of the day.

(2) The less common true personality d/o who will literally fight back with anything you say, and demand increasingly impossible or potentially harmful tests / medications that absolutely aren't indicated. They might have been to 5 other ERs this week. They may have had 100 CT scans in the past year. These are much more rare. You need to remove your emotions, review the chart carefully, and be 100% sure there isn't something going on. Check yourself. Then feel free to discharge and absorb any hate mail you get.

You should find that (1) outnumbers (2) by an order of magnitude or two...

Never worked in Florida, have you? Only half joking; but still commenting in good spirits.

 

[RuralEDDoc]

Whatever you do, don’t burn these people, saying something cruel to make them feel like idiots. A small percent will have something terrible that you will unavoidably miss. When someone leaves the ER feeling dismissed or belittled and then has a bad outcome, they’ll come for you.
When you have these encounters, it’s a good time for a double take (am I missing something huge?) before a polite but firm discharge with appropriate return precautions.

 

[comp1]

I know the poster asking the patient if they would rather have cancer was being sarcastic, but there's some wisdom there. The answer for a lot of patients in the situation is yes, even if they don't verbalize this. Assuming the patient role as a coping skill for whatever traumas they previously experienced is at least a strong unconscious goal.

 

[RustedFox]

I know the poster asking the patient if they would rather have cancer was being sarcastic, but there's some wisdom there. The answer for a lot of patients in the situation is yes, even if they don't verbalize this. Assuming the patient role as a coping skill for whatever traumas they previously experienced is at least a strong unconscious goal.

Lol.

Cool. That's not what we do. Patients need to get a grip, and we need to be protected from their neuroses.

 

[thegenius]

Whatever you do, don’t burn these people, saying something cruel to make them feel like idiots. A small percent will have something terrible that you will unavoidably miss. When someone leaves the ER feeling dismissed or belittled and then has a bad outcome, they’ll come for you.
When you have these encounters, it’s a good time for a double take (am I missing something huge?) before a polite but firm discharge with appropriate return precautions.

I hear ya...and the intersection of "someone being a repeated, certifiable arsehole who constantly disrespects you and staff" AND "they had some hidden, very rare emergency diagnosis that is difficult to make" is exceeding low. Those odds are demonstrably and substantially in our favor.

 

[thegenius]

I know the poster asking the patient if they would rather have cancer was being sarcastic, but there's some wisdom there. The answer for a lot of patients in the situation is yes, even if they don't verbalize this. Assuming the patient role as a coping skill for whatever traumas they previously experienced is at least a strong unconscious goal.

??

 

[Arcan57]

Set the expectation before you walk out of the room the first time. Give them an hour or two to chew on the fact that you’re looking for the bad stuff that would MAKE them HAVE TO be admitted or have emergent SURGERY. Explain that there’s ton of stuff that can make their life miserable that we don’t have tests for in the ED. People come to the ED to feel better or get an answer and get confused and sometimes angry when we tell them to leave with neither goal achieved. Best way to win the game is to change the rules.

 

[clibby]

I see most non critical patients twice: when I first see them and then when I discharge/admit them. A few things that may help, though some patients just are angry.

1. Set expectations from the beginning. This is key to the discharge conversation. "In the ED today, I may not figure out exactly what is going on, but I can make sure it isn't something bad. I suspect you likely have a viral illness of some kind. We can't test for all of them, but can test for the three that we may need to do something about (covid/flu/rsv) +/- strep. I'll also order some medication to help you get more comfortable while you wait for your results as your symptoms sound really uncomfortable right now." Nevermind that I rarely give Tamiflu, but will have the conversation about pros/cons of Paxlovid/Tamiflu which they usually decline and/or avoiding kids with RSV.

2. Validate their discomfort and give a timeline of likely recovery. I let them know that most viral illnesses last 5-10 days and coughs can last a couple weeks before fully better, so they won't feel better tomorrow. I also remind them that antibiotics are not likely to have an effect on a virus and will likely just result in diarrhea. That scares most people when coupled with #3.

3. People want to feel better fast so I let them know that while there isn't anything that will make their body fight a virus faster, I can help them feel a bit better. I offer some combination of "prescription strength" or "cheaper than over the counter" ibuprofen, tessalon pearles, zofran, etc.

4. Offer a work note. I also let people know that they can return to work if they feel like it as long as they take XYZ precautions as many patients need to work to support their families and don't want to have to take time off. It is no big deal for me to offer a work note or reassurance that they can return when fever free as long as they practice good hygiene and don't work in food services.

I do find it a bit harder to do this when everything is already ordered from triage and resulted since I didn't have a chance to set expectations, but I take a similar approach. It basically comes down to validating their discomfort and giving them some sort of plan going home where they know when they can expect to get better. A small minority of patients are still upset at the lack of a discrete diagnosis, but the vast majority seem to be satisfied with this type of approach.

 

[skougess]

I see most non critical patients twice: when I first see them and then when I discharge/admit them. A few things that may help, though some patients just are angry.

1. Set expectations from the beginning. This is key to the discharge conversation. "In the ED today, I may not figure out exactly what is going on, but I can make sure it isn't something bad. I suspect you likely have a viral illness of some kind. We can't test for all of them, but can test for the three that we may need to do something about (covid/flu/rsv) +/- strep. I'll also order some medication to help you get more comfortable while you wait for your results as your symptoms sound really uncomfortable right now." Nevermind that I rarely give Tamiflu, but will have the conversation about pros/cons of Paxlovid/Tamiflu which they usually decline and/or avoiding kids with RSV.

2. Validate their discomfort and give a timeline of likely recovery. I let them know that most viral illnesses last 5-10 days and coughs can last a couple weeks before fully better, so they won't feel better tomorrow. I also remind them that antibiotics are not likely to have an effect on a virus and will likely just result in diarrhea. That scares most people when coupled with #3.

3. People want to feel better fast so I let them know that while there isn't anything that will make their body fight a virus faster, I can help them feel a bit better. I offer some combination of "prescription strength" or "cheaper than over the counter" ibuprofen, tessalon pearles, zofran, etc.

4. Offer a work note. I also let people know that they can return to work if they feel like it as long as they take XYZ precautions as many patients need to work to support their families and don't want to have to take time off. It is no big deal for me to offer a work note or reassurance that they can return when fever free as long as they practice good hygiene and don't work in food services.

I do find it a bit harder to do this when everything is already ordered from triage and resulted since I didn't have a chance to set expectations, but I take a similar approach. It basically comes down to validating their discomfort and giving them some sort of plan going home where they know when they can expect to get better. A small minority of patients are still upset at the lack of a discrete diagnosis, but the vast majority seem to be satisfied with this type of approach.

My practice is very similar. It’s just ridiculous that we have to do it in the first place though.

 

[CoolDoc1729]

Set the expectation before you walk out of the room the first time. Give them an hour or two to chew on the fact that you’re looking for the bad stuff that would MAKE them HAVE TO be admitted or have emergent SURGERY. Explain that there’s ton of stuff that can make their life miserable that we don’t have tests for in the ED. People come to the ED to feel better or get an answer and get confused and sometimes angry when we tell them to leave with neither goal achieved. Best way to win the game is to change the rules.

I’m good at this part. The chronic belly pain, headache, chest pain crowd… no problem. It’s unusual that I can’t establish adequate rapport with someone.

In some cases (19yo sore throat example) they obviously don’t need surgery or admission, that was never even on the table.. she admittedly felt better with her viscous lidocaine and decadron. It’s frustrating when i can’t figure out what they’re even worried about or what they want to happen.. I ask questions to figure out where their expectations aren’t being met and they come back with “You’re the doctor”. It’s so hard not to snark back.

Maybe I need to accept that by the time we get to I DONT KNOW, YOURE THE DOCTOR I have already lost and there is not a reasonable synapse hiding in there anywhere anyway lol

 

[Janders]

Never worked in Florida, have you? Only half joking; but still commenting in good spirits.

Grew up in FL and went to school there. My tact and routine is as variable as my audience 😉

 

[BoardingDoc]

I have already lost and there is not a reasonable synapse hiding in there anywhere anyway

Probably just a few neurons held together by a spirochete.

 

[emergentmd]

Just give them an antibiotic. Saves 10 minutes of <insert whatever you do to placate people with viral infections>.

Yup don't overthink it. Most people in the ER are crazy and unreasonable.

In 20 yrs in EM, I have not had a long debate like OP for URI stuff.

If pt wants an answer, I say, 'Here is a zpak script, if you don't feel better in a few dys you can start it b/c it may be bacterial but I think its viral now". Pt leaves happy

If pt comes in with vague joint pain, weakness, or any other vague complaints. "Everything looks normal, your exam is normal, vitals are normal. I don't think there is anything serious but could be an autoimmune issue which takes weeks to test and not avail in ER". Give it another week, and follow up with PCP for workup if not better.

If pt comes in with Abd pain for months. "Everything looks normal, blah, blah, balh and Nothing serious is occurring. Follow up with your PCP in a few dys if not better because it could be some autoimmune issues like inflammatory bowel"

Tell them things are normal, give them some diagnosis to hang their hat on, and turf it to the outpt setting. No reason trying to explain medicine to them. My job is not to convince them what is really happening, but to get them out of my ER so I can go back to sipping coffee.

 

[sloh]

Just tell them it might be lupus and you can’t test for it it in the ER. Perfect catch all diagnosis for vague non-specific complaints hehe

 

[JacobMcCandles]

Tell them things are normal, give them some diagnosis to hang their hat on, and turf it to the outpt setting. No reason trying to explain medicine to them. My job is not to convince them what is really happening, but to get them out of my ER so I can go back to sipping coffee.

I can't say that giving them a diagnosis that even you know is very unlikely is in their best interest. These patients will continue going to a physician until one gives up and gives them a (likely false) diagnosis that they want. Who knows? Maybe that patient would have ended up on that path anyway but, personally, I don't like encouraging it.

 

[greatnt249]

I can't say that giving them a diagnosis that even you know is very unlikely is in their best interest. These patients will continue going to a physician until one gives up and gives them a (likely false) diagnosis that they want. Who knows? Maybe that patient would have ended up on that path anyway but, personally, I don't like encouraging it.

Yeah, I don't favor that approach either. Even mere speculation of a diagnosis turns into "the doctor said I have [insert X]," which in and of itself is going to back the next poor sap that has to see them into a corner.

 

[ShockIndex]

When it was a young person with a sore throat demanding a diagnosis I’d tell them, “It’s clearly herpes.”

If they insist that herpes wasn’t correct, then I’d tell them, “Well, it could be gonorrhea…it could always be gonorrhea.”

 

[emergentmd]

I can't say that giving them a diagnosis that even you know is very unlikely is in their best interest. These patients will continue going to a physician until one gives up and gives them a (likely false) diagnosis that they want. Who knows? Maybe that patient would have ended up on that path anyway but, personally, I don't like encouraging

Lets be honest with ourselves. Most coming to the ER for nonsense have some Psych component. Those who come in and demand a diagnosis, are the ones who can not be reasoned with. I don't think whatever I saw will change the fact that they will be up late at night googling every known disease, latch on the them, and make all future doctor's miserable.

It is like the Mcdonalds customer jumping over the counter because their fries were not made it "their way".

Good luck reasoning with the unreasonable. This goes with most things in life. When your wife goes "crazy" and unreasonable, do you try to rationalize with them and "tell them" why they are wrong? Of course not, they just want to vent and be "heard". Yeah took me a long time with that one.

I have learned that I will not fix crazy and I choose the easiest path to sipping my coffee.

 

[JacobMcCandles]

I have learned that I will not fix crazy and I choose the easiest path to sipping my coffee.

You’ll be back sipping your coffee in the same amount of time whether you give them an unlikely diagnosis to hang their hat on or not.

 

[emergentmd]

Nope. Been down that road trying to convince someone they had nothing when they know they have something. I think that’s the point of this thread where OP spent way too much time with unreasonable pts.


But you do you. I’m not here to debate who does it right or wrong. I’m just saying it’s the easiest path to sipping my coffee.

My time is valuable and better to deal with really sick pts than trying to convince the unreasonable.

 

[JacobMcCandles]

Nope. Been down that road trying to convince someone they had nothing when they know they have something. I think that’s the point of this thread where OP spent way too much time with unreasonable pts.


But you do you. I’m not here to debate who does it right or wrong. I’m just saying it’s the easiest path to sipping my coffee.

My time is valuable and better to deal with really sick pts than trying to convince the unreasonable.

I guess if you think the only two options are to give them something unlikely to hang their hat on or tell them you don’t know but it’s not an emergency THEN spend unnecessary time in the room arguing with them.

Like you said, to each their own, but you strike me that you’re at the point where you just z-pack everyone because it’s easiest for you and not because it’s good medicine.