For the second time in my life I visited the ER. I woke up early yesterday morning with unremitting, 7.8/10 left lower back pain accompanied by chills, nausea, and vomiting. Why 7.8? Well, I definitely could have imagined pain worse than an 8, but it seemed bad enough to go to the ER, so it surely must be worse than a 7, right? Just like all my patients, I have a strong pain threshold, right? Ever notice how many people end sentences with the word right? Having diagnosed many a kidney stone in my day, I was pretty convinced that was what I had (I had been taking a fair amount of antacids lately), so I did not object to a non-contrast CT scan to confirm what I suspected, even though the urinalysis did not show any blood. When the scan came back negative, and after the Toradol and morphine had eased my discomfort, the doctor suggested a contrasted CT scan to rule out any acute vascular event. Now, I suspected she strongly believed I didn’t have a surgical abdomen, and that wasn’t even on my radar, so I asked whether waiting was an option. She said it was but just to be safe …
The most beautiful thing about being a family doctor is the relationship I had with my patients. I prided myself on not practicing defensive medicine, always trying to give care that was appropriate and using my clinical acumen and experience to guide our mutual decision-making process. Many times, I would say, “I am convinced it is not serious and that we can wait, but if it gets worse, we can do additional testing,” and almost always, the patient agreed to wait because they knew I would be there if they needed me. However, in the ER, you don’t have that long-standing connection and trust. What you have is, “If after we discharge you, and you get worse, come back to the ER.” Who wants to come back to the ER and go through the whole process again?!
I have several observations about yesterday:
1. It is revelatory being on the receiving end of medical care. I did tell them right at the start that I was a family physician, not because I wanted special treatment—at least I sincerely hope that wasn’t my motivation—but because I wanted them to know I understand what they are doing on a different level. I guess being a physician doesn’t make me a “typical patient,” but being in pain and donning a hospital gown makes me very much a typical patient, and that is the way it should be.
2. Being a family physician, I knew there was no use calling my DPC doctor because I needed pain relief, and there was nothing he could do for me at 3 a.m. I know I could have, though, and that was comforting.
3. Would I have gone to the ER if I didn’t have good insurance?
4. I definitely did not want to go back to the ER a second time.
5. As much as I want patients to be good consumers of health care, and ask questions about what is being done to them, when you are hurting and scared, it is very difficult to evaluate the situation objectively and share in the decision-making process. You are left with hoping that the ER knows what they are doing. How do we help patients become active participants in their care in the emergency room? How do we help patients become less passive recipients of health care services in general?
6. There was no discussion about how much things would cost.
7. Do most ER doctors practice appropriate medicine, not defensive?
8. I was overall satisfied with the attending physician, but I suspect modern technology has replaced physical examination skills and the resulting confidence to not order tests that comes with the clinical skill.
9. It is hard sometimes living alone, especially when medical care is needed. How wonderful it was that a friend took me and stayed with me the whole time. I was very grateful for that, and I thought of all the patients who do not have that “someone.” I read somewhere that if you have someone in your life who will be there for you at 3 a.m., no questions asked, you are blessed. I think that is true.
10. I was also very grateful to have my pain relieved. They believed I was hurting and never made me feel like I was “inconveniencing” them by being in their ER. Sometimes we physicians can forget that it is not about us.
I did agree to the contrasted CT scan. Why? First of all, I was trying to be the patient, not the doctor. Secondly, I had good insurance. Third, I had been having some flare-ups of my IBS and reflux, and thought more testing might give me peace of mind. (No wonder patients equate more testing with better medical care!) And lastly, did I mention already that I did not want to come back to the ER?
When the doctor came back to discharge me, she did say, “You know this could be shingles, so watch for a rash.” Duh! I always taught my medical students to look for a rash and consider shingles when any patient came in with pain. Why didn’t I consider that from the start? It seemed to me the pain onset was too sudden and severe, and the associated symptoms were a little atypical for herpes zoster. Maybe the perceived severity of the pain didn’t allow my brain to go there. Why didn’t the ER doctor raise this possibility from the get-go? Part of it may have been me thinking it was a kidney stone and planting that seed in the ER. Maybe my presentation was a little atypical for shingles, but in retrospect, maybe not so much. If she had mentioned this after the urine test and non-contrast CT scan, and before I agreed to the contrasted imaging, would I have declined the test? Is she so entrenched in the “just to be sure” mentality that she only mentions the worst-case scenario to her patients? Of course, the ER is the place where you have to think about worst-case scenarios, but wouldn’t it be good to share all possibilities with the patient for true shared decision-making? Or is the ER the place where actively engaged patients and questioning the need for testing don’t belong? I just hope the additional radiation I received doesn’t release too many free radicals.
I was overall satisfied with my Sunday morning ER visit and was reminded that it is not all bad for physicians to view medical care from the other side once in a while. I have always thought that all of us trying to transform health care for the better have the advantage that we are all patients, too, and have the opportunity to view health care from this lens. Maybe before the next greatest solution or technological advancement, one of the questions we must ask is how this improves the doctor/patient experience.
William Hurt played a physician in the movie The Doctor. In it, because he had to undergo cancer treatment and the many indignities that came along with it, he eventually overcame the burden of his arrogance and subsequently required all of his medical students to become patients for a weekend so that they could live through what their patients have to tolerate. Although this film came out over thirty years ago, its message may be even more powerful and necessary today. I have always thought one of our CME requirements should be to be filmed during a patient encounter to receive constructive feedback on how we are with our patients. Isn’t patient-centered communication a very important component of every doctor/patient interaction? Shouldn’t being sensitive to how we are with patients, and how the system works, or doesn’t work, for our patients be an important part of our ongoing education? Wouldn’t that be at least as important as learning about proper opiate dispensing or human trafficking?
How am I doing? Thanks for asking. I am doing much better, but I still have some pain and am waiting on a rash. Tom Petty has sung that “waiting is the hardest part,” but I think in medicine, we forget that not only is it, not the hardest part, but it is also the most appropriate form of inaction.
Gregg J. Stefanek is a family physician.
