A pediatric emergency department physician shares his inspiring clinical mission and values statement.
My approach to patient care is to treat every patient in a way that I would want to be treated.
At first glance this seems simple, but it involves several important tenets. First, it’s essential to understand the context of patient presentation. This requires reserving all assumptions and spending time to ask the questions to get to know the patient as an individual and uncover other significant issues of concern that might not at first glance be recognized.
Making the most of limited time
As an emergency department physician, I have a limited window of time to work with a patient and their family. This lack of longitudinal relationship requires me to really make the most of that time. In the ED we serve as the portal to the rest of the medical experience. A patient’s experience in my space will influence all subsequent medical experience for them.
Giving my undivided attention
Patients often in their most vulnerable and fearful states come to emergency departments for a multitude of reasons. Sometimes they come because they need to see a doctor, but cannot get in an office because their doctor is busy or because of financial obstacles like lack of access. They come in because they are scared that something is wrong and they need for that fear to be dealt with right away for peace of mind. Their problem may be a true emergency, something that if left another day would be medically disastrous, or just something that has become intolerable and appears from the patient perspective where a delay in care is unimaginable. They come in with no regard to whether the ED is busy or if the providers are reeling from an unsuccessful resuscitation minutes before. I realize that once I walk in an individual patient’s room everything else going on is unimportant. The fact that the unit is at 100% capacity and I am delivering ICU level care to five other patients is irrelevant to this patient who has sought my care. My undivided attention and accuracy is hardly an unreasonable expectation. I strive to be one hundred percent present no matter how long I am in the room.
I want every patient to feel as if they are the only patient with whom I am partnering with to solve a problem any given shift. It is imperative to really actively listen to a patient’s story. Being one hundred percent present allows me to pick up on subtleties of nonverbal and verbal communication allowing me to ascertain important information aiding me in coming up with an accurate diagnosis and an appropriate treatment plan.
Learning from my patients
Being interested in a patient’s story and perspective allows me to make sure that we are on the same page. I never forget that parents are the real experts on their children’s lives. They may not be able to describe their observations in medical terms or come up with a diagnosis, but listening to their concerns and ideas around diagnosis and treatment is essential. Being a good physician requires one to actively check one’s assumptions at the door and actively strive to be nonjudgmental. Respecting cultural differences and spending time to understand them will make for a much more informed clinical pathway.
I also believe it’s important to do due diligence to not close down clinical hypothesis testing too quickly. One must have a willingness to entertain a broad differential diagnosis. Careful utilization of clinical skills should narrow down your competing hypotheses, but one should not be wed to one diagnosis. Keeping an open mind and checking all puzzle pieces that could be a fit is good medicine.
I strive to stay humble. I acknowledge to families when I do not know the answer to their question but reassure them that I will seek consultation to get at the best answer. It’s essential to stay on top of current medical literature of course but especially in a field as broad as emergency medicine, there are times when families know more about a rare genetic syndrome or experimental protocol than I do.
I enjoy learning from the families I take care of. To me that is true partnership. Many parents I see will have looked up things on the Internet before coming. I praise them for that and help them get critical distance to information and unrealistic claims.
Being an emergency department physician provides me a glimpse of the ills of society, but it also allows me to appreciate the resiliency of children and families and the incredible appreciation people have for the work that we do. At times, we see families who are scared, beaten down, and exasperated by what they have experienced. Such encounters come with great emotion. I see it as my role to act as a sounding board for these families. When they are upset, I see it as therapeutic to allow them an emotional outlet.
The care we provide in emergency medicine is a careful choreographed team effort. I love that in my department, a successful patient encounter is the result of a skilled interdisciplinary team effort. I respect the work of my colleagues in nursing, social work, pharmacy, and child life, and count on our combined efforts for successful outcomes.
Advocating for my patients
I strive to provide a family centered, efficient and accurate patient experience for every family who enters the emergency department. I give patients the benefit of the doubt. For me, this might mean advocating for them when no one else is. It might be the homeless teenager with a dental abscess who has no access to dental care who I admit to ensure that dentistry will evaluate and treat her as an inpatient so that she will not be lost to follow-up. It might mean listening to how tired and frustrated the mother of a child with an unknown genetic multisystem condition is and advocating for an admission to the inpatient ward to give the family who are providing twenty four seven care respite and an opportunity for coordination of services that they have not been able to achieve in the outpatient setting.
Being flexible and creative
Flexibility and creativity are essential in my work. One Saturday an oncology patient is brought in to the ED by her parents for fever and weakness. She is hypotensive requiring sepsis management. It just so happens that same evening, the patient’s sister is getting married and it had been everyone’s hope that the patient would be at the wedding. Medically this looked impossible as dopamine was hung to support her blood pressures. I made a few calls and in a few hours the patient’s room was fully outfitted with closed circuit TV and the parents were armed with a computer to bring to the wedding venue. With the assistance of child life and information technology media services we were able to bring our patient to her sister’s wedding site virtually. I will never forget the gratitude in her eyes.
In my clinical role of child abuse physician, I typically meet patients and families who have experienced major trauma. I must ensure that the medical system does not further contribute to that victimization. In such cases it’s essential to treat all family members with equal respect utilizing nonjudgmental honest transparent communication strategies; even when an admission of guilt makes it clear that a caregiver was responsible for inflicting injury to the child. In my experience, it is truly rare for a parent to wake up in the morning with the intention of injuring a child. Internal stressors or mental health concerns coupled with external stressors usually are at play when such unfortunate events happen. It’s my job to do what is best for the family unit and help both the child and family get the best treatment available.
A real privilege
Being a clinician continues to be a real privilege. To be let into the lives of families who are struggling and be allowed to partner with them is truly a gift. The service I provide should be individualized as no two patients or disease trajectories are the same. I strive to stay on top of the latest literature and utilize evidence based reasoning to guide my clinical practice. I love stepping out of my direct clinical role to ensure that our care delivery team is organized, efficient, and on all levels child and family friendly. Observing the flow of the service from the patient’s perspective is essential to coming up with novel initiatives which improve the system of care.