There are many demands in the emergency department, some of which come from patients and their families. Ultimately I see many children that have previously visited a number of different providers, including their primary doctor, urgent care staff, another Emergency Department etc,. It takes real effort to visit that many medical facilities in a short time period. So, I’m sure you’d agree that parents are entitled to a bit of frustration. In these scenarios I’m sure you’ve all heard statements like “I just want answers,” or “I just want to know what’s wrong with him.” Many may go further and demand specific tests and/or therapies. I don’t think I’m making assumptions when I note that these types of demands may make us feel a bit defensive. After all, it’s our job to tell you what tests we need to do (said with a wink and a smile and a hearty dose of humility). So, how should we approach these situations? Indulge me a bit as I offer some advice over a series of a few posts on the blog. Each will tackle a slightly different theme. I felt that it was appropriate to post these when many of our trainees are set to graduate and go off into independent practice.
Find out what they are most concerned about and face that fear head on
Parenting is 98% wonderful and 2% abject terror. When you child is ill the uncertainty of what’s next can beget a paralyzing fear. Parents deal with this in a number of ways. Some may become withdrawn and tearful. Others are seemingly aggressive. The aggressive ones are (subconsciously perhaps) trying to take control of the situation in order to advocate for their child. Their child, who up until this point, has been sick without an answer to the two most important questions on their mind, namely:
What’s wrong with them? AND How do we make it better?
Many parents that come to the ED are legitimately scared about the immediate well-being of their child. The next time you see a happy, smiling 6 month old in the ED at 2 AM with a cold ask the parents what they were most worried about. Don’t be surprised when you hear them say “I thought he was going to choke to death.” We can rationalize the physiology of a clogged nose, a cough and gag reflex and its protective effects against aspiration all we want. What the parent wants to know is whether or not their child is going to be OK. Remember, they were likely woken from a dead sleep (or never went to bed in the first place). Find a way that is true to yourself as a physician to authentically communicate an understanding and recognition of that fear and provide an explanation that is more robust than “It’s just a cold, your son will be fine.” Sure, the aforementioned statement is unequivocally true, but it can also run the risk of trivializing a parent’s concerns. What if you said the following instead;
“Your son really had you sacred tonight didn’t they? (wait for acknowledgement) Fortunately my examination reveals no serious problems with their (insert body part(s) here). Kids with a cold can feel pretty bad, especially when they are congested and are trying to get a good night’s sleep. In my experience kids like yours often cough more at night. Fortunately, because he is developmentally appropriate, has a reassuring physical exam and because you’ve been taking such good care of him his body has the right protective reflexes in place to assure that he won’t choke to death on his mucous. Sure, this is a cold, caused by a virus in the upper respiratory tract, but that doesn’t mean he isn’t sick. Colds can be very frustrating for parents and doctors – because it can be so challenging to deal with the symptoms because very little has been proven to be effective (insert treatment plan here). Despite this, I do expect his symptoms to improve over the next few days – but if any of the following happen (iterate a list of when to return criteria) I want you to know that we are always here to see him again – which will be our pleasure because of how adorable he is.”
Obviously your approach and exact wording will vary. Consider for a moment that the latter approach, if deployed in a sensitive, yet lighthearted manner will likely dissolve a good majority of the tension in the room. After all, that mom just wants to know whether or not their son will be OK if she puts him back in bed so that she can also get some sleep.
Stay tuned for more in the near future, until then – face the fear!