This post originally appeared in a slightly different form on the excellent PEM Fellows Network Blog.

 

Suppose that you are an attending, fellow or senior resident precepting in the ED and your shift has been going well. You supervised a first-time LP—only 2 RBCs (Chardonnay tap?)—and helped with a patellar reduction. With your fellow mojo at an all-time high the last thing you want is a “social disaster.” Unfortunately, a resident comes out of the exam room and says that the mom wants to speak with his supervisor. When you ask why, the trainee says, “I don’t know…” and shrugs. There are strategies that can help a fellow serve as a facilitator and problem-solver and not just middle management.

Sample the room temperature

Instead of directly asking what’s the matter, you may want to consider if there are any external complicating factors. It’s possible that they’ve been waiting a long time. Perhaps they are frustrated and already came from another facility or their PMD’s office. It could also just be that they are scared and want answers.

I also find that it’s easier to diffuse the tension if you pay careful attention to your tone of voice and body language. Be polite, come all the way into the room, and sit down! This will give the impression that you are not in a rush. Use all of those history taking skills you’ve honed and be a good listener. Perhaps the parent just wants to be heard.

Respect their time and knowledge

You may be expert in PEM but the parent is the expert in their child. Try not to subconsciously roll your eyes or shift your posture when they say things like “she has a high pain tolerance” or “he’s so lethargic” when he’s batting a balloon glove. Many conditions have waxing and waning symptoms. Plus, things always look worse at home without the halo-effect of the ED.

Recognize the anger for what it is

Most often it is frustration. Unless someone outright insulted the family or patient (which happens but fortunately very rarely), find out exactly why the parent is upset. Some common scenarios I’ve dealt with include:

“Why did I have to tell the story again?”

Be honest. Getting all of the details is the first step in helping their child. Let them know that repeating some questions is just us physicians being careful and making sure that we don’t miss anything.

“I want test X but your resident/student said we didn’t need that even though our doctor said we did.”

In my experience what parents really want to know is what is going to happen next. They likely trust their primary care doctor based on their ongoing relationship. This can be an opportunity to discuss the specific reasons why you’re proceeding with your plan and educate the parents on the roles and capabilities of the emergency department.

“This hospital missed condition X in the past / my other child chronic medical issues because this facility ignored them.”

What you’re dealing with here is likely a lack of trust. The baggage that parents bring with them can make this a challenging scenario. Make sure that the focus is on the child in the room.

“I just know something’s wrong but no one has been able to figure it out.”

This can come up when a patient has been dealing with symptoms for weeks or longer. An example is the teenager with months of abdominal pain. You ultimately need to be honest with parents about what you’re able to accomplish in the ED. It is important to state that the goal of this emergency department visit may not be to give them “The Answer” but instead to rule out other conditions. Sometime simply ruling out pyelonephritis, pancreatitis, hepatitis or other conditions is enough to put the parents mind at ease as long as you have a plan in place for what’s next. It can be dangerous to promise the moon especially when it comes to easy access to subspecialists. Many parents are under the impression that they will get to see a gastroenterologist when they set foot in the ED.

Should you take the resident/student you are supervising in with you?

If at all possible I say yes. This is a great opportunity to teach good “customer service” and reinforces the team concept we work so hard to foster. When it comes time to make a medical decision in the room—like getting an ultrasound for the evaluation of belly pain or watchful waiting—the junior trainee should be the one who verbalizes the decision. This is a way for you to vouch for them and shows the family that residents can be trusted.

It helps to have discussed things beforehand, but sometimes the plan fluidly develops in the room. This can happen when the resident has been unable to gather sufficient history or has missed physical exam findings. Use this as an opportunity to teach.

What if they ask for your boss?

This is rare but it happens. Try to diffuse the situation, but if you hit a brick wall by all means get the attending/CEO/president. Discuss the situation, and then go back in with the boss. Maybe the parent only trusts somebody with a faculty name badge. This could be due to past experiences or a limited understanding of the hierarchy. Nevertheless don’t let it bruise you ego. Chances are your attending has dealt with something exactly like this before.

Hopefully these tips will enable you to deal with some difficult scenarios while precepting. I’d be happy to continue the conversation online.