Thursday, August 31, 2006

Judge Not. Unless It's Your Job.

I’ve been promising for a while to write a post about race, class and gender in the Emergency Department. This piece is really more about first impressions in the ED and how they can sometimes be affected by those variables. Some of the things I wanted to say here were taken right out of my mouth by Kim in this post, so by all means go read it!

Disclaimer: I’m a volunteer chaplain with no medical training who spends four hours a week in an ED. What follows is based on my observations over the last two years, but I welcome other interpretations from all the people out there who know much more about emergency medicine than I do or ever will. This piece contains my first impressions about first impressions in the ED. If I’m wrong about something, please correct me!

* * *

We all know that our first impressions are often wrong, but we’ve also all been taught that first impressions count. And that’s rarely more true than in an Emergency Department. The ED is an extremely high-pressure environment, and the people who work there have to make expert medical judgments very quickly. That’s their job. They’ve received years of training to do this, and most of them are supremely good at it. But because they’re human, and also because they have so much to do and so little time for introspection, sometimes other judgments creep in, unexamined, along with the medical ones: judgments about lifestyle, manners, behavior. (Some of these judgments may have bearing on medical issues, but some won’t.)

Meanwhile, the patients are also making judgments, because that’s also their job. Every ED patient is in some sense an imperilled organism, and the most urgent task for any imperilled organism is to evaluate its immediate environment, to answer the question, “Am I safe here?” If a caregiver is for any reason curt or rude or insensitive, or even appears to be curt or rude or insensitive, the organism’s answer to that question will be, “No, I’m not safe here,” and the organism will be frightened and unhappy. ED patients are, to varying degrees, profoundly dependent on their caregivers. If the person controlling your oxygen supply appears to dislike you, you will be a very unhappy organism.

So. A patient comes to the ED. A team of medical caregivers -- doctor, nurse, scribe -- arrives to talk to the patient. These conversations are usually fairly brief, but during this interaction, each side is furiously compiling information, recording behavior, and, yes, making judgments: because that’s each side’s job.

All of this happens quickly. It’s largely nonverbal and also largely unconscious. But once those first impressions have been made, they can be hard to shake, especially since the ED isn’t a place where people are likely to have long, involved conversations or interactions. And that’s why it’s profoundly important for both sides, to whatever extent possible, to be aware of the first impressions they may create.

Advice for Patients

The single most important factor in how the ED staff perceive you is your manners. If you are rude to your caregivers, you can still expect conscientious medical care, but you cannot expect warmth or empathy. If, on the other hand, you are polite and appreciative, you have just earned very important brownie points, credit that will make up for many other factors.

Politeness trumps everything. If you come in with meth mouth or swastika tattoos or a t-shirt bearing a hateful political slogan -- and I’ve seen all of those things in the ED, many times -- you can still win friends by being courteous to your caregivers. If you are in any of these categories, in fact, it’s especially important that you be courteous to your caregivers, because these are some of the first impressions that your caregivers, being human, will tend to judge.

Some (not all) ED staff can be less than sympathetic to alcoholics and drug addicts, homeless patients, and patients flagrantly noncompliant with diabetic or cardiac self-care. But I’ve never seen a case where a courteous patient couldn’t overcome such biases. If you’re afraid that your caregivers will judge you for your membership in some large group or category, the best way to make them see you as an individual instead is to be nice to them. Say please and thank you. Don’t interrupt the doctor. Answer questions as succinctly, precisely and accurately as you can. Don’t rail about the universe, the economic system, the medical system, or the so-and-so’s who did this to you. (At least, don’t rail at the medical team. You can rail at me, because I’m the chaplain, and listening to you rail is my job.)

Please do remember that visual signals count. If you have swastika tattoos, you’d be well-advised to cover them up to avoid offending the staff.

If you assume that the medical team is judging you, and if as a result you become hostile and defensive, you’ve probably just reinforced whatever negative stereotypes the medical staff may hold, and then they’ll become hostile in response. Congratulations: you’ve just created a self-fulfilling prophecy.

If your relative is in the code room and the doctor asks you what happened and you start to tell a long winding story about how you found your loved one slumped over at the kitchen table and then you called 911 but the goddamn ambulance didn’t get there for twenty minutes, and if the doctor then interrupts you to ask about your relative’s medical history and medications, answer the question. The doctor needs this information to save your relative’s life. The doctor is not interrupting you because he’s an arrogant so-and-so who thinks he’s so hot because he went to medical school and who’s determined to disrespect you because you have less education than he does. The doctor is interrupting you because he’s trying to save your relative’s life. The doctor doesn’t have time to listen to the long, winding story about the kitchen table and the ambulance.

Tell me the long, winding story about the kitchen table and the ambulance. I’m the chaplain. Listening to long, winding stories is my job.

In general, if the staff seems curt or rude or insensitive, especially after you’ve tried to be polite, remember that their behavior probably has nothing to do with your ethnic origin, ability to pay, addictions, or housing status. If you’re being nice to them and they don’t seem nice back, it’s probably because they’re so busy that they can’t be nice to anybody. If you’ve had to wait, it’s because of the triage system, which is truly non-discriminatory. That person who got seen before you wasn’t treated first because he was white or had insurance. He was treated first because he’s having a heart attack and you have the flu. When you’re having a heart attack and he has the flu, the positions will be reversed.

And yes, it’s hard to be polite and understanding when you’re frightened and in pain. We all know that. But we’ve also all seen patients manage it.

Advice for Staff

Remember that virtually the moment you enter the room, the imperilled organism in the bed will know how you feel. If you're sympathetic to the patient, the patient will know that. If you feel contempt for the patient, the patient will know that, too. If you really don’t give a hoot about this person but you’re doing your best to be polite and professional, the patient will realize that you’re faking it, but will appreciate the effort.

In most cases, these assessments will be very accurate. In some cases, they’ll be skewed by other factors. Patients bring their social histories with them. You see the whole ED; they only see what’s happening in their own rooms. If it’s one of those really busy nights when you don’t have time to be nice to anyone, the patient may assume that you’re being brusque because the patient is an addict, homeless, or of a different ethnicity than yours. People who’ve been shamed for some aspect of their identity may perceive such behavior even where it isn’t present or intended.

One of my jobs as chaplain is to assure such patients that the staff is being brusque with everybody, including me, and that it has nothing to do with skin color or income. (This is, of course, assuming that the patient is being polite.)

Please remember that alcoholics, addicts, psychiatric patients, low-income and homeless patients, and noncompliant diabetics and cardiac patients are usually not, in fact, stupid. They know how you feel about them. They may know much more about their medical conditions than you give them credit for. I’ve heard homeless bipolar suicidal alcoholics deliver extremely concise and elegant analyses of the interactions between these conditions. Please respect patient self-knowledge and expertise. And please remember that in many cases, such patients are judging themselves far more harshly than anyone else ever could.

If you’re caring for a patient with a swastika tattoo, please remember a) that the patient may have gotten the tattoo fifteen years ago, and that it may no longer represent her or his belief system and b) that prisoners often need to display gang insignia as a matter of survival, and that those insignia may not ever have represented their actual values. (Don’t like prisoners? If they’re out, they’ve done their time. If they’re in the ED with corrections escorts, they’re doing their time.) I’ve seen patients with swastika tattoos behave badly towards non-white staff, but I’ve also seen patients with swastika tattoos who wanted to show everybody pictures of their kids and who went out of their way to help other patients. People are complicated. Try to give them the benefit of the doubt. If they’re nice to you, be nice back. If they’re not nice, call security.

If you’re a white staff member, please be especially courteous to and respectful of non-white patients. If you’re a male staff member, please be especially courteous to and respectful of female patients. If you’re a wealthy, well-educated staff member, please be especially courteous to and respectful of Medicaid high-school dropouts with meth mouth. Some patients come in assuming that they’re going to be kicked when they’re down; try to be aware of who such patients might be, so you can be especially careful to avoid anything that might feel like kicking.

And yes, I know, you already have far too many other things to do, and you may really feel like kicking some of these patients (especially if they aren’t being polite). But that isn’t going to improve anyone’s mood or manners, and ultimately, moods and manners affect medical compliance.

It’s worth mentioning here that one of the most admirable bedside manners I’ve ever seen belonged to an individual who was at least eight feet tall. Quite frankly, I’d have crossed the street to avoid this person if I’d first seen him in public after dark. He looked like a hitman or ex-boxer, someone out of a Quentin Tarantino movie. The fact that he had to stoop to avoid major weather systems didn’t help.

But I’ve never seen anyone who was kinder, gentler, or more empathetic towards patients. And I suspect there’s a direct connection; I have a hunch that he figured out pretty early on that he scared people simply by coming into a room, and that he had to compensate to make them feel safe. Sadly, he’s moved on to another hospital. I miss him.

All of us, patients and staff, have the capacity to scare people just by coming into a room. (I can terrify patients just by identifying myself as the chaplain.) If we figure out some of the ways we do that and how to compensate for it, we’ll all be much happier.


  1. This is awesome! I learned so much from reading it. Thank you!

    Being a regular reader of your blog, I am remembering the Gormless post and wondering if you would react differently now that you have gained so much experience from your service.


  2. Thanks, Lee!

    I still think that male ED doc was being really insensitive. (Any male doctor doing a pelvic exam needs to be especially gentle and courteous.) I also think he might have been treating me that way after having jumped, for perfectly valid statistical reasons, to an incorrect conclusions. I was admitted with a diagnosis of PID, and most PID that presents suddenly with extreme pain (as mine did) is caused by untreated gonorrhea. So I think he assumed that that was what I had, although I didn't.

    Even if I HAD had gonorrhea, he should have been kinder. That department wasn't busy, either, so he didn't have that excuse.

    But Saint Nurse, while she was certainly supportive, didn't seem perturbed about how he'd treated me (and nurses judge doctors, although they vent to other staff and not to patients). So maybe I misinterpreted his tone, and he was bored instead of contemptuous. Either way, he doesn't win the Bedside Manner award!

  3. Great post. I have only had to go or take someone to the emergency room a few times. The only time it was actually treated it as urgent is when I took my husband to the ER with hives. They had him on a gurney with a drip before I got the car parked.

    Very scary when you read "See doctor NOW" in the home medical book.

  4. Hi, Elaine, and thanks! Yes, really fast treatment in an ED is pretty scary. This is one of the things I tell patients who are frustrated at having to wait: "You never want to be moved to the front of the line in an emergency room. If you have to wait, that means you're not the sickest person here. This is a Good Thing."

  5. Anonymous2:52 AM

    Fab post!

    *takes copious notes*

  6. Thank you, Barbados Butterfly and anon!


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