Thursday, April 26, 2007

Is there any chance you are pregnant?

A story for all who have been through the multiple rounds of medical histories upon entering an emergency department.

A good friend found herself in a local ED with symptoms of appendicitis. The first medical history was taken by the triage nurse. Then, another nurse. Then, an intern. Then, a resident. Finally, the attending arrived, and he started the process again, writing while talking and making no eye contact.

By this time, my friend had memorized all the questions, and she figured she could speed up the process by anticipating the next questions and giving the answers in advance of their being asked. "Have you ever had abdominal surgery?" "Yes," she replied, and proceeding to the next as yet unasked questions, offered, "It was a complete hysterectomy, and it was three years ago."

Without pause, and without thinking, he said, "Is there any chance you are pregnant?"

She, feverish and in pain, raises up one elbow, looks directly into his eyes and says, "Either you are trying to introduce some levity into this situation, or that is the dumbest question you ever asked."

He turns deep red and leaves the room without another word.

Moral of the story: In a busy environment like an ED, it is all too easy for providers to go on "automatic pilot" and not really pay attention to what the patient is saying.

17 comments:

janinsanfran said...

Oh joy. I'm printing that out for a friend who I frequently have to take to the ED.

margalit said...

Doctors are fallable, even outside the ER. I was on the table being examined by a breast surgeon. He asked me if I had children. I said I had 2, a boy and a girl, and that they were twins. He said, "OH, are they identical." Now, this wasn't a moron...but he sure didn't think!

Rob said...

Yes, doctors are fallable. Sometimes I wonder if they know that. It takes a certain kind of ego to cheat death, and I wish there was some automatic, regular way to remind someone that they need to question their assumptions sometimes.

I know the biz knows this, but it should be made a process. I dunno, maybe a trip to a simulator, like pilots have to do. :)

adamg said...

So, was it appendicitis? Don't leave us hanging (that was the first question my wife and daughter asked after I read them this post).

Paul Levy said...

Oh yes. Everyone who examined her quickly came to that conclusion.

Anonymous said...

Good post. I think the eye contact thing is very important to patients. As a health care provider, whenever I am interviewing a patient I try to make as much eye contact as I can. Patients do NOT want to feel like just ANOTHER patient but rather as a person first. I would only expect that same treatment for myself and my loved one's if in that situation.

Richard

Matt said...

I don't think this signifies any wrong on the MD's side. These questions are often scripted, or even a step by step form on a computer screen that they are just filling out.

I saw my MD this morning for a sinus infection, I noticed the exact same happenings. The nurse went over my history, then the Doctor went over my history again. Once done however, the doctor began to listen and converse with me. There is a big difference in time restraints when comparing a clinic visit and an ED visit.

It's just my opinion, but it seems the problem doesn't lie in the fact that the doctor wasn't listening, but the real problem you can identify from this story is how many needless steps there are in that system, and how it possibly takes away from the time that the doctor could be better listening and diagnosing. The process shouldn't turn your docs into drones.

Improve the process, make it so that the doctor doesn't have to repeat steps, which thereby gives him more time to listen. Of course I work in a process improvement department, this is how I usually approach things.

Matt M.
Decision Analyst

P. A. Kenney said...

Last September I was on a fishing trip off Chatham when our 28' boat hit a fifteen' rogue wave. The wave won and I was flung around the cockpit, dislocating both shoulders. Luckily we had four hundred pounds of ice on board and my friend, the boat owner, is a retired Newton cop an certified EMT. He also served two tours in combat as a helicopter crew chief. Jim knows his stuff around injuries.
He wrapped me and packed me and slung my left arm...the more severely injured. When I arrived at Cape Cod Hospital and was shown into the rocket surgery department the first question I was asked, standing in full light with my left arm in a sling, was, "Which arm, sir?"

Paul Levy said...

matt -- Part of the physician training program is for the interns and residents to go through the history. But, the attending then has to redo it to be sure they have done it correctly.

p.a. -- Actually, the doctor did the right thing under current care rules. Providers are required to make sure they are treating the correct side of the body, and one part of that is to confirm it with the patient. Yes, even if it seems obvious.

Matt said...

Ah, I've never had the privilege to work at a teaching hospital.

Roy M. Poses MD said...

Yes, the physician should have made eye contact.
No, the question is not ridiculous.
If she had a "complete" hysterectomy, but did not have her ovaries removed, she could still have what is called an ectopic pregnancy, in which the fetus implants somewhere other than the uterus. This can lead to severe bleeding and/or inflammation, look all the world like appendicitis, and may be fatal if not treated.
Unless your friend also had her ovaries removed, and clearly told the doctor that, the question was, in fact, fully justified, although it should have explained. Failing to ask this seemingly odd question would have been a very major mistake, on the other hand.

Paul Levy said...

Thanks, Roy. She had had her ovaries removed, which is probably what she meant by "complete." But as you say, he could have asked her about the ovaries. Or, he could have replied, after her remark, "Actually, there is a chance of pregnancy if you still have your ovaries. Do you?"

P. A. Kenney said...

Paul - Thank you for the clarification. The Cape is a small place and inevitably the good doctor and I bump into each other. Now I can look at him with a kinder regard. But, this is a little like an old Abbot and Costello skit...how can he treat the injury to the left side of my body when he has to make sure he is treating the right side?

Paul Levy said...

It depends who's on first . . .

Maxine said...

I have always considered all the questions, even the stupid ones as part of the process to make sure no one made a mistake. But I have to tell you a story about when I took my daughter to a local ER when she hurt her foot. After the questions, the doctor asked what was wrong, I explained, he said, "what do you want me to do?" I said take an x-ray. He said - really - "if I take an x-ray what do you think I'll find?" I said, if I told him that, could I send him the bill.

eeka said...

The physicians at the ED there also state that being sexually active without using birth control means you have to take a pregnancy test before certain procedures, without bothering to ask whether the "sexually active" is with a male.

Anonymous said...

actually the term "complete hysterectomy" is usually reserved for inclusion of ovaries as well as uterus, otherwise simply "hysterectomy"