I am in that autumnal season in which I choose my two areas of study for the academic term. My pursuits have been wide ranging over the years but the recent PBS series on Shakespeare's tetrology history saga made up my mind. I have now plunged headlong into Richard II, the two parts of Henry IV and Henry V, with even more zeal than I did as a youth studying under the legendary G.B. Harrison. Henry IV, like most Shakespeare plays, has a play within the play, as Prince Hal and Falstaff play out their assumed roles, plotting strategy for Hal’s eventual ascension to the throne and figuring how he will maintain his roguish ways.
Hal drank heavily, womanized daily, robbed occasionally. He certainly would not have been thought ill of in any emergency medicine residency of which I’m aware. In fact, the Boar’s Head Tavern could easily be that local bar somewhere between your emergency department and the police department, where all good fellows come to hoist a tankard or two.
It came to me while I was applying my advanced age and various experiences to this study that every emergency department visit is a play within a play. The larger play is the total experience: parking the car, hauling in grandma, the triage process, endless registration, the waiting room, etcetera, etcetera.
Then we pivot into the Third Act. The doctor opens the door. The patient is costumed in a gown so thin that everyone can see through it, and which hopefully has not been put on backwards. The physician is costumed in a white coat and accessorized, not with the ball and scepter of Richard II, but with a stethoscope and a reflex hammer, which are about equally as useful these days. The medical symbols of power and authority, if not knowledge and good judgment, are properly in place.
The chorus in Romeo And Juliet does us the great favor in telling us in the prologue how long we are going to be sitting there. “This now the two hours of traffic of our stage,” tells us important things that we really need to know; like how long until you can go to the bathroom. Oh, that we could only be so precise in our medical micro plays. But just as we discover the real truth in Shakespeare's works, which is often given in prose and spoken in these imbedded dramas, so do we understand the patient’s view of a visit based on this strange doctor/patient event.
I got a phone call the other day from a longtime friend. He’s an attorney, by the way, but not just any attorney – a professor of trial technique at the University of Michigan who has spent most of his career on both sides of the medical/legal malpractice fence. He is the only person to have both sued and defended our group. As they say – it’s complicated.
This person needed to speak to me because he wanted to tell me his ER visit story. Whenever anyone wants to tell you their ER story, it’s never anything good, right? He wanted to complain about the fact that the play within the play, which he experienced a few weeks ago, had left him with a bad taste in his mouth. He didn’t feel he’d been really examined. He did not feel he was the play’s protagonist. He thought the terms used were an amphibology of medical jargon he could not understand. He did not feel the one thing that he was supposed to feel: the intrinsic loyalty to himself and to his problem, which is the reason you go to the doctor. It was not conveyed to this intelligent, educated person. Why? We don’t know why. Granted, most parts of an ER visit we cannot control. We don’t control registration, which has become a joke. We don’t control triage, which has become an overdone ritual, which is, to quote the Bard, “Full of sound and fury, signifying nothing.” To think you as an individual practitioner can make lab, x-ray, and consultants move to your beck and call would be a complete mistake.
But we can control the most important part of the play – our role. We can make people feel we have a professional and personal interest in their well-being. This sense of loyalty to that which a patient is entitled means everything to that person. We see people one at a time. It’s how that one person was treated that counts. The patients don’t care if something took ten minutes longer if they honestly feel you were on their side. The sense of loyalty is nothing you can see but everyone of us can feel it and sense this in a room. There is no patient who doesn’t gauge whether you are working for yourself or them.
If you ever visit Edinburgh, you must stop at the south entrance to Greyfriar’s courtyard by the George IV bridge to admire the statue of Bobby. For those of you who have forgotten the story, Bobby was a Sky Terrier who, following the death of his master, continued to make daily rounds, including a stop at the pub, on his way to spend his day lying on his master’s grave. Upon the death of this animal in 1872, there was a huge outpouring of support for his bronze memorial, which you can now visit. Why do people go? Simple. People love loyalty. This was a meme everyone understood without articulation. People will forgive you most anything if they think you are on their side. We do control that! (As an aside, I must state my dog prejudice. I think dogs were sent by God to teach us how we should behave with regard to unconditional love and respect. The more I see what people say and do, the more I admire dogs.)
But I digress. I have seen thousands of complaint letters over the years which were either part of lawsuits or criticisms directed at my own department. All but a few were directed at things we can control: How we look. How we speak. Did we make the usual bonds of trust and loyalty dictated by our position and mandated by our professional oaths? I wrote last month about decorum. Patients know nothing about the science that is being applied to improve how they feel. But they do know whether they feel cared for. They can tell by what you call them, how you address them, and how you guide them through the process. You are essentially the Virgil to their Dante. Answering questions isn’t optional; it’s mandatory. Making certain they understand and can carry out the instructions shows that you sense their personal needs. They feel you should employ the wonders of science to their personal benefit. Coincidentally, so do I.
The other things you control are obvious: food, water, a warm blanket, relatives in the room. The explanation of what really happened and what you want them to do is all under your control. So the next time you are anxious to blame housekeeping, administration, the nurses, the techs, just rethink your power to control the patient’s perception of the visit, remembering that perception is the only reality when it comes to how people feel about their care.
There has developed a pernicious concept in many of our larger teaching institutions that if you’re smiling more than frowning, the patients love you and the officers attending enjoy dealing with you, you must be a mediocre scientist or on drugs. I have found nothing could be further from the truth. Give good news with enthusiasm and bad news with empathy. Try having patience. If you have a brilliant nasty quip that’ll put a patient in their place, don’t say it. And for the young doctors reading this piece, it’s never over till it’s over. And it’s never over. Patients come back and back and back. If they don’t come back, the attorneys for their estates come back. You might as well be friends with the patient. So think it through.
All of us who live in the play titled “Emergency Medicine” run the risk of being infected with the depression of the daily ebb and flow of human misery which presents to our doors. Don’t be taken in. By controlling our little part of the show, you can save the day. Their expectations as they enter an emergency department are usually low. Exceed them and they will receive thank you’s from places you never would have suspected it.
Daily we are forced to participate in this drama of ideas where science is at best in transition and societal problems beyond our belief – let alone our control – predominate. But small victories like an unexpected thank you makes us return refreshed to continue the struggle.
While we’re looking at the works of the greatest playwright who ever lived, I would humbly beseech those of you with current leadership positions or thoughts of leadership to indulge me. Go home tonight and re-read possibly the greatest pre-game warm-up speech ever written: King Henry V’s address to his troops before the Battle of Agincourt. Steal from it liberally. Let it give you instruction on how to motivate your staff: “We few, we happy few, we band of brothers,” may be the most inspiring line ever stated upon a stage, and it is as relevant today as it was in 1599. Remember, we hope for “A Kingdom for a stage.” We are but rude mechanicals who do ply our trade to the benefit of others.
Exit, stage right.
Greg Henry, MD is Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.