Wednesday, July 23, 2014

Managing Expectations

As we are waiting for the paperwork to be completed for Jamil to travel, I am reminded about our expectations.  We expect that when we flip the light switch, the lights will come one.  We expect that when we sit on a chair, it will hold our weight.  We expect that when we get sick, we can receive treatment.  I could go on and on as we expect so much.  Are our expectations realistic?


On June 4th of 1996, I graduated from the University of Oklahoma College of Medicine.  The next month, on July 1st, I started my training in Emergency Medicine.  Since that day, I have worked in many different hospitals and treated thousands of people across Oklahoma.  Some of these hospitals were a part of my training and many have been since my formal training was completed.  I want to be clear that the quotes and phrases listed below were not sanctioned by any of these hospitals, nor were they said to any patient.  These are things that I have thought, overtime, as comic relief to stressful situations.  They may have been shared with the nursing team or other doctors, but were never relayed to patients or their families.


There have been times, usually in the winter, where ERs are inundated with kids that have fever.  Fever, on its own, is a natural and helpful response that the body has to infection.  In kids, this is usually caused by a virus.  Young children will mount an impressive fever to the same virus that might only cause adults to have a runny nose and feel a little fatigued.  So after the 100th patient that showed up in the ER with a fever, I developed a new phrase that I thought the operators should answer the phone with.  “Hello, this is XYZ hospital, where fever is OK, how can I help you?”  After contemplating this for a while, I figured this would cause more questions than it would solve problems.


I have come up with another thing that I thought would “help” with phone answering.  The ER could be quite busy and we would receive calls from people asking if there is much of a “wait”.  As you might know, treatment in any ER is not based only on when people arrive.  Patients are triaged and the sickest go first.  Usually, if someone has time to check to see if it is a convenient time for them to come to the EMERGENCY room they are not very sick.  So I thought it would be good to have a pre-scripted response to the “How long is the wait” question.  The person answering the phone should say, “If you have a true emergency, there is never a wait!”  This too never happened but made me feel better at the time.


Speaking of triage and how patients are put into the treatment order, there is another factor that I think should be considered.  If the patient and their family stop off at the local convenience store for a “jug-o-cola” before they come to the ER for their abdominal pain, they may not be as ill as they think they are.  Trying to convince me that you have 10 out of 10 abdominal pain while you play angry birds, sip on a Pepsi and eat a moon pie is a hard sell.


I have millions of anecdotal phrases and scenarios that I have come across in the 10’s of thousands of patients that I have treated in the past 18 years.  But the reason I have mentioned the ones above is to get to this one.  One of the most frustrating issues with being an ER doctor is dealing with expectations.  There are expectations that the hospital has that I treat patients well, in a cost effective manner and in a way that receives good scores on the patient satisfaction surveys.  The government has expectations that we have to see everyone, no matter if they have an emergency or not.  The DEA has expectations that we are very careful and judicious in the use of scheduled medications.  Nurses have expectations that the doctor is competent and will write orders in a way that is logical and makes good use of their time.  Malpractice attorneys expect that despite our textbook treatment of patients, bad outcomes will eventually occur and put food on their table.  Insurance companies expect that we will spend 3 times as much time charting our care of the patient than we spent actually caring for the patient.  All of these are fine, but to succeed as an ER doctor, you have to identify and then address the patient and family expectations.  By “address” I don’t mean that you necessarily have to meet them, but I need to acknowledge them.  Sometimes, identifying and addressing patient expectations is easy.  Sometimes it is difficult to determine what the expectations are, but once I do, they are easy to address.  The most trying times, however, are when the expectations are obvious, but they are unrealistic. 


I have had families bring in an elderly parent at 11 pm on a Saturday night for a problem that has not recently changed and has been present for months.  Perhaps the patient has been weak with no appetite for 6 months.  They’ve had many tests and work ups via their primary doctor and associated specialists.  Despite this work up, the problem persists and has prompted an ER visit at 11 pm on a Saturday.  The expectation is that the patient gets admitted and the problem solved.  My dilemma is to figure out how to do either one of those things.


Another example of expectations askew, is when someone comes into the ER at 2:00 am with back pain that has been present for 2 years.  No new injury or worsening of the problem.  They’ve had an MRI and seen a back specialist.  The patient takes pain medicine chronically and has plenty of that available.  I guess that they expect me to solve the problem, but given the scenario, this is unrealistic.  So, believe it or not, I have come up with a new XYZ hospital slogan.  “Welcome to XYZ hospital emergency room where we specialize in meeting your unrealistic expectations.  How can I help you?”  This too has never been approved or used in any hospital, just in my deranged mind.


The reason all of this has occurred to me has been my unrealistic expectations over the past 7 weeks.  Each time that we clear a hurdle in the race to get Jamil’s paperwork together for him to come to the USA for medical treatment, I grossly underestimate the next hurdle.  For instance, when we get X done, it should take a day or two to get Y done.  That lets us get Z done by Friday so we can fly on Saturday.  In each of these steps, I have brought expectations.  Each time they have been unrealistic.  I frustrate myself because I can see myself as the family with an elderly loved one that wants them fixed in the night on a weekend.  As soon as I notice it, I fall into the same trap again.   It is so infuriating.


I think that the only thing that prevents me from becoming overwhelmed is that I know that our God is able to meet our unrealistic expectations.  It is unrealistic to think that the creator of the universe is concerned about me in an intimate way, but he is.  It is unrealistic to think that I can address an almighty God as a friend, but I can.  It is unrealistic to imagine that God loved me enough to see his son Jesus suffer for my sins, but He did.  So perhaps if I had written a book in the bible, it would say this:


Jay 1:1 “Our God is a God that specializes in meeting unrealistic expectations.”


You might call it a miracle, but I am still praying that God will meet our unrealistic expectations and we will travel, with Jamil, soon.



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