25 Years in the Emergency Department -- Lessons Learned: An Expert Interview With Robert McNamara, MD

Daniel Keller, PhD

March 04, 2010

March 4, 2010 Editor's note: Based on 25 years as an emergency medicine attending physician and program director, Robert McNamara, MD, imparted some of the lessons he has learned to attendees at the American Academy of Emergency Medicine (AAEM) 16th Annual Scientific Assembly, held February 15 to 17 in Las Vegas, Nevada. Dr. McNamara is professor and chair of the Department of Emergency Medicine at Temple University School of Medicine in Philadelphia, Pennsylvania, and is a founding director and past president of the AAEM. In this interview with Medscape Emergency Medicine, Dr. McNamara discussed some of these lessons, including the best use of the expertise of other healthcare providers, establishing rapport with patients and with colleagues on other medical services, and an early clue in the diagnosis of some newly emerged soft tissue infections.

Medscape: In your 25 years as an emergency medicine attending physician, and in your time as a program director, what are some of the lessons that you would pass on to physicians entering the field of emergency medicine today?

Dr. McNamara: Emergency physicians get input from many different sources — emergency medical services (EMS), nursing, patients, and families. It's been my experience that physicians really need to pay attention to the nursing staff if they tell you they think the patient is sick. That should be a red flag. Nurses have the same gestalt, a lot of them have a lot of experience, and if they come to you and they want you to take a look at a patient because they are worried about them, you can't ignore that.

On the other hand, if they think the patient is faking or malingering, that should raise an alarm in your mind because often the patients that we have that kind of reaction to actually have something wrong with them. If the nurses think the patient is faking, try to block that out and objectively evaluate the patient.

Medscape: How do you deal with patients' attitudes and anger?

Dr. McNamara: If they're angry, they're usually upset because they had to wait so long. One of the first things you should say to them is that you're sorry they had to wait so long. It kind of defuses their main source of anger, and it can set a good tone for your interaction with the patient.

When we ourselves feel angry at patients, when we're getting a negative reaction, there's a potential for making mistakes. It can cloud your judgment, and you've really got to try to step back and remove yourself from that angry feeling. If you can't and there's another doctor around, sometimes you're better off passing the case on to somebody else who can start off on a better foot with the patient.

Medscape: What are some approaches for establishing a good rapport with the patient?

Dr. McNamara: Make sure that you recognize family members in the room, sit down when possible and try to be at eye level with the patient, don't be the doctor standing at the bedside. If it's a confusing presentation, ask them what they think may be wrong with them, what is their major concern that brought them to the emergency department (ED). If you've got a patient who can't respond to you, you've got to try to tap other resources — find out what EMS knows, find out what the family knows, carefully read what the nursing assessment was, what the triage note is.

If you get a different set of facts, then reconcile that. Document the fact that "although the nurse's note said this, that's not what the patient told me."

Medscape: In your presentation at the AAEM, you noted the importance of tachycardia. Could you discuss how that fits into your assessment of the patient?

Dr. McNamara: It's well known for pulmonary embolism, but a lot of these soft tissue infections can be a little hard to diagnose — necrotizing fasciitis, methicillin-resistant Staphylococcus aureus (MRSA) infections. Oftentimes, patients come in looking relatively benign, and the only clinical clue is tachycardia. Why are they tachycardic? It's not something the patient can fake, and if they remain persistently tachycardic, you've just got to think that maybe you're in the early stages of a serious illness. I've seen a couple of cases of MRSA infections, serious soft tissue infections, in which that was the only initial clinical clue. It can be an early indicator of sepsis. It's amazing the cases you see in which the people have a serious soft tissue infection, and the exam and the history [suggest] a pulled muscle, except the heart rate happens to be up. Why would it be up with a pulled muscle? It's just a scary disease.

Medscape: Do you have any strategies that emergency physicians can use to improve interactions with other specialties in the hospital, especially as they relate to consultation and admission to their services?

Dr. McNamara: You can admit 15% to 25% of your patients to the hospital, or you need other specialists to help you out with the care of the patient. It can be a difficult interaction for the emergency physician because we're doing it 24/7, [including] holidays. It's not like we're calling everybody [during regular business hours] to ask for their help. If you look at the sources of stress for emergency physicians, specialty interaction is one of the things that they report.

The bottom line is that, as a physician, your best friends are other physicians. The better you can work with your colleagues, the more successful your career is going to be. You want to try to work things out ahead of time with the various specialties. It's usually better to figure out who's going to go to medicine, who is going to go to orthopedics during the day, [rather] than at 2 o'clock in the morning. Have your chief or chair, or if you're one of them, sit down with the other departments and work it out ahead of time.

It's very important, as an emergency physician, not to isolate yourself in the ED, to become part of the fabric of the medical staff, to attend medical staff functions, to serve on committees, to go to multidisciplinary conferences. When you do that and you interact with your peers on the medical staff face to face, then when you call them on the phone, it's a whole different ball game. It changes the whole relationship. I think that's one of the problems in emergency medicine. Some people think this is a shift-work job, punch a clock, get in there, do a shift, and get out. I really think it's important to be involved in the greater medical community in terms of the medical staff in a hospital. It'll make your professional life better.

When you do run into a conflict, try to settle it over the phone. Don't send emails. If you think you want to write something up, an incident that's potentially inflammatory, always sit on it for 24 hours. Never send it in the heat of the moment. When you commit something to writing, you might regret it later.

Medscape: What you've described serves to make life in the emergency department smoother. Is there anything you can do to make life with the other services easier?

Dr. McNamara: A good emergency physician is the best friend of a specialist. You're not calling in the orthopedic guy to reduce the shoulders. You're doing it, and you're sending them in for follow up. When one of their patients comes to the hospital in the off hours and they know you, they trust you, and you tell them, "I'm going to admit your patient, and I think it's OK for you to see them tomorrow morning," that kind of relationship is very valuable to those docs. If they don't know you, they don't trust you, they're going to come in. A good emergency medicine physician is valued by their colleagues on the medical staff.

Medscape: The ED sees a lot of patients sent by busy physicians from their offices. When a cardiologist directs a patient to you for chest pain or a surgeon sends you a patient to check out abdominal pain, what kind of narrative do you want from that physician?

Dr. McNamara: There is a skill and an art to presenting a case. Drawing out the story, talking about the history, the physical, presenting it like a medical student, that's not what [we] need. You have to learn the art of communication with your consultants and colleagues.

Medscape: Do you have any advice for dealing with stressful patients or patients who come to the ED frequently? Is there a danger of dismissing their complaints and missing something serious?

Dr. McNamara: Certainly in any ED there are a number of patients that a lot of people would consider undesirable, the charts that you don't really want to pick up. . . . They don't like to see the elderly patient with a nosebleed because they can turn into a menace, or the older patient with abdominal pain. In emergency medicine, you can't pick and choose. The charts are there, and they have to be seen. You've got to develop an approach, [so] focus some reading on it and research it.

Routinely, physicians talk about the patient who is a drug seeker, or chronic pain patients coming in looking for narcotic prescriptions. That's a source of frustration and anger for a lot of emergency physicians. I try to put it in a different frame of reference. Number one is that your denying them pain medication isn't going to cure their underlying problem, which is an addiction. On the other hand, if somebody does get a prescription from you and they truly were a drug seeker, it's not really going to make them any worse. The consequences of what we do in the individual visit are not huge either way.

You're going to know who is in too often for pain medications, and the typical reaction is we get angry and want to kick the patient out. What we really should be doing is confronting the patient and saying. . . "You've got a problem here." You ought to be trying to steer these patients into detox programs rather than getting angry at them and kicking them out of the ED. You need to realize that addiction is a medical problem.

The other undesirable cases are intravenous drugs abusers. They have a high disease burden. They get some serious infectious diseases. Again, you get initial negative visceral reactions, but you have to realize that oftentimes they are there for a very serious condition, [such as] spinal epidural abscess, a frequently delayed diagnosis or misdiagnosis. This is a patient population that is at high risk for that.

Medscape: Are there pitfalls in dealing with even routine cases?

Dr. McNamara: I work in an inner city ED, and we routinely see several asthmatics a day, and you can be lulled into the trap of [thinking] they all do well. When you actually look at it across the board, asthma kills patients. So you just have to take the extra step and make sure you don't develop a cavalier attitude toward some of the routine cases.

You know you're going to admit the chest pain patient, [but] if you don't make a diagnosis in the ED, it's often hard for the next physician to make that difficult diagnosis, like aortic dissection. Our diagnosis influences the inpatient scene. So a slam dunk admission can be a trap. Make sure you pay attention to those high-risk components.

Medscape: You described working in an inner city ED and that patient population. Do you have any tips for the physician working in the nice suburban hospital? Are there any traps they might encounter?

Dr, McNamara: They have the issues with the "entitled" patients. "Where's my private doctor? My private doctor said I have this . . ., why are you telling me something different?" The more informed patient population, as opposed to the inner city population, has its own set of problems to deal with. They expect more. They want better customer service, and you've got to realize that in emergency medicine, that's part of the game. You have to retain your patients and try not to get angry at that. Sometimes it's a matter of showing somebody an article, and saying, "Look, this is why I'm making this decision."

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