A patient presents with respiratory distress and COPD. She is very dramatic in her gestures, very upset and emotional. The first time you saw her you had given her lorazepam and sent her home. It turns out she frequently gets that. You and your colleagues eventually set boundaries on that but she continues to present daily for respiratory distress. This case turns out to involve the deeper human side of medicine. How do you access that?


How do we not only know medicine but know the human condition? Read Shakespeare? Go to bedside medicine skills sessions with actors? Do an ED fellowship in emergency psychiatry?


I particularly enjoyed reading the articles by Frederick Platt from the University of Colorado. He was an internist who would put on workshops on difficult patients/encounters. In role playing, the clinician would learn to recognize strong affect, stop, and name the affect. “I sense you are feeling…upset…scared…angry…etc.” The patient then is invited to explain their fears and concerns.


Emotions, as the Latin root “motere” tells us, serve to “move” us. They motivate us and impel us to action. They are faster and more intuitive than verbal language. But they are not enough for us. We need to move the patient from nonverbal to verbal expression.


“I sense you are feeling scared.”


The patient starts crying. You ask why she is scared.


She is afraid of dying.


You then address that fundamental concern with her. You write “fear of death” as the diagnosis, knowing that future providers can at a glance review the primary diagnosis for each visit. As your colleagues and you empathetically address her concerns, the visits drop from daily to weekly to a couple times a year. She starts taking care of herself better and gets off the sedatives.



-if there is strong affect, stop, name it, and inquire about it

-transition the patient from nonverbal to verbal communication

-identify the concerns and needs behind each visit with a question like “what concerns you the most?”

-review the post on agenda setting for related suggestions



Patients often lie about drug use and that can interfere with care. Part of practicing emergency medicine is using skill in communication to get through those communication pitfalls.


To get patients to tell the truth on drug use, start with asking about past use. Then ask current.


Furthermore, sometimes it helps to ask the question specifically In my area, I tend not to ask “do you use drugs?” I ask “did you try amphetamines when you were younger?”


If they answer affirmatively then can expand to “when was the last time?”


If you have doubts about their answer, you can say “may I test your urine and confirm?” Their response is often revealing.



-Ask about past drug use first

-Then ask about recent drug use

-Ask permission for a drug screen


A patient presents to the emergency department on a 5150 hold. He is yelling and straining against police restraints. Of course you will use medications but also want to try calming him down through bedside interaction.


The human mind, unhinged by disease and drugs and high emotions, needs simple, calm communication that is easy to understand. Talk to the patient in a story format. Introduce the characters and organize it chronologically (past, present, future). Make it very clear that they are safe, and you are on their side.



Hi Mr. ____, I am Dr. ____. My job is to help people who are sick or hurt get better.”



“You are here because somebody called 911. They could tell something was wrong. When the police evaluated you they determined something was wrong also.”



“My job is to make you better. I am going to be talking to you and doing a physical examination.”



“When we are done we will determine the best treatments and the best place for you to continue to get better.”



You will be safe here and you will be treated with respect.”

” Everything we do will be in your ultimate best interest.



“Just as I promise to keep you safe and treat you with respect, I expect you to do the same for my staff.”



To get started I would like to calm you down with a medication. That can be through a shot or a pill. If you are willing to take the pill you can choose that. The medicine will calm you and make it easier for us to talk.”



“I know you will be safer if you get some medication. We are going to give you the shot and 4 people will hold you down. They will not hurt you. They are to keep you from hurting yourself and anyone else. When it is done I will talk to you some more.”



Go back to being therapeutic right away so the patient is reassured.

“Are you feeling better after the shot? I want to talk to you about what to expect going forward.”



“What are you most concerned about?”

“What would you most like to see accomplished today?”


How does your emergency department treat the patient with psychosis? This is a stress test for genuine patient-centeredness. If you can be sincerely non-judgmental with them, it reminds everyone that we are serious about our caring culture.



-Explain their care like a story. Introduce yourself and explain the past (how they got here), present (what you are doing now) and future.

-Everything you do is ultimately in their best interest (say that!)

-Reassure their safety first, and respect, and require them to abide by it also.

-Stay therapeutic before, during, and after conflict



Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. West J Emerg Med. 2012 Feb;13(1):17-25.


A patient presents with a scalp hematoma from a remote fall. When you press on it, it feels very soft but is not swollen. You are confused, and order a CT, which shows complete lysis of the bone,. Further workup suggests metastatic renal cell carcinoma. The patient is avoidant on history and keeps explaining away the findings and concerns. Hours later, while he is awaiting a bed upstairs, he reveals that a year ago his doctor suspected renal cell carcinoma but he refused a workup.


This patient suffers from denial. Whether that is a perfect term is debatable. In this case it is severe but so often denial seems to overlap with avoidance, perhaps even procrastination. It is at times the unwillingness to address an unpleasant reality. In medicine all too often we judge “denial” as a break with reality but we need to understand it as a human experience. Denial is the way some patients try to grasp onto hope. Go read Arthur Miller’s Death of a Salesman if you want a literary exploration of denial and hope.


We shouldn’t always oppose denial. Don’t argue over code status. If they want to be full code don’t gripe about them at the nurse’s station. They are dying. If knowing they will get 30 minutes of CPR in the end gives them comfort then let them have that consolation. If the patient-centered reasons aren’t enough, remember that practicing code situations only makes you better at it.


The literature is accumulating articles portraying denial as a positive thing. Denial mitigates terror and allows patients to continue to function. But in the emergency department we sometimes see patients at an earlier stage, where denial gets in the way of potentially curative treatment. So what should we do?


Accentuate the positive

Without distorting the truth, emphasize the safety and efficacy of your recommendations.


Build a relationship of trust by genuinely connecting as people

Spend some time getting to know them as people. Share anecdotes of those who have had good experiences, which not only illustrates safety but also displays your connection to patients. As emergency physicians we will not get long-term rapport, so build it for your consultants, whose expertise and caring we should commend to the patient (assuming we can do so truthfully).


Tools of persuasion – allowing an “out” lowers the cost of an “in”

Finally, point out that they can always choose to stop treatment later. That way they can say yes without feeling stuck. By giving them an “out” you are lowering the cost of going “in.”


Ultimately, denial is their choice. We will not be able to convince everyone to face the unpleasant reality but we should use the skills and techniques that best address their frame of feeling.


Take Home Points:

-Denial is often a way for the patient to have hope

-Give such patients hope through emphasizing the positives of treatment

-Connect on a genuine, human level

-Remind them they can change their minds later


In the last 2 posts we discussed techniques for winning rapport and trust with children and for using distraction and play. We discussed a case of a 16 month old with scalp tenderness. In that case none of these techniques worked. So what do you do next?

Parent’s Arms

Most children between the ages of 1 and 3 will become more calm when examined in the arms of their mother or father. The child calms down, and clings to the mother and sometimes that is enough for examination.

Examination By Proxy

If all else fails you can deputize the mother to do the localizing examination. In this case she tries but the child still cries. You decide to leave the room to let her calm down and you ask the mother try to better define the area that is tender. You suggest a gentle scalp massage starting away from any areas of pain.

Come Back Later

Once the limbic system is aroused and heated it takes a few minutes to cool off. Come back later to reassess the child. Of course, treating pain is important for enabling a good examination.

You come back and she thinks it is the left ear. You expect external otitis but see nothing. Then you look at the scalp in that area and see bulging and redness behind the ear. You order a CT scan and find mastoiditis with abscess formation.

Take Home Points:

-Examine the child in the parent’s arms if needed for calmness

-In the uncooperative child, try localization by proxy


In the previous post we talked about using proper greetings and explanation to win rapport and trust. We talked about a 16 month old with scalp pain that could not be localized. Often efforts at rapport and trust do not work. What do you do next?

For straightforward presentations there is nothing wrong with physical restraint and looking in the ears against resistance etc. William Carlos Williams has a short story “The Use of Force” where he makes this into a morally ambiguous act about subduing another person. Nonsense! Tell the child that you help kids feel better and you are going to check for owies. If you see resistance, have the parent hold the kid and proceed.

But sometimes the presentation is not clear and we need skill in winning a child’s compliance.


Use objects in the room for distraction but these do not always work. Blowing up a glove into a balloon and drawing a happy face works pretty well. Having the glove talk to them is even better. Smartphone photos are great, the child is usually mesmerized.


You might tell them a story; “there is a mouse on the loose in here, have you seen the mouse?” The mouse story, if it works, is good because the mouse can run to wherever you want to examine. “Let me check your ears for the mouse.”

Other forms of play might be to state your commands in ways that captivate the child’s imagination; “pant like a dog” elicits better compliance for oropharyngeal examination than “say ah.” For the abdominal examination, say “let me check your abdomen and see what you had for lunch.”

Take Home Points:

-Use distraction to help localize tenderness

-Use imaginative play to make the examination more fun


A 16 month old presented with pain in the scalp. The examiner was not able to localize it further because the child was uncooperative and crying. What now?

To localize pain in a toddler, we need the child’s cooperation. There are three ways to achieve this. The first approach is to win rapport and trust.

Introduction: I start with a proper introduction to the child on eye to eye level. If they are old enough to understand, I might say “I am the guy who fixes owies.” (sometimes followed by a comical search for “owies” well away from the affected area).

Non-clinical touch: The first touch should be non-threatening. I sometimes do a formal handshake for humor, or a pat on the back, or a light touch of the foot as I say hello.

Say his or her name:

Use his or her first name frequently to enhance familiarity.

Anticipatory Guidance

Demonstrate the exam on yourself or on the child’s mother first. This is really important with the otoscope. The best model is a cooperative older sibling.

If this works, great! Sometimes it does not. Read my next post for the second approach, on distraction and play.

Take Home Points:

-Treat kids like little adults: With respect. Introduce yourself, use an age-appropriate physical greeting, and address them by their name.

-Explain things in advance: model the examination on yourself or a family member.


It is possible to adequately address a chief complaint but not identify or meet the patient’s concerns.

Agenda setting is defined as that process of the medical encounter where the doctor and patient agree on the plan for the visit. If agenda setting is not done, it defaults to whatever the doctor thinks is needed, and sometimes patients feel their concerns were not addressed.

Interpersonal skills are often portrayed as something we do in addition to our normal duties. The implication is that it would add time demands. But a group of researchers reported that certain interpersonal skills actually saved time.(Mauksch Arch Intern Med 2008) Those skills included rapport building, empathy, and agenda setting.

How do we conduct agenda setting? Here are two scripted phrases:

“What concerns you the most?” (addresses the patient’s fears)

“How can I be of most help to you?” (addresses the patient’s goals)

Another way of asking the second question is “what is your goal for this visit?” or “what would you most like to see accomplished?”

When we ask those sorts of questions we are identifying the patient’s concerns and needs, and setting the course for a more effective patient encounter.

Take home points:

-Set the agenda for the visit collaboratively with the patient

-“What concerns you the most?”

-“What would you most like to see accomplished today?”