Michael Daley
Chicago, Illinois, United States

Mr. Bob Stevenson was fifty-one and had a history of intravenous drug abuse. He was sent to our emergency department on a Friday afternoon from the local detention center, with a chief complaint of chest pain. He said he had been watching television when he suddenly developed a crushing left sided chest pain that radiated down to his left hand. “The security guard said to me, ‘Hey Bob, why is your arm so purple?!’” exclaimed Mr. B.S. during the interview. He had negative blood tests for a heart attack, but his EKG was borderline. His medical acumen was remarkable, which quickly raised several red flags as to the authenticity of his complaint.

“Is he malingering? He likely wants morphine or Dilaudid and a get-out-of-jail-for-a-weekend pass.” These were among the ideas that permeated my racing thoughts. His history was just too perfect. His family history even included several close family members who had died of heart attacks in their early 50s. This fact only raised my suspicions more. “This guy is good,” I thought. “No, he is really good.” In addition to frequent requests for pain medicines, it was also difficult to access his veins because of his previous drug use. The work-up of his condition was delayed due to several factors, including a lack of officers to escort him to the cardiac catheter lab and perpetually losing his one IV access. It became a nightmare to figure out what to do with him. When we were finally able to obtain his studies, to my consternation Mr. B.S. actually did have a significant occlusion of his coronary artery with heart damage. I felt defeated. He was not full of manure, as I and the rest of the medical team had believed. He was the real deal Bob.

As Emergency Medicine physicians, we are inadvertently well trained in the art of bias. From the moment we encounter a patient it becomes imperative to determine the sick versus not sick, which is often based on both objective data (i.e. vital signs and clinical appearance) or subjective data (i.e. “I don’t think this patient is sick based on gut feelings” or “I have seen him before for the same complaint two days ago”). We profile or risk-stratify our chest pain patients based on probabilities of bad outcome. Identifying patients at higher risk is an integral part of our job function. Our bias can become problematic when it is entangled with emotions. Emotional entanglement can arise in the setting of attenuated trust in the patient-physician relationship. To this end, detainees evaluated at a public hospital like ours can be a particularly challenging group. They are exposed to additional biases that may compromise the delivery of comprehensive health care free of disparities. We are provided with a laundry list of “do nots” when dealing with patients from jail: do not show or tell them your full name, do not keep a pen in your top pocket, do not wear your stethoscope around your neck, do not leave any sharps near them, keep officers close by etc. etc. With these ever growing precautions and call for a hyper vigilant state of mind, it is not surprising that the typical trusting relationship is attenuated. We are often guarded in our approach to these patients both physically and mentally, which can be both exhausting and time-consuming during a busy ER shift. Errors in judgment can become more commonplace. What we can learn from this experience is to always take a step back, make an active attempt to remove the emotional entanglement, and allow for an impartial assessment of this group of people. To actively listen and not let underlying assumptions govern our decision-making algorithms is also an integral part of our work as ER doctors. A patient is a patient who is a patient.

End note

1. In accordance with HIPAA, actual name and health information have been altered to protect patient privacy.