Why it’s so important to look at the big picture


One of the last things my dad said to me before he passed was, “remember to always look at the big picture.” He said this many times throughout my childhood and teenage years, but it never quite resonated until I was thinking about it in retrospect.

As I near the end of my intern year, my dad’s words hold true. As an emergency medicine resident, I am often running on adrenaline. I take care of sick people and not-so-sick people. I see kids, adults, senior citizens, men, women, LGBTQ, immigrants, drug addicts, alcoholics, nomads, prisoners, and psychopaths, to name a few. They all have different needs. I am quick to act and react. I triage, and I fix things. That is what I am trained to do.

It is reflexive to categorize in emergency medicine. If a patient comes in with chest pain, we ask the same questions, perform our standard physical exam, and run through the list of possible deadly diagnoses in our head. We order the “chest pain labs” and treat the symptoms, risk-stratify, and predict the most likely outcome of the ER visit. A few clicks and we are moving onto the next patient. It is mechanical and monotonous.

This is the easy part.

What we often forget is that most people come to the ER because they are scared. We do anyone a disservice if we do not feel their concerns as our own. We are so quick to work-up a chief complaint, categorize, and act, that we forget to ask, “How can I help you today?” I think we would be surprised how many times our own perceived goals misalign with the patients’.

I recently took care of a patient with squamous cell carcinoma that had metastasized to her heart, lungs, liver, and bones. She was young, and she was going to die. Her chief complaint, according to the triage note, was shortness of breath. I ordered the labs. I put her on oxygen because her sats were in the low 90s. I gave her fluids because she was borderline hypotensive and tachycardic. “Probably sepsis from pneumonia,” I said. I even scanned her chest to rule out a PE, because a good ER doctor rules out the bad things first. When all her labs came back, and her CT scan did indeed show a PE (as well as worsening metastases and a new malignant pericardial effusion), I paged the MICU for admission.

When all of this was said and done, I walked back into my patient’s room to address her lab and CT results and inform her that she would be coming into the hospital. She looked at me and said, “I didn’t come to be admitted. I don’t want to spend the time I have left in the hospital. I just came to the ER to get checked out because I was worried. I didn’t want to be at home and suddenly not be able to breathe. I am scared of dying that way.”

At that moment, I was reminded that diagnosing and treating a problem doesn’t necessarily mean you’re treating the patient. I didn’t step back and look at the big picture.

After lengthy discussions with my patient, her mother, the ICU team, oncology, and case management, I put in my discharge order. She would go home with hospice.

She was relieved.

I urge everyone, regardless of your medical training or background, to not always be so quick to act. Rather, be swift to inquire, listen, and empathize. Step away from what you think a patient needs and instead, hear his/her concerns.

Look at the big picture.

You would be surprised how many times doing nothing is worth more than doing something.

Joy Hallmark is an emergency medicine resident.

Image credit: Shutterstock.com


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