Updated: Mar 6, 2021
Today Dr. Haleh Van Vliet joins us on the blog to discuss gender, algorithms and the evolution of Emergency Medicine. She shares why she chose Emergency Medicine as a field. She also delves into how gender influences medical care and how stereotypically "feminine" traits can and should be valued in the field of Emergency Medicine, and even in medicine in general. So starting reading and start the conversation about=breaking down barriers and abolishing gender labels in order to deliver the BEST patient care possible.
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Emergency medicine was born out of the wild west of acute unscheduled care, which became a particularly prominent problem with the widespread adoption of motor vehicle transportation in the mid 20th century. In this way, cowboy clinicians who were willing to chart a new frontier have come to define our field. Their stereotypically male bravado has been the topic of legendary tales in the EM community. It is only natural then that the more cerebral amongst us - let’s say the quieter, more sensitive, and reflective type - might feel a little out of place. To also be a woman in this arena can further deepen the sense of otherness. Nevertheless, it only takes one simple case to demonstrate why stereotypically female attributes deserve just as much recognition and praise as traditional male traits…
“He freaked out and told me I had appendicitis,” states a 17 year-old athletic male resting nonchalantly in his ED bed. His mother, who brought him for evaluation, is sitting at his side. She informs you that she picked him up from school after receiving a phone call from his football coach. During class that morning, the patient mentioned that his right lower quadrant hurt. The patient denies any nausea or vomiting whatsoever. He states he had a normal breakfast without any issues. He also reports similar pain in the past with constipation and admits he doesn’t drink as much water as he should. In fact, his last bowel movement was three days ago. He reports only minimal discomfort at present.
On exam, he is literally the healthiest appearing young man you have ever seen in your department. Perfect vital signs. Lean muscular body habitus. Warm skin with brisk capillary refill. Completely benign abdomen. No flinching, grimacing, wincing, or even so much as a twitch of the lip to suggest pain when you push firmly and repeatedly on his abdomen, including the right lower quadrant.
You proceed to engage both the patient and his mother in shared decision making, explaining your very low clinical suspicion for appendicitis. The patient is eager to take a wait-and-watch approach, stating repeatedly “I’m fine,” while smiling and laughing at his mom’s degree of concern. However, mom’s hesitancy to depart the ED without any labs or imaging is palpable. She describes her son as a minimizer of symptoms stating that he almost never complains of anything. You explain the risks associated with IV placement, lab work-up, and imaging. Your medical director has recently informed you that your CT utilization rate is sky high and needs to be tapered down. This seems like the perfect opportunity to avoid excessive imaging. Then dad arrives and the conversation is re-hashed.
While mom is willing to respect her son’s wishes, dad is not. He states “if this is appendicitis and we catch it before it ruptures, then we can avoid an even bigger problem.” You know he is not wrong. The patient acquiesces to his father, and you place all the orders. When labs return normal, you double back to update them on the information, hoping this will provide enough reassurance. Nevertheless, dad remains steadfast in his desire to push forward with a CT scan. When imaging returns one hour later, early acute appendicitis is diagnosed (at least radiographically). The family and patient are updated. Despite appearing to be the epitome of macho, you watch your young patient break down in tears. His football team has a major game in a few days, and he is the star quarterback, explain his parents. You call the surgeon and the patient undergoes an uneventful laparoscopic appendectomy that night.
Many clinicians might argue that this is an anomalous presentation. Yet, “anomalous” is what we see in the ER with disproportionate frequency. Nothing is textbook - particularly in the emergency department. On initial glance, no red flags popped out in this case. The patient happened to have pain in his abdomen and his coach seemingly over-reacted when the patient mentioned his discomfort. No leukocytosis. No left-shift. No fever. No abdominal tenderness. In other words, his Alvarado score is zero.
But then the question arises, why did the patient tell his coach about the pain in the first place? Why do his parents seem so concerned despite his reassuring clinical appearance? Details such as these may get disregarded as “fluff” in the ED. Yet they are also key to identifying the patient’s underlying pathology. Had the psychosocial nuances of his presentation been disregarded, his symptoms could have been more easily attributed to constipation, which brings us to the topic of algorithms.
While clinical decision making tools such as the Alvarado score may take physician judgement into consideration to some degree, that judgement is not always given the weight or regard that it deserves. If there was a numerical equation that could reliably yield optimal patient outcomes, the emergency department would certainly be an easier place to navigate. But the human element of health care is essential and irreplaceable. There are subtleties in the physician-patient interaction that can immensely influence patient well-being. This brings us back to cowboys… and cowgirls.
Women tend to be more sensitive to the “fluff” of patient presentations - the intangible emotional and interpersonal elements of a patient’s story. The word “sensitive” is rarely used in a positive way when describing people. However, in the context of clinical testing, sensitivity has value. So maybe we need to reframe our thinking on what it means to be a “sensitive” provider. Maybe, the details surrounding a patient’s presentation which often get disregarded as “fluff” are actually critically important “stuff” that can mean the difference between a positive versus adverse outcome.
This more thoughtful approach to patient care has not always been valued in the historical wild west of emergency medicine. Words like “sensitive” and “cerebral” do not traditionally have a favorable connotation amongst cowboys. But emergency medicine is also no longer uncharted territory. Decades of research has refined our methods and techniques. An appropriate emphasis on patient outcomes and process improvement has brought data analysis and quality metrics to the forefront. In other words, a new breed of EM physicians are taking center stage. They are more inquisitive and more mindful young physicians eager to make a lasting difference in their communities. They have recognized that acute unscheduled care can be more than just a transient band-aid to the health needs of our communities.
When I was preparing to graduate from my residency program, two big questions sat heavily in my mind.
How can I provide high quality, conscientious, and empathic care to each individual emergency department patient without compromising efficiency?
What exactly is Emergency Medicine?
To start with the latter, our specialty has been defined as provision of care to those in crisis. Whether or not that crisis is imminent, theoretical, or imagined is a whole other can of worms. Regardless, with this in mind, some EM physicians might respond to my first question by simply stating “you don’t.” In other words, the purpose of our practice is to rule out time-sensitive diagnoses. Empathy and excessive attention to detail may compromise care delivery to the other 5 or 50 patients waiting to be seen.
Yet, as outlined in my anecdote above, there are clearly circumstances where paying attention to detail and harnessing empathy can have immense benefit in catching a critical diagnosis before it renders more havoc not only on a body but on the lives of an entire family (or football team). Furthermore, nurturing a healthy doctor patient relationship, particularly when the validity of a patient’s crisis might be hard for us to recognize, yields immense long-term benefits. When patients know that they can trust the healthcare system to listen to their concerns and be kind, they will return when crisis is apparent instead of waiting at home until it is too late. This is vital for the sustainability of our healthcare infrastructure.
With regard to the second question, EM remains unique among medical specialties in that its scope is arguably fluid, a dynamic mosaic shaped by circumstance. What procedure or practice should an EM provider never under any circumstances what-so-ever attempt? I would argue that there is no definitive universal answer to this question, nor will there ever be. It depends on your location, your experience, and your resources. Clearly, the anticipated scope of practice of a rural ED physician without obstetrical back-up is quite different from that of a provider at a quaternary academic powerhouse that trains top-notch left pinky finger surgeons.
At the end of the day, the chaos and unpredictability of the ED will always echo some aspects of the American wild west. Our providers must know the limitations of clinical decision rules, be willing to set aside the time to listen and reflect when it is needed most, and have the courage to take action in unprecedented situations. And if the past year could be summed up in a word, unprecedented might be an appropriate one. Cowboys will always have a place in EM. But one can not be courageous without also being vulnerable, a trait that has traditionally been considered feminine in nature. And just as vulnerability brings value to the ED clinician, so does sensitivity and a thoughtful eye toward detail. It is for this reason (and many others) that I argue traditional dichotomous classification of gender traits must be questioned as we recognize the inherent value of any human attribute as just that - human.
What unites us as a species is what will push emergency medicine (and all of healthcare) into a brighter future. Algorithms and androids may offer some assistance, but it is time that we recognized the human element of health care delivery as critical to its success. In order to do this, we must also confront the reality of what it means to be human. And this in turn necessitates an examination of the labels we use to falsely create fences instead of bridges. The male versus female dichotomy is one of these fences. It has been used to silo women into certain societal niches, just as race and religion have been used to suppress other groups. To release women from the marginalized corners of society (and our profession), we must start by recognizing how traditional female traits have value. But to move forward as a profession that honors human life by optimizing patient care delivery, the complete abandonment of traditional gender labels may very well be necessary.