Pitfalls in Practice: Judging Patients by the Cover

The other day at work, I noticed a colleague immediately discount a patient’s request for pain medication. The patient was a frequent visitor to the emergency department and chronic pain patient. While the patient certainly was prescribed a significant number of narcotics, a look back at her medical history would have justified such behavior. However, she was waived aside to the waiting room, discounted as a malingerer and a ‘frequent flier’

The patient turned out to have a medical condition that warranted narcotic pain medication in addition to those she was prescribed. I couldn’t help but be bothered by the way this particular patient was dismissed as a bother when in reality she was being quite agreeable given her current condition. 

The emergency department certainly attracts a few malingerers here and there. Seeking pain medication, patients stride through the parking lot, suddenly stricken with a limp the moment they walk through the waiting room doors. I can often spot these individuals for a mile away or am warned of a suspicion for such behavior be the triage nurse. 

External pressure to limit the prescribing of narcotics and internal moral convictions lead nurse practitioners to be wary of patients requesting pain medications. Enabling substance abuse is certainly not the goal of our practices. So, we do the best we can to determine which patients have true pain and which are looking to get a quick fix as part of a dangerous addiction.

Working as a nurse practitioner in the emergency department, my decision making process for prescribing narcotics first and foremost involves the diagnosis at hand. Patients with fractures or other acute, painful conditions may require pain medication regardless of their substance use history. Resources such as state controlled substance databases and past medical records are helpful in the decision making process when the patient’s pain level and presentation are called into question.

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It’s easy to become disillusioned, frustrated or just plain burnt out working in healthcare. But, we cannot let the preconceived notions we develop cloud our clinical judgment. Quick judgments can be helpful in triaging patients, and even in planning initial steps in care for critical patients, but once time sensitive issues have been addressed, taking a second look is a must.

Do you notice yourself judging patients ‘by the cover’? How do you keep preconceived notions from clouding your practice?


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