By 2 a.m., the ED had slowed down quite a bit and there was only one patient left in the waiting room. He was a middle-aged man with a chief complaint of foot pain. He looked a bit unkempt and walked with a limp. As I walked with the patient from the waiting room to triage, I racked my brain for all the reasons that would cause foot pain. I didn’t want to miss anything and for quite possibly the first instance that evening, I felt like I had time to really do a thorough investigation.
While I asked the man questions, I was also actively filling out his note in the EMR and as I made my way through my differential, I started to struggle. There didn’t seem to be anything wrong with him. He had abrasions on the backs of his feet, mostly likely caused by his shoes being too tight and he noted that he had lost his socks. In that moment, I made a mistake. Instead of just focusing on his chief complaint, I started to try to figure out if there was anything else wrong with him. I observed that he was talking rather quickly, his skin looked a tad redder than what I would consider normal, and that limp was confusing me.
When I presented this patient to my resident, she gave me an odd look and said, “Do you know why he came to the ED?” I honestly had no good response; in my mind there really wasn’t anything wrong with the man. She went up to the patient and simply asked him, “What is it you were hoping to get out of today’s visit?” His response was even simpler, “Socks!” It was in that moment I had what I like to call the “face-palm” experience. It’s a situation many medical students find themselves in time and time again during clinical training. These are the times when you’ve failed to think about the obvious or what you thought wasn’t relevant turns out the be the most important factor in the patient’s case. While these situations can initially feel a tad humiliating, upon reflection, they become humorous and frankly great learning experiences. In this instance I realized that medicine doesn’t always need to be complicated, and in many ways, it can be quite simple. All this man wanted and needed from us was a pair of socks. The trap I fell into was overthinking and failing to ask the right questions.
It may seem weird that it is possible to overthink in medicine. After all, medicine is a cerebral practice in many ways; we come to our diagnosis and plan after careful consideration of the evidence presented to us. Thinking is integral to this field. However, that “thinking” — though vital to the practice of medicine — can also be a double-edged sword; needing to analyze every detail can lead us astray and cause us to get distracted by irrelevant factors. Anchoring the visit on the patient’s chief complaint and goals can help to guide your questions and allow you to focus on the principal problem. Furthermore, simply asking what the patient is hoping to get out of their visit can provide the simple answer to their question.
In this current era of medicine, a patient encounter isn’t just between the doctor and the patient. It isn’t a simple question and answer session with a physical exam and discussion of a plan. We must deal with the EMR, sifting through checklists, and documenting every detail of the visit. During my encounter with this patient and many other patients, I have found that a percentage of my attention is often focused on actively taking notes and going through their EMR. The patient does not have my undivided attention, and this is not only a disservice to them, but also leads to overthinking. The need to fill out the various checklists in the EMR can distract us from the purpose of the visit and lead us astray.
In addition, physicians also fall into the trap of overthinking due to fear of litigation. I remember quite distinctly being told that in the ED I needed to thoroughly document that I had thought of every potentially fatal diagnosis and ruled them out. Otherwise, if something were to go wrong, I would be asked in court why I missed something. Of course it is important to rule out potential fatal diagnoses for the purposes of best treating the patient but the idea that this should be done due to fears of litigation is where the problem lies. While it’s important for medical students and residents to be aware of the realities of avoiding litigation, being hyper-focused on this in the day to day can lead to being distracted from the patient themselves. This fear of legal ramifications for wrongdoings has been demonstrated to lead to the practice of “defensive medicine” which results in the ordering of unnecessary labs and test.
As a student, navigating the world of medicine can be daunting. We are trying to find our footing in this complex system. But taking a step back to remember that ultimately a patient encounter should be about the patient rather than the EMR or about a future in which we may be solely responsible for this patient’s care can help to stymie a racing mind. Sometimes medicine is simpler than we think. Sometimes, it’s just about socks.
All names and identifying information have been modified to protect patient privacy.
Ruchi Desai is a current fourth-year medical student at UC Irvine School of Medicine. She is planning to pursue a residency in internal medicine. During her free time she loves to read, listen to podcasts, and learn as much as she can about the world. She is a 2021–2022 Doximity Op-Med Fellow.
Image by Denis Novikov / Getty
