Check your bias (and your HR) at the door

[cmocarroll]

Recently, I had an evaluation that became eventful before I was even able to bring the patient back into the room. I walked up front to greet the patient and found that she was exchanging words (a nice way to put it) with our front desk staff regarding wearing a mask. The whole situation was very hostile and the patient ended up leaving the clinic to wait in her car instead of sitting in the lobby with a mask on. At this point, we all thought that the patient would cancel and find another place to go. Instead, she agreed to wear a mask in the common areas and was told that the therapist (me) would allow her to remove the mask once in an exam room. The patient returned to the lobby and followed me back to a room, but only before she called out “mask nazis” at the front desk personnel.

Looking back, I really wish I would’ve checked my heart rate at that moment. Nothing gets me more worked up than people being irrationally disrespectful to others, especially when the variable factor is out of their control. I was fully prepared for this evaluation to be hostile and chaotic. I was thinking that the patient would likely rip off the mask as soon as we got in the room, bring up the mask requirement throughout the session and gripe about the front desk personnel – none of which I would have tolerated. What I did not expect was for the complete opposite to occur. Upon entering the exam room, my patient began shaking her hands, eyes closed, breathing deeply, repeating “just breathe, okay relax. I need to calm down”. I set up the room while this was happening and even suggested that the pt remove her mask if she was uncomfortable. She seemed to ignore this and kept the mask on.

As I started the subjective exam, this patient launched into her story. I felt that this was an appropriate time just to listen and let her speak. This pt had an elaborate history of ankle injuries and pain that she described with exuberant energy and intensity. She had gotten minimal explanations for why her ankle hurt and had an endless list of questions. As I worked through these questions, the patient became more excited. At one point she loudly exclaimed, “EXACTLY!” as I described neurosensitivity and “smudging” of pain signals from the brain to the periphery. There are numerous learning moments from this encounter and one aspect I’ve reflected on is that because of my reaction or lack thereof during the initial evaluation, I think I created really good rapport with this patient and in our subsequent visit she was extremely pleasant, excited for PT and seemed to truly trust me. I became quite empathetic towards this patient. Clearly she had never received an appropriate explanation regarding the anatomy of her ankle, why she may have increased pain, or what the state of her injury was.

Looking back at this encounter, I realized that I was quick to judge this patient from the situation in the lobby. Never once did she bring up wearing the mask and even apologized to everyone at the end of the visit. While I’m glad that I reacted calmly and did not exacerbate the situation, internally my “fight or flight” instincts were raging. I could feel my heartbeat pounding in my chest as the subjective exam began just because I was so ready for the situation to escalate. Sure, this is good in some capacity, but I think I could have lowered my expectations of the situation and given the patient the benefit of the doubt. In reality, I think this was a prime example of someone who was fed up with the healthcare system failing her, was under increased stress from working on an insufficient ankle for 12 hr shifts per day, and the mask issue just sent her over the edge. We all have days like this and it’s important not to judge someone based off one incident – which is what I carried with me into the next visits.

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