25 March 2008

Fluorescent Therapy: Corollary

One corollary to the Fluorescent Therapy outlined in my previous post is what is commonly called "Boredom Therapy." This is most commonly applied to patients with complaints which are factitious or derived from personality disorders, or those with complaints most likely related to drug-seeking behavior, or other presentations in which there is clearly little to no medical urgency coupled with a patient interaction which is likely to be difficult, complex, and confrontational.

Theses cases differ from fluorescent therapy in that there is no obligatory time delay built in by reasonable and justifiable medical tests. Patients view such a time interval and its attendant fluorescent exposure as valuable and itself therapeutic.

Boredom therapy is that in which the physician provider simply ignores the patient and leaves them neglected in the room for an extended time, while nothing happens. Although this may seem callous or even abusive, it is usually not, nor is it even deliberate in most cases. For example in a typical busy ER, the doctor is likely juggling coordinating the care of several critically ill patients, and simply does not have the spare time to sit down and explain to the patient with Chronic Recurrent Abdominal Pain why, in this the seventh ER visit in two months, we will not be able to provide a definitive diagnosis for their pain. Or perhaps the doctor is simply scared of what is certain to be a challenging confrontation and "ducks" the problem patient, paying attention instead to all his other patients until the nurses, who cannot avoid the increasingly annoyed glares from the patient, who is now standing in the doorway of their room, force the doctor out from his hiding spot to go discharge the patient.

In some rare cases, with patients who clearly are abusing the ER, deliberate boredom therapy is applied, with the intent of making the patient understand that the ER is not a fun or productive place to be, and to negatively reinforce the behavior that brought them in.

In all cases, "Boredom therapy" facilitates the discharge of the patient, by wasting enough of their time that they simply don't want to be in the ER any more and want to go home. The value is that these patients would otherwise be resistant to discharge, either because they had unrealistic expectations of what could or would be accomplished in the ER, or because they somehow enjoy coming in. The cost, which must be balanced, is that the patient, who really didn't need to come into the ER in the first place, ties up a bed for several hours, and makes your nurses hate you. If the waiting room is full, it's generally better to forgo the boredom therapy and just discharge them directly, even though that usually means an ugly fight.

[Please note: if you ever came in to the ER as a patient and had to wait a long time, it was most likely because ERs are busy and inefficient. Boredom therapy as described above is reserved for patients who are clearly abusing the ER. This is in all likelihood not you. Please don't rant in the comments about how long it took when you went in for "x" -- I've heard it a million times, and really, we're sorry about it, but it's off-topic. On the other hand, if you are a malingerer or psychologically disturbed person who has been abusing the ER, then by all means, go right ahead and flame on! (dons asbestos underpants)]


  1. I'm actually thinking of going to the ER tonight. You see, I have this one spot on the toenail of my big toe on my right foot where the polish just won't stay on, no matter how many coats I use. I've even switched colors. Same thing with the lighter color.

    I'm glad you mentioned the boredom thing. I'll be sure to take a nice thick book with me.

    I would call my PCP, but he's probably about to leave for the day and I doubt he would stay to see me. Maybe I'll see you tonight, Shadowfax.

    Oh, I think I'll take an ambulance. I wanted to buy gas today, but I didn't have any cash, and I don't get paid until next Thursday.

  2. When you say "one corollary" you mean the exact same thing, right?

  3. Jim2,

    They're similar but the difference is intent, and process. in FT, there is a necessary and useful step (testing) which induces the delay. In BT, the delay is purely wasted time for the patient.

    The outcomes differ, too. In FT, the patient smiles and tells me they feel better and they are happy (often). In BT, the patient is pissed off and just no longer wants to be there anymore.

    Subtle distinction for semi-imaginary treatments...

  4. Sigh. That is negative punishment, not negative reinforcement.

    Punishment decreases the likelihood of a behaviour; reinforcement increases it.

    Positive is doing something; negative is not doing something.

    The classic example of negative reinforcement is nagging. If you put away your laundry I'll stop nagging you. The blessed relief of silence is such that it makes you think that next time you should put away your laundry right away so as not to have to listen to me nagging.

    In the case of the malingerer in the ER, you want to decrease their malingering (reducing a behaviour = punishment), so you withhold (not doing something = negative) stimulation.

    Likewise, spanking is positive punishment.

    Anyway. This is one of my little nits, and I pick it whenever I have the occasion.

  5. I have a suggestion. Instead of tying up the bed with the patient who doesn't need to be there try telling the patient "I'm sorry I can't help you" and then discharging them. Its very effective. Quit being so fucking passive aggressive. You're probably as irritating as your patients are to the nurses who have to work with you.

    Just discharge them already. Say "no" to the drug seekers. Its a one syllable word. Say "I don't use narcotics to treat this."

    Have some backbone. Show some spine. That's why you get paid the big bucks.

  6. Wow.
    This actually upsets me. I am a patient who has abdominal pain that noone has been able to pinpoint until recently. Its such a shame you actually treat people like that. What if someone treated your family members like that??? I realize you do deal with people who are seeking drugs, but what about the people who are actually seeking relief and answers. I am glad I finally have a diagnosis, I almost want to go back to the smug doctors and nurses who acted like I was trash and show them that not everyone who is a mystery diagnosis is a drug seeker.

  7. Anons 7:39 and 9:14 do a great job of illustrating the needle I have to thread:

    "Just throw 'em out!"
    "How dare you treat patients like that!"


    Just for reference:
    1. I am undoubtedly the most blunt ER doctor in my group, and by far the most likely to call bullshit on a patient I think needs to hear it.
    2. As I said pretty clearly, in most cases the boredom is not deliberate, but due to prioritizing the important stuff over the non-urgent time-consuming stuff. Sometimes it's passive-aggressive, but usually not.
    3. The hard thing about chronic abdominal pain is the expectations management. I don't know your story, but when someone has come in half a dozen times in a month, gotten three CT scans, bloodwork, scopes, etc etc, there's no way I'm going to figure it out on the seventh visit if nothing else has changed. People with this are typically frustrated and demanding, and it takes a long time to talk them down. And that necessarily will fall low in my sequencing matrix, so they have to wait a while to hear the reason why we're not going to re-invent the wheel (and the same can be said for chronic anxiety, headaches, etc etc etc).

  8. So instead of being passive aggressive some of the time how about none of the time. I'm not an asshole most of the time is a pretty lame excuse for being an asshole some of the time.

    To the other annonymous:

    If you have a complicated abdominal pain problem that you have been seen for repeatedly in the ER without diagnosis why would you return to ER for the same thing? Go to a gastroenterologist. See a specialist.

    What was your diagnosis anyway? My curiousity is piqued.

  9. Me too. I also use BT for young mothers who bring Infant in with routine spit up/choking episodes. "Breathed funny." I ask the mom to point out an episode in real time when it recurs. She gets bored waiting and eventually asks to be discharged. The process is accelerated by having her other rambunctious toddler child in the room.

  10. Its Crohns. And I have seen a specialist. The reason I went to the ER a few times, was because my pain was horrible and my doctor told me to go to the ER. Before they pinpointed what I had, I had bad episodes where I was severely dehydrated and passed blood.
    As frustrating as it was to the ER docs, it was even more for me.
    But I certainly did not go to the ER 7 times in one month.
    I apologize if I attacked you, it just sounded like you were treating all abdominal pain people like that.

  11. I wonder, Shadowfax, if you could comment on when it is appropriate for someone with undiagnosed abdominal pain to return to their doctor or to the ER. At some point I suppose you would agree they should seek medical care again. What is that point?

    Your comment may help people make a better decision.

  12. Teresa,

    Bearing in mind that I am not giving anybody medical advice, in general pain which is new, pain which is different (in location, quality, timing), or pain which has new associated symptoms (fever, etc) are most appropriate for ER evaluation.

    Otherwise, coordination of care with the PCP is always appropriate.

  13. Actually, being dehydrated and passing blood is worthy of a look in the ER. And anonymous 7:39--what do you do if the patient in question WANTS to be in the ER. For the hot meal/cot whatever? Is resistant to leaving? And will complain to the press/hospital/whatever that the BIG DOCTOR was MEAN to them? Sheesh. Better to have them leave of their own volition.

  14. Bloody stools and dehydration are objective signs warranting an er visit.

    What doesn't warrant an er visit is no objective symptoms. Normal vital signs. Just the same pain without any other symptoms that the patient has had for the past month, year, 2 years etc.


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