Casey Butler Harwood

Triage By Design: Emergency Physician Bianca Jacobs, MD

Bianca Jacobs is an ER doctor who lives in the Eugene, Oregon, area and practices at not one but three local PeaceHealth hospitals: Sacred Heart Medical Center at Riverbend, Sacred Heart Medical Center University District, and Cottage Grove Community Medical Center. In addition to being a doctor, of course, Jacobs is a human. A human who has been drawn to science and problem solving for as long as she can remember. She uses a version of the design thinking methodology on the daily to give her patients the best possible emergency room experiences. Read on to hear about how empathy and creativity factor into her high-stakes job, as well as how she navigates failure.

What do you enjoy about being a doctor?

I like helping people, and I like the problem-solving aspect of it. I like the challenge of being presented with a list of symptoms and having to put all of the puzzle pieces together to try to figure out the answer to a problem. 

Is there much room for a creative approach to your work?

Yes and no. I think that emergency doctors are considered like the MacGyvers of medicine. We work in different environments with varying levels of resources, and we have to be prepared to see and take care of anybody that walks through the door at any moment. There are certain times that you have to get creative. For example, during the height of the COVID pandemic, when there were ventilator shortages, people were coming up with ways to T-off ventilator hoses so that one ventilator could ventilate two patients.

That’s cool. Sad, but cool.

Yes, sad, but innovative. And there are other things that I think I maybe take for granted that are very creative [and] useful in my day-to-day work. As far as being creative from a medical standpoint, there’s different ways to do everything and everyone has their own style, but I would say that being creative in gathering symptoms, making diagnoses, and doing the work-up — there is maybe less creativity in that, but [there is] creativity in [the] problem solving. And I think that when you’re working in a more resource-limited environment, you do have to be more creative. Like, I want to evaluate this problem, but I only have these tests available, so what can I do to do the best work-up I can with the resources I have to make the best decision that I can? And patients also have limitations, like taking care of children or pregnant patients or people with allergies to medications — you do have to get creative in what you’re doing to evaluate them or treat them because sometimes, the straightforward answer is not always the best for the patient.

So, this was actually one of my questions. How do you tailor your approach to meet different patients’ needs?

I think the first thing that I do to tailor my approach is to try to figure out what the patient’s needs actually are. People come to the ER for all sorts of different reasons and trying to get to that underlying reason takes, sometimes, a lot of reassessments. Sometimes skill, sometimes luck. And sometimes, I mean, patients are also just straightforward. But I think getting to the root of why they are there is the first step. Some people are there for something very straightforward: They are concerned about x and they want to make sure that it’s not x. Sometimes, it’s a fear or a concern that it could be something really bad. Other times, it’s just pain [and they are] there because they’re really uncomfortable… Not only do they want to know what’s going on, but also they just want to feel better. Getting to the root of why they are there and how I can help them helps me to tailor their experience and, hopefully, make their experience a good one — or as good as it can be.

What kind of experience do you hope that your patients have when they’re in the ER?

My goal is to meet their needs, make sure that their expectations are as appropriate as they can be [given] our limitations, and relieve any pain and suffering that may be afflicting them. And you know, I want people to feel like we cared about them. I try to do my best to treat my patients as if they were family members.

That’s pretty awesome. How does empathy play a role in what you do?

I wouldn’t be able to do my job without empathy, but I think that having all of the empathy would make it difficult to do my job. Because we see so much sadness. I try to be very empathic toward patients and their situations, but at the same time, I have to have some dissociation, because if I cried every time I told someone they had a cancer diagnosis, I wouldn’t be able to… well, let’s see. Back that up — I almost cry every time I tell someone they have a cancer diagnosis. But it’s a fine line of being empathetic and also having some separation, and I think that’s a skill that has to be developed over time.

That seems like such a hard thing to balance.

It’s very difficult and it’s ongoing work for me and, I think, for everybody that’s in my job. Sometimes, you have to go from one patient to another and so, you have to be able to role-switch quickly and really compartmentalize some of those emotions. I think learning how to safely process them, in a healthy way, is an important skill that I think most people work on continuously.

It seems like you would constantly be learning as an ER doctor. Is that the case?

Yes, that is definitely the case, which I think is part of the cool thing about my job — that I’m always learning.

How do you handle failure?

You know, like I said earlier, we’re not perfect and there are times that I’ve made a mistake or missed something. As a general rule, usually, there are quality improvement or practice improvement meetings that happen, where they go through cases and talk about what could have been better. One of the ways that I try to address something if I do it poorly or miss something is, first of all, to go back and refresh my knowledge — if it was a knowledge issue. Usually, in those cases, most people do not make the same mistake twice. Because it’s something that you just remember; it’s not something that’s easily forgotten. For a procedure, there are certain procedures that we do that are tricky. So, practicing the procedure to make it go more smoothly. Or going back and reassessing the situation and saying, “What could we have done better?” And even in things that don’t feel like a failure, especially for critical patients, having a debrief at the end, I think, is useful for the staff. [It’s] a way to continuously improve. 

Emotionally, dealing with failure is something that I’m still working on. I think most physicians, if they fail, it’s like a pit in your stomach that follows you because no one goes to work and says, “I want to make a mistake,” or “I want to cause harm.” That’s not who we are or what we do. When we’re trying to help people, and we’re not perfect, it weighs on us. I try to go back and be somewhat systematic about it [to determine] how I can prevent this in the future; why did this happen? It’s tough.

I keep thinking about what you said about how no one wants to go to work and make a mistake. It really resonates because I feel like that’s true of every occupation, I think, but in your case, the stakes are particularly high. That seems obvious to say, but, you know. I think it’s cool to hear about the debriefs and how you can go back and think through the whole process, and ask, “What could we have done differently?” We also do that — for different reasons and with different consequences, but it’s interesting to see those parallels between what you do and what we do. It can be hard to accept the imperfection sometimes, but it's important to keep growing.

Right, I think that having a fixed mindset will set you up for failure.

So, how does it feel when you find a creative solution to a problem?

It feels good. That’s what keeps me going — really helping people and working through the problem with them. Like you guys, I’m guessing, involve your clients in some of the decision-making processes — we do the same. [We work] with patients to say, “Hey, this is what I’m thinking. These are the tests that I have available, and this is what I would recommend.” And sometimes, they say no. Then maybe we try [an] alternative. I think having both parties satisfied with that decision feels like a win. Also, just having little tricks up my sleeve to do… simple things like getting rings off of fingers — there are certain tricks that are pretty creative.

That makes a lot of sense. I feel like I need to ask how you get rings off of fingers.

Probably the best would be — I’m sure that there are videos on YouTube — there’s a way to wrap various different types of string… You put it under the ring and then you kind of wrap it around the finger and it slowly pulls the ring off. The mostly commonly used is umbilical tape, but in places where you don’t have a lot of umbilical tape laying around (that’s what you use to tie off an umbilical cord when you have to deliver a baby), you can pull the little elastic string off of certain oxygen masks and use that instead.

Yeah, that’s pretty MacGyver-y.

There are all sorts of MacGyver things — random, creative things. [When you get to use some of those, it feels good because you feel like you’re kind of expanding your mind and accomplishing something.]