In the 200 years since José Gaspar held women for ransom on Captiva Island in Florida, things have changed a bit. Pirates don’t stalk the waters any more, but osprey, dolphin, and manatee still make an easy living among the mangroves and bright-green waters. Condos and houses line the beaches and bays, and 100-foot yachts find safe harbor.

My family and I traveled there for spring break this year. We enjoyed the water, the warm temperatures, and the abundant wildlife. I also enjoyed having time to do nothing but sit on the porch and read a novel. I read “The Lincoln Lawyer.”

The main character in this story is a criminal defense attorney, Mickey Haller. I grew to like Mickey as the story moved along – as much as you can like a bottom feeder. He says that the most dangerous client a defense attorney can have is an innocent man. This got me thinking about the parallels between criminal defense and emergency medicine.

Both professions deal with people and matters that are actively avoided by others in their general profession. Often these people are down on their luck, and the doctor or the lawyer is their last stop – death or jail. I can empathize with defense attorneys because, like emergency physicians, their acts and their omissions have life-changing consequences.

Now, a large portion of the folks that come through our criminal justice system are, in fact, guilty. I don’t believe that defense attorneys lose much sleep when a three-time felon gets a

20-year sentence for an armed robbery witnessed by five people. What I imagine keeps them up at night is the person who they believe to be truly innocent but who is convicted of a crime. For them, this is the dangerous client.

For us, I think the most dangerous patient is the one who appears well but who turns out to have something bad. This is your average malpractice case. Maybe the person presented too early, or a significant historical point was missed, or too much emphasis was placed on a particular test. Then the patient returns with something like meningitis, sepsis, or appendicitis.

And then you get to have that fateful conversation that starts with the words, “Remember that patient you sent home?”

We see these well-appearing patients all day long. They look well because the great majority of them are, in fact, well. We see benign viral illnesses and minor injuries galore. We give a strong dose of reassurance and a smile and send them on their way.

This ability to separate the wheat from the chaff is an essential skill for emergency physicians, and it improves with time.

Residents will occasionally ask me why I did a thorough work-up on one patient and discharged what seemed to be a similar patient with a lesser evaluation. Sometimes the explanation is clear and other times I can’t completely put my finger on the reason.

I wonder how many well patients one needs to see in training to become adept at discerning who is sick and who is not. If you boil it down, this is essentially our purpose in life. I’d like to think that it is 3 years, but it’s probably longer than that. A lot of learning goes on during those first few years out of residency.

The art of it is being able to tell a mother that her teenager does not have meningitis without spending $3,000 in the process. After all, anyone can order a bunch of tests on every patient who comes in. There is no skill in that. The art and skill is seen in reaching a conclusion with the minimum of testing and poking.

There was a time when a seasoned emergency physician could lay his hand on the abdomen of a 25-year-old man at 4:00 in the afternoon and then call a seasoned surgeon to tell him that the patient will be hydrated and ready for an appendectomy by the time he is done with his office hours.

This is the quiet competence of emergency physicians that often goes unnoticed by patients, nurses, and other doctors. It is the ability to tell a patient with confidence that she has renal colic and that she does not need another CT scan to prove it. It is the expertise to tell a young man that his cough is due to a virus and that a chest radiograph and a blood count will alter your treatment plan little.

This underappreciated talent will probably always be thus. What you don’t do will rarely get noticed. This is not on the Press Ganey radar, nor will it ever be. Just keeping going with your quiet competence, leave them with a smile and good discharge instructions, and be happy that you did your job well.

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center. Your feedback is welcome at David.Baehren@utoledo.edu.