Recent thoughts on Pain meds and Patient satisfaction

[LaBusqueda]

Recent EM periodical had a section by Dr. A. Katz and I think the this section in the May edition is worth a little discussion.
This piece informs us that pain medication is, in fact, not the driver of patient satisfaction scores.
I would agree. And I think we all know this, as far as an overall driver of these scores goes.
But that is NOT what is important about these scores. It is not what individuals who are bonused and/or paid on these scores care about.

I think from what I know from previous practice (currently do not get any pay or bonus from them) and talking with guys/gals is the thought on liberal pain med prescribing is a fear of that ONE BAD SCORE. Why? Because, like a credit report, one horrible score can ruin your percentile ranking m for a long time...until you can flood it out. And this can mean less $$$ and sometimes more scrutiny from higher ups (a hospital employee gig I moonlight with has their employee docs getting letters every time they get a 3 or lower on PG).

There is also a HUGE experiential conflict with this. I used to work for a group that enabled us to view all of our PGs and I would regularly have written comments from patients to the effect of my pain control (I do not liberally Rx opioids) This ran from only giving a Rx and no shot/IV/something stronger, to complaints about the # of opioids Rx, and a couple of my favorites were actually commentary that chastised me for trying to talk to them about "their" pain and how pompous it is for a doctor to tell the patient what should work for their pain. These were exclusively from non Fx, non CA, benign exam pts BTW. A lot were dental and MS strain.

My problem was not getting high scores. My scores were awesomeness vast majority of the time. 4/5-5/5.bBut that does not matter. All it takes is one, unless you have a ridiculous n, and all your praise and thoughtful doctoring gets reduced to you are on the 80th percentile on PG....No Soup For You this month!
However...even getting a good amount of 4/5 (which is pretty damn good), can screw you out of the top percentile as we know.

If you where graded as simply as your overall trend this would not be a problem. But as it is, guys/gals are trying to save against that one bad score!
Does this work? Who knows, maybe not.

Why does this need to be a contest against our peers instead of each individual's long term trend?

PG doesn't care about outliers, does not allow any longer the "do not send survey" option, and when you score folks on percentiles it is not going to be any real use to those that actually give the care, take the time, and take the risk every day.
But, that isn't what it is about anyway.

I see articles like this as either academia fantasy BS and/or CMG propaganda/brainwashing.

Also...with many EMRs we can see a LOT more than previous and I know it will vary with location/EMR , but I can see exactly what was Rx on any previous visit (when reviewing previous visits for an acute visit). And even with the partners that talk a good game about not Rx'ing opioids, etc...
I see a LOT, LOT, LOT, of opioids/z packs/abx and with much more frequency and more #s/Rx than I would have thought! :

Thumb-typed from iPhone.

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[USCDiver]

You wrote that whole thing on your phone?

 

[LaBusqueda]

You wrote that whole thing on your phone?

Yes. Can't remember last time I accessed SDN from any other platform other than Tapatalk.

 

[GeneralVeers]

As I stated in another thread: it's only going to get worse as our individual scores will be put out by the government on a website for the public to see. Hospitals and administrators only care about > 90th percentile for everything, and that includes doctors. Anything less than 90th percentile is a fail. It's really going to do some bizarre and interesting things for physicians as we'll essentially be split into two groups: doctors who score > 90th percentile, and those who score below. The "top" hospitals are going to fight over the former group. Not because they are excellent physicians, but because they scored highly on a subjective, and largely irrelevant survey.

 

[Birdstrike]

Recent EM periodical had a section by Dr. A. Katz and I think the this section in the May edition is worth a little discussion.
This piece informs us that pain medication is, in fact, not the driver of patient satisfaction scores.
I would agree. And I think we all know this, as far as an overall driver of these scores goes.
But that is NOT what is important about these scores. It is not what individuals who are bonused and/or paid on these scores care about.

I think from what I know from previous practice (currently do not get any pay or bonus from them) and talking with guys/gals is the thought on liberal pain med prescribing is a fear of that ONE BAD SCORE. Why? Because, like a credit report, one horrible score can ruin your percentile ranking m for a long time...until you can flood it out. And this can mean less $$$ and sometimes more scrutiny from higher ups (a hospital employee gig I moonlight with has their employee docs getting letters every time they get a 3 or lower on PG).

There is also a HUGE experiential conflict with this. I used to work for a group that enabled us to view all of our PGs and I would regularly have written comments from patients to the effect of my pain control (I do not liberally Rx opioids) This ran from only giving a Rx and no shot/IV/something stronger, to complaints about the # of opioids Rx, and a couple of my favorites were actually commentary that chastised me for trying to talk to them about "their" pain and how pompous it is for a doctor to tell the patient what should work for their pain. These were exclusively from non Fx, non CA, benign exam pts BTW. A lot were dental and MS strain.

My problem was not getting high scores. My scores were awesomeness vast majority of the time. 4/5-5/5.bBut that does not matter. All it takes is one, unless you have a ridiculous n, and all your praise and thoughtful doctoring gets reduced to you are on the 80th percentile on PG....No Soup For You this month!
However...even getting a good amount of 4/5 (which is pretty damn good), can screw you out of the top percentile as we know.

If you where graded as simply as your overall trend this would not be a problem. But as it is, guys/gals are trying to save against that one bad score!
Does this work? Who knows, maybe not.

Why does this need to be a contest against our peers instead of each individual's long term trend?

PG doesn't care about outliers, does not allow any longer the "do not send survey" option, and when you score folks on percentiles it is not going to be any real use to those that actually give the care, take the time, and take the risk every day.
But, that isn't what it is about anyway.

I see articles like this as either academia fantasy BS and/or CMG propaganda/brainwashing.

Also...with many EMRs we can see a LOT more than previous and I know it will vary with location/EMR , but I can see exactly what was Rx on any previous visit (when reviewing previous visits for an acute visit). And even with the partners that talk a good game about not Rx'ing opioids, etc...
I see a LOT, LOT, LOT, of opioids/z packs/abx and with much more frequency and more #s/Rx than I would have thought! :

Thumb-typed from iPhone.

It's a disaster. Just as we're starting to get the "opiates aren't addictive, opiates for all!" disaster reversed, with some stabilization and even reversal of prescription drug overdose deaths, the federal government is adding fuel to the fire, tying doctor pay to "performance" which they define, in part, as how you emotionally "satisfy" your patients. They ignore the fact that a huge portion of health ills are due to people seeking instant gratification, other wise know as "satisfaction." Therefore the doctors that ignore and encourage enabling of addiction, over-eating, over-testing, over-treating, over-admitting will be rewarded and paid more to do so. Whereas those that promote patients to do the right thing, the healthy thing and make the difficult but correct choices (weight loss, exercise, sobriety, moderation in eating), will be punished, unless this insanity is reversed. Our society, patients and their health are worse off for this.

It's disastrous, it's wrong and it's entirely about multi-million dollar hospitals and insurance companies, who line the pockets of the politicians who make these rules, attracting more paying "customers" to enrich themselves.

We must find a way to ensure a good patient experience without incentivizing the enablement of the urge for instant gratification, which often is tied into impulses that are very self destructive and unhealthy. Can anyone deny that there is a huge portion of the American patient population with very self destructive habits and demands, and as doctors we should not be enabling those, but work to temper them and that that is not always as "satisfying" to some as enabling poor choices and unhealthy demands?

 

[LaBusqueda]

Agree with both of you. This is where I have a huge problem with this summary article, and the studies quoted.
Much like bench science research, this is stuff real docs in the trench cannot take to the bedside.

 

[Birdstrike]

Agree with both of you. This is where I have a huge problem with this summary article, and the studies quoted.
Much like bench science research, this is stuff real docs in the trench cannot take to the bedside.

This is 100% about money. Period. It's about making doctors controllable pawns to fuel repeat and return customers, while throwing health and proper Medicine to the side.

 

[LaBusqueda]

This is 100% about money. Period. It's about making doctors controllable pawns to fuel repeat and return customers, while throwing health and proper Medicine to the side.

Yup!

 

[Groove]

Agree with all that's been said. Of course making a stand with narc dispensing and forming a personal pain policy is going to influence PG scores. It just doesn't work unless every provider is on board and the ED has some sort of formal policy in place.

What's funny is that hospital administration wants repeat customers, but not repeat admissions. We have a little sticker that registration puts on the door of each pt in the ED that's been admitted in the last 30 days. As if my knowledge of this is supposed to influence how I treat them? It's insulting. Pressure to dispo them home from the ED. The hospitalists feel it too as they get whipped over LOS and other metrics. Hell, I had them discharge home a DKA other day with a bicarb of 16 who showed back up within 24 hours with a bicarb of 6. Non compliant, of course, but still... I'm like... "You guys discharged a DKA. I'm all about keeping the LOS down but c'mon guys..."

 

[LaBusqueda]

Agree with all that's been said. Of course making a stand with narc dispensing and forming a personal pain policy is going to influence PG scores. It just doesn't work unless every provider is on board and the ED has some sort of formal policy in place. I don't even care anymore and have written my share of

What's funny is that hospital administration wants repeat customers, but not repeat admissions. We have a little sticker that registration puts on the door of each pt in the ED that's been admitted in the last 30 days. As if my knowledge of this is supposed to influence how I treat them? It's insulting. Pressure to dispo them home from the ED. The hospitalists feel it too as they get whipped over LOS and other metrics. Hell, I had them discharge home a DKA other day with a bicarb of 16 who showed back up within 24 hours with a bicarb of 6. Non compliant, of course, but still... I'm like... "You guys discharged a DKA. I'm all about keeping the LOS down but c'mon guys..."

Yup!
I wonder when CMS will realize that slapping around hospitals for decr LOS and punishing for readmissions is not viable.
Of course, Pt compliance is a HUGE factor here. But I am repeatedly amazed at some of the turn around a of some pretty sick peeps.
Sure, a lot go to SNF...but guess what???? SNF just sends them to ER!

That sticker thing is inappropriate and dangerous!

May as well just put out who is self pay with a sticker too...same thing!

 

[WilcoWorld]

It's bad medicine.
It's raising costs.
It's raising mortality.
It's wrong.

Don't do it.

I am the 90%

 

[TooMuchResearch]

Agree with all that's been said. Of course making a stand with narc dispensing and forming a personal pain policy is going to influence PG scores. It just doesn't work unless every provider is on board and the ED has some sort of formal policy in place.

What's funny is that hospital administration wants repeat customers, but not repeat admissions. We have a little sticker that registration puts on the door of each pt in the ED that's been admitted in the last 30 days. As if my knowledge of this is supposed to influence how I treat them? It's insulting. Pressure to dispo them home from the ED. The hospitalists feel it too as they get whipped over LOS and other metrics. Hell, I had them discharge home a DKA other day with a bicarb of 16 who showed back up within 24 hours with a bicarb of 6. Non compliant, of course, but still... I'm like... "You guys discharged a DKA. I'm all about keeping the LOS down but c'mon guys..."

Just accidentally drop the sticker on the ground.

Not related to bounce backs, but our ED charge nurses always tell us when we're "out" of certain types of beds. This does not change my management or disposition.

 

[The White Coat Investor]

Just accidentally drop the sticker on the ground.

Not related to bounce backs, but our ED charge nurses always tell us when we're "out" of certain types of beds. This does not change my management or disposition.

For us it's the house supervisor. Well, when you come down every day for months and tell me there are no beds, but all of my patients seem to get put into a bed, are you surprised when I start ignoring you?

I've started reporting these house sups to the CEO. "Did you know that Nurse Nancy keeps coming down to the ED to discourage us from admitting well-insured patients?"

I assure you the CEO does not want me to admit fewer patients to his hospital, but somehow that message is getting lost somewhere down the line.

Use the fact that medicine is a business to your (and your patients') advantage when you can, and do what you can to keep your patients from being hurt by it when you need to.

 

[LaBusqueda]

For us it's the house supervisor. Well, when you come down every day for months and tell me there are no beds, but all of my patients seem to get put into a bed, are you surprised when I start ignoring you?

I've started reporting these house sups to the CEO. "Did you know that Nurse Nancy keeps coming down to the ED to discourage us from admitting well-insured patients?"

I assure you the CEO does not want me to admit fewer patients to his hospital, but somehow that message is getting lost somewhere down the line.

Use the fact that medicine is a business to your (and your patients') advantage when you can, and do what you can to keep your patients from being hurt by it when you need to.

I have found this to be true also

But what if the curse word "REadmissions"

 

[Hair Police]

Not related to bounce backs, but our ED charge nurses always tell us when we're "out" of certain types of beds. This does not change my management or disposition.

It shouldn't. It will change some things - like you will have to transfer the critically ill patient if you don't have ICU beds at your hospital - but your job is to determine what the patient needs.

One of my personal favorites is when the ICU tells you "This is the last ICU bed!" in that reprimanding tone of voice, as if that's somebow going to stop dying patients coming through the door.

 

[TooMuchResearch]

It shouldn't. It will change some things - like you will have to transfer the critically ill patient if you don't have ICU beds at your hospital - but your job is to determine what the patient needs.

One of my personal favorites is when the ICU tells you "This is the last ICU bed!" in that reprimanding tone of voice, as if that's somebow going to stop dying patients coming through the door.

Several of our residents have taken care of SICU patients in the PACU when we were actually out of places to put ICU beds.

We also literally, not figuratively, ran out of ventilators at least once this winter.

It didn't prevent us from taking care of the patients.