“and then I checked my blood pressure and…”

[WhatJobDoIPick]

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I'd rather you didn't, but I won't make a fuss if you do.

So you're essentially saying an NP can start these meds better than a physician.

 

[JacobMcCandles]

So you're essentially saying an NP can start these meds better than a physician.

How did you get to that? He’s saying they’re better off being started in a more appropriate clinical setting. You’re the one bringing NPs into it.

 

[Brigade4Radiant]

The doctor would get sued and lose if you discharge a patient and they commit suicide regardless. You do know anxiety is a risk factor for suicide right? Also the plan for discharge is coem to the ED if it gets worse. I mean what is the plan for a family doctor who starts it what was their plan to monitor?

You explain that suicidal tendicies can come from SSRI and for Georgia you have to prove

They can come to the ED anytime.

 

[VA Hopeful Dr]

So you're essentially saying an NP can start these meds better than a physician.

No, I'm saying in an ideal world I would rather by the one to start meds like that for a myriad of reasons none of which have anything to do with you.

Same thing with most chronic meds if I'm being honest.

 

[TooMuchResearch]

Maybe just the pertinent parts but definitely highlighting all the non-emergent sections. I've also sent it to referring doctors ...

Of course this usually gets the Press Ganey comment of "the doctor didn't seem to care about me"

A consortium of local emergency departments did clinic education on the topic for a major local health system. It worked really well for a few years, but it might be time to reeducate.

 

[TooMuchResearch]

CCBs are preferred unless you're going to check a creatinine at the same time (note: I'm not saying you should be doing that).

I put people on amlodipine if their BP is arbitrarily way too high, especially if I can see previous high BPs that haven't been addressed. I'll write for three months just in case they can't get into clinic or choose to wait awhile. I always say they will probably need more medicine than I can start for them.

 

[TooMuchResearch]

You can make these cases a 99285 so easily too:

-review prior records
-order labs
-independent interpretation of EKG
-high risk differential
-prescribe 5 mg lisinopril

Easy peasy

Skip the labs and ecg unless triage did them on standing orders and just bill lower.

 

[TooMuchResearch]

GymBro here. I say this to patients all the time, too.

Tell them that on max effort attempts, you can blow tiny capillaries all over your body and live.

 

[TooMuchResearch]

I realize you can get sued for anything at anytime. But dabbling in primary care as an ER physician is just playing Russian roulette. Starting an SSRI is easy but not part of our training. How are you going to defend yourself when a patient commits suicide 3 days after initiation of an SSRI and the prosecution asks you if you were aware that certain SSRIs can increase suicidality in the first few weeks and what was your plan to monitor this patient? Oh and here are 99% of ER physicians as expert witnesses saying they would never start an SSRI in the ER setting.

Things can get away from you quickly in the courtroom if you don’t stay in your lane in the ER.

You can fill out an online survey, talk (or possibly not even) to an out of state NP with no specific training for 3 minutes, and get your ssri delivered in three days. I honestly probably can do it better. Not that it should be my job.

 

[WhatJobDoIPick]

Skip the labs and ecg unless triage did them on standing orders and just bill lower.

So bill lower and get a bad PG. Got it

 

[TooMuchResearch]

So bill lower and get a bad PG. Got it

I delete emails related to customer satisfaction. We have no shortage of people to go in the room to replace the discharged patient.

 

[JacobMcCandles]

So bill lower and get a bad PG. Got it

But you’re actually practicing good medicine.

 

[southerndoc]

I delete emails related to customer satisfaction. We have no shortage of people to go in the room to replace the discharged patient.

I initially misread your email as you deleting patients related to customer satisfaction.

Got my hopes up for a bit!

 

[WhatJobDoIPick]

But you’re actually practicing good medicine.

I'm sure you practice perfect evidence based medicine every time. Lulz

 

[VA Hopeful Dr]

But you’re actually practicing good medicine.

Yeah sorry, until patient satisfaction isn't such a big part of our jobs then I will not always do the correct thing if the alternative that makes the patient happy isn't dangerous.

 

[gruemd]

Tell them that on max effort attempts, you can blow tiny capillaries all over your body and live.

"Patient bro, do you even lift?"

 

[JacobMcCandles]

I'm sure you practice perfect evidence based medicine every time. Lulz

Of course I don’t. But, I’m not thinking about my billing or Press Ganey’s when I’m making my decisions.

 

[JacobMcCandles]

Yeah sorry, until patient satisfaction isn't such a big part of our jobs then I will not always do the correct thing if the alternative that makes the patient happy isn't dangerous.

I guess the solution is to get a job where patient satisfaction isn’t a big part of your job or affects your patient satisfaction. Granted, there’s less of those jobs out there than the alternative but they’re out there.

 

[VA Hopeful Dr]

I guess the solution is to get a job where patient satisfaction isn’t a big part of your job or affects your patient satisfaction. Granted, there’s less of those jobs out there than the alternative but they’re out there.

That is an option.

Or, I can keep the job that I generally enjoy, in the locations I like, that pays me shocking well for primary care and just pick my battles

 

[WhatJobDoIPick]

Of course I don’t. But, I’m not thinking about my billing or Press Ganey’s when I’m making my decisions.

Someone get this man a nobel prize. He doesn't care about patient satisfaction.

 

[JacobMcCandles]

Someone get this man a nobel prize. He doesn't care about patient satisfaction.

You take it from one extreme to the other on what you take away from various posts. Did I say I don’t care about patient satisfaction? I want to practice good medicine and for the patient to be happy. I try not to let patient satisfaction get in the way of good medicine, within reason. I also don’t let billing get in the way of how I practice medicine (i.e. I don’t do stuff I wouldn’t normally do just because I can bill higher). We all know that PG is a very flawed survey anyway. It’s already surveying a cohort of patients (discharged patients) that are more likely to be unhappy. It doesn’t even take into account that we’re not seeking patients out like other businesses may seek customers. We get patients that come see us. Some need to see us and some don’t. We can’t control that. If every patient you see is upset with you then there’s probably an issue. On the other hand, I don’t get too worked up if a patient is upset over reasonable medicine on their 30th ED visit in the first 6 months of the year.

 

[JacobMcCandles]

That is an option.

Or, I can keep the job that I generally enjoy, in the locations I like, that pays me shocking well for primary care and just pick my battles

Touché on picking battles but if the patient satisfaction battle is the one you’re picking, you’ve probably got a decent gig.

 

[DOswag]

As a psychiatrist I'm pretty surprised that an EP would be willing to start or really even consider an SSRI. Of course it's not wrong to use it for pretty straight forward anxiety and you're a physician that is certainly capable, but I'd assume most ER docs aren't looking to treat something that is a chronic condition. It's not something that's going to do anything in the acute time period as it takes weeks to see some effect. 5mg of lexapro is a pretty small dose but still can have side effects as what was mentioned above with increased suicidal thoughts in late teens/early 20's along with sexual side effects, weight gain etc. Maybe in the right set of circumstances someone may make an exception but I wouldn't expect this to be a typical regular practice of EM.

 

[ERMudPhud]

I delete emails related to customer satisfaction. We have no shortage of people to go in the room to replace the discharged patient.

During a PG discussion I once had the CEO of the hospital say, "Truthfully probably 30% of our ER patients you don't want so satisfied they are coming back" I didn't worry about PG before that but definitely didn't worry after that.

Also, one of my happiest moments during the dark days of late 2020 was telling a patient who was leaving AMA because they didn't like our isolation rules, "You know 5 seconds after you walk out that door I'm going to have someone else in your bed"

I like most of my patients but its not Burger King and you can't "Have it Your Way!"

 

[JacobMcCandles]

During a PG discussion I once had the CEO of the hospital say, "Truthfully probably 30% of our ER patients you don't want so satisfied they are coming back" I didn't worry about PG before that but definitely didn't worry after that.

Was this in regards to uninsured patients? I can’t see a CEO saying this about insured patients. Hospital systems actively encourage people to come to the ED.