Sep 12, 2011
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I've been trying to work on customer service since I started my new attending job, and I think I usually have pretty good patient interactions. Today I had a guy with a back spasm - had been going on intermittently x2 years and had prior surgery that relieved it, and it was coming back. Sounded like radicular pain and back spasm. I treated him with pain meds and explained that we'd put in a referral and do outpatient pain meds and muscle relaxers. He had no red flags for back pain. Seemed legit.

Then dad showed up. This guy was like 30, and his dad in his 70's insisted that he needed a million dollar workup. It was like talking to a wall and they would not leave. I could tell that the dad thought I had no idea what I was doing when he asked who the staff was on and I said it was me. I know I look young, I know what people think sometimes... Anyway I tried to work with them and did an x-ray to placate them. The guy was hurting but the pain improved, and I finally got them out the door. He didn't warrant a pain control admission, MRI, or emergent surgery consult. I even ran this by the other attending on to make sure I wasn't missing anything before I discharged him.

How do you guys deal with tough patients (short of booting them with UPD?) They seemed a little less annoyed after I x-rayed him, but I'll still probably get a complaint on this one. Sigh.
 

Daiphon

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Truthfully, you did pretty good. Hard to overcome familial bias (i.e. taking dad's word over yours) in these situations - sometimes you need to bend a little.

As for the complaints, well, to paraphrase P.T. Barnum:

You can please all of the people some of the time, or you can please some of the people all of the time - but you can't please all of the people all of the time.

Come to think of it, considering the circus that is Obamacare & HCAHPS, quoting P.T. may not be that far off.
 
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Arcan57

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I'd just caution about ordering tests after a patient demand. If you're doing it to relieve patient anxiety then that may be ok. If you're doing it to salvage a PG score then its singularly ineffective. Caving doesn't impress the patient and then you are in a situation where you've compromised your clinical judgment and you are still going to get reamed out on the survey.
 

erdoc00

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I wouldve ordered an mri with and without contrast, 2 mg dilaudid, labs and moved on...

they're never going to be satisfied. Might as well make the hospital some money and also make sure they don't have any merit to a complaint after you narced them into painless bliss and ruled out any emergency with an mri.

this is why people love Nurse Practitioners btw... false confidence and just give the patients whatever they want.

And actually on that first guy I probably would've also ordered a non contrast lumbar CT too... you know just to give the bones a double look over... and maybe even a CTA thorax to check the aorta as well... but only after a non contrast CT abd/pelvis to rule out a stone.

and then home with #120 percocet, #90 valium, my personal business card with cell phone included. .and I would personally schedule their appt to see the neurosurgeon later that day...
 

Spinach Dip

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I wouldve ordered an mri with and without contrast, 2 mg dilaudid, labs and moved on...

they're never going to be satisfied. Might as well make the hospital some money and also make sure they don't have any merit to a complaint after you narced them into painless bliss and ruled out any emergency with an mri.

this is why people love Nurse Practitioners btw... false confidence and just give the patients whatever they want.

And actually on that first guy I probably would've also ordered a non contrast lumbar CT too... you know just to give the bones a double look over... and maybe even a CTA thorax to check the aorta as well... but only after a non contrast CT abd/pelvis to rule out a stone.

and then home with #120 percocet, #90 valium, my personal business card with cell phone included. .and I would personally schedule their appt to see the neurosurgeon later that day...
Now THAT is customer service!

Welcome to McHospital, where the customer is always right.
 
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Doctor Bob

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I've been trying to work on customer service since I started my new attending job, and I think I usually have pretty good patient interactions. Today I had a guy with a back spasm - had been going on intermittently x2 years and had prior surgery that relieved it, and it was coming back. Sounded like radicular pain and back spasm. I treated him with pain meds and explained that we'd put in a referral and do outpatient pain meds and muscle relaxers. He had no red flags for back pain. Seemed legit.

Then dad showed up. This guy was like 30, and his dad in his 70's insisted that he needed a million dollar workup. It was like talking to a wall and they would not leave. I could tell that the dad thought I had no idea what I was doing when he asked who the staff was on and I said it was me. I know I look young, I know what people think sometimes... Anyway I tried to work with them and did an x-ray to placate them. The guy was hurting but the pain improved, and I finally got them out the door. He didn't warrant a pain control admission, MRI, or emergent surgery consult. I even ran this by the other attending on to make sure I wasn't missing anything before I discharged him.

How do you guys deal with tough patients (short of booting them with UPD?) They seemed a little less annoyed after I x-rayed him, but I'll still probably get a complaint on this one. Sigh.
What I would have done would have most certainly guaranteed a complaint.
This person gets an IM shot, a talk about how the goal of the ED for acute exacerbation of chronic conditions is very limited (eval for emergent conditions which can be done with physical exam alone, and a dose of meds to make the pain tolerable), and a discharge with no meds... controlled substances for chronic conditions should only be prescribed by one provider.

If it's been going on for 2 years, and there are no red flags, then I wouldn't have done the XR either.

I am much more of a hardass than my colleagues though...
 
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Birdstrike

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I've been trying to work on customer service since I started my new attending job, and I think I usually have pretty good patient interactions. Today I had a guy with a back spasm - had been going on intermittently x2 years and had prior surgery that relieved it, and it was coming back. Sounded like radicular pain and back spasm. I treated him with pain meds and explained that we'd put in a referral and do outpatient pain meds and muscle relaxers. He had no red flags for back pain. Seemed legit.

Then dad showed up. This guy was like 30, and his dad in his 70's insisted that he needed a million dollar workup. It was like talking to a wall and they would not leave. I could tell that the dad thought I had no idea what I was doing when he asked who the staff was on and I said it was me. I know I look young, I know what people think sometimes... Anyway I tried to work with them and did an x-ray to placate them. The guy was hurting but the pain improved, and I finally got them out the door. He didn't warrant a pain control admission, MRI, or emergent surgery consult. I even ran this by the other attending on to make sure I wasn't missing anything before I discharged him.

How do you guys deal with tough patients (short of booting them with UPD?) They seemed a little less annoyed after I x-rayed him, but I'll still probably get a complaint on this one. Sigh.
So you ordered a pointless test to pacify an angry patient's family member demanding to direct patient care and override your years of training, because your back is continuously against the wall in a system that rewards poorer, less efficient and dumbed-down care, so that you could avoid being punished by a patient-satisfaction/gratification system that is associated with higher death and morbidity rates?

It sounds like you did exactly what you are expected to do, exactly what you will be rewarded for doing, and that the system is working exactly as its set up to work by those in position to profit the most from it (hospital administrators, insurance administrators and politicians).

JAMA- Higher death and morbidity rates are associated with higher patient satisfaction scores.

http://archinte.jamanetwork.com/Mobile/article.aspx?articleid=1108766

Where there is patient/customer satisfaction there is big, big money. Follow the money and you'll find the answers to the way things are.
 
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Sounds like tou did a vood job. No red flags = no imaging. Would've explained that the goal of the ED is to rule out life threatening emergencies, and not cure chronic pain... that being said, Ketamine 0.3mg/kg works wonders for all sorts of pain in the ED... have been using it more often....
 

e30ftw

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I've decided in most cases this is a battle not worth fighting. I'm too busy with sicker patients, spending quality time with higher risk discharges and generally managing the ED to fight this kind of thing..

20 y/o M w/ lateral thigh pain and family members convinced he has a dvt? sure here's your U/S.. discharge.

30 y/o w/ URI symptoms convinced she has pneumonia requesting CXR? sure zap there's your radiation. go away.

I start off by giving folks the "Here is what you likely have based on my exam and this is why further testing is not indicated and may be harmful due to risk of a false positive result" speech but if they push back or if there's the token "educated older family member" who is looking up stuff on their phone, I don't fight it at all and order whatever pointless test will cost the least and do the least harm to the patient while placating all involved.

#reallife.
 
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Doctor Bob

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Ha; fortuitous timing. I just got an email about how a patient was angry that I refused to order a musculoskeletal ultrasound on Labor Day weekend for their bicep pain which had been ongoing for 8 months.

Mind you our sono tech only comes in on weekends if called and only for emergencies.
 

WilcoWorld

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Ha; fortuitous timing. I just got an email about how a patient was angry that I refused to order a musculoskeletal ultrasound on Labor Day weekend for their bicep pain which had been ongoing for 8 months.

Mind you our sono tech only comes in on weekends if called and only for emergencies.
So, how did your administration handle the complaint?
 

Arcan57

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So, how did your administration handle the complaint?
With a restraint and understanding. We all know how touchy docs get when keeping the CEOs bonus high involves questioning the judgment they've spent thousands of hours acquiring. So they let him off light with a referral to peer review, a complaint packet to the patient with pre-printed forms and stamped envelopes for sending to the state board, and a 8 hr mandatory patient experience on-line course that must be completed prior to the provider's next shift. Oh, they worked last night and they're on the schedule tonight? In that case, I'd go ahead and wake them up so they don't get in trouble for showing up late for their shift.
 

Angry Birds

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The patient scenario you describe is actually very common. You will actually be seeing a LOT of back pain in the ER, so you (and us all) should be prepared to deal with this.

First, I just want to point out that it is actually reasonable on the part of patients to expect some sort of imaging. Pick random people on the street and ask what they would expect if they were to present to the ER with back pain, and I'll bet a majority of them say "get an x-ray to make sure something isn't broken." In fact, I'll bet that most of us would have said the same thing if we hadn't gone through medical school and residency. So, think of it from the patient's perspective: when you DON'T order any imaging, it is not what they were expecting.

Even so, I don't think you should order a pointless x-ray. I'm just trying to clarify that it is not completely inane that patients expect this.

What you need is an "elegant" way of explaining this to the patient--that is, of "failing" to meet the patient's expectation. I disagree with the speech about "false positives"... It's too confusing for patients, and I've never had success with it. (This is just me, of course--maybe others have found success with it. But, I've never really seen a "satisfied customer" after having that speech.)

The first thing I do is *validate* the patient's concern: I acknowledge the patient's pain and the seriousness of the situation. You will be surprised at how a patient's guard will be lowered once you validate. I generally do this with upset patients in general... For example, I had a patient who was upset that all the previous doctors were "blaming" him for his respiratory infections (due to his smoking), and were discriminating against him because he was a smoker. I immediately fixed the patient-physician encounter by saying, "I can see how it can be frustrating to be discriminated against. I'm sorry you experienced that, etc. etc."

So, validate by acknowledging the patient's pain and the seriousness of the problem. I do this like so: "It seems like you are in a lot of pain. I'm really concerned about that. Back pain can be really debilitating." I've acknowledged the patient's pain and validated his concern.

It's only after this that I say, "This is most likely a muscular spasm, and muscular spasms can be extremely painful." Notice that I AVOIDED saying that "it's *just* a muscle spasm" and I quickly followed it up by saying it is "extremely painful." I also point to where they said their pain was worst (usually paraspinal and muscular), and ask rhetorically: "Your pain was worst here, right? In the muscle?" (Patient nods. What a genius doctor.)

Then, I say: "The problem is that x-rays don't show muscle spasms. They only show bones, not muscles." (I show the patient that I considered x-ray, and then I explain why I'm not ordering it. It's a simple, easy to understand explanation....Not one where you have to take about False Negatives and False Positives, etc.)

Or, if the patient has sciatica: "Based on your description and my clinical exam, it seems that your pain is nerve-related. The problem is that x-rays don't show nerves."

I keep going: "But, if your pain doesn't get better, then I think an MRI might be a good idea. An MRI shows soft tissues, and it doesn't have any radiation either."

Then, I say: "The problem is that I can't order an MRI in the ER.It's an outpatient test." [If it's after hours or a weekend, I also add: "MRI is a big machine, requiring a staff to operate it. Unfortunately, they are at home sleeping right now...unlike us ER doctors." (I'm the good guy.) I'm also trying to explain why their request is unreasonable.] But, I quickly add: "Your primary care doctor, on the other hand, can schedule an MRI appointment for you, so that you don't even have to wait hours to get one." (Most patients don't like to wait... first, I can't wake up staff and bring them to the hospital, and even if I could, would you really want to wait a few hours for that??)

I add what I'll do: "What I'll do is write very explicitly on your discharge instructions that your primary care doctor should consider an MRI if your pain doesn't go away. That way you can hand your discharge instructions to your doctor." (I don't know if this is a jerk move to the PCP, but they punt stuff to us all the time, and I actually *do* think an MRI should be *considered* if pain doesn't resolve in a reasonable amount of time.) More importantly, it is important to put this down from a medico-legal standpoint. That way you're not the guy who said a whopping mass was "just a muscular spasm." Instead, you were the concerned doctor who said, "Even though I think this is likely muscular spasm, if your pain DOESN'T go away, then you should talk to your doctor about getting an MRI, to make sure it's not something worse."

But, I don't want to close by saying I'm not going to do anything. So, I clearly say what *I* will do: "BUT, what I'm going to do is control your pain. I'm going to give you POWERFUL pain killers to BREAK your pain and get you to your primary care doctor." (Even if you prescribe Naproxen, remember: it is a POWERFUL anti-inflammatory pain killer.)

"I'm also going to give you a STRONG muscle relaxant, which should really make you feel better."

"Can I also give you a work note so that you can get a day's rest?" I really want to show that I'm offering multiple things to the patient.

IF even after all of that the patient insisted on an x-ray, I would order it, with the thought that it would rule out big masses. A patient who insists and is angry is more likely to sue if you were to miss a mass. This way, if brought to trial, I can say: "I ordered the test I could order in the ER, and I urged an outpatient MRI as well."

So far, I haven't had any problems with this approach.
 
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Spinach Dip

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The patient scenario you describe is actually very common. You will actually be seeing a LOT of back pain in the ER, so you (and us all) should be prepared to deal with this.

First, I just want to point out that it is actually reasonable on the part of patients to expect some sort of imaging. Pick random people on the street and ask what they would expect if they were to present to the ER with back pain, and I'll bet a majority of them say "get an x-ray to make sure something isn't broken." In fact, I'll bet that most of us would have said the same thing if we hadn't gone through medical school and residency. So, think of it from the patient's perspective: when you DON'T order any imaging, it is not what they were expecting.

Even so, I don't think you should order a pointless x-ray. I'm just trying to clarify that it is not completely inane that patients expect this.

What you need is an "elegant" way of explaining this to the patient--that is, of "failing" to meet the patient's expectation. I disagree with the speech about "false positives"... It's too confusing for patients, and I've never had success with it. (This is just me, of course--maybe others have found success with it. But, I've never really seen a "satisfied customer" after having that speech.)

The first thing I do is *validate* the patient's concern: I acknowledge the patient's pain and the seriousness of the situation. You will be surprised at how a patient's guard will be lowered once you validate. I generally do this with upset patients in general... For example, I had a patient who was upset that all the previous doctors were "blaming" him for his respiratory infections (due to his smoking), and were discriminating against him because he was a smoker. I immediately fixed the patient-physician encounter by saying, "I can see how it can be frustrating to be discriminated against. I'm sorry you experienced that, etc. etc."

So, validate by acknowledging the patient's pain and the seriousness of the problem. I do this like so: "It seems like you are in a lot of pain. I'm really concerned about that. Back pain can be really debilitating." I've acknowledged the patient's pain and validated his concern.

It's only after this that I say, "This is most likely a muscular spasm, and muscular spasms can be extremely painful." Notice that I AVOIDED saying that "it's *just* a muscle spasm" and I quickly followed it up by saying it is "extremely painful." I also point to where they said their pain was worst (usually paraspinal and muscular), and ask rhetorically: "Your pain was worst here, right? In the muscle?" (Patient nods. What a genius doctor.)

Then, I say: "The problem is that x-rays don't show muscle spasms. They only show bones, not muscles." (I show the patient that I considered x-ray, and then I explain why I'm not ordering it. It's a simple, easy to understand explanation....Not one where you have to take about False Negatives and False Positives, etc.)

Or, if the patient has sciatica: "Based on your description and my clinical exam, it seems that your pain is nerve-related. The problem is that x-rays don't show nerves."

I keep going: "But, if your pain doesn't get better, then I think an MRI might be a good idea. An MRI shows soft tissues, and it doesn't have any radiation either."

Then, I say: "The problem is that I can't order an MRI in the ER.It's an outpatient test." [If it's after hours or a weekend, I also add: "MRI is a big machine, requiring a staff to operate it. Unfortunately, they are at home sleeping right now...unlike us ER doctors." (I'm the good guy.) I'm also trying to explain why their request is unreasonable.] But, I quickly add: "Your primary care doctor, on the other hand, can schedule an MRI appointment for you, so that you don't even have to wait hours to get one." (Most patients don't like to wait... first, I can't wake up staff and bring them to the hospital, and even if I could, would you really want to wait a few hours for that??)

I add what I'll do: "What I'll do is write very explicitly on your discharge instructions that your primary care doctor should consider an MRI if your pain doesn't go away. That way you can hand your discharge instructions to your doctor." (I don't know if this is a jerk move to the PCP, but they punt stuff to us all the time, and I actually *do* think an MRI should be *considered* if pain doesn't resolve in a reasonable amount of time.) More importantly, it is important to put this down from a medico-legal standpoint. That way you're not the guy who said a whopping mass was "just a muscular spasm." Instead, you were the concerned doctor who said, "Even though I think this is likely muscular spasm, if your pain DOESN'T go away, then you should talk to your doctor about getting an MRI, to make sure it's not something worse."

But, I don't want to close by saying I'm not going to do anything. So, I clearly say what *I* will do: "BUT, what I'm going to do is control your pain. I'm going to give you POWERFUL pain killers to BREAK your pain and get you to your primary care doctor." (Even if you prescribe Naproxen, remember: it is a POWERFUL anti-inflammatory pain killer.)

"I'm also going to give you a STRONG muscle relaxant, which should really make you feel better."

"Can I also give you a work note so that you can get a day's rest?" I really want to show that I'm offering multiple things to the patient.

IF even after all of that the patient insisted on an x-ray, I would order it, with the thought that it would rule out big masses. A patient who insists and is angry is more likely to sue if you were to miss a mass. This way, if brought to trial, I can say: "I ordered the test I could order in the ER, and I urged an outpatient MRI as well."

So far, I haven't had any problems with this approach.

Every doctor in the country should be taught to respond to patient complaints like this.
 
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Yeah as a couple people said, I had a lot of stuff going on and it was easier to just get the x-ray than to argue. But Angry Birds, I love that means of dealing with back pain. By the end of your post, I wanted to go home and curl up in a blanket with my strong muscle relaxer and NSAID!
 

Janders

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Angry Birds FTW.
Textbook approach.

Back pain works well like this. URI/Viral syndrome as well. Knee pain... etc

Sometimes if its a more vague/chronic complaint, I just directly ask if there is a specific thing they want checked. Often they are afraid of "bad infection" / tumor / anemia / lyme, and than way I can either do a simple test to relieve their anxiety or target my explanation to their specific concern.
 
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Angry Birds FTW.
Textbook approach.

Back pain works well like this. URI/Viral syndrome as well. Knee pain... etc

Sometimes if its a more vague/chronic complaint, I just directly ask if there is a specific thing they want checked. Often they are afraid of "bad infection" / tumor / anemia / lyme, and than way I can either do a simple test to relieve their anxiety or target my explanation to their specific concern.
Often patients are afraid of something specific... once you find and address it, they feel much better.
 
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dchristismi

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Totally agree. Discover what the thing is that the patient is worried about = happier patients. Also, for the most part, acknowledging that something is indeed painful always seems to make it easier to treat said pain - muscle spasms in particular. I use the "well, you've had a charley horse, right? Imaging that pain, in the huge muscles in your back. Of course it's going to hurt!"

Along those lines, when I see an overtly anxious parent, I ask specifics. You might very well learn that mom's first child was diagnosed with leukemia and had an identical presentation to kid #2's pain tonight, or some other tragedy that, although not really changing your pretest probability that this kid has anything serious, you can really drive home that it's NOT what mom is most terrified of.
 

gman33

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The patient scenario you describe is actually very common. You will actually be seeing a LOT of back pain in the ER, so you (and us all) should be prepared to deal with this.

First, I just want to point out that it is actually reasonable on the part of patients to expect some sort of imaging. Pick random people on the street and ask what they would expect if they were to present to the ER with back pain, and I'll bet a majority of them say "get an x-ray to make sure something isn't broken." In fact, I'll bet that most of us would have said the same thing if we hadn't gone through medical school and residency. So, think of it from the patient's perspective: when you DON'T order any imaging, it is not what they were expecting.

Even so, I don't think you should order a pointless x-ray. I'm just trying to clarify that it is not completely inane that patients expect this.

What you need is an "elegant" way of explaining this to the patient--that is, of "failing" to meet the patient's expectation. I disagree with the speech about "false positives"... It's too confusing for patients, and I've never had success with it. (This is just me, of course--maybe others have found success with it. But, I've never really seen a "satisfied customer" after having that speech.)


The first thing I do is *validate* the patient's concern: I acknowledge the patient's pain and the seriousness of the situation. You will be surprised at how a patient's guard will be lowered once you validate. I generally do this with upset patients in general... For example, I had a patient who was upset that all the previous doctors were "blaming" him for his respiratory infections (due to his smoking), and were discriminating against him because he was a smoker. I immediately fixed the patient-physician encounter by saying, "I can see how it can be frustrating to be discriminated against. I'm sorry you experienced that, etc. etc."

So, validate by acknowledging the patient's pain and the seriousness of the problem. I do this like so: "It seems like you are in a lot of pain. I'm really concerned about that. Back pain can be really debilitating." I've acknowledged the patient's pain and validated his concern.

It's only after this that I say, "This is most likely a muscular spasm, and muscular spasms can be extremely painful." Notice that I AVOIDED saying that "it's *just* a muscle spasm" and I quickly followed it up by saying it is "extremely painful." I also point to where they said their pain was worst (usually paraspinal and muscular), and ask rhetorically: "Your pain was worst here, right? In the muscle?" (Patient nods. What a genius doctor.)

Then, I say: "The problem is that x-rays don't show muscle spasms. They only show bones, not muscles." (I show the patient that I considered x-ray, and then I explain why I'm not ordering it. It's a simple, easy to understand explanation....Not one where you have to take about False Negatives and False Positives, etc.)

Or, if the patient has sciatica: "Based on your description and my clinical exam, it seems that your pain is nerve-related. The problem is that x-rays don't show nerves."

I keep going: "But, if your pain doesn't get better, then I think an MRI might be a good idea. An MRI shows soft tissues, and it doesn't have any radiation either."

Then, I say: "The problem is that I can't order an MRI in the ER.It's an outpatient test." [If it's after hours or a weekend, I also add: "MRI is a big machine, requiring a staff to operate it. Unfortunately, they are at home sleeping right now...unlike us ER doctors." (I'm the good guy.) I'm also trying to explain why their request is unreasonable.] But, I quickly add: "Your primary care doctor, on the other hand, can schedule an MRI appointment for you, so that you don't even have to wait hours to get one." (Most patients don't like to wait... first, I can't wake up staff and bring them to the hospital, and even if I could, would you really want to wait a few hours for that??)

I add what I'll do: "What I'll do is write very explicitly on your discharge instructions that your primary care doctor should consider an MRI if your pain doesn't go away. That way you can hand your discharge instructions to your doctor." (I don't know if this is a jerk move to the PCP, but they punt stuff to us all the time, and I actually *do* think an MRI should be *considered* if pain doesn't resolve in a reasonable amount of time.) More importantly, it is important to put this down from a medico-legal standpoint. That way you're not the guy who said a whopping mass was "just a muscular spasm." Instead, you were the concerned doctor who said, "Even though I think this is likely muscular spasm, if your pain DOESN'T go away, then you should talk to your doctor about getting an MRI, to make sure it's not something worse."

But, I don't want to close by saying I'm not going to do anything. So, I clearly say what *I* will do: "BUT, what I'm going to do is control your pain. I'm going to give you POWERFUL pain killers to BREAK your pain and get you to your primary care doctor." (Even if you prescribe Naproxen, remember: it is a POWERFUL anti-inflammatory pain killer.)

"I'm also going to give you a STRONG muscle relaxant, which should really make you feel better."

"Can I also give you a work note so that you can get a day's rest?" I really want to show that I'm offering multiple things to the patient.

IF even after all of that the patient insisted on an x-ray, I would order it, with the thought that it would rule out big masses. A patient who insists and is angry is more likely to sue if you were to miss a mass. This way, if brought to trial, I can say: "I ordered the test I could order in the ER, and I urged an outpatient MRI as well."

So far, I haven't had any problems with this approach.
I have a similar practice.
What do you do when the patient doesn't buy any of that and wants admission, MRI, narcs etc?

I think I am pretty good at my interactions with patients, but sometime what they want is just not realistic.
Belly pain for 3 years with every test in the world done, won't leave without admission to have it all done again.

If there are things I can easily get, I usually just order the test.

At some point, I get to a standoff with demands and it's not always clear how to proceed.

If I've exhausted all the options I think are reasonable, I d/c.
If they still won't leave, I will give it a little thought to see if there is anything else I can do.
If I still come up with nothing, I tell them they are d/c and ask them to leave.
In rare cases I get security to show them to the door.
 

GeneralVeers

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I have a similar practice.
What do you do when the patient doesn't buy any of that and wants admission, MRI, narcs etc?

I think I am pretty good at my interactions with patients, but sometime what they want is just not realistic.
Belly pain for 3 years with every test in the world done, won't leave without admission to have it all done again.

If there are things I can easily get, I usually just order the test.

At some point, I get to a standoff with demands and it's not always clear how to proceed.

If I've exhausted all the options I think are reasonable, I d/c.
If they still won't leave, I will give it a little thought to see if there is anything else I can do.
If I still come up with nothing, I tell them they are d/c and ask them to leave.
In rare cases I get security to show them to the door.
Often these patients will have seen multiple doctors. I'll check to see if the hospitalist on-call is familiar with the patient, or if they have a PCP that I can call if it's still business hours. I'll then tell the patient that I discussed the case with Dr. X who is more familiar with them than I, and here it the outpatient plan. It often helps a lot do to this.

If I can't contact another doctor for assistance, then I will do what is medically necessary and discharge the patient home, while documenting fully why they didn't meet criteria and that there is nothing a hospital admission would add to their workup or therapy.
 

The White Coat Investor

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Here is the honest to goodness truth about this sort of chief complaint. Like drug-seekers, chronic abdominal painers etc the key to a successful interaction is spending a long time with the patient. I just plan to be in there a while. I run the state CSD report and have it on the chart when I walk in. Then I do a careful history, a overly thorough exam, and then do A LOT of education about medicine in general, emergency medicine, proper use of narcotics, my concerns about their narcotic use and how I don't want to have to code them, red flags for imaging etc. I mean, if an MSIV came in with me, by the time he left the room he would know everything there is to know about the emergent work-up of back pain. And in the end, I typically tell the patient the honest truth. I tell them a back x-ray isn't going to do them any good because they're not old, don't have a history of cancer, and had no trauma. If they need imaging, they need an MRI. In my opinion, they don't have to get imaging today, but can safely wait 4-6 weeks to see if the pain goes away on its own. I also tell them the hospital would love for me to order an MRI, and if they want it, I'll order it, but that I wouldn't order it on myself or my wife. This is all after I explain that an MRI is a surgical planning tool, and if they're not willing to be operated on in the next week, they shouldn't bother getting an MRI since it is not therapeutic at all.

You want to cut down on your complaints and boost your PG scores? Spend more time with the patient. Trying to save "the system" the cost of an MRI is NOT a sword worth falling onto. Medicine is an art, not a science, and good medicine sometimes means doing things today that don't absolutely have to be done today. I've fired a doc who couldn't understand that. Running around with this sort of attitude:

So you ordered a pointless test to pacify an angry patient's family member demanding to direct patient care and override your years of training, because your back is continuously against the wall in a system that rewards poorer, less efficient and dumbed-down care, so that you could avoid being punished by a patient-satisfaction/gratification system that is associated with higher death and morbidity rates?

It sounds like you did exactly what you are expected to do, exactly what you will be rewarded for doing, and that the system is working exactly as its set up to work by those in position to profit the most from it (hospital administrators, insurance administrators and politicians).
just increases your own burnout.

By the way, at least 90% of the patients don't elect to get the MRI when I give them the choice to do it. And for that 10% that do, all it costs is a little time, a little money, and a rare false positive. No radiation whatsoever (my conversation about CTs is quite different.) I can live with that and so can they.
 

Janders

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Great write up by WCI above.

You can solve SO much by pulling up a chair and talking to the patient (and the family! especially the female relative in charge of healthcare [statistically likely])

Now, you just can't do this to 8+ different patients in one shift. Part of the art is to get people to like you in a 2 minute interaction. Then, you can pick your battles, 1-2 difficult patients a day to spend extra time with, just like WCI explains. If I'm feeling spunky, I'll pick a patient I just LIKE and sit and talk to them for 5 minutes about their life/stories/job, that way I get a treat too.

I think one thing we are afraid of as medical students and residents is saying "I don't know". But it is powerful to say that. My last patient tonight was a normal seeming guy with a month of right sided belly pain, worse today. Normal labs, normal vitals, PCP sent him in concerned something was going on, my exam reasonably benign. CT stone cold normal. RN told him he was going to be discharged, and you could tell from the body language he and his son weren't happy. So I went in, sat down, told them all the things the tests told us about his health, and the diagnoses we ruled out, and the simple fact that a lot of belly pains leave the ER with no firm diagnosis, but at least knowing there is no big tumor/infection/emergency. The old "I DON'T know what you have, but I do know what you don't have" routine. And I empathized that its frustrating not to have a firm diagnosis both for him AND for me. But that I felt he was very safe to go home, and then to pursue short interval f/u with his PCP, and consideration of some further outpatient testing / referrals if it wasn't getting better on its own.

The left very happy at that point. And all that it really took was me taking the time to sit down, really explain the results, and show that we did care about him and his chief complaint.

Now of course this touchy-feeling talking to people thing doesn't work on the truly sociopathic drug seekers of doom, but they are the vast minority.

Specific to admission requests, I usually go into detail with precisely WHY they want to be admitted (pain control? think they'll get an MRI faster? Afraid of not having help at home? frustrated with the length of symptoms?). At lot of times they have a valid concern which will NOT be helped by admission, but we CAN help in some way (call and set up the MRI with their PCP, have the case manager come over and discuss VNA or home PT, etc). Our case managers are also good at realistically explaining the difference between observation and admission, and the unfortunate financial repercussions of observation to some patients...
 

gman33

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Good points. I think I do all those things.
I work at a very high volume shop.
I can get any test I want with no pushback.
Getting an MRI is a time killer. MRI = OBS in my practice.
In the back back example, I'd essentially have to OBS for intractable pain and order the MRI.
I have some partners who will order an MRI and then sign the patient out to someone else.
I'm not a fan of being on the receiving end of that signout.
Especially as the patient is probably going to be a time suck when I have to d/c them.

If they want to be admitted for additional testing, I try to talk to them about what will actually occur.
Usually the answer is nothing.
Chronic belly pain, want to be admitted for EGD.
The test just won't happen without anemia or HD instability.
GI won't get reimbursed for non-emergent EGD.

I will generally do almost anything I can for these types of patients.
Sometimes it's just hard to get someone to understand our limitations.
 

The White Coat Investor

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I work at a very high volume shop.
This is part of the problem. We average <1.5 pph. Why? Because we want to and we own our business and can control that. Volumes go up? We add coverage. Then you can give better medicine. The only reason to be in a high volume shop is if you are willing to sacrifice good care for more dough or if you don't control the job, because you're unwilling to go to another geographic area.
 
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VA Hopeful Dr

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This is part of the problem. We average <1.5 pph. Why? Because we want to and we own our business and can control that. Volumes go up? We add coverage. Then you can give better medicine. The only reason to be in a high volume shop is if you are willing to sacrifice good care for more dough or if you don't control the job, because you're unwilling to go to another geographic area.
I think this is the major problem facing all of medicine - from the 8 minute PCP appointment to the hospitalist rounding on 30+ patients per day. Patients don't like the lack of face-to-face time, none of us like having to doctor at breakneck speed, and quality suffers.
 

exsanguination

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I think this is the major problem facing all of medicine - from the 8 minute PCP appointment to the hospitalist rounding on 30+ patients per day. Patients don't like the lack of face-to-face time, none of us like having to doctor at breakneck speed, and quality suffers.
Exactly. This pervades all specialties, practice environments, and even extends towards midlevels, RNs, and other health care staff.

The question is not really whether this will get better (I firmly believe that it will definitely get worse and we will all be continuously squeezed to see more and do more all with maintaining the same quality). The REAL question is HOW we can take back control and FIX this from a healthcare-worker point of view and not an administrative point of view.

I suppose if you are lucky/well-connected/?geographically privileged?, you can do what WCI has done, and own your practice environment. Keep full 100% control on all aspects of care.

However this seems increasingly rare and like he pointed out so aptly, if you have any desire for geographical location or monetary requirements you're gonna have to bend over and take it.
 

VA Hopeful Dr

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Exactly. This pervades all specialties, practice environments, and even extends towards midlevels, RNs, and other health care staff.

The question is not really whether this will get better (I firmly believe that it will definitely get worse and we will all be continuously squeezed to see more and do more all with maintaining the same quality). The REAL question is HOW we can take back control and FIX this from a healthcare-worker point of view and not an administrative point of view.

I suppose if you are lucky/well-connected/?geographically privileged?, you can do what WCI has done, and own your practice environment. Keep full 100% control on all aspects of care.

However this seems increasingly rare and like he pointed out so aptly, if you have any desire for geographical location or monetary requirements you're gonna have to bend over and take it.
I think any hospital-based specialty is going to have a harder time with this (y'all and hospitalists being the most screwed). For the rest of us, the key is to both be in charge yourself (WCI's solution) and to try and maximize revenue to a sufficient degree to allow you to slow down a bit - own your own surgical center/endoscopy for procedural folks, offer ancillary services/get away from insurance all together for us PCP types.
 

gman33

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We actually have fantastic coverage. The reason I brought that up is that it is difficult to tie up a room for eight hours in order to get an MRI. I can get it but if I do so I put them in OBS so they can wait there while getting the test and results.
 

The White Coat Investor

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We actually have fantastic coverage. The reason I brought that up is that it is difficult to tie up a room for eight hours in order to get an MRI. I can get it but if I do so I put them in OBS so they can wait there while getting the test and results.
Yes, I suppose high volume can mean many things and really nothing at all. It's all about volume per doc and volume per available bed, isn't it?
 

GeneralVeers

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The conundrum is that working for a CMG or hospital and seeing 1.5 pts per hour, reimbursement would be in the $100/hr range. Not really worth it considering the risks, and stress.
 

Janders

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Even in a democratic, low-overhead group 1.5pt/hr doesn't pay that hot unless you have a nice reimbursement mix...
 

Janders

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Even in a democratic, low-overhead group 1.5pt/hr doesn't pay that hot unless you have a nice reimbursement mix...
Or have cash coming from other sources... i.e. hospital, etc...
 

exsanguination

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Even in a democratic, low-overhead group 1.5pt/hr doesn't pay that hot unless you have a nice reimbursement mix...
I assumed it was 1.5/hr of higher acuity patients with PAs skimming the fast track stuff though still under "supervision" of the doc. Effective rate of 3pph?
 

GeneralVeers

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I assumed it was 1.5/hr of higher acuity patients with PAs skimming the fast track stuff though still under "supervision" of the doc. Effective rate of 3pph?
I see 2-2.5 pph right now with midlevels "skimming" another 2 pph of low acuity stuff. At 1.5 pts/hr it would be hard to see administration or group leadership justify having midlevels. If they can save $50-$70/hr by not having the physician just see the patients as well that's what they do.
 

The White Coat Investor

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I see 2-2.5 pph right now with midlevels "skimming" another 2 pph of low acuity stuff. At 1.5 pts/hr it would be hard to see administration or group leadership justify having midlevels. If they can save $50-$70/hr by not having the physician just see the patients as well that's what they do.
Maybe if you WERE administration. :) My PAs are my employees. It's beyond me why lots of docs out there are willing to supervise PAs without an appropriate bump in their hourly. I figure that's worth $30-50 an hour extra if I'm supervising a PA.
 

The White Coat Investor

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Even in a democratic, low-overhead group 1.5pt/hr doesn't pay that hot unless you have a nice reimbursement mix...
Several factors at work here:
1) Acuity
2) How well you document
3) Payor mix
4) Insurance contracts
5) PPH

Your pay goes up every time you increase one of those things. When you own the business, your incentive is to continually work to increase all five. Our payor mix is good, but not incredible. Our insurance contracts are awesome, our documentation is awesome, and our acuity is continually going up. But if you're only getting $100 an hour at 1.5 pph, going to 2 pph is only going to give you $133. That's pretty crummy unless it's a prepartner rate IMHO.
 

The White Coat Investor

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I assumed it was 1.5/hr of higher acuity patients with PAs skimming the fast track stuff though still under "supervision" of the doc. Effective rate of 3pph?
A good point. We do have PAs. At our busiest times, it's two docs and one PA. So maybe an effective rate of 2.25 sometimes (16 hours a day), 3 sometimes (2 hours a day), and 1.5 sometimes (6 hours a day).
 

The White Coat Investor

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The conundrum is that working for a CMG or hospital and seeing 1.5 pts per hour, reimbursement would be in the $100/hr range. Not really worth it considering the risks, and stress.
I agree it's not worth working for a CMG or hospital. If docs would quit doing it, there would be no CMGs or hospital employed emergency physicians. All the best docs would be in democratic groups, and so administrators would go contract with democratic groups because that's the only way to get good docs.
 
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Old_Mil

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I've decided in most cases this is a battle not worth fighting. I'm too busy with sicker patients, spending quality time with higher risk discharges and generally managing the ED to fight this kind of thing..

20 y/o M w/ lateral thigh pain and family members convinced he has a dvt? sure here's your U/S.. discharge.

30 y/o w/ URI symptoms convinced she has pneumonia requesting CXR? sure zap there's your radiation. go away.

I start off by giving folks the "Here is what you likely have based on my exam and this is why further testing is not indicated and may be harmful due to risk of a false positive result" speech but if they push back or if there's the token "educated older family member" who is looking up stuff on their phone, I don't fight it at all and order whatever pointless test will cost the least and do the least harm to the patient while placating all involved.

#reallife.
Yep, that's the reality of patient centered medicine mediated by MBAs and JDs. The opinions and preferences of MDs and DOs have very little to do with it, we only facilitate obtaining what other people want. I don't even waste my time with the speech.
 

Old_Mil

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the key to a successful interaction is spending a long time with the patient. I just plan to be in there a while. I run the state CSD report and have it on the chart when I walk in. Then I do a careful history, a overly thorough exam, and then do A LOT of education about medicine in general
For the patient who isn't in it for secondary gain, this works pretty well. I've found that multiple visits to a room also work pretty well. Up front I tell them what I'm going to do and then bounce back into the room a handful of times on my way to see other patients to trickle out bits and pieces of data as they become available and ask how they are doing. That seems to reset the "I've been in here without seeing anyone for X minutes/hours" timer patients seem to have. I also print out lab/rads results and give them to the patient when they are discharged so they have an objective sense of "they actually did a lot of stuff for me" - and in the miraculous event that they do obtain outpatient follow up, the guy in the clinic is has a leg up.

This works best in a < 2 pph setting. Between 2 and 2.5 you are only doing it selectively. Above 3, you're just throwing crap at a wall and seeing what sticks.

I can't overemphasize the importance of carrying a really fast tablet computer that's on a fast, secure intranet connection. It eliminates the time you waste logging into and out of computers, and you're always connected for CPOE, charting, or showing patients test results.
 
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