Dealing with crazy/secondary gain patients

[GeneralVeers]

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I've had some problems this week dealing with "crazy" patients who come into the ER every day for non-emergent problems. I can deal with normal people, and drug seekers, but I still don't have a good approach for the crazy munchausen and/or hypochondriac ones.

Example: 46 year old lady, with long history of "migraines", psych problems multiple surgeries. Has visited our department over 20 times since January. Initially it was for abdominal pain/flank pain, but now she's having "seizures" almost every day and her husband drives her to the hospital for her "seizures". No one has ever witnessed them, and she does not have a neurologist. She has been admitted 3 times this year for the same "seizures" with complete workups that have been negative.

I saw her last night for the 2nd time this week (a total of 4 visits in the last 7 days). I told her basically that there was nothing we could do for chronic problem as all the tests have been done, and that she should come back if something changes, or something new happens. Now she's pissed off because I wouldn't do anything for her and launching a complaint.

Do you guys just do the bogus, wasteful tests on these people at every visit to placate them, or do you take the hit with a patient complaint and not do what they want?

This is seriously distressing, and I can't figure out how to deal with this lady if she comes back.

 

[WilcoWorld]

I generally try to explain why I don't think they need a work-up again, but I spin it in such a way that it comes across as if I'm doing something (for example, a thorough neuro exam, punctuated with a lot of "hmm, that's reassuring" type comments, coupled with an explanation of my thought process seems to go a long way). However, I suspect you know most of those tricks as well as I do. If I can't convince the person that not doing a work-up is to their benefit, and they're really demanding, then I'll do as little as I can get away with, reassure, and try once again to discharge. If all that fails then I either admit them or kick them out - which one depends on my level of certainty that they're OK, the difficulty of getting them admitted at that time, and their belligerence (if they threaten me or my staff I'll make it very easy for them to leave and I feel very comfortable with my dispo when I can write "Patient ambulated out of ED without assistance while yelling "you're a m*therf^cking piece of **** doctor!").

 

[GeneralVeers]

I generally try to explain why I don't think they need a work-up again, but I spin it in such a way that it comes across as if I'm doing something (for example, a thorough neuro exam, punctuated with a lot of "hmm, that's reassuring" type comments, coupled with an explanation of my thought process seems to go a long way). However, I suspect you know most of those tricks as well as I do. If I can't convince the person that not doing a work-up is to their benefit, and they're really demanding, then I'll do as little as I can get away with, reassure, and try once again to discharge. If all that fails then I either admit them or kick them out - which one depends on my level of certainty that they're OK, the difficulty of getting them admitted at that time, and their belligerence (if they threaten me or my staff I'll make it very easy for them to leave and I feel very comfortable with my dispo when I can write "Patient ambulated out of ED without assistance while yelling "you're a m*therf^cking piece of **** doctor!").

I have no problem with most of the above. My problem is that the hospital "investigates" all "client complaints" even from the crazies. That stresses me out far more than the patient interaction.

 

[docB]

I feel your pain. This is one of the biggest problems facing EM as a specialty. As our administrators become more and more fixated on "customer" satisfaction and as regulators embrace it as a way of limiting payment we will simply have to give in to more and more unreasonable demands by patients. There is no way to be the kind of steward of antibiotics and resource utilization and diagnostic radiation and all the other crap we are now supposed to be the stewards of and make the crazies happy.

The admins need to start to understand this.

The immediate and regrettable outcome of this is that the used car salesman doctor, i.e. the guy who can BS and back slap and make the wackies happy will be more valuable than the competent doctors.

 

[roja]

I agree this is stressful, more from the investigative stand point. I would make sure that you are comfortable with your dispo (thorough exam, etc.) and document VERY well.

Do you feel your chair doesn't back you in your department? this can make these investigations just a slight annoyance (departmental support) or truly painful (lack of support).

I document very well, explain to the patient, and document that. and take lots of DEEEEP breaths.

Here is a great discussion on patient vs customer
http://allbleedingstops.blogspot.com/2011/04/why-patients-are-not-consumers.html

 

[jbar]

I've heard of situations (usually on an inpatient team) where they get together with the patient, the PMD and the team and lay out in writing what the plan in. Ie "follow up with neurology, don't come back to the ED for the same problem. If you return for the same complaint you will not be admitted or CTed and will be discharged to this scheduled follow up." Then when they show up you can pull out the contract and say, you've agreed this is what we are going to do.

Sounds like a lot of work for the ED, but might be worth it for those "super utilizers," people who are coming in multiple times per week. Of course when they suddenly start complaining of chest pain you start all over.

 

[Birdstrike]

It can be brutal, yes. What set me free here was when this light bulb went off in my head: "I no longer care if they think they've faked me out. Let them! In fact, that's exactly what will get them happily on their way. This way everybody is happy". So I just work everybody up the same. You can never go wrong with that. Like WilcoWorld said, if I really know them well and I'm positive they aren't sick, I titrate the workup, and the hand holding up to a level that makes everyone happy, and then we're done.

However, when the chronic back pain-er develops the AAA, and I miss it because I'm in a battle of wills, or when the psuedo-seizure develops a real seizure, when the cocaine chest pain "jail-itis" has a real MI, when the chronic headache patient blows an aneurysm, then we've both lost.

I finally decided it's not personal. When I finally let go of "If I can prove you're crazy, I win" was when it got easier. I could care less if they're a hypochondriac, I could care less if the chronic migrain-er wants drugs, I could care less if the jail-itis person gets out of jail for the night. As long as the chart proves they don't have an aneurysm or an MI, I'm happy. I could care less if the hospitalist laughs, he's in the same boat. He'll learn eventually. The seasoned one's don't want to spend all their days off in depositions over a faker who finally has the big one, either.

I worked up a "chest pain jail-itis" one night who had enzymes through the roof.

A partner of mine had security shovel a "pseudoseizure" patient out into the parking lot and he had a real seizure, went into status, almost got run over by a car and got intubated.

One of our drug seekers got a PE and my partner missed it.

Another one of our worst "chest-pain-I-want-Dilaudid" patients came in with neck pain one day out of the blue, after a minor mva. My first thought, "he finally moved on to another complaint, huh?". I take one look at him, order a c-spine series without even examining him (yet) and he's got jumped c-spine facets! I couldn't believe it.

I could care less if they think they've faked me out. In fact, if they think they've faked you out, that's when they're really happy! They'll never write that complaint letter if they think you bought their act and worked them up! Because really, once they walk in the door, you've already lost, right? You've go to see them one way or the other. You've already started the game down 0-1. How hard is it to work up someone you know isn't sick? There's no stress at all. Every once in a while you'll get surprised and one's really sick! You've just got to get through that patient interaction with as little liability as possible. A chronic back pain-er that ends up paralyzed from an epidural abscess is a guaranteed lawsuit and an uphill defense. So treat everyone with respect (even if you have to fake it) for your sake, and give them the benefit of the doubt for your sake and let them think they've faked you out for your sake. That doesn't mean I acquiesce to every unreasonable drug demand, but I do the work up knowing that to "win" I have to get through the interaction avoiding liability, not prove to them that I know they have secondary gain.

 

[BJJVP]

I see Birdstrike's point of view. I wish I could do it...just haven't been able to. It's like a mental block.

There are guys in my group that work over 20 shifts a month and handle it like it's nothing. They never stress out, don't complain a lot, and are generally pleasant in the ER. Not surprisingly, they are the ones that can see crazy pts and work them up with Birdstrike's philosophy.

I've taken a different approach. I told myself that I don't care if this chronic back pain pt has a AAA. I don't care if this 4x/month migraine pt has an aneurysm. I don't care if you had a PE 10yrs ago after having your baby, your CTs have been negative once a month for 2 yrs...I am willing to blow off today's episode of chest pain. I simply tell myself, they've cried wolf too many times.

We've all heard someone say, "Crazy people get sick too." And while I agree, I also feel that they usually are not sick. I see their past ED visits as a way of helping me determine a pretest probability. When that probability gets low enough, no testing is warranted. I simply dictate a defensive chart with a lot of things that we all know really don't rule out anything...no abd bruits for AAA, no tachycardia for PE, nl EKG for ACS, nl neuro exam for SAH, etc.

We can debate the morality and ethics of this and undoubtly this would be a controversial topic. But as far as getting in trouble with administration, I am not too worried. I have the advantage of a very supportive chairman, and all complaints are reviewed through a peer review process done by ED physicians. I have come to believe that these kinds of misses are rare. When they happen, I will live with them. I am relatively young (4 yrs as attending) and so I may see things differently later on.

I really feel for those physicians without a supportive ED chair or director. I already feel burnout on many days but if the leadership of the dept were a press ganey *****, I would become downright suicidal.

 

[TysonCook]

Depends on how crushed we are, but in general I take BJJVP's stance. I don't "fight" much, I look at the chart, see what tests/workup have been done recently, and then talk it through with the patient.

I definitely do NOT cow to complaints, and I buff the chart. My mainstay is I start off with "how is this different?" if its the same I politely let them know that by definition their problem is NOT an emergency, but chronic. I validate their symptoms ("I don't deny that it hurts, or causes you stress"), but ultimately let them know that this HAS to be worked up as an outpatient.

....yes, I've also been known to have security escort them out.

Lastly, dictate in your note at the first line "Mr. X is a 33 year old female with 19 visits in the last 3 weeks for various complaints, including multiple workups for her presenting complaint tonight which is Y."

Reasoning is that the admin that gets your complaint is NOT going to do a huge chart biopsy, look up the patient on the DEA list, and frankly is probably not going to read more than the first few lines of your HPI. By getting in there at the beginning it helps paint the picture for them and allows you to convey the patients "situation".

 

[deleted77919]

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[TysonCook]

🙂 good catch! ummmmm....I'll go with a yes 🙂 it was a SHim.
😀

 

[Stitch]

I totally agree that these kinds of patients are one of the most difficult to deal with in EM, especially with increasing pressure to keep everyone happy. It's so draining because even if you did spend all day getting test after test after test, your workup would be negative, and they'd still leave unhappy.

I had some teenage girl who had months of abdominal pain that kept her from going to school (and in my book severity of disease is inversely proportional to number of missed work/school days). GI had seen her a few times and basically said there's nothing wrong with her. Mom, who was a nurse, and 'knew how things worked,' came in late at night on a weekend saying she wouldn't leave until her kid had been scoped. Needless to say, she left unhappy and I'm waiting for the complaint.

Often I'll ask people straight up what they're looking for. What do you feel hasn't been done yet? If it's something simple, like repeating the chest x ray, then I'll just do it. If they want an MRI or a scope or something I can't provide I just tell them that it's not within my power to get that done. I'll also try and find them follow up with a PCP and tell them that their PCP can be their best advocate and can better arrange further testing or referral whereas I can't. I also usually get the patient advocate in the room early. Where I am, they are more like physician advocates, and can set the bar of 'we can't help you more here.'

It doesn't always work, but I document thoroughly. I also usually document something empathetic sounding. "Understandably, Mrs X is quite frustrated that no answer has been found for her condition. After reviewing her lab work and previous work ups, I can find nothing acutely emergent with her current exam, however further evaluation as an outpatient is certainly needed to get to the bottom of her condition.

 

[The White Coat Investor]

It helps to remember the patient is the one with the disease. As unpleasant as it is for us for a few minutes or a few hours to interact with said person, can you imagine what it is to live your entire life as that person? That's gotta suck. Imagine what it's like to spend your spare time getting work-ups in the ER. Or feeling so addicted to a substance that you visit every ED in the city every couple of days trying to get 10 lortabs at a time? How big of a loser would you be?

It also helps to set clear limits. "I'm not going to give you any narcotics here or to go home with." After 2 or 3 repetitions most people get it. Then, when I leave the room to order a test or two or some toradol and tylenol, they elope.

The ones I hate are the ones with legitimate problems we can't fix. They keep coming back not because they're crazy, but because they hurt or are nauseated. There's usually some psych component to it, but chronic pain sucks.

 

[TommyTiger]

It helps to remember the patient is the one with the disease. As unpleasant as it is for us for a few minutes or a few hours to interact with said person, can you imagine what it is to live your entire life as that person? That's gotta suck.

Indeed, yet I don't care.

I don't get frustrated with patients because their problems seem illegitimate. Everything is legitimate. Nobody can be blamed for the indeterministic molecular chaos that has caused the snapshot that is today. Blaming is human rationalization, because social convention has it, you are only allowed to be angry with somebody, if they are not at fault.

The real and honest explanation is that whenever I act like a jerk, it is because my coping mechanisms are exhausted, and I am frustrated.

I don't have time, or want to have time, to dish out psychotherapy in the ER. I don't want to listen to every complaint, completely unrelated to the alleged problem, when I have to figure out fast whether there is something dangerous going on, and if not, whether admission is warranted.

However, these patients wouldn't frustrate me, if it wasn't for my colleagues. My co-workers have a different view on how patients should be treated with respect, than I have. For most of my co-workers (nurses, attendings), being polite and reserved comes first, even if it compromises diagnostic acuity. Furthermore, I am a PGY-1 in a European ****hole, and securing a license to work requires a few years of mandatory slavery. Consequently, I have to gauge diagnostics according to what the nurses believe is the best approach, to minimize snitching behind my back, not what will actually bring about the best result.

 

[deleted307836]

Question for the EM docs here: What percent of your patients present with actual emergencies? What percent falls into the "chronic but non-emergent" category? And what I'm most curious about... how many fall into the "complete BS" category?

 

[Rendar5]

Question for the EM docs here: What percent of your patients present with actual emergencies? What percent falls into the "chronic but non-emergent" category? And what I'm most curious about... how many fall into the "complete BS" category?

depends on the section of the emergency room i'm in. In non-fast track general ED areas, I'd say 10% of my patients come in with a true true emergency. But that's not a fair measurement to go by. How the hell is my patient supposed to know if they have a true emergency or not? Even if it's BS, how are they supposed to know if it's an emergency or not. So what you should be asking is what percentage of our patients should go to the ER to determine if what they're having is an emergency or not. And the truth is the vast majority are appropriate patients with maybe 5-10% of people presenting with BS and knowing it.

 

[deleted307836]

depends on the section of the emergency room i'm in. In non-fast track general ED areas, I'd say 10% of my patients come in with a true true emergency. But that's not a fair measurement to go by. How the hell is my patient supposed to know if they have a true emergency or not? Even if it's BS, how are they supposed to know if it's an emergency or not. So what you should be asking is what percentage of our patients should go to the ER to determine if what they're having is an emergency or not. And the truth is the vast majority are appropriate patients with maybe 5-10% of people presenting with BS.

Very good point, thanks 👍.

 

[deleted65604]

Marx: Rosen's Emergency Medicine, 7th ed.

Dealing with difficult patients is a common problem in the ED. The impaired patient-physician relationships associated with them have multiple negative implications for both patients and physicians. Their treatment may be optimized by using the general principles discussed in this chapter, by dealing realistically with one's own negative reactions, and by using techniques of crisis intervention where appropriate. These strategies are best applied within the context of a behavioral classification that avoids pejorative terms and stereotypes, labels that differentiate them from "worthier" patients.[11] Although this approach is not a panacea for dealing with difficult patients, the framework may help physicians render appropriate care while minimizing personal frustration, medicolegal exposure, and eventual physician burnout.

One of the great challenges of medical practice is to maintain humanity when caring for these difficult and highly vulnerable individuals. By focusing on their humanity, we have the best chance of preserving our own.[11] It is easy to care for patients who generate sympathy and noble to care for those who do not.[13]

In the end, the ability to accept distressing behavior as a symptom and to treat even the most irritating individuals with compassion and kindness may be the key to surviving them. When asked how he had avoided burnout after decades in emergency medicine, one well-known patriarch of the specialty simply responded, "You've got to love the patients."[31] This is a tall order, and not meant in the literal sense. But the degree to which we can show caring and empathy, even to the unlovable, may be the key to maintaining the quality of our care, our satisfaction with the specialty, and our long-term survival in practice.

I like the above quote.

I too, have an extremely hard time with these patients, so me giving you advice is like an obese person giving a lecture on weight-loss. However, I grew up with a borderline mother, so I think I have some insight into their monstrous inner psyche. There is something missing in certain people... a gaping defect in their personality, self esteem, judgement, and maturity.

I think that a lot of the patients that are most difficult could be diagnosed as having borderline personality disorder. One particular patient who we see in the ER a lot at my shop seems to read the borderline chapter like a script when she comes in to the ER. She really escalates with argumentation, and confrontation. I got in trouble one out of the 20 visits I've had with her, because I got exasperated with her and lost my cool. Borderlines read hostility in people and sense when they have lost support. When they sense that loss of support, they turn nasty and act out in an attempt to force you into submission. This is their specialty, manipulation, and splitting people into sides...for me and against me. They always win. It is like fighting with a grizzly bear. Eventually, you realize that it causes so much pain that you quit and just let them win.

Our psychiatrist has actually admitted this patient before to the psych ward, as well as come down into the ER to evaluate her (first and only time that a psychiatrist has been in my ER in 3 years). He recommended to us to minimize clinical contact, as this particular woman thrives on medical therapy. She is just so happy when she gets admitted (5% of the time) that it really escalates her behavior afterwards.

On those patient encounters where I know that things are going to be potentially ugly, I try to bring a nurse or tech in with me on initial evaluation and discharge. That way, I have a witness that I'm more likely to behave myself for, and there is a witness to what exactly transpired, as borderlines consistently misinterpret and misrepresent words and actions.

 

[Flopotomist]

I sorta do what Birdstrike does, but with an additional twist - If a patient has been in the ED 10 times in a month for some nebulous pain or weird cluster of non-life-threatening symptoms, I START my interaction with the patient by setting the expectations low for them so that at the end of the ED encounter, those low expectations are met.

"Wow, I see you have been here 10 times for these seizures, that must be scary - it sounds like you are going to need the help of advanced specialists that are more experienced in dealing with your complaint, so lets check and make sure that you don't have anything life threatening that I need to fix tonight, and then I will get you some phone numbers of people that can help you with this"

My other favorite tool is the ultrasound machine - these patients LOVE to have tests done, and the ultrasound is low risk to them, makes them happy, and gives me practice looking at normal anatomy.

"Mrs X, lets do an ultrasound of your belly and look at your heart, liver, kidneys, spleen, pelvic organs just to make sure everything is OK, and that there is nothing life-threatening that we need to fix before you can be seen next month by the specialist"

...takes a max of 5 minutes, and is way faster than spending 10 minutes explaining why you "aren't doing anything."

 

[WilcoWorld]

Jaracoba makes a good point - whenever possible I will ask another provider (nurse, tech, etc) to write a note about inappropriate behavior. This is supposition, but I expect that corroborating notes about someone's untenable behavior would be protective should complaints/lawsuits arise.

 

[doctorFred]

from my limited experience, i also find it helpful to specifically document as many of the patient's quotations and demands as possible. i've heard when cases like this go to administrative review, or (worse) legal review, it's damning to the patient's case to have things on the t-sheet like "pt. states she will 'sue the whole emergency department' if she is not CT scanned", "pt. calling nursing and physician staff 'incompetent'", etc. if your nurses will document as much as well, even better.

it also just makes me feel better at the end of the day when the official records portray me as a calm, sensible professional and the pt. as a nutjob. that is only, of course, if "loving the patients" doesn't work first. 😎

 

[loveoforganic]

My senior year of undergrad, I took a class under a health psychologist specializing in psychosomatic medicine - regularly works with internal medicine in hospitals to both work with those patients and train the IM docs how to work with those patients as well. I know EM works under a different set of rules and goals than IM, but might be something worth looking into.

 

[Old_Mil]

Now she's pissed off because I wouldn't do anything for her and launching a complaint.

Do you guys just do the bogus, wasteful tests on these people at every visit to placate them, or do you take the hit with a patient complaint and not do what they want?

This is seriously distressing, and I can't figure out how to deal with this lady if she comes back.

"Some Customers Aren't Worth Having"
http://www.amamember.org/sales/2004/nov_01.htm

(an idea that clearly hasn't quite made it from the board rooms of business to the board rooms of hospitals yet...). Yes, sometimes it is a good management strategy to piss someone off enough that they (and their friends) simply don't come back. Even if they file a complaint.

But lets face it...most hospital management is nurse-heavy, top-heavy, and inbred. These aren't Wharton school graduates who have had their business skills honed by free market competition in cut throat industries like investment banking... Most of them aren't nearly intelligent enough to get into medical school.

 

[Apollyon]

But lets face it...most hospital management is nurse-heavy, top-heavy, and inbred. These aren't Wharton school graduates who have had their business skills honed by free market competition in cut throat industries like investment banking... Most of them aren't nearly intelligent enough to get into medical school.

Ouch! But oh so true...

 

[GeneralVeers]

Ouch! But oh so true...

The nurse managers and administrators are told by the hospital elites that we must have "customer service" and "encourage people to return". This is exactly opposite of what I was taught in medical school. We should be encouraging people to find a primary doctor and seek care from them, not return to the ER for "any other concerns".

Why my admin cares what druggies/crazies have to say is beyond me. If normal people start complaining then it would be a problem.

 

[docB]

The nurse managers and administrators are told by the hospital elites that we must have "customer service" and "encourage people to return". This is exactly opposite of what I was taught in medical school. We should be encouraging people to find a primary doctor and seek care from them, not return to the ER for "any other concerns".

Why my admin cares what druggies/crazies have to say is beyond me. If normal people start complaining then it would be a problem.

This disconnect between reality and what ERs should be doing and the administrators trying to maximize reimbursing events is one thing that will make more people look to socialism.

I (and for anyone who doesn't know I'm an ardent anti-socialist) think that a benefit we would get out of single payer, universal is that "customer satisfaction" would go out the window and doing appropriate care would be the only mandate.

 

[AmoryBlaine]

It can be brutal, yes. What set me free here was when this light bulb went off in my head: "I no longer care if they think they've faked me out. Let them! In fact, that's exactly what will get them happily on their way. This way everybody is happy". So I just work everybody up the same. You can never go wrong with that. Like WilcoWorld said, if I really know them well and I'm positive they aren't sick, I titrate the workup, and the hand holding up to a level that makes everyone happy, and then we're done.

However, when the chronic back pain-er develops the AAA, and I miss it because I'm in a battle of wills, or when the psuedo-seizure develops a real seizure, when the cocaine chest pain "jail-itis" has a real MI, when the chronic headache patient blows an aneurysm, then we've both lost.

I finally decided it's not personal. When I finally let go of "If I can prove you're crazy, I win" was when it got easier. I could care less if they're a hypochondriac, I could care less if the chronic migrain-er wants drugs, I could care less if the jail-itis person gets out of jail for the night. As long as the chart proves they don't have an aneurysm or an MI, I'm happy. I could care less if the hospitalist laughs, he's in the same boat. He'll learn eventually. The seasoned one's don't want to spend all their days off in depositions over a faker who finally has the big one, either.

I worked up a "chest pain jail-itis" one night who had enzymes through the roof.

A partner of mine had security shovel a "pseudoseizure" patient out into the parking lot and he had a real seizure, went into status, almost got run over by a car and got intubated.

One of our drug seekers got a PE and my partner missed it.

Another one of our worst "chest-pain-I-want-Dilaudid" patients came in with neck pain one day out of the blue, after a minor mva. My first thought, "he finally moved on to another complaint, huh?". I take one look at him, order a c-spine series without even examining him (yet) and he's got jumped c-spine facets! I couldn't believe it.

I could care less if they think they've faked me out. In fact, if they think they've faked you out, that's when they're really happy! They'll never write that complaint letter if they think you bought their act and worked them up! Because really, once they walk in the door, you've already lost, right? You've go to see them one way or the other. You've already started the game down 0-1. How hard is it to work up someone you know isn't sick? There's no stress at all. Every once in a while you'll get surprised and one's really sick! You've just got to get through that patient interaction with as little liability as possible. A chronic back pain-er that ends up paralyzed from an epidural abscess is a guaranteed lawsuit and an uphill defense. So treat everyone with respect (even if you have to fake it) for your sake, and give them the benefit of the doubt for your sake and let them think they've faked you out for your sake. That doesn't mean I acquiesce to every unreasonable drug demand, but I do the work up knowing that to "win" I have to get through the interaction avoiding liability, not prove to them that I know they have secondary gain.

While I respect this approach I genuinely disagree with it.

I think these patients have broken the doctor-patient relationship. All this stuff about professional ethics and that relationship was conceived in a time when 90% of people who went to the doctor were sick and probably 98% of them were thankful and expected to pay their bill in full.

I would argue that with the abusive, borderline ED frequent flier there is no therapeutic relationship. This person represents all risk and no benefit to the treating physician. If you were running a family med office and a patient continually showed up, abused your staff, never paid their bill, and refused to leave your office you would call the police to have them removed and ban them from your practice.

We simply do not have a professional obligation to these people, we only have an unfunded federal mandate.

If the lady with chest pain x 3 years who comes in 3x/week and demands extensive testing ends up with a PE and you "miss" it, so what? Obviously there may be legal and administrative fallout but that doesn't mean you did anything wrong.

The ethics of the doctor-pt relationship demand that when someone presents to you in acute pain or distress that you make an honest, thoughtful effort to diagnose them and treat them appropriately. They do not demand that you have 100% diagnostic accuracy in picking the one time out of 100 that the patient with continued vague complaints is actually sick.

If something is missed, it is their fault, not yours.

 

[RustedFox]

Amory - I've held this standpoint for a long time, and have voiced my opinion several times in our weekly conferences. I was shocked when I heard the majority of my attendings disagree and say things like - 'no, no, no - you have to maintain the.... whatever... relationship'. The one or two attendings that do agree with me are visibly regarded as 'lunatic fringe' by the others.

I had an idea the other day. The first time I am named in a frivolous, ridiculous lawsuit - I'm countersuing for whatever I can. Lost time/wages, defamation of character, slander, libel, "emotional pain and suffering", whatever. I don't even care if its a phyrric victory. What I want to have happen is this; "if" there is a next time, I want that attorney to pick up that piece of paperwork and say - "Nope, we're not going after Dr. RustedFox.... he comes back... with teeth."

Maybe then, those *falkers* will learn.

 

[Old_Mil]

The ethics of the doctor-pt relationship demand that when someone presents to you in acute pain or distress that you make an honest, thoughtful effort to diagnose them and treat them appropriately. They do not demand that you have 100% diagnostic accuracy in picking the one time out of 100 that the patient with continued vague complaints is actually sick.

If something is missed, it is their fault, not yours.

Unfortunately, the workings of the legal system demand something a bit different.

I'm perfectly content spending millions of dollars of a government that won't give me appropriate malpractice protections so I can use my brain working up people.

I'm just not willing to give them narcotics in the process.

 

[GeneralVeers]

I agree that there is no patient-doctor relationship with these people. I will treat them professionally, but I'm not going to go out of my way to be nice to them. I will do the bare minimum of labs/imaging etc. to get them out of the ER but I will not give pain medications or do invasive unnecessary testing that they want.