LouisianaDoctor

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Hi all,

I'm am FM resident that moonlights extensively in a ER that sees around 150-160 patients per day. We serve a somewhat dysfunctional population and the majority of our patients ... you know the story. My question is how do you guys deal with unhappy patients that cannot begin to understand your medical decision making?

Example: Yesterday a female in her 30s came in complaining that she was in some type of wreck and hurt the "whole right side of her body." I examined her thoroughly and found nothing that made me feel the need to x-ray her or her sore shoulder. I explained this to her carefully, and she looked at me blankly and said "I need you to x-ray my shoulder." I again explained it to her and she then said "I need you to x-ray my other shoulder then." I again explained that I did not think it was necessary, that it would likely cause more harm than good, but again she says "Ok. But can you x-ray my shoulder?"

Yes, she probably was crazy. So, in our ER, when a patient complains about you, it goes to administration, who then sends you an e-mail and pulls the chart, and you have to write a long summary of why the complaint happened, what happened, and explained your side of the story. The last one I had to write took me about 20 minutes.

So, would you:

1. Again explain that you do not need to x-ray her, wish her a good day, and discharge her. Only to have her file a complaint against you, which will then require headaches outside of work time, a complaint in your file, and possibly jeopardize your supplemental source of income while you're being paid $42,000 as a resident supporting a family and a newborn, or:

2. Needlessly x-ray her arm, expose her arm and chest to radiation, needlessly increase the cost of healthcare, and prolong her 5 minutes triage level 4 stay to a 35 minutes stay?

I chose #2. It's not the best decision making, I 100% acknowledge that. But how do you balance practicing the best medicine without putting your livelihood at risk? During every patient encounter I ask myself "What is the best thing I can do for this patient?" But it seems often what is best for the patient is not what they want. And in the world of "customer"-review based medicine and reimbursement, how do you deal with this?
 

TimesNewRoman

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You're the doctor, not her. If she doesn't need a test, rx, work excuse, etc. don't do it.

I know it's a lot more complicated than that, but there's a reason why patients can't order their own tests.
 

Birdstrike

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Hi all,

I'm am FM resident that moonlights extensively in a ER that sees around 150-160 patients per day. We serve a somewhat dysfunctional population and the majority of our patients ... you know the story. My question is how do you guys deal with unhappy patients that cannot begin to understand your medical decision making?

Example: Yesterday a female in her 30s came in complaining that she was in some type of wreck and hurt the "whole right side of her body." I examined her thoroughly and found nothing that made me feel the need to x-ray her or her sore shoulder. I explained this to her carefully, and she looked at me blankly and said "I need you to x-ray my shoulder." I again explained it to her and she then said "I need you to x-ray my other shoulder then." I again explained that I did not think it was necessary, that it would likely cause more harm than good, but again she says "Ok. But can you x-ray my shoulder?"

Yes, she probably was crazy. So, in our ER, when a patient complains about you, it goes to administration, who then sends you an e-mail and pulls the chart, and you have to write a long summary of why the complaint happened, what happened, and explained your side of the story. The last one I had to write took me about 20 minutes.

So, would you:

1. Again explain that you do not need to x-ray her, wish her a good day, and discharge her. Only to have her file a complaint against you, which will then require headaches outside of work time, a complaint in your file, and possibly jeopardize your supplemental source of income while you're being paid $42,000 as a resident supporting a family and a newborn, or:

2. Needlessly x-ray her arm, expose her arm and chest to radiation, needlessly increase the cost of healthcare, and prolong her 5 minutes triage level 4 stay to a 35 minutes stay?

I chose #2. It's not the best decision making, I 100% acknowledge that. But how do you balance practicing the best medicine without putting your livelihood at risk? During every patient encounter I ask myself "What is the best thing I can do for this patient?" But it seems often what is best for the patient is not what they want. And in the world of "customer"-review based medicine and reimbursement, how do you deal with this?
In reality, most people do #2. Is that the "right thing"?

You tell me.

I'm about to post a long post about this that will explain my views on this whole problem more. It's an ethical dilemma. The above scenario is pretty mild. It gets much more uncomfortable when a parent inappropriately demands that you irradiate the brain of their kid with an unnecessary CT or a patient demands a prescription you think might fuel an addiction or diversion. This is just one more example of how customer satisfaction obsessed medicine promotes lower quality, more expensive and in many cases, more harmful care. Get used to it.

Another thought is this. This patient may not have been "crazy" as you state. Often times, people come to the ER a few days after an accident with no apparent injury. Sometimes it's because they've contacted a lawyer that advises them to go the the ER immediately to "get some X-rays" to document an injury, anything, even a scratch or bruise, which gives them a basis on which to sue over the accident. Pain and suffering, disability payments, lost wages, and all the rest follow. It's a huge industry.

I've had many patients, when asked why they came to the ER after a seemingly insignificant accident, admit bluntly, "My lawyer told me to."

Everyone has to decide where their comfort level is on these issues. The "Textbook of Customer Satisfaction Based Medicine" will have a whole different set of acceptable differential diagnoses, tests and treatment, as compared to the medical textbooks you were taught from.
 
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Mr. Hat

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This is a tough subject. Obviously we should be able to practice good medicine, and do what we know is really in the patient's best interests. However, we also live with the reality of customer satisfaction metrics and hospital administration.

I worked at an ED which had a long-standing democratic group. They were committed to the community, had a long-standing relationship with the hospital, provided excellent care for which they won several awards, and were a generally awesome group of people to work with. The first ominous sign came when a well-loved physician was barred from hospital privileges (and thus had to be fired from the group), after getting on the CEO's bad side due to not giving into the unreasonable demands of some unfortunately well connected patients (or so the story goes at least). Fast forward a year and the entire group, with minimal notice, is pushed out of the door and a national staffing group is brought in. Thanks for the decades of service guys, hit the street. The reason they were given? "Satisfaction scores". They hadn't really gone down or anything, and in fact were still among the highest ED scores within the corporate system - I actually verified this - but hospital leadership just wanted them to go up up up and decided a new group was the way to achieve this. Men and women who had made lives in the community, built homes, and had kids in the local schools suddenly found themselves jobless. A select few were offered jobs with the new staffing company at substantially reduced pay, but most were just out. I watched many of them go through months of uncertainty trying to find new local-ish jobs, and watched several have to uproot their entire lives and move elsewhere.

The new group came in and while some of them were pretty good, many were not nearly up to the level of our previous group. BUT they were willing to do the hospital's bidding. Several drug seekers we hadn't seen in ages started showing back up, and a few even admitted to the nurses that word on the street was you could score the narc's again here. Docs who couldn't meet satisfaction metrics were out the door - and a revolving door it truly was - as we would see docs coming and going every couple of months. In the first year alone we went through something crazy like 20 new doctors. You couldn't walk in for a shift without seeing a doctor you didn't recognize. In the end they ended up with a stable group of generally decent people, but "customer satisfaction" truly rules that shop now.

The moral of the story for me? We can talk about doing "the right thing" all day long, but at the end of the day most of us also have families to support and want to be able to settle down somewhere and buy a house. Would you rather order the unnecessary ankle x-ray and write the soft Vicodin scrip, or would you rather have to sell your house, pull your kids out of their school, and move? It's a real dilemma that is only becoming more and more real, as idiot administrators sell their souls to Press-Gainey.

At the end of the day it's a personal choice, but after watching what I did, I will never blame any emergency physician for doing what they have to do in order to preserve their own livelihood and happiness. It's a sad, sad state of affairs to be sure. But it is what it is.
 
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dotcb

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The right answer is #1. In reality, most days I would do #2 if I'd given it my best shot at trying to explain my way out of it. Paying for the XR becomes the patient's or their insurance company's problem. I am not afraid of patient complaints or defending my clinical decisions, but having to write an explanation about things like after the fact this is completely not worth the hassle.

For longevity and happiness in EM, you just can't be dogmatic. Refuse to bend, and you'll get broken.

A patient this week told me "I'm not leaving without a head CT. I think it would be negligent if we didn't rule out a stroke." I tried to explain myself. He refused to listen. Then I ordered a CTH. Totally not worth it. After we were done, he requested an echo. Didn't do that.
 

EM4life

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I agree with the above posters, I think also it really matters why you think the patient is demanding the imaging/test that you don't think is necessary. It reminds of a case many years ago I had of an old lady with constipation, she pooped, and then refused to go home, yelling in the room about she needed to stay in case it happened again. No one could talk any sense into her, until my attending brought her a box of gloves and lube and told her she can disimpact herself if it happens again. She just wanted to have her way or for us to give her something.

Generally in cases, where the patient and I clearly are not in the same wavelength, I try to figure out why they want the test so bad. Is it due to accident/lawsuit pending/work comp issue? Is it because they are legitimately batsh*t crazy, is it a genuine concern that truly isn't warranted that would benefit from me sitting down with them and doing a little education, or is it a lack of understanding of what we can or cannot do in the ED, in which case I often will call the PMD to establish proper fu and outpatient wu.

If I end up conceding to ordering an unnecessary test, I will also usually tell the patient that I think it is highly likely that the test result will be negative and fully document an informed consent "pt understands radiation risk with doing head CT etc versus alternatively trialing a period of observation." I figure once the test comes back negative, maybe they won't the next doc's clinical judgement as much (though I agree that is overly optimistic :)
 

RustedFox

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There's no way to win. Simple as that.

I'm a guy that says - "Fine, have your negative shoulder x-ray and your negative CT brain. Whatev. Stay 'satisfied', whatever that means to you."

Then, I had to have a 'discussion' with management about my 'length of stay times being too long'. Nevermind that 'length of stay' is entirely dependent on the availability of resources such as rads/nursing/consultants/etc, and has less to do with the time that I actually spend with a patient.


There's no way to win when you're being 'managed' by bean-counters, or worse; what I like to call "SuckerMDs"; those who stopped being clinicians and started being 'managers'.
 

Rendar5

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You give her a Rx, give her a cool-sounding diagnosis that sounds good to a jury, and you talk about how, fortunately, the cause of the pain is so obvious that you don't even need an x-ray to diagnose it. just talk em up. Oh, and you tell them that they're going to be in more pain the next 2 days after it, but fortunately, they'll be feeling a lot better after that. That way they don't return just because the pain is worse.

Oh, and I'm only really supposed to give narcs out for broken bones. They unfortunately won't let me do it for anything less or i'll start getting in trouble.
 

dotcb

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XR's or CT scans - I'm open to doing these things in the right circumstances. I'm humble and have been wrong before. MRI's or unnecessary antibiotics - I will put in quite a bit more time & effort to avoid. But I'll never say never.
 

Daiphon

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Depends on what they want... isolated extremity XR is unlikely to cause any problems down the road, but spending an extra 10 minutes arguing with an uninformed and entitled "customer" impacts my other patients. Getting said XR gets them out faster and opens up a room for someone who actually (maybe) needs it.

Now, when we start talking about CTs and whatnot, then I'll spend the time talking and documenting.

When they start asking about MRIs and the like, well, then I flat out refuse (unless I think they actually need it, which is *very* rarely).

It comes down to what fights you want to fight, and how much intellectual capital you want to spend on people that don't get it... and will likely go down the street to another ED and get the XR anyway. In a perverse manner, it's actually more cost effective to just get the worthless XR in your own shop - they won't go elsewhere & generate a new E&M code.

Plus, if on Medicaid, then when I get paid by it it's somewhat of a tax return, no? d=)
 

EM_Rebuilder

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Take this a step further and tie a significant part of your pay to invalid Press Ganey scores....

We get a score that follows a quarterly segment (last 3 months). My most recent had an n of 7; the last one I got was an n of 9. I scored mid 80s both times; it took ONE patient of those 7 to give me low scores to bring me into the 80s. I guess that makes me a bad doctor, right? Best part was that one of my comments stated "Dr EM_Rebuilder and his student was excellent, the Ophthalmologist not so much".. yet I get the ding! A colleagues this month physician section stated the TV did not work right; another said the Ortho resident did not know what he was doing.

The problem is that we are looking at a pay restructure with potentially up to 25% or so of our pay TIED directly to the PG score, with the pay falling exponentially below 90%.

Now what do you do? Whats right for the patient or whats right to feed my family? Sure, my family wont starve if I do not get that 25% of pay, but something will suffer that I worked hard for. Retirement funding?? College funding?? Maybe I should move into a smaller house or no longer travel?? At what point do you cave and salute, Narcotics for all!! Xrays for all!!
 

Arcan57

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As a matter of practicality, if you're arguing with a patient over whether to get a test then you've already bought a poor PG. A good PG score requires VGs on the survey and if you're arguing with the pt then you're not getting a VG. If you cave and order the test, it doesn't give the patient warm and fuzzies. It makes them think that you've weren't paying enough attention on your initial exam and that your medical judgment is poor.

Now some will hear this and despair but it's actually liberating. Once you know that the patient's going to give you low scores, you're free to do what's medically indicated. Now if you're interested in not getting into the situation in the first place, then you have to find out what the patient's expectations are up front. Then it becomes a negotiation with the patient about redefining expectations and DIRECTLY addressing what they are afraid of happening. There is no substitute for communication in getting good PG scores. You can order all the narcs and MRIs you want and without that piece you're still going to fail. And with that piece, you can be a hard ass to drug-seekers and do what's medically indicated and still get >90% (if your system gives you a chance to succeed). This doesn't help with the patients backdooring admin to complain but if your PG scores look good then it's much easier just to point up and go "Scoreboard".
 

WilcoWorld

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The problem is that we are looking at a pay restructure with potentially up to 25% or so of our pay TIED directly to the PG score, with the pay falling exponentially below 90%.

Now what do you do? Whats right for the patient or whats right to feed my family? Sure, my family wont starve if I do not get that 25% of pay, but something will suffer that I worked hard for. Retirement funding?? College funding?? Maybe I should move into a smaller house or no longer travel?? At what point do you cave and salute, Narcotics for all!! Xrays for all!!
What about finding another job (aka voting with your feet)? Just today I've deleted multiple emails offering me jobs that I wouldn't have to move for.
 

Dr.McNinja

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Satisfaction=Performance/Expectations. If you don't set reasonable expectations, no performance will give satisfaction.
Also, it's no longer your PG score, it is the "top box", which is the percent that are 5's. Thus, the random low score won't hurt you as bad as the guy that's always just kind of good.
 

emergentmd

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We all know which patients are reasonable and which wants xrays/CT/Labs.

Once I start talking to them, I can tell that they want an Xray/abx no matter what. I can speak til I am blue but its easier to just give in right off the bat. We all Do it to an extent and the ones who denies it is lying to themselves.

If we all practice correct medicine, We would probably draw blood in 20% of our patients, xray 10%, CT 5% of our patients. But the fact is I draw blood on 60%, xrays 40%, CT 20%.

Think about it.

Xray pt = happy pt, happy admin, pt will not come back
Do not xray = unhappy pt, compaints to admin, pt will come back later to get their xray.

Pick you battles, its not worth it to fight all mcdonald's type pts. They want it supersized sometimes