Does anyone just like....hate this?

[dadaddadaBATMAN]

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I assume you probably mean just discharge. I’ve seen some physicians make rude or disruptive patients without emergencies leave AMA, which never made sense to me. It isn’t your advice for them to stay, and making them leave AMA doesn’t really ‘punish’ them or even protect you if not truly indicated. If you make them leave AMA, then that implies you wanted them to stay, which you don’t. AMA paperwork by itself also doesn’t offer a ton of legal protection vs. the actual conversation and charting in your MDM. If I don’t think a rude or disruptive patient has an emergency, then I discharge them and have security escort them out if they won’t leave peacefully. Luckily I’m not as beholden to patient satisfaction at my job like some others, so I don’t have to bend over backwards for clearly obnoxious patients. I also chart quotes. I try to keep the charting as objective and non-judgmental as I can. On the rare off chance I was wrong and it comes back to bite me, then I don’t want it to easily look like my care was clouded by being judgmental.

If they are saying “or else” I am presuming they are declining some sort of workup. If they are refusing a workup, they can leave ama. I treat them like any other discharge and tell them to come back if they change their mind. I will let people choose not to be npo after documenting it, but I’m not getting them coffee or a tray.

if no workup was indicated, then I was already writing the dc order anyway. If they’re a jerk they get security.

quotes aren’t adversarial. Quotes are quotes. I don’t interpret them, I just write pt informed me he was refusing workup and demanded coffee. Pt then left.

 

[Mount Asclepius]

Agree with the above. I feel like this job trains you to hate people

It’s almost impossible to work as an EP over a long period of time without developing a dislike for people. These are the changes that I think are key to restoring physician satisfaction as an EP:

1) In an EMTALA bound environment, autonomy has to be increased to dictate patients’ ED course, care and disposition. We can’t select or fire our patients. They just show up 24/7/365. Therefore, we need to have more control over those that we do see. If it isn’t an emergency, then we shouldn’t be obligated to continue to provide care for them unless we want to and there is a clear financial benefit to doing so that both the patient and physician mutually agree upon. Patient satisfaction for ED patients doesn’t correlate with improved care. Our work shouldn’t be tied to patient satisfaction metrics. Even if you wanted to use patient satisfaction, the metric should be applied to patients with emergencies that you stabilized and not the worried well without emergencies that you discharged home.

2) Improved medicolegal protection. A high percentage of testing we do in the ED is for medicolegal protection, and also a large percentage for patient satisfaction. We often don’t feel testing is indicated or want to order, but pretty much have to a lot of the time for the above reasons. We can’t practice medicine if the lawyers and patients are doing it for us.

3) Decrease the level of charting required. Most charting is medicolegal protection. The second biggest reason is billing. Very little is actually done for future patient care.

4) Payment for services provided needs to primarily go to those providing the services. I’m lucky to work in an environment where this is the case, but many aren’t who are employed by CMGs. Also, billing shouldn’t be so tedious. A certain number of ROS elements shouldn’t dictate how much we are paid. No one honestly goes through and documents an entire ROS for every level 5 encounter.

5) Decrease circadian rhythm disruption. Most presentations to the ED aren’t emergencies. If it’s not an emergency, it can wait until the morning. No one pays a plumber or an electrician to come to their house in the middle of the night because a toilet won’t flush or their TV stops working. Many things can wait until the morning. If EDs can significantly decrease overnight staffing, then it will dramatically improve the quality of life of EPs. We can be on call with a quick response time like other physicians. It’s not perfect, but seems like a satisfactory compromise.

None of these are easy to address, hence why the odds of EPs continuing to dislike people and burnout is high. The solution is potentially there though.

 

[dadaddadaBATMAN]

It’s almost impossible to work as an EP over a long period of time without developing a dislike for people. These are the changes that I think are key to restoring physician satisfaction as an EP:

1) In an EMTALA bound environment, autonomy has to be increased to dictate patients’ ED course, care and disposition. We can’t select or fire our patients. They just show up 24/7/365. Therefore, we need to have more control over those that we do see. If it isn’t an emergency, then we shouldn’t be obligated to continue to provide care for them unless we want to and there is a clear financial benefit to doing so that both the patient and physician mutually agree upon. Patient satisfaction for ED patients doesn’t correlate with improved care. Our work shouldn’t be tied to patient satisfaction metrics. Even if you wanted to use patient satisfaction, the metric should be applied to patients with emergencies that you stabilized and not the worried well without emergencies that you discharged home.

2) Improved medicolegal protection. A high percentage of testing we do in the ED is for medicolegal protection, and also a large percentage for patient satisfaction. We often don’t feel testing is indicated or want to order, but pretty much have to a lot of the time for the above reasons. We can’t practice medicine if the lawyers and patients are doing it for us.

3) Decrease the level of charting required. Most charting is medicolegal protection. The second biggest reason is billing. Very little is actually done for future patient care.

4) Payment for services provided needs to primarily go to those providing the services. I’m lucky to work in an environment where this is the case, but many aren’t who are employed by CMGs. Also, billing shouldn’t be so tedious. A certain number of ROS elements shouldn’t dictate how much we are paid. No one honestly goes through and documents an entire ROS for every level 5 encounter.

5) Decrease circadian rhythm disruption. Most presentations to the ED aren’t emergencies. If it’s not an emergency, it can wait until the morning. No one pays a plumber or an electrician to come to their house in the middle of the night because a toilet won’t flush or their TV stops working. Many things can wait until the morning. If EDs can significantly decrease overnight staffing, then it will dramatically improve the quality of life of EPs. We can be on call with a quick response time like other physicians. It’s not perfect, but seems like a satisfactory compromise.

None of these are easy to address, hence why the odds of EPs continuing to dislike people and burnout is high. The solution is potentially there though.

I have daydreams too. Mostly that I can shoot energy beams with my hands or that I could magically blast Ken/Karen to a third world country for two weeks with no resources.

 

[Mount Asclepius]

If they are saying “or else” I am presuming they are declining some sort of workup. If they are refusing a workup, they can leave ama. I treat them like any other discharge and tell them to come back if they change their mind. I will let people choose not to be npo after documenting it, but I’m not getting them coffee or a tray.

if no workup was indicated, then I was already writing the dc order anyway. If they’re a jerk they get security.

quotes aren’t adversarial. Quotes are quotes. I don’t interpret them, I just write pt informed me he was refusing workup and demanded coffee. Pt then left.

I think I agree with most of your points. Maybe it’s just splitting hairs. I guess I practice that you do everything you can to keep a patient from leaving AMA and rarely utilize it. If allowing them to have a coffee (and it’s easily available) will keep them from leaving so that you can complete a workup, then just let them have it. If they are rude and disruptive, but I think they still need further evaluation to determine that there isn’t anything emergent occurring, then I have a terse conversation with them outlining what kind of speech and behavior is tolerated (still ridiculous that its necessary to interact with adults who act like children). I don’t assume that they are declining a workup without confronting them. These aren’t pleasant conversations, but I’m sometimes surprised by jerks who completely change their demeanor and the whole encounter through deescalation over something minor like a coffee. I don’t like talking to patients as much as the next person, but I find myself stewing more so over the difficult patient that storms out of the ED than if I find a different workable solution.

 

[zurned]

Why get the patient a turkey sandwich? I don't get a tip, and don't get extra money. My time is better spent seeing another patient and racking up more RVUs. If the hospital allows me to accept cash tips, or pays me to do other people's jobs too then I have no problem.

Cuz it takes 5 minutes off your 12 hours doing an unimportant and mindless easy task that you are getting paid for time-wise. I guess I could be intubating Someone for 5 minutes for the same amount of money.

 

[RustedFox]

Cuz it takes 5 minutes off your 12 hours doing an unimportant and mindless easy task that you are getting paid for time-wise. I guess I could be intubating Someone for 5 minutes for the same amount of money.

You're either a resident, or you aren't paid for productivity.

 

[Dr Mantis Toboggan]

He would do...I mean make the intern do, anything for the Press Ganies.

What a weak pathetic man.

 

[lucid_leprechaun]

Bizarre move by the attending. My response would have been ama paperwork. I would also have probably put in his quotes verbatim in the chart

Agreed I document the behavior and tell to person to leave my ER until they can act like an adult.

 

[dadaddadaBATMAN]

I think I agree with most of your points. Maybe it’s just splitting hairs. I guess I practice that you do everything you can to keep a patient from leaving AMA and rarely utilize it. If allowing them to have a coffee (and it’s easily available) will keep them from leaving so that you can complete a workup, then just let them have it. If they are rude and disruptive, but I think they still need further evaluation to determine that there isn’t anything emergent occurring, then I have a terse conversation with them outlining what kind of speech and behavior is tolerated (still ridiculous that its necessary to interact with adults who act like children). I don’t assume that they are declining a workup without confronting them. These aren’t pleasant conversations, but I’m sometimes surprised by jerks who completely change their demeanor and the whole encounter through deescalation over something minor like a coffee. I don’t like talking to patients as much as the next person, but I find myself stewing more so over the difficult patient that storms out of the ED than if I find a different workable solution.

I don’t send these people without talking to them. If I hear them saying something like that or the nurse tells me I walk in and tell them that I recommend they not eat/drink if they should be npo, but if it’s that or no workup they can have it but might delay blah blah blah. If they aren’t reasonable or are demanding we use our staff to perform non clinical duties i point out the door. I don’t lose sleep over this. If the whole thing is documented, I have trouble believing they’ll find a sympathetic jury, but I’m in a pretty good malpractice environment.

I don’t document ama for legal purposes, though I think it doesn’t hurt anything there. I do it for communication with other docs regarding why a standard workup didn’t happen, I do it for the ombudsman, and I do it for the Monday morning qbs (the qa comittee and abrasive specialists). I find that it does seem to prevent these things from escalating.

edit: if they leave without my having a chance to talk to them I just write that down and don’t lose sleep over it. I make a reasonable attempt to contact them (phone call x2) to have ama conversation, document that, then go about my business. I always discuss my differential during my initial pass, and so I note the life threats/disabling conditions pt was aware of and that they left before we could rule these out and knew it.

 

[zurned]

You're either a resident, or you aren't paid for productivity

Yep, hourly only. Truly a cog’s job.

 

[GeneralVeers]

I don’t send these people without talking to them. If I hear them saying something like that or the nurse tells me I walk in and tell them that I recommend they not eat/drink if they should be npo, but if it’s that or no workup they can have it but might delay blah blah blah. If they aren’t reasonable or are demanding we use our staff to perform non clinical duties i point out the door. I don’t lose sleep over this. If the whole thing is documented, I have trouble believing they’ll find a sympathetic jury, but I’m in a pretty good malpractice environment.

I don’t document ama for legal purposes, though I think it doesn’t hurt anything there. I do it for communication with other docs regarding why a standard workup didn’t happen, I do it for the ombudsman, and I do it for the Monday morning qbs (the qa comittee and abrasive specialists). I find that it does seem to prevent these things from escalating.

edit: if they leave without my having a chance to talk to them I just write that down and don’t lose sleep over it. I make a reasonable attempt to contact them (phone call x2) to have ama conversation, document that, then go about my business. I always discuss my differential during my initial pass, and so I note the life threats/disabling conditions pt was aware of and that they left before we could rule these out and knew it.

I don't waste my time with these people. They need to leave and I don't care how. If you are screaming and yelling, and making threats, and can walk out of the department you likely don't have an emergent condition.

 

[Mount Asclepius]

I don't waste my time with these people. They need to leave and I don't care how. If you are screaming and yelling, and making threats, and can walk out of the department you likely don't have an emergent condition.

You’ll be right the vast majority of the time. The problem is the rare time you aren’t. These ridiculous people can occasionally have something going on. A bad outcome plus an angry patient is what leads to litigation. It’s rare you’ll be in that situation, but this is how you get there. I can’t say I won’t be in the same boat, but I think it’s important to be cognizant of this fallacy.

 

[GeneralVeers]

You’ll be right the vast majority of the time. The problem is the rare time you aren’t. These ridiculous people can occasionally have something going on. A bad outcome plus an angry patient is what leads to litigation. It’s rare you’ll be in that situation, but this is how you get there. I can’t say I won’t be in the same boat, but I think it’s important to be cognizant of this fallacy.

Just document you discussed it with them, whether or not you did. Who's going to take Crazy McCrazyFace at his word?

 

[Mount Asclepius]

Just document you discussed it with them, whether or not you did. Who's going to take Crazy McCrazyFace at his word?

You are potentially right. I don’t like being drug into the muck of dishonesty though just because that is commonplace of many of the patients we interact with in the ED. We shouldn’t have to manipulate truth because our medicolegal risk is more important than the patient in front of us. Sadly that frequently seems to be the case. This is a window into a much bigger philosophical discussion regarding if it is okay to to be dishonest or ‘harm’ (theoretically, or in some seemingly insignificant manner) someone who is ‘evil’ for the benefit of the rest of the ‘good’ you provide to everyone else.

 

[GeneralVeers]

You are potentially right. I don’t like being drug into the muck of dishonesty though just because that is commonplace of many of the patients we interact with in the ED. We shouldn’t have to manipulate truth because our medicolegal risk is more important than the patient in front of us. Sadly that frequently seems to be the case. This is a window into a much bigger philosophical discussion regarding if it is okay to to be dishonest or ‘harm’ (theoretically, or in some seemingly insignificant manner) someone who is ‘evil’ for the benefit of the rest of the ‘good’ you provide to everyone else.

If you aren't manipulating the truth, then you aren't charting correctly. See our discussions on documentation of chest pain patient.s

 

[Mount Asclepius]

If you aren't manipulating the truth, then you aren't charting correctly. See our discussions on documentation of chest pain patient.s

I’m fairly comfortable documenting their description of chest pain pretty close to how they describe it. I aggressively workup chest pain in the ED obtaining an EKG and troponin(s) on almost everyone even those in their teens (evaluate for myocarditis) and 20s/30s as I have seen ACS in that age group more than once. I heavily utilize ddimers and CTAs. I also aggressively discharge these patients with negative workups, which is the vast majority. I don’t care if they describe their chest pain as heavy, pressure or someone sitting on their chest. If their workup is negative, I’m not concerned, and I don’t worry the least bit that documenting truthfully is going to come back to bite me down the road. Similarly, if their pain is sharp, located in their neck, reproducible on exam or resolving with a GI cocktail, it doesn’t matter if their EKG reveals a STEMI. You only get sued if there is a bad outcome, not because a patient hoots and hollers that an elephant is sitting on their chest causing crushing pain. I’m not terribly worried of missing ACS if they are that dramatic with a normal EKG and high sensitivity troponin x2 that is negative. We are all likely going to have a chest pain patient go home and die shortly thereafter at some point in our careers. I don’t think that because I called their pain sharp, it is going to prevent me from being sued or potentially losing. I think that I practice good care that is standardized, but that doesn’t make me infallible from litigation in our ridiculous environment. Nor in my opinion does innacurately calling all discharged chest pain sharp and reproducible.