Patient Complaints

[thegenius]

Now I just don't care. I ignore the appeals from admit to hand out business cards, sit, tell them "We are going to take VERY GOOD care of you" and all of the other nonsense. I just smile and nod when they suggest this, and continue doing things my own way. Want to send a secret shopper? GREAT! you caught me red-handed.

That's happened to you?!?!?!

Someone willing to get blood draws and testing done just to see how good you are at "being a doctor" / customer service?

---

Members don't see this ad.

 

[thegenius]

My goal is to save ~$2M while helping my patients as much as possible, or at least not harming them. Financially as well as health-wise.

When I have saved ~$2M, I may not feel empowered, but I will truly be empowered more than I am today, as I will have the option to stop receiving any of this BS.

Just 2M? at 3-4% a year that isn't much money to live on

 

[Old_Mil]

Also, we aren't the only ones dealing with this kind of stuff. I've heard some PCP office stories that would make for equally entertaining reality t.v. when compared to some of our encounters in the ER. Those pt's can get equally nasty in escalating their complaints.

A PCP can fire problem patients...

 

[hundreddaysoff]

Just 2M? at 3-4% a year that isn't much money to live on

I'm really assuming just 2%/y return going forward, so like $30--40k/y income. Maybe even less, effectively, if those crazy hyperinflation theorists end up being right within our lifetimes.

Also assuming $2M after we buy a house free and clear first, so won't have a mortgage to worry about in there. And have various experiments in mind to further reduce living expenses including permaculture and learning to hunt and fish, although the point is to have enough money not to need these as most of them will probably fail.

Unlike me, my wife does self-actualize from her stable middle-class job and wants to do it forever, so altogether we have say $60--80k/y. We're never been interested in all that fancy fatFIRE stuff; aiming more for the lifestyle of Mr Money Mustache. (I hope without the divorce!)

Mostly I'm just interested in learning new stuff, raising my kid(s), and trying out weird ideas.

I am always curious to hear any critiques of this plan as I have no idea whether it'll work long-term or if I'll be back to bagging groceries in 20 years.

 

[BoardingDoc]

I'm really assuming just 2%/y return going forward, so like $30--40k/y income. Maybe even less, effectively, if those crazy hyperinflation theorists end up being right within our lifetimes.

Also assuming $2M after we buy a house free and clear first, so won't have a mortgage to worry about in there. And have various experiments in mind to further reduce living expenses including permaculture and learning to hunt and fish, although the point is to have enough money not to need these as most of them will probably fail.

Unlike me, my wife does self-actualize from her stable middle-class job and wants to do it forever, so altogether we have say $60--80k/y. We're never been interested in all that fancy fatFIRE stuff; aiming more for the lifestyle of Mr Money Mustache. (I hope without the divorce!)

Mostly I'm just interested in learning new stuff, raising my kid(s), and trying out weird ideas.

I am always curious to hear any critiques of this plan as I have no idea whether it'll work long-term or if I'll be back to bagging groceries in 20 years.

If you remove your mortgage expenses, are you currently living on 60-80k/yr? If so, this may work assuming your wife actually wants to work forever (hint: she probably doesn't).

 

[TooMuchResearch]

Have to remove mortgage, life insurance, disability insurance, and anything else you'd drop once unneeded.

If you remove your mortgage expenses, are you currently living on 60-80k/yr? If so, this may work assuming your wife actually wants to work forever (hint: she probably doesn't).

 

[Mad Jack]

Because of the ridiculous import given to "patient experience" (the current buzzphrase to avoid calling it customer satisfaction) our group treats every complaint as a real issue. This has resulted in some truly absurd issues being communicated to the physicians as though they are real, actionable or rational.

To kick things off here's one I got the other day. My group has people in the office call some discharged patients from each doc to look for dirt.
Patient callback - child in ED, spoke to mom "I don't know how he's feeling. CPS took him away." Mom rates experience as negative.
Of note CPS wasn't involved due to anything that happened in the ED. But mom rated her "experience" as negative so I took the hit. Not sure if the caller explained that they were asking about the experience in the ED not with CPS but oh well.

This wasn't mine. From one of my colleagues:
"I was only there for a little while. It felt like an in and out experience." We are taught that patients want be be in and out super fast but some want to stay and chill. The "coaching" on this one was that we should "discuss with the patient their perception of what would be an appropriate time to spend in the ER for their particular problem," i.e. we're now supposed to ask them how long they want to hang out.

You should see the complaints we get in inpatient psychiatry

 

[thegenius]

You should see the complaints we get in inpatient psychiatry

Give us a quick taste. Just enough to keep us going in EM
Please!

 

[Mad Jack]

Give us a quick taste. Just enough to keep us going in EM
Please!

I'll dig some up tomortow. Let's just say people aren't going to write the best reviews of the people that involuntarily commit them

 

[docB]

I'll dig some up tomortow. Let's just say people aren't going to write the best reviews of the people that involuntarily commit them

I suspect you're right. I'm continually amazed by the things people can comment on and be taken seriously.

 

[hundreddaysoff]

If you remove your mortgage expenses, are you currently living on 60-80k/yr? If so, this may work assuming your wife actually wants to work forever (hint: she probably doesn't).

Yup, our living expenses were ~70k in 2019 when you exclude my business expenses, disability+life, rent, 10k HDHP hospital charge for my son's completely uncomplicated birth (!), etc. That 70k included some fancy vacations which obviously are dispensable if needed. And we are debt-free and intend to stay that way.

By "forever", I actually meant "until I turn 65--70 and can start on SS", although I think wife will be working even longer than that. She tried not working after she had the kid and went stir-crazy within a few weeks. Almost drove me crazy too! Her mom is 70 and does the same job and has no desire to quit. So not a bad risk.

If she does quit, our challenge will be to make ends meet on ~40k/y. Mr Money Mustache and more importantly millions of other working-class Americans have proven that a family of 3 can do fine on less. We mostly don't have expensive tastes and I'm not above dipping into principal for a few years if needed or using all that free time to figure out how to make ~10--20k more on my own terms. Heck, I might get bored and end up just doing that anyway.

"Never minded working hard; it's who I'm working for." - Gillian Welch

 

[calvnandhobbs68]

You are, of course, totally correct. The problem is that being right does not equate to setting policy.

The idea of making patient's experiences in the ED "outstanding" across the board is demonstrably bad policy regarding the finite resource of emergency services. EMTALA has for the most part eliminated any supply and demand forces in this sector. We are already more convenient that primary care. Don't bother making an appointment. Just call 911 and be shuttled to your walk in visit in an air conditioned taxi that can run though red lights. Go to the ER where the staff are flogged to have you seen moments after your arrival. Want something and the doctor won't give it to you? Threaten to drop a negative Yelp and watch them bend over backward for you. So why would anyone ever go to a PMD?

My point, minus the rant, is that EMTALA forces us to allow the patients to self triage to or away from the ED. They are bad at this. Customer satisfaction makes this poor triage even worse. It wastes the resource.

Yep. The amount of ambulance rides I saw for kids with “fever” or “fussy” made me think I was losing my mind. And there really was not a severe shortage of pediatricians in the area taking Medicaid...

 

[bravotwozero]

Yup, our living expenses were ~70k in 2019 when you exclude my business expenses, disability+life, rent, 10k HDHP hospital charge for my son's completely uncomplicated birth (!), etc. That 70k included some fancy vacations which obviously are dispensable if needed. And we are debt-free and intend to stay that way.

By "forever", I actually meant "until I turn 65--70 and can start on SS", although I think wife will be working even longer than that. She tried not working after she had the kid and went stir-crazy within a few weeks. Almost drove me crazy too! Her mom is 70 and does the same job and has no desire to quit. So not a bad risk.

If she does quit, our challenge will be to make ends meet on ~40k/y. Mr Money Mustache and more importantly millions of other working-class Americans have proven that a family of 3 can do fine on less. We mostly don't have expensive tastes and I'm not above dipping into principal for a few years if needed or using all that free time to figure out how to make ~10--20k more on my own terms. Heck, I might get bored and end up just doing that anyway.

"Never minded working hard; it's who I'm working for." - Gillian Welch

+1 For Mr Money Mustache. That guy is badass. He was the inspiration for me to switch jobs so I can bike commute.

 

[ShockIndex]

Yep. The amount of ambulance rides I saw for kids with “fever” or “fussy” made me think I was losing my mind. And there really was not a severe shortage of pediatricians in the area taking Medicaid...

Stop calling social work to hand out cab vouchers and bus passes at discharge. Nothing disincentivizes that behavior like a 2 mile walk home...in 30 degree weather...while carrying a toddler.

 

[BoardingDoc]

Stop calling social work to hand out cab vouchers and bus passes at discharge. Nothing disincentivizes that behavior like a 2 mile walk home...in 30 degree weather...while carrying a toddler.

Our ED has completely stopped handing out cab vouchers. In some cases we will give out a bus voucher and cover the $2 cost, but that's it.

 

[TheSingularity]

He's a bit crazy. Believe it or not you can be financially solvent and still not ride your bike to the grocery store.

+1 For Mr Money Mustache. That guy is badass. He was the inspiration for me to switch jobs so I can bike commute.

Sent from my Pixel 3 using SDN mobile

 

[GeneralVeers]

My hospital will call Lyfts for people....it's insane.

I'm not completely opposed to it, but I think there should be several tracks:

1. Normal person brought to the hospital via ambulance because a business or other bystander called -------> Lyft
2. Normal scared person with serious-sounding symptoms who is not a frequent flier ----------> Lyft
3. Frequent visitor, but relatively normal, pleasant person --------> Bus Pass
4. Homeless ---------> Ambulation
5. Malingering --------> Ambulation
6. Drugs ------------> Ambulation

 

[hundreddaysoff]

He's a bit crazy. Believe it or not you can be financially solvent and still not ride your bike to the grocery store.

Sent from my Pixel 3 using SDN mobile

Of course you can. And he is a bit crazy and he gets repetitive and I'm not quite sure if he's a real guy or just a persona as WCI seems to think.

But dammit, I still like riding my bike to the grocery store and it's good exercise. Gotta get me one of those baby trailers though.

 

[bravotwozero]

He's a bit crazy. Believe it or not you can be financially solvent and still not ride your bike to the grocery store.

Sent from my Pixel 3 using SDN mobile

I think the people who disagree with him tend to be crazier


Sent from my iPhone using Tapatalk

 

[deleted1027621]

I also like MMM. He goes extreme sometimes, but I think that is so people consider at least implementing some of his suggestions in their lives. I mean, if this dude can bike in the rain pulling a trailer to hull his mulch home, I can ride my bike a couple of miles to a social function/coffee shop/work sometimes.

 

[docB]

Our ED has completely stopped handing out cab vouchers. In some cases we will give out a bus voucher and cover the $2 cost, but that's it.

My hospital will call Lyfts for people....it's insane.

My hospital is on the "everyone gets a Lyft or at least a bus pass" bandwagon right now. This pendulum is a good example of how poisonous reacting to complaints is. For a long time we couldn't get a cab voucher for anything. It took approval of an out of house admin. But then someone complained that grandpa didn't get ferried to his door and something bad happened. So the doc, nurse and charge in that case were scapegoated and we were told that everyone gets a Lyft. Pretty soon there'll be a cost cutting initiative and they'll cut off the Lyfts and fire whichever charge nurse gave out the most rides (Gasp!!! Punish the outlier!!!) and we'll be back to no rides. We do have openings for charge nurses. No idea why.

 

[TooMuchResearch]

I think if you read it, you might find he mentions her certainly can afford it but prefers the simplicity, fresh air, and exercise.

He's a bit crazy. Believe it or not you can be financially solvent and still not ride your bike to the grocery store.

Sent from my Pixel 3 using SDN mobile

 

[TheSingularity]

I think if you read it, you might find he mentions her certainly can afford it but prefers the simplicity, fresh air, and exercise.

Cool. Then do it.

"I can live like a king but choose to live like a pauper" doesn't make interesting blog fodder.

 

[thegenius]

Think you'll get a patient complaint from this event?

A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays.


Posit:
What does an ER do if you have 10 beds, and 15 critically ill people all show up around the same time?

Either EMTALA has to change, or hospitals need to support ER Doc decisions to summarily discharge what are clearly nonsense emergency medical problems that comes to the ER which consequently forgoes that income.

 

[deleted109597]

Either EMTALA has to change, or hospitals need to support ER Doc decisions to summarily discharge what are clearly nonsense emergency medical problems that comes to the ER which consequently forgoes that income.

Yeah, neither of those will change.
Hospitals will blame docs. Why do you think there are clipboard nurses downstairs telling you to go faster? The hospital might get sued, but they're still throwing you under the bus no matter what. But they aren't going to give up that income. Besides, you can bill for an MSE after the fact.
EMTALA also won't go away. Sure, the nidus for it will disappear if M4A happens (the gov't probably won't allow private hospitals, just like the ACA banned physician owned ones if you wanted to work in one). But you'll still have to see everyone. And with a zero miss rate.

 

[turkeyjerky]

Think you'll get a patient complaint from this event?

A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays.


Posit:
What does an ER do if you have 10 beds, and 15 critically ill people all show up around the same time?

Either EMTALA has to change, or hospitals need to support ER Doc decisions to summarily discharge what are clearly nonsense emergency medical problems that comes to the ER which consequently forgoes that income.

I remember when that story came out. The criticicism was even more ridiculous than that in the Rory Stanton case. She made a bad decision to elope from the ER waiting room after a (lets be honest) not outlandish waiting time. She was evidently lucid enough to be posting on facebook at the time.

How about this--instead of hyperventilating about these types of cases, maybe the newsmedia can come out with stories about when, and more importantly, when not to go to the ER. You don't need to come in for the sniffles or for a twinge of chest pain that lasted 5 sec. Maybe we need a culture change in this country and to start viewing medical care (especially emergent) as a community resource that a select few of us are abusing.

 

[SamtheWise]

My absolute personal favorite is when a patient comes to the ED and then refuses lab draw, because 'they're scared of needles' or some other reason, this happens probably once every 2-3 months for me. 'Doc do you really think I need labs?' - Lol I don't know, you think you're having an emergency, so yes? I just summarily discharge them and say to come back if they decide they want a full evaluation, and I write on their discharge paperwork that they were offered a full workup but refused and to return for any further concerns.

 

[ShockIndex]

My absolute personal favorite is when a patient comes to the ED and then refuses lab draw, because 'they're scared of needles' or some other reason, this happens probably once every 2-3 months for me. 'Doc do you really think I need labs?' - Lol I don't know, you think you're having an emergency, so yes? I just summarily discharge them and say to come back if they decide they want a full evaluation, and I write on their discharge paperwork that they were offered a full workup but refused and to return for any further concerns.

You’re not living up to your name...

 

[thegenius]

You’re not living up to your name...

It depends on how it's worded. An MSE can involve blood work, imaging, interventions, etc. It may not just be a physical exam. If a patient comes in with chest pain and does not want an EKG, blood work and a CXR, which all ER doctors would say is the standard of care (unless there are specific conditions in that patient's case), the patient has the right to say no. If the patient does not want an MSE as laid out by the physician, not only is it the patient's right it's defined in the EMTALA statute that the medical screening requirement has been met (after doctor talks about risks / benefits and gets it in writing). 1395dd-(b)(2).

It gets a little sticky if the patient agrees to x and y of the MSE, but not z.

I'm guessing that @SamtheWise doesn't just walk out of the room and discharge them, he probably talks to the patient for a few minutes. Ideally you get all that stuff on paper in the form of an AMA. Documentation is quite important here.

 

[ShockIndex]

It depends on how it's worded. An MSE can involve blood work, imaging, interventions, etc. It may not just be a physical exam. If a patient comes in with chest pain and does not want an EKG, blood work and a CXR, which all ER doctors would say is the standard of care (unless there are specific conditions in that patient's case), the patient has the right to say no. If the patient does not want an MSE as laid out by the physician, not only is it the patient's right it's defined in the EMTALA statute that the medical screening requirement has been met (after doctor talks about risks / benefits and gets it in writing). 1395dd-(b)(2).

It gets a little sticky if the patient agrees to x and y of the MSE, but not z.

I'm guessing that @SamtheWise doesn't just walk out of the room and discharge them, he probably talks to the patient for a few minutes. Ideally you get all that stuff on paper in the form of an AMA. Documentation is quite important here.

It could be just me and the fact that I just watched Michigan go down in flames to that vocational school, but I detected a distinct “My way or the highway” tone from that post. I submit that such an approach can pose some problems. Here is why:

1) Sam mentioned nothing about explaining the rationale for the tests aside from an off-hand remark about the patient thinking they have an emergency. Those types of remarks just piss patients off and drive up complaints. They also don’t play well before juries when the patient has a legit reason to want to limit unnecessary testing such as a ton of family medical bills. Part of a patient leaving against medical advice is an explanation for why the tests are needed and any reasonable alternatives. I’m also thinking back to a case that I saw with a resident a couple of years ago. The resident told me that the guy wanted to be checked for appendicitis but didn’t want labs or an IV, so he was having the guy signout “AMA.” I caught the guy as he was walking down the hall and convinced him to come back in so that we could talk. He didn’t want the labs or the IV because his insurance deductible was more than $2K. We agreed to start with a non-con CT of his belly since it was the most cost-effective means to determine if he had appendicitis. That required some calls because appy protocol CTs at my shop were generally performed with IV contrast. It was positive and he went to the OR without a CBC, metabolic panel, or coags on his chart. Should I have lol’ed if he had left? Who was practicing more cost effective medicine - the patient or the doctor? I submit that a bunch of labs we order are crap, and we had better make damn sure that we can justify their utility if we are using them as a justification for the patient being discharged AMA.

2) Sam said nothing about offering less ideal stabilizing treatments. For example, if your patient with a PORT Score of 110 wants to go home with PNA, I bet you offer them oral antibiotics even though it is a less ideal option. If your patient with unstable angina or a TIA signs out AMA, I bet you send them home with at least an ASA. You may even go the extra mile and send an email to their PCP letting them know to get some follow-up. These little things go a long way to letting juries know that you cared about the patient.

In other words, feeling good about your patients leaving AMA as indicated by coupling it with a “lol” is a head scratcher to me. That’s because I view AMA’s as inherently high-risk situations that require MORE work on my part to cover my backside.

 

[thegenius]

It could be just me and the fact that I just watched Michigan go down in flames to that vocational school, but I detected a distinct “My way or the highway” tone from that post. I submit that such an approach can pose some problems. Here is why:

1) Sam mentioned nothing about explaining the rationale for the tests aside from an off-hand remark about the patient thinking they have an emergency. Those types of remarks just piss patients off and drive up complaints. They also don’t play well before juries when the patient has a legit reason to want to limit unnecessary testing such as a ton of family medical bills. Part of a patient leaving against medical advice is an explanation for why the tests are needed and any reasonable alternatives. I’m also thinking back to a case that I saw with a resident a couple of years ago. The resident told me that the guy wanted to be checked for appendicitis but didn’t want labs or an IV, so he was having the guy signout “AMA.” I caught the guy as he was walking down the hall and convinced him to come back in so that we could talk. He didn’t want the labs or the IV because his insurance deductible was more than $2K. We agreed to start with a non-con CT of his belly since it was the most cost-effective means to determine if he had appendicitis. That required some calls because appy protocol CTs at my shop were generally performed with IV contrast. It was positive and he went to the OR without a CBC, metabolic panel, or coags on his chart. Should I have lol’ed if he had left? Who was practicing more cost effective medicine - the patient or the doctor? I submit that a bunch of labs we order are crap, and we had better make damn sure that we can justify their utility if we are using them as a justification for the patient being discharged AMA.

2) Sam said nothing about offering less ideal stabilizing treatments. For example, if your patient with a PORT Score of 110 wants to go home with PNA, I bet you offer them oral antibiotics even though it is a less ideal option. If your patient with unstable angina or a TIA signs out AMA, I bet you send them home with at least an ASA. You may even go the extra mile and send an email to their PCP letting them know to get some follow-up. These little things go a long way to letting juries know that you cared about the patient.

In other words, feeling good about your patients leaving AMA as indicated by coupling it with a “lol” is a head scratcher to me. That’s because I view AMA’s as inherently high-risk situations that require MORE work on my part to cover my backside.

I understand ya.

You referring to Mich vs OSU in basketball? Do you have allegiances to Michigan?

 

[ShockIndex]

I understand ya.

You referring to Mich vs OSU in basketball? Do you have allegiances to Michigan?

Yep. That game was tough to watch. Blue really need that win headed into the post-season.

 

[GeneralVeers]

Patients generally want MORE tests. It's extremely rare that I have to talk them into doing something.

 

[SamtheWise]

It could be just me and the fact that I just watched Michigan go down in flames to that vocational school, but I detected a distinct “My way or the highway” tone from that post. I submit that such an approach can pose some problems. Here is why:

1) Sam mentioned nothing about explaining the rationale for the tests aside from an off-hand remark about the patient thinking they have an emergency. Those types of remarks just piss patients off and drive up complaints. They also don’t play well before juries when the patient has a legit reason to want to limit unnecessary testing such as a ton of family medical bills. Part of a patient leaving against medical advice is an explanation for why the tests are needed and any reasonable alternatives. I’m also thinking back to a case that I saw with a resident a couple of years ago. The resident told me that the guy wanted to be checked for appendicitis but didn’t want labs or an IV, so he was having the guy signout “AMA.” I caught the guy as he was walking down the hall and convinced him to come back in so that we could talk. He didn’t want the labs or the IV because his insurance deductible was more than $2K. We agreed to start with a non-con CT of his belly since it was the most cost-effective means to determine if he had appendicitis. That required some calls because appy protocol CTs at my shop were generally performed with IV contrast. It was positive and he went to the OR without a CBC, metabolic panel, or coags on his chart. Should I have lol’ed if he had left? Who was practicing more cost effective medicine - the patient or the doctor? I submit that a bunch of labs we order are crap, and we had better make damn sure that we can justify their utility if we are using them as a justification for the patient being discharged AMA.

2) Sam said nothing about offering less ideal stabilizing treatments. For example, if your patient with a PORT Score of 110 wants to go home with PNA, I bet you offer them oral antibiotics even though it is a less ideal option. If your patient with unstable angina or a TIA signs out AMA, I bet you send them home with at least an ASA. You may even go the extra mile and send an email to their PCP letting them know to get some follow-up. These little things go a long way to letting juries know that you cared about the patient.

In other words, feeling good about your patients leaving AMA as indicated by coupling it with a “lol” is a head scratcher to me. That’s because I view AMA’s as inherently high-risk situations that require MORE work on my part to cover my backside.

In real life I am much more humanistic and patient centered than I am on the internet when I'm venting anonymously. I have a lengthy conversation, discuss pros and cons. I have found that occasionally in my experience patients come to the ED for reasons other than wanting extensive testing, sometimes people just want to say they saw a doctor to placate their family members, sometimes they just want a warm place to be. In any case, if patients do not want an appropriate work up for their chief complaint, after an appropriate discussion and thorough documentation and offering reasonable alternatives, I will discharge them without said testing. I don't feel good or bad about it, it is what it is, but I do laugh and will not apologize for doing so because it is just one of the many quirks of providing emergency medical care in the US. Next time I cynically comment on the futility of seeking emergency evaluation, then refusing emergency evaluation, I will be sure to word it in a way that does not offend your sensibilities, though I wouldn't expect anything less from a Michigan fan.

 

[bravotwozero]

Yep. That game was tough to watch. Blue really need that win headed into the post-season.

Oh how I hate,

Ohio State!

Said a Michigan fan to me once.

 

[d2305]

There's no way I would ride my bike on the street. I did it regularly 20 years ago, but I was nuts back then to trust drivers.

 

[ShockIndex]

Oh how I hate,

Ohio State!

Said a Michigan fan to me once.

The only thing worse is the Florida State Criminoles.

 

[thegenius]

The best day of the year is when Duke basketball loses during March Madness.
The second best day is when Ohio State loses. Unfortunately that hasn't happened enough recently.

I love it when gasbags Saban and Meyer lose.

 

[Dr Mantis Toboggan]

You mean Ryan Day? Urbs = retired (for now)

 

[thegenius]

Yea I guess Urbs can't lose anymore. But when he did it was glorious.

 

[RustedFox]

Uggh.

College sports.

 

[SamtheWise]

Michigan fans see themselves as the harvard of ann arbor and love to make jokes about OSU being a trade school, while being wholly unable to mount a decent challenge to their only true rival. And Buckeyes are the worst winners in the history of college sports.

My own personal bad place would be a groundhog day style scenario where every day I have to wake up and go watch 'The Game' at a college bar in either Columbus or Ann Arbor alternating each day. Each day Ohio State wins, I drink a pitcher or two of whatever mediocre semi-local IPA is on special at whatever bar I'm at, and then I fall asleep on the couch at 8pm with a pounding headache simultaneously mildly drunk and hung over.

 

[thegenius]

Hey man I remember the good old days when Michigan was very very good, OSU was probably better and we beat them regularly. This was like 88-2000. All those John Cooper teams.

OSU now is simply a better football program. Has been for 20 years. Tressel then Meyer makes for a very very good program.

At some point Michigan will come around but I don't think it's going to happen anytime soon.

 

[ShockIndex]

Hey man I remember the good old days when Michigan was very very good, OSU was probably better and we beat them regularly. This was like 88-2000. All those John Cooper teams.

OSU now is simply a better football program. Has been for 20 years. Tressel then Meyer makes for a very very good program.

At some point Michigan will come around but I don't think it's going to happen anytime soon.

Yep. Right now, Michigan is paying Harbaugh $7.5M to coach the 5th best team in the Big 10 (behind OSU, Penn State, WI, and MN). I understand that Harbaugh is an alum, but his salary is the 3rd highest in the NCAA. I’m curious to see what comes of his contract negotiations which are probably ongoing this month since recruitment demands some closure real soon. I can’t see them getting rid of him in 2021 since there is nobody to fill his shoes for 2020, but will they give him another 7 year deal or something shorter like 3 years? Will they continue to overpay him to the tune of $8M/yr? It is an interesting predicament.

 

[thegenius]

Yep. Right now, Michigan is paying Harbaugh $7.5M to coach the 5th best team in the Big 10 (behind OSU, Penn State, WI, and MN). I understand that Harbaugh is an alum, but his salary is the 3rd highest in the NCAA. I’m curious to see what comes of his contract negotiations which are probably ongoing this month since recruitment demands some closure real soon. I can’t see them getting rid of him in 2021 since there is nobody to fill his shoes for 2020, but will they give him another 7 year deal or something shorter like 3 years? Will they continue to overpay him to the tune of $8M/yr? It is an interesting predicament.

Yup. I think it's safe to say that UM has been, or will be, approx. the third-fourth best team in the Big Ten year in and year out. How long does Michigan pay 7.5M to get 3-4 losses a year? Could Michigan find another coach, pay him 4.5M a year to get the same result? Brady Hoke couldn't do it, Rich Rodriguez couldn't either. I'm happy not to make that decision because it ain't my money.

LSU averaged about 3 losses a year for the past 10 years (although they won the championship in like 2007 or something). Then they get a star quarterback and go undefeated. Michigan is going to need something like that to happen I reckon.

 

[deleted836128]

It could be just me and the fact that I just watched Michigan go down in flames to that vocational school, but I detected a distinct “My way or the highway” tone from that post. I submit that such an approach can pose some problems. Here is why:

1) Sam mentioned nothing about explaining the rationale for the tests aside from an off-hand remark about the patient thinking they have an emergency. Those types of remarks just piss patients off and drive up complaints. They also don’t play well before juries when the patient has a legit reason to want to limit unnecessary testing such as a ton of family medical bills. Part of a patient leaving against medical advice is an explanation for why the tests are needed and any reasonable alternatives. I’m also thinking back to a case that I saw with a resident a couple of years ago. The resident told me that the guy wanted to be checked for appendicitis but didn’t want labs or an IV, so he was having the guy signout “AMA.” I caught the guy as he was walking down the hall and convinced him to come back in so that we could talk. He didn’t want the labs or the IV because his insurance deductible was more than $2K. We agreed to start with a non-con CT of his belly since it was the most cost-effective means to determine if he had appendicitis. That required some calls because appy protocol CTs at my shop were generally performed with IV contrast. It was positive and he went to the OR without a CBC, metabolic panel, or coags on his chart. Should I have lol’ed if he had left? Who was practicing more cost effective medicine - the patient or the doctor? I submit that a bunch of labs we order are crap, and we had better make damn sure that we can justify their utility if we are using them as a justification for the patient being discharged AMA.

2) Sam said nothing about offering less ideal stabilizing treatments. For example, if your patient with a PORT Score of 110 wants to go home with PNA, I bet you offer them oral antibiotics even though it is a less ideal option. If your patient with unstable angina or a TIA signs out AMA, I bet you send them home with at least an ASA. You may even go the extra mile and send an email to their PCP letting them know to get some follow-up. These little things go a long way to letting juries know that you cared about the patient.

In other words, feeling good about your patients leaving AMA as indicated by coupling it with a “lol” is a head scratcher to me. That’s because I view AMA’s as inherently high-risk situations that require MORE work on my part to cover my backside.

Thanks for posting this little story... it’ll give me something to think about the next time someone wants to leave AMA... usually I think of it as “my work up or the highway”...

Otherwise, though, I share the same philosophy with AMA patients. You document that you discussed risks and benefits of leaving, you document any alternative options discussed, you document if a family member or friend was present and involved in the decision, you document that the patient understood and did have good decision making capacity, you document that they understood they could come back at any time. I hardly ever see this documented. And I never see anyone giving patient education and follow up instructions - why? The patient wants to leave and so you leave them hanging? They should all be set up for success. Any relevant education, follow up info and prescriptions including antibiotics. It’s gotta be done.

 

[SamtheWise]

Otherwise, though, I share the same philosophy with AMA patients. You document that you discussed risks and benefits of leaving, you document any alternative options discussed, you document if a family member or friend was present and involved in the decision, you document that the patient understood and did have good decision making capacity, you document that they understood they could come back at any time. I hardly ever see this documented. And I never see anyone giving patient education and follow up instructions - why? The patient wants to leave and so you leave them hanging? They should all be set up for success. Any relevant education, follow up info and prescriptions including antibiotics. It’s gotta be done.

That's odd that you don't see that because all those things are standard of care not just nice things to do. I feel like medicolegally just writing 'AMA' holds no weight. It's an interactive discharge just like any other, and if theres a bad outcome and in 5 years in court the documentation, the patient or the patient's family doesn't support the fact that the patient had capacity, could logically manipulate and vocalize the risks of leaving and potential consequences, reasonable alternatives were offered and discussed, and you arranged all possible appropriate outpatient care, you're f'd.

I never beg people to stay, AMA is a disposition just like any other and gotta get that door 2 dispo time if you wanna get paaaaaiiid, but at the same time there's been times I'm like 'Look, you have a very high risk of death or disability and as a physician and human I think you're making a bad decision that may have profound consequences to you', but whatever, there's no accounting for taste in life. I've had some interesting AMA discharges in my time, a couple that I still think back on and am like 'well, hope they didn't go home and immediately die', but if somebody has capacity and understands the risks you can't give them ketamine and force them to stay for their endocarditis antibiotics or whatever.

 

[GeneralVeers]

When the nurse comes and tells me someone wants to leave AMA, I ask them to have the patient wait and I'll go talk to them. I'm not dropping whatever else I'm doing to go talk to an ornery patient. 80% of the time they just up and leave without me talking to them. I actually like that dispo the best because it makes the charting easy.

 

[wareagle726]

They should all be set up for success. Any relevant education, follow up info and prescriptions including antibiotics. It’s gotta be done.

I had a nurse yell at me in front of the patient that I couldn't give a work excuse or ABX to a patient that wanted to leave AMA and that "no other doc here has ever done that." It was during one of my recent moonlighting shifts. Not sure what is more disturbing...the nurse's actions or that it seemed so out-of-place to try and give good care regardless of the patient's circumstances

 

[Apollyon]

I had a nurse yell at me in front of the patient that I couldn't give a work excuse or ABX to a patient that wanted to leave AMA and that "no other doc here has ever done that." It was during one of my recent moonlighting shifts. Not sure what is more disturbing...the nurse's actions or that it seemed so out-of-place to try and give good care regardless of the patient's circumstances

I know that frustration - "nobody else here does that!" - when what you are doing is good medicine. Perception is reality, and everyone is the hero of their own story. Few will admit that they don't know something, and some double down on that.