Patient scripts for non emergent complaints

Started by bravotwozero
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bravotwozero

bravotwozero

Chronically ambitious
20+ Year Member
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I don't know how this thread will go, I'm sure some people will be annoyed/irritated with the dumb garbage/unreasonable expectations seen with this complaints, but it's just the nature of the beast and we have to deal with it.

I think this may (hopefully) help calm reasonable patients and fend off some bs complaints (again, one can hope).

Peripheral leg edema "my legs are swollen":

- I've worked you up for potentially emergent causes, chf/kidney/liver disease/dvt etc, and it's none of that. You likely have venous insufficiency, which can be helped with compression stockings. It unfortunately can be a difficult thing to treat. I understand you want a 'water pill', but diuretics are unfortunately unhelpful, and cause more harm than good, in the form of hypotension, electrolyte abnormalities, being bad for your kidneys etc.

Please share some for any other non emergent stuff that we frequently see in the ED.
 
bravotwozero said:
I don't know how this thread will go, I'm sure some people will be annoyed/irritated with the dumb garbage/unreasonable expectations seen with this complaints, but it's just the nature of the beast and we have to deal with it.

I think this may (hopefully) help calm reasonable patients and fend off some bs complaints (again, one can hope).

Peripheral leg edema "my legs are swollen":

- I've worked you up for potentially emergent causes, chf/kidney/liver disease/dvt etc, and it's none of that. You likely have venous insufficiency, which can be helped with compression stockings. It unfortunately can be a difficult thing to treat. I understand you want a 'water pill', but diuretics are unfortunately unhelpful, and cause more harm than good, in the form of hypotension, electrolyte abnormalities, being bad for your kidneys etc.

Please share some for any other non emergent stuff that we frequently see in the ED.
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I am confused as to what you're trying to accomplish. I can not count the number of patients I've seen with non emergent complaints.

Virtually all of them have left with some version of "you need to see your PCP for this."

If they argue, they get some version of "I'd love to help, but you're in home Depot and you're asking for spaghetti. I can't help you even if I wanted to."

I don't think you need a custom script to rehearse for every variety of BS that rolls in. Just politely tell them to see their PCP, DC and move on.

If this generates a complaint that your admin actually chastises you for... That is an admin problem, not a you problem. That said, I freely admit that I say this as someone who had a sane human for a dept chief who only bugged me for patient complaints when they were real issues (or if they weren't but were particularly insane and amusing).
 
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BoardingDoc said:
I am confused as to what you're trying to accomplish. I can not count the number of patients I've seen with non emergent complaints.

I don't think you need a custom script to rehearse for every variety of BS that rolls in. Just politely tell them to see their PCP, DC and move on.
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Ok, fair enough. I guess my aim was to enhance patient understanding of what caused their complaint, and why it can't really be managed in the ED. Obviously I'm assuming the patient is a reasonable person willing to listen.
 
bravotwozero said:
Ok, fair enough. I guess my aim was to enhance patient understanding of what caused their complaint, and why it can't really be managed in the ED. Obviously I'm assuming the patient is a reasonable person willing to listen.
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Most physicians who work outside of the ED don't understand how the ED functions. You're not going to educate a random patient on how the ED functions.
 
There is a term in New Orleans, lagniappe, which is basically a freebie you get with another purchase. Like a bakers dozen donuts, or a bundle of herbs if you buy $20 of veggies at a stand.

My stance is most ED patients need a lagniappe. They need something from their visit. It can be an Rx. It can be a work note. It can be actual appreciated education.

For a lot of these complaints, I’ve gotten better at feeling their pain / frustration, explaining the tools we have in the ED, and then at least giving them some realistic outpatient plan they could start working on (PCP visit for X, PT for Y, referral to specialist Z).

I’m certainly not magic, but I tend to convince people I believe they DO have a problem, that problem isn’t something emergent we can solve (yay!) and there is a path forward for them to pursue.

Avoid the complaint “they did nothing for me”. A lot of this is just terminology / vocabulary choice.
 
Based off what’s been ordered: “so, everything we looked at today was negative.” I rattle off all the pertinent labs, etc. “so, you’re not anemic, no signs of infection, kidneys, liver, etc are looking good, not having-haven’t had a heart attack, no blood clots, CT/XR/US is negative” “we’re gonna let ya get out of here, but imma do this for you: call in toradol/zofran/bentyl/lomotil/prednisone/tessalon perles/ etc. that should get you some relief until you can see your PCP”

If no PCP: “imma refer you to the family medicine residency clinic, they keep appointments for ER follow ups and can get you the testing that I can’t get here today and get you to the right people”

in the spirit of lagniappe, I teach my residents “what’s their prize for coming in?” Work note, etc.
 
I may be the di%khead in this discussion, but I strongly disagree with the concept of "langiappe".

Yeah, @CajunMedic . You called me about two hours ago, but I was up a ladder in my neighbor's place and I wasn't gonna talk to you or else I was gonna end up something wrangled. By the time we were finished, I figured it was too late to call back. Call me; I'm home all day tomorrow, save for the damn HVAC crew which needs direction.

Back to the "langiappe". Once upon a time, it was a honorable tradition, originally meant to evade the law of "shorting a buyer of bread", but that was then, and this is now. The world has changed. Radically.

"What's their prize for coming in??"

No. All this does in my neck of the woods is encourage them to act like I'm a CVS, where they can go and purchase ibuprofen, benadryl, or other simple things.
 
I’m willing to prescribe almost anything short of narcs and antibiotics. I’ll order whatever plain film you want. If you’re over 60, that comes with a complimentary CT.

This is not the hill to die on. You will change nothing and just shout yourself hoarse.

I wouldn’t RX diuretics for that leg edema. But I’ll give them a “referral” to lymphedema clinic where they will “fit you for special socks”.

I remember a time when I had strongly held beliefs about not RX’ing Tamiflu to flu patients based on data and suicidal Japanese teenagers. Now I could not give less of a ****. I’ll RX you a five-pack for the whole family.

Honestly, I’ve just come to terms that I will not do anything meaningful for the bulk of my patients, BUT if I can clear them all out I’ll make room for the few that actually do benefit from our training and expertise.
 
RustedFox said:
I may be the di%khead in this discussion, but I strongly disagree with the concept of "langiappe".

Yeah, @CajunMedic . You called me about two hours ago, but I was up a ladder in my neighbor's place and I wasn't gonna talk to you or else I was gonna end up something wrangled. By the time we were finished, I figured it was too late to call back. Call me; I'm home all day tomorrow, save for the damn HVAC crew which needs direction.

Back to the "langiappe". Once upon a time, it was a honorable tradition, originally meant to evade the law of "shorting a buyer of bread", but that was then, and this is now. The world has changed. Radically.

"What's their prize for coming in??"

No. All this does in my neck of the woods is encourage them to act like I'm a CVS, where they can go and purchase ibuprofen, benadryl, or other simple things.
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I don't disagree with the sentiment, but as indicated above already, you not doing this isn't going to keep the losers away.

Also, when my goodie bag is an Rx, it almost always lets me justify billing as a 99214 instead of a 99213. Takes 10 extra seconds, and even with Medicaid I get an extra 30 bucks or so. Medicare is more like 45. Easy pocket money, and the idiots leave easier. Win win.
 
BoardingDoc said:
I don't disagree with the sentiment, but as indicated above already, you not doing this isn't going to keep the losers away.

Also, when my goodie bag is an Rx, it almost always lets me justify billing as a 99214 instead of a 99213. Takes 10 extra seconds, and even with Medicaid I get an extra 30 bucks or so. Medicare is more like 45. Easy pocket money, and the idiots leave easier. Win win.
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#1 priority every shift is getting the *****s out without a patient complaint.
 
Mount Asclepius said:
Another common expression used is “everyone gets a goody bag.” We all know it’s a little bit of a game, but it’s worth playing because dealing with any headaches on the back end with poor patient experience that could have been prevented with a basic prescription isn’t worth it. You aren’t going to keep the hordes away by refusing, and they are also what churn the compensation machine. I value high quality county/academic clinical training as much as anyone, but community skills are important in the real world.
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YMMV but the goody bag doesn't keep the complaints away, it just delays them until the patient gets hit with the bill. Most patients view the doctor's hourly rate as some version of "total ED bill x minutes doctor was actively interacting with me divided by 60 min/hr" unless they feel like they got enough of the doctor's time and attention. Many of them know or at least feel when an RX (that's not going to work) is being tossed at them so the doctor doesn't have to deal with actually explaining what the path going forward looks like.
 
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Arcan57 said:
YMMV but the goody bag doesn't keep the complaints away, it just delays them until the patient gets hit with the bill. For a lot of patients, most of them view the doctor's hourly rate as some version of "total ED bill x minutes doctor was actively interacting with me divided by 60 min/hr" unless they feel like they got enough of the doctor's time and attention. Many of them know or at least feel when an RX (that's not going to work) is being tossed at them so the doctor doesn't have to deal with actually explaining what the path going forward looks like.
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Some people never going to be satisfied...and who cares
 
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And to be clear,
It doesn’t HAVE to be an Rx. And certainly not an opiate Rx or truly ridiculous med.

But an Rx for Motrin 600mg actually pleases some people. And if they want to try tessalon or tamiflu or flexeril after we briefly discuss it, that’s great by me.

And absolutely I can refer you to vascular clinic or neuro or rheum. Happy to. And spine clinic. It exists for a reason.

And you don’t need an MRI today, but I agree if things aren’t getting better in 2-4weeks, an outpatient MRI via your PcP may be a smart move.

And I absolutely WILL give you a work note for today. If you are sick, maybe for a couple days!

And I always hammer that I want them to touch base with thier pcp for guidance and to make sure things are improving in a few days.

It won’t make everyone happy, but I also find very few people are actually abusing my ED for a “free” Motrin Rx or one day work note. even those that do are usually caught in a bad system issue (some of these jobs telling people to return to the ED for a “return to work note”! The gall! But the enemy is the stupid job, not the patient who has checked in to see me to… try and return to work!)
 
RustedFox said:
I would have an endless stream of people coming for Tylenol/ibuprofen/Benadryl.
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Ya? Interesting. I suppose in my fee for service system I wouldn't mind seeing a dozen people who just wanted an IBUPROFEN 600mg refill Rx a shift. Cash money. But that volume would eventually gum up the works.

I have enough visibility in regional EMRs now that I RARELY see someone who's clearly had multiple ED visits in a year for motrin/etc. You see a that are hopping around for BP med refills, or asthma refills, but frankly its a very tiny wedge of my population.

Most of my frequent flyer traffic is the truly behavioral health, severe personality d/o, homeless but "can't stand" shelters, bad substance abuse, etc. Much harder to fix. Plus I don't mind refilling an albuterol inhaler and giving a 2 minute speech about GETTING A DARNED PCP AND GETTING ON A DAILY INHALER SO YOU DON'T HAVE TO COME VISIT ME HERE *waves at chaos*

But yeah, every site and region is different.
 
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Janders said:
Most of my frequent flyer traffic is the truly behavioral health, severe personality d/o, homeless but "can't stand" shelters, bad substance abuse, etc. Much harder to fix.
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Bonus points for personality disorder + life-threatening chronic condition. We can all pour one out for the dialysis player that's been blacklisted from every outpatient center in the region.
 
What I really need a script on is something generic to say to prevent patients from asking me about their trivial lab abnormalities when they look at their patient app after I tell them everything appears to be reassuring. It’s like they think I’m hiding something. “Well I know you said everything is fine but how come my RDW is 15%, my monocytes are 3.5%, and my bun/creatinine ratio is low?”
Otherwise telling people to see their pcp is one of the best things i love about my job because it means I did my job as an ER doc, and a patient is about to leave the department. I see most ER patients as like an annoying in-law at your house that you just can’t wait to get rid of.
 
Arcan57 said:
Bonus points for personality disorder + life-threatening chronic condition. We can all pour one out for the dialysis player that's been blacklisted from every outpatient center in the region.
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Man, one freaking guy on HD who was a pain in the ass, and I don't know if he was either blacklisted from every dialysis place or simply refused to go. He would show up to the ED every 1-2 days. It got to the point where we would check his chem, and if his K was fine we'd just kick him out. If it was above 5.5 or something we'd dialyze him. I know CM got involved a bunch of times and I don't know if they either figured out a solution for him that wasn't coming to the ER nearly every day, or if he just dropped dead, but either way he stopped coming after about 6 months.
 
prolene60 said:
What I really need a script on is something generic to say to prevent patients from asking me about their trivial lab abnormalities when they look at their patient app after I tell them everything appears to be reassuring. It’s like they think I’m hiding something. “Well I know you said everything is fine but how come my RDW is 15%, my monocytes are 3.5%, and my bun/creatinine ratio is low?”
Otherwise telling people to see their pcp is one of the best things i love about my job because it means I did my job as an ER doc, and a patient is about to leave the department. I see most ER patients as like an annoying in-law at your house that you just can’t wait to get rid of.
Click to expand...

I use some flavor of "The normal values for those labs are based on healthy volunteers who feel well. Almost every patient we see in the emergency department has a few borderline values but I don't see anything that I think we need to be concerned about." Seems to work fine.
 
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