namethatsmell

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As if Vegemite wasn't offensive enough.

Who knew the fate medicine of medicine wouldn't be decided by MD vs DO or doctor vs midlevel but iOS vs Android.

Calling John Connor...
 
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RustedFox

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Can anyone post data about the general litigiousness of the UK system? For as much of an Anglophile as I am, I have limited insight as to their NHS woes.
 
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Vandalia

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Can anyone post data about the general litigiousness of the UK system? For as much of an Anglophile as I am, I have limited insight as to their NHS woes.
On the way to vacation and I am checking this board. I freely admit I am an idiot.

In the UK, as I understand it, the risk of litigation is the same, but the type would be different. It is unlikely you will face a civil suit, but perhaps as a result of that there are a fair number of physicians, dentists, pharmacists, nurses, etc. who are criminally prosecuted for negligence and sentenced to prison. For the thing that in the US would get you sued, in the UK you will end up facing prison time.

One example: surgeon sentenced to prison for a delay in operating on a patient s/p knee replacement: https://www.theguardian.com/uk-news/2013/nov/05/surgeon-convicted-manslaughter-negligence-patient

Or a pharmacist convicted and sentenced to 3 months in prison for a dispensing error (likey not hers, but a subordinate): http://www.pharmaceutical-journal.com/news-and-analysis/former-locum-handed-suspended-jail-term-for-dispensing-error/10882780.article
 
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Old_Mil

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Can anyone post data about the general litigiousness of the UK system? For as much of an Anglophile as I am, I have limited insight as to their NHS woes.
It is about the same as the US. Significantly more risk than Canada or New Zealand. That is the one thing that will make medicine in the US intolerable as we move towards socialized medicine...continuing to be on the hook for outcomes of decisions you are forced to make.

You have no idea how glad I am to be out.
 

dchristismi

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Damned if I know, but ended up holding a c-spine on the side of a road the other day until the Scottish EMS showed up and had a great time talking to 999. Well, I made the other half hold c-spine. He's the medic/CCRN and jumped right to it. Guy just collapsed, prolonged AMS, pupils sluggish, probably a bleed coupled with a head injury from the fall. Still minimally responsive when ems showed up what seemed like an eternity later. I hate being in the field...
 

GeneralVeers

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The massive "junior doctor" strikes also demonstrate how poor their system is. The government needed to get more work out the residents for less pay so unilaterally implemented a "non-negotiable" contract. The horrors of single-payer medicine continue.....
 

UKEMdoc

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Created an account to post here-

The NHS is difficult for Americans to understand. The British public are overwhelmingly proud and defensive of it while simultaneously complaining about every possible failing. One thing to remember is that the British system is cheap - we pay about half as much as you do for healthcare as a proportion of GDP

We spend about half as much as you do per capita on healthcare. In exchange everyone has a Family Physician who is gatekeeper for any hospital referrals and does one hell of a lot in-house. Unless clinically urgent/cancer you probably need to wait weeks/months for appointments or operations. You can come to the ED (and lots do) where you will see a resident/fellow equivalent, if you're not sick then the idea is you're turfed at the door. Hospitals are busy, overcrowded (100% bed occupancy and boarding) and under the same stresses as everywhere else. Private care does exist and means you get any elective scan/operation you want, when you want it and performed by a very sweet talking surgeon with 2 ex-wives and a porsche.

There's lots of stresses in the system, essentially the money supply has been frozen - not good when you remember our aging demographic and increasing burden of chronic disease. In addition the NHS is now a political football so every five minutes a politician somewhere creates a new campaign and more layers of bureaucracy and targets get added on. Over the past 3-4 years these seem to becoming worse and stress is a major problem.

From the doctors point of view, medical education used to be cheap (I got free tuition & $5000 a year during med school) and you developed responsibility early - by PGY4-5 you are a registrar (similar to fellow) and running the ED overnight with a consultant (attending) on call at home for major trauma etc. Pay isn't as good as the US, 150$ an hour locumming or 150000$ a year for a 40hr/wk job with no night shifts.

Malpractice - look up crown indemnity. Essentially we're not liable - the hospital is. I pay 700$ a year for a medico-legal service who will provide me with legal advice, help answer complaints, help me if I'm in front of the medical board or heaven forbid a criminal charge. Every year a couple of doctors get prosecuted for manslaughter and worryingly the bar is lowering - the classic case was giving intra-thecal vincristine

Happy to answer any questions about the UK, the good, the bad and the ugly.


PS - I'm typing this in a halo brace 4 weeks after a climbing accident. Pan-scan within 30 minutes of ED attendance, amazing care on a dedicated major trauma unit and got my halo the next day because a neurosurgical fellow stayed late to do it. It was a hospital I've worked in but I would have got the same care as a homeless illegal immigrant - and that makes me a bit proud
 

UKEMdoc

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Junior doctor strike - this one is a big problem. Historically every hospital in the UK has had a handful of consultants (attendings) and lots of junior doctors providing day to day care. Being a junior in the UK is different to the US - hell of a lot of scut and you hope to learn inbetween - added to a 48 hour work week. You are generally a junior for 4-5 years before becoming a general practitioner or 8-15 years before hospital work (psychiatry vs paediatric surgery).
The idea was you work hard but get paid. Medical education used to be free and we got a reasonable salary by UK standards (i.e 60000-100000$ pa).

A bigger complaint than salary was under-appreciation, bullying, overwork and being set ridiculous "educational" targets for career progression.

Unfortunately current government is desperately trying to safe money on the NHS and most of the healthcare spend anywhere goes on people - the junior doctors were the guinea pigs. The current system of calculating pay was grossly unfair and I cannot recall hearing a single person defending it. The government came up with a deal so bad that 99% of the juniors voted for strike action and created the biggest healthcare strikes in 40 years.

British politics(and the economy) have imploded in recent months so who knows whats going to happen.
 
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Birdstrike

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It is about the same as the US. Significantly more risk than Canada or New Zealand. That is the one thing that will make medicine in the US intolerable as we move towards socialized medicine...continuing to be on the hook for outcomes of decisions you are forced to make.

You have no idea how glad I am to be out.
In what way are you "out"?
 

Psai

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Junior doctor strike - this one is a big problem. Historically every hospital in the UK has had a handful of consultants (attendings) and lots of junior doctors providing day to day care. Being a junior in the UK is different to the US - hell of a lot of scut and you hope to learn inbetween - added to a 48 hour work week. You are generally a junior for 4-5 years before becoming a general practitioner or 8-15 years before hospital work (psychiatry vs paediatric surgery).
The idea was you work hard but get paid. Medical education used to be free and we got a reasonable salary by UK standards (i.e 60000-100000$ pa).

A bigger complaint than salary was under-appreciation, bullying, overwork and being set ridiculous "educational" targets for career progression.

Unfortunately current government is desperately trying to safe money on the NHS and most of the healthcare spend anywhere goes on people - the junior doctors were the guinea pigs. The current system of calculating pay was grossly unfair and I cannot recall hearing a single person defending it. The government came up with a deal so bad that 99% of the juniors voted for strike action and created the biggest healthcare strikes in 40 years.

British politics(and the economy) have imploded in recent months so who knows whats going to happen.
Wow 48 hours a week? Man you guys are overworked, that's over full time!
 

UKEMdoc

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Wow 48 hours a week? Man you guys are overworked, that's over full time!
Work to Live - don't Live to Work.

No 0630 pre-rounds, no more 36 hour on-calls. Disadvantage is being sent round hospitals that can be 60-70 miles away. Education/CPD etc is almost all in your own time - service comes first.
 

BoardingDoc

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Work to Live - don't Live to Work.

No 0630 pre-rounds, no more 36 hour on-calls. Disadvantage is being sent round hospitals that can be 60-70 miles away. Education/CPD etc is almost all in your own time - service comes first.
I think psai was being sarcastic. Any residents (juniors) in the US who got to work 48hrs a week or less would be celebrating. 80 hrs/week is the cap in the US for residents and that cap is frequently unofficially violated.
 

GeneralVeers

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Work to Live - don't Live to Work.

No 0630 pre-rounds, no more 36 hour on-calls. Disadvantage is being sent round hospitals that can be 60-70 miles away. Education/CPD etc is almost all in your own time - service comes first.
You also forgot to mention that in the U.S. we are residents for ~ 3 years. If I remember correctly, you are an indentured service to the NHS for at least 6 years before becoming a full doctor. Is that corret?

Honestly, your system sounds awful. The only part of it I would keep is turfing non-emergent patients at the door (meaning triage nurse).
 

UKEMdoc

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You also forgot to mention that in the U.S. we are residents for ~ 3 years. If I remember correctly, you are an indentured service to the NHS for at least 6 years before becoming a full doctor. Is that corret?

Honestly, your system sounds awful. The only part of it I would keep is turfing non-emergent patients at the door (meaning triage nurse).
It's changing slowly but historically a lot of hospital doctors quit training after 2-3 years and worked as service providers without jumping through the hoops to finish training.

A lot of junior doctors go abroad after PGY2 - some even sit USMLE at that point and are pretty successful(for foreign graduates). For some reason British training is held in high esteem in some centres.
 

Vandalia

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You also forgot to mention that in the U.S. we are residents for ~ 3 years. If I remember correctly, you are an indentured service to the NHS for at least 6 years before becoming a full doctor. Is that corret?

Honestly, your system sounds awful. The only part of it I would keep is turfing non-emergent patients at the door (meaning triage nurse).
Others are more qualified to comment, but one of the dangers in comparing the two systems is that terms like "residents" and "medical students" are not exactly interchangeable. So the answer is not exactly. What is counted as the "6 years resident" in the UK includes what in the US would be the clinical years of medical school. So the comparison (using EM) would be "6 years resident in the UK" versus "5/6 years resident" ("residency"+"MS 3/4")" in the US. The big difference is that in the US you are paying $30-40K for two of those years instead of being paid.

The bottom line is that the training for similar specialties is pretty much identical between the two countries, it just has a different terminology in each.
 
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Dr.McNinja

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And there's your problem.
The hospital said the Cornwall ER had fewer than two patient visits per hour last year and that closing it will save $3.2 million.
If they're seeing 30-40 pts per day, and if those patients had private insurance, they would be rolling. FSEDs break even at 7 or fewer per day. Chalk up another win for the government.
 

Vandalia

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FSEDs break even at 7 or fewer per day.
If that is the case, it can be considered pretty clear proof that they are dramatically over-charging their patients. The bills should be reduced by a factor of about 5, since it appears they are paying for care they did not receive.

Except the country cannot afford private health insurance. It has bankrupted us. There is a reason why no other country in the world uses it, yet we still have patients leaving by the plane-load to get care in Mexico or India.
 
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Dr.McNinja

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I would argue that this thread demonstrates pretty well that those other countries can't afford their systems either. It just so happens that we had an unhealthier population sooner, but they're catching up.

Hospitals make up over 85% of the bill for patients anywhere. FSEDs bill at the same rates (ignoring the unethical ones, but there are unethical hospitals too) as regular EDs. The "surprise bill" phenomenon is really "surprise deductible" that applies in every healthcare situation.
 

alpinism

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The fact that Cornwall even has its own ED is ridiculous in the first place.

There's another ED less than 6 miles away up the road in Newburgh. Every rural american town doesn't need its own ED staffed 24 hrs per day.
 

oldanddone

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It is about the same as the US. Significantly more risk than Canada or New Zealand. That is the one thing that will make medicine in the US intolerable as we move towards socialized medicine...continuing to be on the hook for outcomes of decisions you are forced to make.

You have no idea how glad I am to be out.
Hey old mil
Are you following the ontario medical politics? The beaurocratic total quality management metric nightmare is locking in with bill 410. Whether via single payer govt or via the u.s. system the beaurocracy is eroding physician autonomy. Hope you're voting no today if you are in Ontario! #oncall4on concerned ontario doctors/facebook
 

GeneralVeers

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If that is the case, it can be considered pretty clear proof that they are dramatically over-charging their patients. The bills should be reduced by a factor of about 5, since it appears they are paying for care they did not receive.

Except the country cannot afford private health insurance. It has bankrupted us. There is a reason why no other country in the world uses it, yet we still have patients leaving by the plane-load to get care in Mexico or India.
It's pretty clear that NO country can afford "free" healthcare for everyone. When you make something free, demand will approach infinity. Either the patient rations their own care via co-pays and deductibles, or the government rations it via waiting lists and denial of care.

I'd much rather have a free market insurance system where patients ration their own care. Is it worth it to you to go the ER for a runny nose? Make people pay for it and they won't do it. Unfortunately we are rapidly approaching the leftist utopia of "free" healthcare for all.
 

Angry Birds

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It's pretty clear that NO country can afford "free" healthcare for everyone. When you make something free, demand will approach infinity. Either the patient rations their own care via co-pays and deductibles, or the government rations it via waiting lists and denial of care.

I'd much rather have a free market insurance system where patients ration their own care. Is it worth it to you to go the ER for a runny nose? Make people pay for it and they won't do it. Unfortunately we are rapidly approaching the leftist utopia of "free" healthcare for all.
Conservatives always smudge facts and arguments. What liberals argue for is universal health care, and this is done in virtually every Western country save the United States.

The "government" can limit care to what is deemed to be appropriate. Therefore, using the ER for a runny nose can be disallowed, and such a person would be told to follow up with their PCP.

The United States does not have universal healthcare, and yet we get the runny nose patients, both with and without insurance/medicaid. And, unlike in many of the universal healthcare countries (where care in the ER could or would be denied), we have to see the runny nose patients in the ER.
 

GeneralVeers

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Conservatives always smudge facts and arguments. What liberals argue for is universal health care, and this is done in virtually every Western country save the United States.
No smudging. I simply stated that both systems ration care. You can do it on the patient end, or on the government end. I for one would prefer to make my own decisions about care, and not have to beg the government.

The "government" can limit care to what is deemed to be appropriate. Therefore, using the ER for a runny nose can be disallowed, and such a person would be told to follow up with their PCP.
We can't do this in the U.S. Fear of liability prevents us from medically screening out stuff when it hits the door. At the point it gets to the doctor to medically screen, then there's no point. Enact tort reforms (which Democrats are against) and this would be feasible.

The United States does not have universal healthcare, and yet we get the runny nose patients, both with and without insurance/medicaid. And, unlike in many of the universal healthcare countries (where care in the ER could or would be denied), we have to see the runny nose patients in the ER.
Agreed. I think it should be medically screened by triage nurse. At that point they either pay cash/credit card up front or go home. As has been pointed out in many threads in some ways we have the worst of both systems. We are forced to be indentured servants to the state, and get no reimbursement or even tax benefits for the care we provide, all while still sucking up the liability and having to deal with "patient satisfaction". I'm still astonished that we care about patient satisfaction in patients who get free care, and have no intention of paying their bill.
 
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Angry Birds

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No smudging. I simply stated that both systems ration care. You can do it on the patient end, or on the government end. I for one would prefer to make my own decisions about care, and not have to beg the government.
There are European countries where the government rations "free" care, but you can pay to have additional care. I believe this is the system in the UK--someone correct me if I'm wrong.

We can't do this in the U.S. Fear of liability prevents us from medically screening out stuff when it hits the door. At the point it gets to the doctor to medically screen, then there's no point. Enact tort reforms (which Democrats are against) and this would be feasible.
Agree with you on this.

Agreed. I think it should be medically screened by triage nurse. At that point they either pay cash/credit card up front or go home. As has been pointed out in many threads in some ways we have the worst of both systems. We are forced to be indentured servants to the state, and get no reimbursement or even tax benefits for the care we provide, all while still sucking up the liability and having to deal with "patient satisfaction".
I agree that the heavy emphasis on "patient satisfaction" is disturbing, but this is probably because of our consumerist, capitalist, and for-profit healthcare system. It would likely be much less of an issue if, for example, the government ran healthcare, such as in the VA system.

I'm still astonished that we care about patient satisfaction in patients who get free care, and have no intention of paying their bill.
You don't see an ethical issue with caring about patient satisfaction for richer patients, and ignoring this for poor patients?
 

enalli

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The massive "junior doctor" strikes also demonstrate how poor their system is. The government needed to get more work out the residents for less pay so unilaterally implemented a "non-negotiable" contract. The horrors of single-payer medicine continue.....
Are things somehow better here? Resident salaries are artificially lower than they should be and it has nothing to do with the antitrust exemptions of the match. A reputable hospital could decide it would start paying its new residents $20,000 and it would still fill all its spots because there are so many more applicants than spots available. More to your point, my hospital could unilaterally decide to give me a massive paycut next year and I would have less negotiating leverage than my UK counterparts because striking is simply not an option.
 

clausewitz2

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Are things somehow better here? Resident salaries are artificially lower than they should be and it has nothing to do with the antitrust exemptions of the match. A reputable hospital could decide it would start paying its new residents $20,000 and it would still fill all its spots because there are so many more applicants than spots available. More to your point, my hospital could unilaterally decide to give me a massive paycut next year and I would have less negotiating leverage than my UK counterparts because striking is simply not an option.
Current resident salaries are actually the result of a salary floor promulgated by the ACGME. They are much higher than they would be if hospitals has free reign to set them, and much higher in terms of purchasing power than they were within relatively recent historical time. If it was possible to pay residents nothing, there are still some programs that would fill.

What you would see in the absence of the current set of regulations is a very wide spectrum of salaries, with wild variation based on specialty in a way you simply do not at present.
 
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alpinism

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There are European countries where the government rations "free" care, but you can pay to have additional care. I believe this is the system in the UK--someone correct me if I'm wrong.
This is exactly the case.

The UK doesn't have a socialized medical system with "rationed care and waiting lists" by any means. They have both a public and a private medical system which together provide universal health coverage for everyone. Immediate high quality care is available to everyone at private hospitals, you just have to pay for it just like at any hospital here in the US.
 
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Dr.McNinja

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I agree that the heavy emphasis on "patient satisfaction" is disturbing, but this is probably because of our consumerist, capitalist, and for-profit healthcare system. It would likely be much less of an issue if, for example, the government ran healthcare, such as in the VA system.
HCAPS is purely government. It's a way to have them pay less, and nothing else. If the government cared about customer satisfaction, the IRS and DMV wouldn't suck so hard.

You don't see an ethical issue with caring about patient satisfaction for richer patients, and ignoring this for poor patients?
During Katrina when I was volunteering, we were handing out water. One of the people complained that the water was warm. Yeah, if you don't pay for it, you don't get to complain. Beggars can't be choosers and all.
Although, I don't care about satisfaction for rich patients either.
 
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MSmentor018

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During Katrina when I was volunteering, we were handing out water. One of the people complained that the water was warm. Yeah, if you don't pay for it, you don't get to complain. Beggars can't be choosers and all.
Although, I don't care about satisfaction for rich patients either.
everyone thinks their entitled. when your only survival skill is holding out your hand to wait for the check and/or complaining, that's what happens. it should be plain and simple. if you're getting assistance you should be required to 1. put in some work, however menial to better society 2. can't complain about it
 
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Mad Jack

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Others are more qualified to comment, but one of the dangers in comparing the two systems is that terms like "residents" and "medical students" are not exactly interchangeable. So the answer is not exactly. What is counted as the "6 years resident" in the UK includes what in the US would be the clinical years of medical school. So the comparison (using EM) would be "6 years resident in the UK" versus "5/6 years resident" ("residency"+"MS 3/4")" in the US. The big difference is that in the US you are paying $30-40K for two of those years instead of being paid.

The bottom line is that the training for similar specialties is pretty much identical between the two countries, it just has a different terminology in each.
That is incorrect- in the UK, you have to practice for 5-11+ years after six years of medical school to be a consultant. Medical school is still medical school, but internship is foundation year(s), residents are junior doctors, and attendings are consultants.
 

Mad Jack

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Are things somehow better here? Resident salaries are artificially lower than they should be and it has nothing to do with the antitrust exemptions of the match. A reputable hospital could decide it would start paying its new residents $20,000 and it would still fill all its spots because there are so many more applicants than spots available. More to your point, my hospital could unilaterally decide to give me a massive paycut next year and I would have less negotiating leverage than my UK counterparts because striking is simply not an option.
Residents were paid 30k not even fifteen years ago, and decades before that were only provided with room and board. The ACGME ended the practice of indentured servitude in exchange for training, which was the norm prior to rules requiring that they pay a living wage.
 

GeneralVeers

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I'm all for charity. Medicaid, Medicare, and foodstamps are forms of charity, albeit government-enforced charity through the threat of violence. When society is nice enough to give you something for free, you shouldn't have the right to complain about those things. Hence patient satisfaction should not apply to Medicaid patients.
 
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Dr.McNinja

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When society is nice enough to give you something for free, you shouldn't have the right to complain about those things.
Eh, even I have a caveat to that. They do have the right to complain about something being unsafe, or unsanitary, or the like. But no, they don't have the right to complain about the temperature of their soup at the soup kitchen.
 

GeneralVeers

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Eh, even I have a caveat to that. They do have the right to complain about something being unsafe, or unsanitary, or the like. But no, they don't have the right to complain about the temperature of their soup at the soup kitchen.
Right which is what patient satisfaction is about. Did the ER see you and treat you FOR FREE to determine if you had a life-threatening condition? If yes, then that's it. You don't get to complain about the wait times, not getting a sandwich, the temperature of the room, or that the nurse was mean to you.
 

WilcoWorld

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Eh, even I have a caveat to that. They do have the right to complain about something being unsafe, or unsanitary, or the like. But no, they don't have the right to complain about the temperature of their soup at the soup kitchen.
Right which is what patient satisfaction is about. Did the ER see you and treat you FOR FREE to determine if you had a life-threatening condition? If yes, then that's it. You don't get to complain about the wait times, not getting a sandwich, the temperature of the room, or that the nurse was mean to you.
You're both right, as usual.
 

WilcoWorld

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Why you kissing their asses?
I'm not kissing ass.

I agree with McNinja that, just because someone isn't paying for something doesn't require that person to just accept whatever you give them without question. (The soup at the soup kitchen better not transmit cholera.)

I agree with Veers that striving for patient satisfaction has compelled most ED's to start catering to a lot of non-emergent issues. In doing so, we've become worse at treating emergencies. Ironically, through our efforts to improve, we have made ourselves worse at what we started out trying to do (treating emergencies).

As for the "as usual" part, I suppose I posted it because I thought it might surprise people for me to say that. I often feel like one of the few liberal voices among the veterans of this forum. I would guess that most casual readers would expect me to disagree with everything Veers says and a lot of what McNinja posts.
 

MSmentor018

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I agree with Veers that striving for patient satisfaction has compelled most ED's to start catering to a lot of non-emergent issues. In doing so, we've become worse at treating emergencies. Ironically, through our efforts to improve, we have made ourselves worse at what we started out trying to do (treating emergencies).
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probably the best short summary of all this bull**** that we've been doing in medicine. i am going to use it (and give you credit) when I go to the hill.
 

emergentmd

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Jul 6, 2008
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Metics and patient sats are one of the stupidest and poorly used ways to rate how well an ED runs.

I can go to even the worst hospital and cheaply bring up presentation to Provider times, and satisfaction in 3 months but this woul dnot change how terrible the ED is.

I work in a well run ED by most standards. Our door to ED doc/provider time is less than 10 minutes but they want to bring this down even more. These times are legit times where you are seen by a doc or ML, history/exam taken, labs ordered, and your true care is started. Pts are usually out the door in 2 hrs.

I work at a locums place that has presentation to provider time of prob 1 minute. They put a ML in triage, they click seen, order either the wrong/incorrect labs/too much labs, and I finally see them 2-3 hrs later which requires me to either add labs, or wait for unneccessary labs to come back. They are out the door in 5 hrs.

But my well run ED admin keeps pointing at my locums place (same big national hopital chain) and want us to throw a ML in triage. I can't argue with stupidity anymore
 
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GeneralVeers

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Mar 19, 2005
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Metics and patient sats are one of the stupidest and poorly used ways to rate how well an ED runs.
Agree completely. Due to "poor patient satisfaction", one of my EmCare sites has now mandated that EVERY patient be seen by a physician. That means the level 4 tooth pain, or the level 5 med refill that is seen by an APP has to sit and wait until a physician comes to say hi. We are not really sure how this going to work yet as the patient volume is already very high just for the physicians. Would seeing a physician increase patient satisfaction moreso than than the extra hour wait would tend to decrease it?

I've basically stated that at his point I don't need an APP. If I have to see all the patients, just give me the $70/hour that they make, plus two scribes.
 

WilcoWorld

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Nov 2, 2004
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Due to "poor patient satisfaction", one of my EmCare sites has now mandated that EVERY patient be seen by a physician. That means the level 4 tooth pain, or the level 5 med refill that is seen by an APP has to sit and wait until a physician comes to say hi.
Yep, that's going to have the exact opposite of it's intended effect.