The average patient doesn't know what antibiotics are used for.

[RustedFox]

The thread title shouldn't come as a surprise, but...

- I fielded a patient complaint about my care recently. 60-ish year old female who came in for aphthous stomatitis. She was quick to attribute (and probably correctly so) the development of the ulcers to a recent prescription of Bactrim DS (for uncomplicated UTI). She even used the term "allergic reaction", which although not entirely correct... fits the bill. I took 3-4 minutes and explained my plan for care. Viscous lido. Magic mouthwash. Discontinuation of abx (as she reported resolution of urinary sx). Discharge home.

Complaint: "Wasn't given antibiotics to treat the infection in my mouth."


#1 source of burnout: the patient.

---

Members don't see this ad.

 

[southerndoc]

Unfortunately, if this person filled out a patient satisfaction survey and gave you poor scores, you can't exclude it for their ignorance.

 

[RustedFox]

No amount of time and education can help 50% of patients (in my estimate).

I'm on-shift right now. 23 year old female head injury 3 days ago. New Orleans and Nexus negative.
I actually sat with her and let her click the buttons on the CDM rules on the MDCalc app on my phone to show her why the CT wasn't indicated.
Her first words to the discharge RN were: "So why aren't you guys doing anything? I could have a concussion, you know."

 

[turkeyjerky]

No amount of time and education can help 50% of patients (in my estimate).

I'm on-shift right now. 23 year old female head injury 3 days ago. New Orleans and Nexus negative.
I actually sat with her and let her click the buttons on the CDM rules on the MDCalc app on my phone to show her why the CT wasn't indicated.
Her first words to the discharge RN were: "So why aren't you guys doing anything? I could have a concussion, you know."

Lol. I love it when you spend a ton of time in the room, sit down, really explain everything, walk out thinking that everything's hunky-dory, and then they say **** like that to the RN.

Had a similar case not too long ago--14 year old with a really minor headinjury (think he got hit a dodgeball in gym class or something), had a minor headache but was obviously fine. After going through pecarn with mom, I discharged him. She says to RN, "I'm just so confused, the last time this happened he got a head CT and then an MRI"

 

[turkeyjerky]

Got an antibiotic story too. A while back a woman brings in her kid for a mosquito bite. It was obviously an arthropod bite, with maybe 3-4 cm of surrounding erythema from him scratching at it. Definitely not cellulitic. I explained symptomatic care, she asked about antibiotics. I explained, that yes insect bites can sometimes get secondarily infected, but that this clearly wasn't. She was super persistent, kept saying it was a "mosquito infection" and repeatedly asked for a zpak. I finally just told her, "you keep using that word 'infection' but it doesn't mean what you think it means"

After she nearly began to cry thinking her son was going to die from a "mosquito infection" I agreed to prescribe her some clinda post-dated for two days in case of worsening. The next morning (i.e. 8 hrs later) she has the pharmacist call in trying to fill early and also says we prescribed her the wrong antibiotic (I had explained to her that azithro wouldn't even be indicated for a soft tissue infection)

 

[GonnaBeADoc2222]

The thread title shouldn't come as a surprise, but...

- I fielded a patient complaint about my care recently. 60-ish year old female who came in for aphthous stomatitis. She was quick to attribute (and probably correctly so) the development of the ulcers to a recent prescription of Bactrim DS (for uncomplicated UTI). She even used the term "allergic reaction", which although not entirely correct... fits the bill. I took 3-4 minutes and explained my plan for care. Viscous lido. Magic mouthwash. Discontinuation of abx (as she reported resolution of urinary sx). Discharge home.

Complaint: "Wasn't given antibiotics to treat the infection in my mouth."


#1 source of burnout: the patient.

If your medical director was worth their salt, they would have shielded you from this complaint and it never should have come to your attention.

No amount of time and education can help 50% of patients (in my estimate).

I'm on-shift right now. 23 year old female head injury 3 days ago. New Orleans and Nexus negative.
I actually sat with her and let her click the buttons on the CDM rules on the MDCalc app on my phone to show her why the CT wasn't indicated.
Her first words to the discharge RN were: "So why aren't you guys doing anything? I could have a concussion, you know."

In reference to this and the other stories above, wholeheartedly agree. There is an extremely small subset of patients/parents that are receptive to explanations of medical rationale. Probably 5%-ish. I find those people to be extremely engaging, very appreciative of my explanations, and very satisfied to know my logic behind why I am or am not doing x, y, or z.

The rest of them think they know the indications and differences between modes of radiolologic imaging, nuances of antimicrobial treatment, indications for admission / discharge, etc. Paradoxically, my attempts at explanation just sour the interaction even more. I often get the sense that they think I am "withholding" something. Most of the time, these people just get told what is happening and nothing more.

 

[RustedFox]

If your medical director was worth their salt, they would have shielded you from this complaint and it never should have come to your attention.

Corporate policy, my man. Plus; the director wasn't taking it seriously, either. It was more presented to me as: "Did you see this idiot? Can you believe what she said?"

 

[southerndoc]

No amount of time and education can help 50% of patients (in my estimate).

I'm on-shift right now. 23 year old female head injury 3 days ago. New Orleans and Nexus negative.
I actually sat with her and let her click the buttons on the CDM rules on the MDCalc app on my phone to show her why the CT wasn't indicated.
Her first words to the discharge RN were: "So why aren't you guys doing anything? I could have a concussion, you know."

I copied a speech used by one of our docs. I've had a good deal of success telling patients we use strict criteria to determine who needs a CT. Tell them they don't meet criteria, CT's are a lot of radiation (100 x-rays worth), they don't rule out concussion.

"I think you have a concussion, but based on scoring systems, you don't need a CT. A CT is designed to see if you have enough blood in your brain to determine if you need surgery. It's not worth the radiation risk of 100 x-rays as it increases your risk of cancer. Insurance companies have also refused to pay lately because CT's are expensive and must be justified. The hospital charges $3,000 for a head CT. Now, if you still want it, I'll order it, but realize that you may get stuck with the bill, may have an increased risk of cancer, and you still won't be able to tell if you have a concussion by the CT since it's a clinical diagnosis."

 

[theseeker4]

I copied a speech used by one of our docs. I've had a good deal of success telling patients we use strict criteria to determine who needs a CT. Tell them they don't meet criteria, CT's are a lot of radiation (100 x-rays worth), they don't rule out concussion.

"I think you have a concussion, but based on scoring systems, you don't need a CT. A CT is designed to see if you have enough blood in your brain to determine if you need surgery. It's not worth the radiation risk of 100 x-rays as it increases your risk of cancer. Insurance companies have also refused to pay lately because CT's are expensive and must be justified. The hospital charges $3,000 for a head CT. Now, if you still want it, I'll order it, but realize that you may get stuck with the bill, may have an increased risk of cancer, and you still won't be able to tell if you have a concussion by the CT since it's a clinical diagnosis."

what proportion say "yeah, I still want the CT?" Also, do you really just order the test if they ask enough times/insist enough?

 

[southerndoc]

Very little. Some ask, and sometimes I have to go through the spill again when their spouse, parent, etc. shows up.

If a patient insists on something, frequently I just order it. It's less of a headache, not worth the risk of ticking the patient off, and not worth the litigation risk. This is not saying I do unreasonable things. A head CT in a head injured patient who doesn't meet criteria isn't unreasonable. 100 Percocet for a stubbed toe is unreasonable.

 

[deleted859535]

Very little. Some ask, and sometimes I have to go through the spill again when their spouse, parent, etc. shows up.

If a patient insists on something, frequently I just order it. It's less of a headache, not worth the risk of ticking the patient off, and not worth the litigation risk. This is not saying I do unreasonable things. A head CT in a head injured patient who doesn't meet criteria isn't unreasonable. 100 Percocet for a stubbed toe is unreasonable.

Similar. I explain and try to do the right thing in as brief/efficient a way as possible. EM makes all of us pretty good at "reading the room" after enough time -- so if I have someone I know will really appreciate some elaboration, I'm happy to oblige. I typically enjoy these conversations.

By that same token, I usually know when I'm wasting my time. I'm too busy to waste my time beyond a simple explanation and agreeing on a course of care so as to do the right, or at least reasonable if not academically perfect, thing. I'd rather save my finite effort and energy for those who need it -- you know, for the people who need to be in the ED.

Sort of the EM version of the Serenity Prayer.

 

[engineeredout]

 

[Perrotfish]

If a patient insists on something, frequently I just order it. It's less of a headache, not worth the risk of ticking the patient off, and not worth the litigation risk. This is not saying I do unreasonable things. A head CT in a head injured patient who doesn't meet criteria isn't unreasonable. 100 Percocet for a stubbed toe is unreasonable.

Does your philosophy change when they're making decisions for their child vs. themselves?

 

[BoardingDoc]

Does your philosophy change when they're making decisions for their child vs. themselves?

Yes. I know you weren't addressing me, but I have the same practice as what you quoted from Southerndoc. Again, not always, but if a patient is demanding a NCHCT, I'll occasionally just get it after explaining the risks.

If a parent wants a NCHCT for their 6 year old who is completely PECARN negative and looks great clinically, I will try to explain why it isn't needed. If they are insistent, I explain that what they are requesting would be harmful and I cannot ethically do it. I have never had anyone push it past that point but if they did, there is a children's hospital not too far from my shop that I'd tell them they could go to after I discharged them... and warn them that they're going to get the same answer there that they did here.

 

[VA Hopeful Dr]

Yes. I know you weren't addressing me, but I have the same practice as what you quoted from Southerndoc. Again, not always, but if a patient is demanding a NCHCT, I'll occasionally just get it after explaining the risks.

If a parent wants a NCHCT for their 6 year old who is completely PECARN negative and looks great clinically, I will try to explain why it isn't needed. If they are insistent, I explain that what they are requesting would be harmful and I cannot ethically do it. I have never had anyone push it past that point but if they did, there is a children's hospital not too far from my shop that I'd tell them they could go to after I discharged them... and warn them that they're going to get the same answer there that they did here.

I do find that I fight a more about doing unnecessary things to children versus adults for the obvious reasons

 

[GonnaBeADoc2222]

Does your philosophy change when they're making decisions for their child vs. themselves?

Totally.

If antibiotics or radiation are not indicated for your 6 yo, I'm not giving it. Go ahead and file a complaint.

 

[southerndoc]

Does your philosophy change when they're making decisions for their child vs. themselves?

I don't see kids.

 

[emergentmd]

Early years being EM doc and wasting 10 min
Me - Sit down, long discussion about virus and how abx makes things worse.
Parents - nods head like they understand and agrees
Me - start to walk out and explained discharge happening soon.
Parents - Odd look and wonder why pt not getting anything like abx.
Me - Sit down and explain again
Parents - leave and unhappy. VERY unhappy when they come back 3 dys later and given abx.

Me now after 15+ Yrs and Spending 2 min
Me - You got an infection, here is amoxil
Parents - Thank you doc, you are the best.
Me - get to go back and continue to relax and surf the internet with a satisfied patient/parent
Parents - Comes back in 3 dys and kids not better. We came 3 dys ago, given abx, and still with cough. Told that its post tussive symptoms that will go away in a few wks...... parents greatly appreciative of my care.

Hmmmmmmmmm......... give me the amoxil path.

 

[GonnaBeADoc2222]

Early years being EM doc and wasting 10 min
Me - Sit down, long discussion about virus and how abx makes things worse.
Parents - nods head like they understand and agrees
Me - start to walk out and explained discharge happening soon.
Parents - Odd look and wonder why pt not getting anything like abx.
Me - Sit down and explain again
Parents - leave and unhappy. VERY unhappy when they come back 3 dys later and given abx.

Me now after 15+ Yrs and Spending 2 min
Me - You got an infection, here is amoxil
Parents - Thank you doc, you are the best.
Me - get to go back and continue to relax and surf the internet with a satisfied patient/parent
Parents - Comes back in 3 dys and kids not better. We came 3 dys ago, given abx, and still with cough. Told that its post tussive symptoms that will go away in a few wks...... parents greatly appreciative of my care.

Hmmmmmmmmm......... give me the amoxil path.

Meh. That's certainly the burnt out way to approach it.

I would say it's likely ~1-2% of my peds population whose parents demand antibiotics despite explanation. In these cases, I am more than comfortable refusing. Takes me the same amount of time. I also go back to surfing the internet with the satisfaction that I didn't contribute to abx resistance, set an expectation of abx on demand, contribute to antibiotic associated diarrhea, actually practiced proper medicine.

 

[emergentmd]

Meh. That's certainly the burnt out way to approach it.

I would say it's likely ~1-2% of my peds population whose parents demand antibiotics despite explanation. In these cases, I am more than comfortable refusing. Takes me the same amount of time. I also go back to surfing the internet with the satisfaction that I didn't contribute to abx resistance, set an expectation of abx on demand, contribute to antibiotic associated diarrhea, actually practiced proper medicine.

I have been through the battle. If a pt/family seems reasonable, I still go down the teaching road. Half the pts have no clue what I am talking about even when I explain to them in 1st grade terms. The 25% that seems reasonable, I fight the fight, but even a portion of those wants abx...

Why am I here if you are not giving me anything?

 

[VA Hopeful Dr]

Meh. That's certainly the burnt out way to approach it.

I would say it's likely ~1-2% of my peds population whose parents demand antibiotics despite explanation. In these cases, I am more than comfortable refusing. Takes me the same amount of time. I also go back to surfing the internet with the satisfaction that I didn't contribute to abx resistance, set an expectation of abx on demand, contribute to antibiotic associated diarrhea, actually practiced proper medicine.

That's why everybody gets a z-pack. Everything's already resistant to it so you're not making anything worse, it's fairly safe as far as c diff goes, and I'm not sure I've ever seen a true allergic reaction to it.

It's absolutely Bad Medicine, but as someone who fought the good fight and lost it two jobs over it, it's just not worth it most of the time.

 

[Rendar5]

That's why everybody gets a z-pack. Everything's already resistant to it so you're not making anything worse, it's fairly safe as far as c diff goes, and I'm not sure I've ever seen a true allergic reaction to it..

I had a pretty bad allergic reaction to it. Angioedema of feet and hands with urticarial rash x3 days. Occurred two days after I completed the pack and lasted for 3 more days while it was still in my system. Allergist confirmed.

 

[GonnaBeADoc2222]

I have been through the battle. If a pt/family seems reasonable, I still go down the teaching road. Half the pts have no clue what I am talking about even when I explain to them in 1st grade terms. The 25% that seems reasonable, I fight the fight, but even a portion of those wants abx...

Why am I here if you are not giving me anything?

That's why everybody gets a z-pack. Everything's already resistant to it so you're not making anything worse, it's fairly safe as far as c diff goes, and I'm not sure I've ever seen a true allergic reaction to it.

It's absolutely Bad Medicine, but as someone who fought the good fight and lost it two jobs over it, it's just not worth it most of the time.

Yeah I mean if I were gonna lose a job over it, sure. Luckily I'm not in that situation. Just cause a patient demands bad medicine from me, doesn't mean they are entitled to it. Just like I can demand that my accountant sign off on shady deductions, but they don't have to do it.

 

[emergentmd]

Do you really think CMS, FDA, CDC, Csuite, CMGs really care about good vs bad medicine?

If they really care about abx resistance, then why are indiscriminately giving 4th gen antibiotics for someone with a viral infection?

Yeah I mean if I were gonna lose a job over it, sure. Luckily I'm not in that situation. Just cause a patient demands bad medicine from me, doesn't mean they are entitled to it. Just like I can demand that my accountant sign off on shady deductions, but they don't have to do it.

But you can fire your Accountant.

I am not scared to be fired..... If they fire me over bad medicine, then I can find a better job.

I pick my battles. Ill fight drug seekers while many others don't. Everyone has their own way to practice and I am the last to judge.

If practicing medicine is all we do without having to deal with admin, sure that sounds great. But we don't live in this Utopia, and have to answer to the metrics god, sepsis god, stroke god, press ganey god, janitor god