unrealistic patient expectations

[gman33]

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This has been discussed before, but looking for more tips.

I've had a string of patients lately who left the ED angry.
How do you guys manage patient expectations?

I think generally I do very well with patient interaction.
I could use some help with the patient who wants things that probably aren't going to happen.

A few examples.

Patient sent in from clinic with the expectation that their cardiologist would be waiting to see them in the ER to adjust their lasix. Clinic closed. Never called the ED.

Patient wants a head CT to r/o a brain tumor. No signs/symptoms. Normal neuro exam.

6 months low back pain. No red flags, PMD told patient NSG wanted them to come to ED for a stat MRI.
Spoke to NSG, they never heard of the patient, didn't want test. PMD doesn't return call.

If something is not indicated, I try to have a conversation with the patient about the risks/benefits.
If there is no indication at all, I will sometimes not get a particular test even if the patient really wants it.
For patients who are too unreasonable, I will end up getting tests at their request.
Not a stat MRI that isn't needed.
But if they want a head CT that I think is worthless, I'll give in a lot of the time.

What I'm really looking for are tips on how to have these types of conversations with patients.
Someday soon I'll probably have a job where I have to worry about patient satisfaction, elopments, patients leaving without completing treatment and all the rest.

 

[Szent]

I wish I could contribute more than my agreement that I, too, would like to know more about this sort of stuff.

I started off my interview season asking whether or not the program provided any training in the management of patient expectations, and I got a lot of "oh, you'll figure it out as you go along" so I stopped asking and focused on other areas important to me. It'll be nice to get more input about this from you guys. I was just wondering if there was literature regarding the efficient approach to these situations, with key areas to discuss, because I feel like I could spend an inordinate amount of time placating people.

 

[deleted128562]

Would love to hear some ideas too. Full disclosure: Just came off an awful shift in which I considered quitting more than once....

It almost seems impossible to me to meet patient expectations many days. The problem as I see it is that the ED is frequently advertised as a one-stop convenience shop by people ranging from administrators to primary care providers to just about everyone else who doesn't actually work the grind there on a daily basis. Need a med refill? Go to the ER. PCP wants a quick study and specialist consult? Go to the ER. Chronic pain of 15 years? Maybe the ER can magically diagnose it. WebMD says your vague symptoms might be hemorrhagic brain eating lupus? Quick, to the ER for a CT! Drunk guy found wandering on street? Better take him to the ER! Your mom kicked you out of the house and you don't know where to go? Sounds like a problem for the ER! And on and on and on.

How am I supposed to convince a patient it's not reasonable for me to write a prescription for a month supply of ativan? How am I supposed to magically fix an asymptomatic BP of 170/100 that primary care hasn't gotten under control in 6 months? How do I satisfy the parents of the kid with behavioral problems who doesn't qualify for psych admission, while they yell at me that if he hurts someone it will be my fault? How do I get a good satisfaction score from someone who expected me to be able to diagnose and cure the "real cause" of their 17 year old kid's IBS symptoms of 5 years?

The more and more the ED is sold to the public as a "convenience mart", the more and more difficult it will be to meet expectations. Thus ends my rant.

 

[Birdstrike]

This has been discussed before, but looking for more tips.

I've had a string of patients lately who left the ED angry.
How do you guys manage patient expectations?

I think generally I do very well with patient interaction.
I could use some help with the patient who wants things that probably aren't going to happen.

A few examples.

Patient sent in from clinic with the expectation that their cardiologist would be waiting to see them in the ER to adjust their lasix. Clinic closed. Never called the ED.

Patient wants a head CT to r/o a brain tumor. No signs/symptoms. Normal neuro exam.

6 months low back pain. No red flags, PMD told patient NSG wanted them to come to ED for a stat MRI.
Spoke to NSG, they never heard of the patient, didn't want test. PMD doesn't return call.

If something is not indicated, I try to have a conversation with the patient about the risks/benefits.
If there is no indication at all, I will sometimes not get a particular test even if the patient really wants it.
For patients who are too unreasonable, I will end up getting tests at their request.
Not a stat MRI that isn't needed.
But if they want a head CT that I think is worthless, I'll give in a lot of the time.

What I'm really looking for are tips on how to have these types of conversations with patients.
Someday soon I'll probably have a job where I have to worry about patient satisfaction, elopments, patients leaving without completing treatment and all the rest.

Patient sat will be the bane of your existence. It will constantly pressure you to practice bad, yet "patient satisfying," medicine. Get used to it. Make peace with it in a way that allows you to sleep at night. For all doctors in private practice, patient sat is their friend, because they want to build a practice. You however, will be overwhelmed with insane volume all the time. Therefore, patient sat will torture you, unless you somehow make peace with it.

(That's the two line summary of my full thoughts on the subject, if you haven't already read them. Posted on SDN first, then cross poster here-

Director's cut: http://www.epmonthly.com/whitecoat/2012/06/you-can-tie-you-can-lose-but-you-can-never-win/

G-rated version: http://www.kevinmd.com/blog/2013/11/focus-patient-satisfaction-sick.html )

 

[Birdstrike]

Here's your BBE Test (Birdstrike board exam). PM me your answers and I'll grade your test, and tell you if you are ready for the real world, Padawan.

How am I supposed to convince a patient it's not reasonable for me to write a prescription for a month supply of ativan?

Choose:

A: give a firm, "No, way in hell, that's not my job," and get complaint letter vs.

B: a single ED dose of Ativan for the "acute psych emergency" and advise to call PCP in the am for months refill.

How am I supposed to magically fix an asymptomatic BP of 170/100 that primary care hasn't gotten under control in 6 months?

Choose:

A: follow strict guidelines and kick patient OTD and have meeting with admin Monday 8am, vs

B: give an unnecessary ED dose of clonidine and recheck BP in 30 min prior to discharge.

How do I satisfy the parents of the kid with behavioral problems who doesn't qualify for psych admission, while they yell at me that if he hurts someone it will be my fault?

Choose:

A: take the purist hard-line to save money for the health care system and have complaint letter # 3, and meeting with admin #2 or

B: make the chart show that he absolutely might shoot up every schoolyard this side of Texas qualifying him for the psych hold making everyone happy, so you don't get yelled at, and do live to fight another day.

How do I get a good satisfaction score from someone who expected me to be able to diagnose and cure the "real cause" of their 17 year old kid's IBS symptoms of 5 years?

Choose:

A: truthfully imply to family how wasteful and unnecessary the ED visit was taking the bed of a kid who might have an acute ruptured appy and/or grandpa with AAA, vs

B: do a basic workup and/or handholding, and/or call to their doctor and/or any trumped-up nonsense window-dressing to keep them convinced you didn't blow them off and at least ruled something catastrophic out and not get bitched at or threatened by the guys who allow you to buy your toys and food for your baby birds to eat.

Must have 100% correct to be fit for the real world.


#birdstrikesbeenthere

 

[Rendar5]

5 years of IBS sx's? abdominal film for the win, lol. "Thank god we didn't find anything like brain-eating cancerous bacteria on the Xray, your kid would've ended up dead!"

Honestly, a straight-forward honest conversation, giving them something to do in the meantime (asymptomatic BP's always get told to keep a very careful BP diary so that their doctor can give them the best BP med because if I just give it to you based on one BP reading, I could overdose and kill you'make you faint), and giving them very clear instructiosn to return here with anything, we are open 24/7 for a reason, and what emergencies they DO need to look for, usually gets them out of here. Lets them know you do care about their emergencies, and empowers them to look for them.

Of course, telling them I can write off this ED visit and they won't get billed works wonders, lol. Got a little thing at my hospital that I fill out for medical screening exams that saves them a bill IF I don't treat them or do any testing on them. Saying free medical advice from doctor or bogus Rx and they have to get a bill usually gets them to take the free advice.

Sometimes you just have to say know to the truly pathologic factitious ones. Just NEVER challenge their delusion. Just redirect it. (unless they're truly pure narcotic seekers in which case kick them out and diagnos them with drug-seeking behavior. I do that once every several months)

 

[Rendar5]

I wish I could contribute more than my agreement that I, too, would like to know more about this sort of stuff.

I started off my interview season asking whether or not the program provided any training in the management of patient expectations, and I got a lot of "oh, you'll figure it out as you go along" so I stopped asking and focused on other areas important to me. It'll be nice to get more input about this from you guys. I was just wondering if there was literature regarding the efficient approach to these situations, with key areas to discuss, because I feel like I could spend an inordinate amount of time placating people.

AFAIK, there is no literature. The only thing to do is to just see how other people handle them, and emulate those that seem best to you. Empowering the pt in general is a good strategy. Give them something to monitor or work on so that they can go to their PMD prepared with their concerns, get them to recognize specific things as emergencies, give them autonomy to make their own medical decisions (explaining risks:benefits), all can take uncomfortable situations and make them easier for you. And just recognize that these only work on the uninformed or partially pathologic patients. The truly pathologic you either have to compromise, kick them out, or do what they want.

 

[Tiger26]

Satisfaction = Results divided by expectations. I find things are much better now when I learned to downplay expectations early in the workup rather than after everything comes back.

After seeing the patient with chronic abdominal pain, I'll often say that the plan is to rule out life threatening or surgical causes, but a lot of times we just don't know. Same with headaches, chest pain, etc.

Some things, I just don't fight anymore, like antibiotics for otitis, but I give the kid Auralgan in the ED to show the parents how well it works and then do antibiotics as a rescue script.

When it comes to CT, I'm not gonna put up a huge fight generally. Quick test, I'll explain risks/benefits and leave that on them.

Hypertension: I tell patients we're really good at emergencies and not very good at controlling BP as an outpatient and I don't want to start them on something that could lower it too much and result in a syncopal event-->fall-->head bleed, etc. Usually works pretty well.

In general, though, this is way easier as an attending, since you can do what you think is right

 

[Venko]

I agree with Tiger26 entirely, but I would also add that the earlier I can reach the patient from when they arrive to the ED, the easier the conversation goes.

Other areas where I too like to set expectations up front:
1. length of work up and need for potentially both US and CT in low abdominal pain in women
2. LP difficulties (traumatic tap, not able to get fluid, time required)
3. chest pain may not result in any obvious diagnosis
4. Delay in consultative services
5. Possibility of over-read of radiologic studies in AM with callbacks

 

[Arcan57]

To the OP,
Many of the examples you posted are no win because you've been set up to fail by the experience the patient had before ever seeing you. With the almost complete segregation of inpatient and outpatient work (except for specialists), there's really no social pressure to avoid screwing the EP because it's not like they're ever going to have to look across the table at me in the lunchroom. The only positive side on this is that with the fraying of the traditional PCP/pt relationship, more and more patients are starting to realize their doctors suck and you can sometimes satisfy them with a referral to one of your better IM colleagues (except if they're managed Medicare and then everyone involved is screwed).

Most of the ridiculous workup requests I'm dealing with aren't as the result of face to face communication with an MD, which makes things easier. I have no qualms about pulling rank if they got sent in by a nurse or explaining the reasoning of why the PCP may have told you to come to the ED because they couldn't rule out x/y/z over the phone but you don't have x/y/z because of a/b/c on H&P +/- EKG.

For the chronic complaints, my standard spiel is that I'm really good at things you need to be admitted to the hospital or have surgery for but there a lot of very painful/bothersome conditions that aren't life-threatening that I don't have any testing for.

"Well can't you just admit me to get the test?"
I'll give them a quick and apologetic review of the current state of inpatient medicine which is to stabilize you long enough to get the expensive testing that isn't covered by the diagnostic DRG done as an outpatient (although I don't usually mention the financial part, just that that test isn't done except in crashing patients).

 

[WilcoWorld]

Here's your BBE Test (Birdstrike board exam). PM me your answers and I'll grade your test, and tell you if you are ready for the real world, Padawan.




Choose:

A: give a firm, "No, way in hell, that's not my job," and get complaint letter vs.

B: a single ED dose of Ativan for the "acute psych emergency" and advise to call PCP in the am for months refill.




Choose:

A: follow strict guidelines and kick patient OTD and have meeting with admin Monday 8am, vs

B: give an unnecessary ED dose of clonidine and recheck BP in 30 min prior to discharge.




Choose:

A: take the purist hard-line to save money for the health care system and have complaint letter # 3, and meeting with admin #2 or

B: make the chart show that he absolutely might shoot up every schoolyard this side of Texas qualifying him for the psych hold making everyone happy, so you don't get yelled at, and do live to fight another day.



Choose:

A: truthfully imply to family how wasteful and unnecessary the ED visit was taking the bed of a kid who might have an acute ruptured appy and/or grandpa with AAA, vs

B: do a basic workup and/or handholding, and/or call to their doctor and/or any trumped-up nonsense window-dressing to keep them convinced you didn't blow them off and at least ruled something catastrophic out and not get bitched at or threatened by the guys who allow you to buy your toys and food for your baby birds to eat.

Must have 100% correct to be fit for the real world.


#birdstrikesbeenthere

This post is what music fans call an instant classic, so I'm "…"proofing it.

 

[WilcoWorld]

Wouldn't ya know, Voltaire predicted the future of medicine all the way back in the 18th century; “The role of the Physician is to entertain the patient while Nature takes it's course. ”

 

[Birdstrike]

This post is what music fans call an instant classic, so I'm "…"proofing it.

Lol

FYI: So, far, no one has signed up to take the exam. Not sure why. Lol

 

[Birdstrike]

Wouldn't ya know, Voltaire predicted the future of medicine all the way back in the 18th century; “The role of the Physician is to entertain the patient while Nature takes it's course. ”

That's a great quote and so true. We're set up to fail from day 1. The one thing we are expected to insure against, is one of the two absolutes guaranteed to happen in life: Death (and the other being taxes). Thank God people don't expect is to keep them from having to pay their taxes, too!

“Tis impossible to be sure of any thing but Death and Taxes"- Christopher Bullock

 

[gman33]

Thanks for the responses.
I like the idea of doing "something" for the patient.
Even if that something isn't going to be very helpful from a diagnostic standpoint.

One aspect that makes this difficult is a resident, is I have to please my attending at the same time.
I might have plan A, but they want plan B.
Don't want to derail the thread talking about that mess.

Birdstrike points out how doing the correct EBM isn't what the patient wants in some cases.
I don't mind giving the patient something that I think is worthless as long as there isn't a major downside.

I think with some of these patients I need to just start asking them why they came to the ED and what they expected to have done (if it's not obvious).
That way we can have a brief conversation and decide together what will happen.

There will still be cases where what they want just won't happen.
Some of these people will leave pissed and will complain.
I'll continue to try to have more effective conversations in this area.

 

[Arcan57]

Thanks for the responses.
I like the idea of doing "something" for the patient.
Even if that something isn't going to be very helpful from a diagnostic standpoint.

One aspect that makes this difficult is a resident, is I have to please my attending at the same time.
I might have plan A, but they want plan B.
Don't want to derail the thread talking about that mess.

Birdstrike points out how doing the correct EBM isn't what the patient wants in some cases.
I don't mind giving the patient something that I think is worthless as long as there isn't a major downside.

That's a somewhat dangerous road to go down, because once you cave into patient demands for unindicated testing it gets difficult to put on the brakes later. This can be mitigated somewhat by setting clear expectations for what happens after a non-diagnostic test. Beware of committing yourself to a dealing with a problem you can't fix.

I think with some of these patients I need to just start asking them why they came to the ED and what they expected to have done (if it's not obvious).
That way we can have a brief conversation and decide together what will happen.

Always a good idea. Getting hidden agendas out in the open puts you in a much better negotiating position than trying to blindly guess at where the patient is coming from.

 

[gman33]

I don't want to go crazy with unessential tests. Sometimes patients just really want that ankle xray or whatever.
I do try to set expectations before I start a workup.

I had one patient in particular the other day that turned into a cluster-f.

Just trying to find ideas about how to mitigate this for the future.

 

[TysonCook]

This is unfortunate, not easy, and really cheesy, but become comfortable with being able to say "no". Patient satisfaction is just one facet to what we do, and the reality is that satisfaction is the difference between a patients expectations and the reality of modern medicine. Getting to a place where you can say no, and explain why you're saying no is a huge part of the art of medicine.

After I get past no, and why not, if they persist, I (in a very nice way) just let them know that we can't help them today, and I'll get their DC papers to an RN and have them out of there soon. Yes, I get the occasional "I want to see your boss", etc. But in the end, if you have zero support from Admin, than YOYOMF. IMHO I don't see a lot of complaints on why I didn't do what the patient wanted.

A quick point is set the expectation from the first interaction (e.g. "...the triage note says that you wanted to have X test done today. We will help you today with your medical problem, and if we find we need to do test X , than we will. But I want to set your expectations realistically early on that test X may not indicated, and if that is the case we'll have you follow up with person Y for further evaluation..."). The key is doing this and being honest the first step in the room.

Lastly, I've found that the more I've said "no" (with the explanation why), I've become much more comfortable with doing it, (almost scripted), and in a weird way it becomes easier to do.

 

[RustedFox]

I have a couple of catchphrases that I like to use:

For the patient who wants more testing done, but isn't realistic to do right here and now:

"I do care about you, and I want you to get the best care; even if it's not here with me today. I need to stress how important it is that you find a doctor who is licensed to both perform and interpret an (endoscopy/MRI/etc), because that's not my branch of medicine.

For the low-risk chest pain patient who "needs an answer":

"Chest pain is always scary; but its not always dangerous. Given the testing that we can do here and now in the ER, I feel that your chest pain isn't dangerous, and you can safely go home tonight to further look into this in the right timeframe and fashion."

For the simple head injury who "needs an MRI":

"Yes, there's a very popular myth out there that an MRI is the best test for head injury; in the immediate aftermath of a head injury, what we need is the fastest test to look for the most dangerous things: bleeds, fractures, collections of blood, etc. An MRI is simply not the best tool for that job. Furthermore, there are as many flavors of MRI out there as there are flavors of ice cream. I'm not the expert in determining which type of study to use in those certain situations."

This one is useful in a variety of settings:

"Your story does sound troublesome. You did the right thing; you came in today to be seen. Thanks for coming. We need to start from the big, the bad, and the sinister/dangerous, and work our way backwards from there. You could be here for several hours before we can figure out whether you should stay here or you can safely go home."

The "CT/US female abdomen":

"An ultrasound might be very helpful to further look at causes of your abdominal pain; but in order for it to be a worthwhile study, they'll likely need you to not have eaten/urinated for some time prior to the test to get the best quality images. Nothing is worse than trying to look through a sea of bowel gas or an empty bladder and get a fuzzy, worthless study. Seeing as how we've already taken urine and given you oral contrast; its not likely worthwhile to do the ultrasound here and now."

The angry guy who is "not going to stay no matter what":

"You're welcome to go home today; I can't make you do anything that you don't want to, but I see a lot of these cases, and I'm afraid that if we don't do the right thing now, that I'll see you in 1-2 days on my next shift when its a whole lot worse, and we need to do (something more drastic)." Think about that.

 

[EvoDevo]

Sometimes you just have to say know to the truly pathologic factitious ones. Just NEVER challenge their delusion. Just redirect it. (unless they're truly pure narcotic seekers in which case kick them out and diagnos them with drug-seeking behavior. I do that once every several months)

The bolded part is pure gold.

 

[Pinner Doc]

I have to chuckle at this thread, in light of the patient who thought she was 3 months pregnant and called EMS for her self-diagnosed "serotonin syndrome," despite the fact that she was on no SSRIs and her u-preg was negative. She feigned seizures throughout her (brief) stay and demanded an ultrasound of her nonexistent child.

Far out!

 

[JediZero]

I get a lot of mileage out of, "You know, in the emergency room, we're really good at making sure you're not dying. But when it comes to pain, sometimes we can't fix it. We can give you some referrals to some people who might be able to help, but ultimately, we just don't have those answers for you."

 

[tkim]

Basically how many ways to tactfully say ... GTFO.

 

[deuist]

AFAIK, there is no literature.

There actually is quite a bit of literature on the "difficult patient," mostly from the psych literature. I had to read up on lots of it in residency. Some techniques:

1. The Theory of Yes. When the back pain patient comes in demanding an MRI, say, "You know, you might need an MRI. Unfortunately, the way MRI works here is that you have to schedule an appointment in advanced then go through a questionnaire at your scheduled time on your scheduled date. The bad news is that back pain is an ongoing problem; and since you're always using your back muscles, you're going to keep having pain. The good news is that there are some options for your back pain. I can give you a shot of hospital-strength tordadol, and you may even benefit from physical therapy."

2. Normalize the Behavior. This technique involves showing the patient that she's not alone. "I've seen a few children in here recently with cough and fever and they looked as sick as your son. The good news is that they all got better after a few days without needing antibiotics."

3. Paradoxical Strategy. Get the patient to do a behavior by telling him that you want him to do another. "I heard you say that you're not answering any personal questions. Just give me a few minutes to get some basic medical information."

 

[gman33]

There actually is quite a bit of literature on the "difficult patient," mostly from the psych literature. I had to read up on lots of it in residency. Some techniques:

1. The Theory of Yes. When the back pain patient comes in demanding an MRI, say, "You know, you might need an MRI. Unfortunately, the way MRI works here is that you have to schedule an appointment in advanced then go through a questionnaire at your scheduled time on your scheduled date. The bad news is that back pain is an ongoing problem; and since you're always using your back muscles, you're going to keep having pain. The good news is that there are some options for your back pain. I can give you a shot of hospital-strength tordadol, and you may even benefit from physical therapy."

2. Normalize the Behavior. This technique involves showing the patient that she's not alone. "I've seen a few children in here recently with cough and fever and they looked as sick as your son. The good news is that they all got better after a few days without needing antibiotics."

3. Paradoxical Strategy. Get the patient to do a behavior by telling him that you want him to do another. "I heard you say that you're not answering any personal questions. Just give me a few minutes to get some basic medical information."

Do you have links to any articles you found helpful?

 

[deuist]

The Bulletin of the American College of Surgeons did an entire issue on the subject
Patient Encounters of the Difficult Kind - from inFocus
If you subscribe to Clinics, there are 2 articles about the difficult patient and the general approach the difficult patient
Finally, you can read the following PMID's:
21264521
21173004
18545907
21452642
15622815
7494768
10335683
8553423
17598632
16342837
3256645
21249058
21452641
9328775
10645340

 

[GeneralVeers]

I handle it by mentally checking out. We had a thread about "widgets" last year that was instructive for most. When you treat the patients like widgets, you will understand. My job is to get the widgets out by any means necessary. I am an hourly-paid cog in the giant machine, and all I want to do is work my shift and get paid. Here are some strategies:.

1. Chronic abdominal pain for years (not obviously narc-seeking): I try to convince them to go home. If I get a lot of pushback from patient and/or their hover-parent, then I just admit them under the "intractable abdominal pain/nausea" category. If it requires a little exaggeration to do so, it's not my problem. I've now passed this turd of of a patient off to the hospitalist, and saved myself a complaint letter.

2. Chronic abdominal pain (obviously drug-seeking): I kick them out without narcotics. I document all over the chart their visit/prescription history. I also document how I am terribly concerned about the toxic doses of oxycodone they are taking, and I am doing what I think best for the patient. I further document that I believe it is dangerous and that this person will die if I prescribe them one more percocet. Generally you can avoid complaint letters on these.

3. Unnecessary test wanter. In general if it's an X-ray or CBC I do it, because the harm is minimal. I will not do CTs on people under 40. I document all over the chart how I don't think the CT is unwarranted, and that in fact I will cause their head to explode with malignant tumors if I do the CT. I still get complaint letters, but I will not actively harm a patient just to satisfy Press-Ganey.

4. Antibiotic abuser. Patient just wants antibiotics for their runny nose/sore throat/cough. I explain why I don't think they are indicated. If they give any pushback, I just prescribe a Z-pack, because patients love the name, and think they are the best thing ever. I know it's a worthless antibiotic with high resistance, so who cares about building more resistance to it.

5. Worried well. People with colds/flus, etc who are otherwise well, but convinced they have a medical mystery that needs immediate diagnosing! These are challenging and require a little bit of subterfuge. We all know that routine labs or X-ray are useless at diagnosing these things. The patient does not. Most patients think that "tests" can pick up anything and everything. I therefore tell patients that we will run intensive tests to figure out what's wrong. I just order a quick CBC and/or BMP, which in reality tells me nothing, but the patient doesn't know that. This is the one case where the patient's complete ignorance of science and medicine can actually help you. When you explain that these exhaustive tests are normal, and that you've ruled-out Ebola, the plague, and Smallpox, the patient is reassured and will usually go home happy.

A general rule of thumb is that patients expect you to do "something" even if it's a placebo. Just order an EKG/CXR/CBC or dose of po meds on every patient who walks in the door and you will see your complaints go down by a huge amount.