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“So how is your pain doing after the morphine shot?” I asked the 87 year old little old lady who had fallen at home.
“I don’t have pain any more,” she replied.
“That’s great! Well I have some good news. The x-rays show a lot of arthritis, but no fractures.”
I thought that the patient and the growing numbers of family members in the room would have been happy with that statement.
I was wrong.

Grandma had fallen when trying to get out of her chair. She appeared frail and it was apparent that ambulation was always going to present a risk of another fall. But she had a walker and she refused nursing home placement, so there wasn’t much else to do to help her.

When I explained my plans to discharge her, I started getting a bunch of questions.

The patient’s husband wanted to know why the patient’s hand shook when she was using a fork at the dinner table.
“Yeah, and why do her teeth chatter when she talks?” asked a granddaughter.
Another granddaughter wanted to know why Grandma wouldn’t use her walker.
Then the patient remembered that her fifth toe and the side of her foot had been bothering her for the past few months.
“Yeah. What are you going to do about that?” demanded a strange male in the room.

“Did all of this happen after her fall?”
“Heck no, she’s been having the teeth chattering problem for months.” Other family members related prolonged and intermittent course of the patient’s other symptoms.
“Have you spoken to your family physician about these problems?”
“No. He doesn’t listen to me,” the patient responded.
Looking around the room, by that time, two of the four family members had their arms folded and were scowling at me. A third was squeezing the patient’s hand – literally to the point that the patient’s fingertips were red. The fourth was pecking away on his CrackBerry.

With multiple family members who appeared dissatisfied, I was faced with a choice: Do I go ahead with my plans at discharging the patient and risk complaints and a bad Press Ganey score or do I perform the Big Medical Workup “BMW” on a patient who could just as easily have had an outpatient evaluation of her chronic symptoms?

I caved.

“Hold on a minute. I’ll go get the chart so that I can make sure I get all of these other problems written down.”

I spent a lot of time writing down all the other issues, doing a re-examination that showed nothing unexpected for a patient her age, ordering a bunch of low-yield screening lab tests, and even getting an x-ray of that painful toe. Not surprisingly, everything was normal.

“Well, you have arthritis in your foot and all your blood tests were normal. I don’t have a good answer for why your teeth chatter or why your hand shakes. Given your history of falls, you really need to use your walker any time you’re moving about. It’s possible that these symptoms might be the beginning of Parkinson’s Disease but you’ll …”

“WHAAAAT?!?!” blurted out the daughter who had been squeezing the patient’s hand. “How can you say that?!?”

“You didn’t let me finish. I was going to tell you all that she’ll have to follow up either with her primary care physician or with a neurologist to have more testing done.”
Her son momentarily looked up from his CrackBerry screen to ask “If you knew she needed more testing, then why didn’t you just do it here?”
“There are a lot of tests we can’t do in the emergency department. Besides, those types of tests are better done as an outpatient, anyway.”
The hand squeezer mumbled “Great. What a wasted trip.”

So the patient and her family were discharged … most of them unhappily … with hospital charges to Medicare that would easily total several thousand dollars. As the nurse handed the discharge papers to the patient, the hand squeezer told the nurse “that doctor is lucky I didn’t punch him right in the face.”

When the nurse told me that, I sat and tried to retrospectively analyze what I could have done different to make the family happy. I couldn’t think of anything.

The emphasis on patient satisfaction at the expense of proper medical care is a major reason why health care costs in this country will only continue to increase and why medical practitioners are becoming more and more disgusted with the system …

… that is … until the “game changer” is implemented ….

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  1. “The emphasis on patient satisfaction at the expense of proper medical care is a major reason why health care costs in this country will only continue to increase”

    So why’d you do it?

  2. When I was 20 I wrecked my motorcycle. I had some scrapes and a grade 3 AC separation. I’d always assumed that any reasonable injury could be repaired. My ortho consult taught me otherwise.

  3. I’m only a psychiatrist and haven’t worked in an ED since my residency. But I wonder if it would help to tell the family that since all of this has been going on for months, they could see the PCP (and you would write down all the complaints as a referral to make them think you’re doing something) as an OP which would be easier on Granny than waiting hours and hours and hours (even if it would only be just hours) in the ED for these important tests?

    Obviously, if Granny had to pay coinsurance for all these nonemergent tests in an emergency dept, this would be a nonissue.

  4. As an engineer my response would be “is teeth chattering life threatening? no, now get the f out of the *emergency* department!”

    Might not go over so well with admin though.

  5. There is some buzz going around that in the not so distant future, certain accreditation and government agencies will begin to use satisfaction scores as a way to be able to pay even lower reimbursements.

    What do you think of that take?

    I, personally, think that is crap. A huge bunch of stinking crap.

    With society’s ever increasing entitlement complex- our satisfaction scores will only go down.

    We already have patients who have told us that they know if they complain to our director and the rep enough, they don’t pay for their visits. Really?! We even caught one of them telling another patient in another room the same, and how to “complain right”.

    • the irony is hilarious. they are desperate to find ways to save money without having to acknowledge the need for (already ongoing) rationing. but to do so like this… “make your patients happy or we will reimburse less!” okay… in this country where “more is always better” i guarantee you the strategy will lead to more health care spending, not less.

  6. Two points: First, some people are entitled assholes, like the mother we had demanding more juice for her little darling[ on a routine peds floor (not ICU)] in the middle of a CODE! She actually stood in the doorway of the involved patient’s room bitching until a brave older LPN physically got her the heck out of the way!!!

    Second, patients and families need to understand that, besides being for real emergencies, the ED is a sit-down resturant, not a buffet. If you order the chicken or the falls workup, you cannot simply “go back” for the pasta or the trembling hands/chattering teeth/sore foot. This is NOT a “all you can complain about” buffet!

  7. So… I went to the emergency department last month as a patient. If I get one of these evil forms, what would be the best thing to say? “Customer satisfaction is not the goal in the ED?”

    Frankly, I had more to complain about the next day when my ‘magic mouthwash’ set up in the bottle.

  8. All I want is the ability to say “No” to unreasonable demands and not suffer untoward consequences. I don’t think that’s too much to ask.

  9. I detest these verbal cowards. I hear about it retrospectively from nurses occasionally. (re, the I’d punch him stupidity).

    It is telling about their mindset, though.

  10. Funny how everyone wants all Docs to “gatekeep” the system, and then tie anchors like satisfaction scores around our necks an throw us overboard.
    Reminds me of a PR seminar the wizards of carpeted section made us take…”how to deal with the dissatisfied customer”. The presenter was asked “what happens with the customer who’s anger is escalating and threatening violence?”. The reply … “call the police”. Which begged the question “what if the police are already here in the ED and refuse to take him away because he is not medically clear… as the patient punched a nurse trying help the police restrain him?”. Confounded the dood into “admin speak”… the old “let me say this about that…” and said nothing for 15 min.

  11. A few questions and comments:

    1.) Has the family gone with her when she visits her family doctor? I’m sure they could get him/her to listen to her.

    2.) This family has clearly not spent enough time with the elderly that they can be VERY stubborn about not using ambulation devices (walker, cane, wheelchair, etc.,) to the point where they will risk a fall until they have a “wake-up” fall that encourages them to use the devices.

    That family seems wrapped in other issues, like who’s getting what in the will when she finally passes…

  12. My GF does home health care for a 92 yo man.

    He needs to use a walker, but tries to come up with excuses not to.

    2 weeks ago, he went outside at 3am to “cover up the pipes so they don’t freeze”, it was 38F outside.

    No walker, he fell, couldn’t get up on his own. It was 4 hours before someone found him. No injuries, but he did get mild hypothermia.

    He claims he will use his walker more regularly now and won’t go outside without telling someone.

    My GF has much more patience than I do.

  13. The attitude of this family is the reason I can’t wait to retire. More and more, people bring their anger and unhappiness into the ER and treat us like shit. I’m plain sick and tired of it.
    As people get more and more difficult to deal with and hospitals bend over backwards to make everybody happy, I pity the nurses and docs of the future.

  14. I am constantly amazed at how you see exactly the same patients that I do, seemingly on a daily basis. Your blog really helps me to realize that it is not just me or my ED or the (crazy) people in my town who have this problem, it is the whole bleeping country!
    Although why that thought should make me feel better is curious…
    I have had this situation more times than I can count, often complicated by the, “You’ve got to do something! Can’t you just admit her to the hospital?”
    Sometimes I can explain that the ED is not the place for dealing with these kinds of chronic problems, sometimes I counter with, “Well, there is nothing here tonight that qualifies her for admission; if I admit her, Medicare will probably deny payment and you’ll get a bill for the hospital stay.” Occasionally I am shocked to discover that though everyone has time to come to the ED and complain about Grandma’s lack of good medical care, no one has the time to take care of her themselves.
    We are losing our civilization with each of these little events.

  15. As someone who will be soon be taking my disabled, elderly mom into my home (really into my home — we can’t afford guest rooms or whatever), I can understand how difficult/frustrating it can be to care for an older person. Esp. because they don’t really tell you everything or don’t remember everything. But my mom tends to ask ME the weird questions, and I’m just a nursing student, and we’re not about to end up in the ER for it.

  16. What was the ratio of nurse scowls to family scowls based on this big work-up?

    PS Reason #12983003 to only let a maximum of two family members in each room. ER rooms are not conference halls.

  17. OR you could assure them you will get to the bottom of all her problems, admit to gen med for “the dwindles” and stick them with the task of discussing long-term placement.

    a year and a half ago, my son was born at one of our health system’s hospitals. the care was exemplary and we got a p-g in the mail. i was very tempted to give them all “1’s” and say “the care was great but we hate press-ganey. now you are stuck averaging in these “1’s” in spite of how happy we were about our care. what are you gonna do about it?”

    …instead i threw the survey away.

    • Stalwart Hospitalist

      I suspect the day will soon come, given the impending lack of reimbursement for marginal admissions or readmissions, that “general medicine” (me) will refuse to accept an admission for “the dwindles”, and recommend disposition from the Emergency Department. I’ll even be happy to do a formal internal medicine consult confirming the absence of criteria for admission to an acute care hospital.

      • yeah great. so you and i get to split the risk, while the insurance execs who get to pocket the money instead of spending it on an admission assumes no risk for bad outcomes. that sounds super.

        this line of thinking is already here. the biggest offender is probably chest pain, which routinely doesn’t get paid for once they figure out retrospectively that the patient “didn’t need to be admitted.”

  18. Some of our newer (younger) docs respond to these situations by saying we are only here to rule out “emergent, life threatening” ailments (and they really do decline to order more tests mostly), and the rest is best dealt with with your PMD. But yeah, their PG’s are in the toilet, too.

  19. Former EDPhysicianwannabe

    Why is it that patient satisfaction is trumping decision making based on evidence based medicine or the standard of care? Do the administrators who create these satisfaction scores even know what EBM is? If I worked in a pediatric ED would I be penalized if a five-year-old is “unsatisfied” because I won’t give him what he wants but I make decisions based on recent EBM that are in the best interests of the child? Perhaps hospitals should think about the health of their workforce and how well they treat (or have been failing to treat) their workforce as educated medical professionals who deserve respect.

  20. This country just does not understand that people just get “OLD” and shake and ache and wither. A trillion dollars of care won’t stop it.

  21. Satisfaction scores in my book: “I’m satisfied, you should be be too”.
    BTW, I would have gone back in and confronted that douchebag who threatened you. Sat scores or naught. I would have told them that is potential felonious and I will document that I was threatened with violence.
    Then afterwards I would have gotten an ER tech to run out and slash his tires….

  22. Minimedic makes some great points.

    My solution is an atomized Ativan atmosphere, and not just for the alliteration.

    In California, if Prop 19 passes, hand out free marijuana. Satisfaction scores will soar, leading to increasing reimbursement. The main problem would be choosing a designated driver. It isn’t as if the decision-making capabilities of this family could be any more impaired than it already is.

  23. Thank you all – i have to meet with my boss tomorrow to discuss why the lawyer wasn’t happy with the discomfort of nasal packing (even though I warned him that nasal packing was the worst thing we do to people). I guess he thought I was exaggerating.

  24. Many patients that come through the ED don’t have a PCP and expect the hospital and doctors of the ED to work miracles. Some patients are aware of the limitations of the ED, while others see the ED as a “clinic”, seeking treatment (drug) for minor things such tooth pain. There is a big difference between life threatening and an minor ache and pain. Somehow people need to be educated on the meaning of “emergency”. It can be serious if an elderly person falls and It’s wonderful if the elderly has an advocate to speak for them, to question things, however, it’s not acceptable for them to be verablly abusive and threatening to staff and doctors. Often times, I see the patient shaking their head in disbelieve, not at the staff and doctors, but at their advocates. Where did respect go?

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