Director’s Corner: Difficult conversations with patients

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Ways to stay positive when dishing out negative responses.

It’s not unusual for my docs to let me know about difficult conversations they’ve had with patients.  Sometimes they’re giving me a heads up in case the patient complains.  Other times, they’re looking for advice so the conversation is smoother next time. Through the years, I’ve noticed that providers don’t always know the “why” behind the answer and thus have a hard time explaining things to patients. Below are responses to challenging situations that we regularly face.  As much as we generally want to please the patients and say yes to things, unfortunately, in many instances, we just have to say “no” and then give the background as to why we can’t do what they want.  For all of the below discussions, it’s important to be as empathetic as possible.


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Patient statement: I won’t sign out AMA because my insurance won’t pay for it. 

Backstory: While I can’t speak for every insurance company, this appears to be a myth that we have helped to perpetuate.  There is no evidence to suggest that insurance companies deny payment when patients leave AMA. I’ve also never received a complaint from a patient who left AMA about payment issues. Perhaps a more interesting spin on AMA discharges is that more hospitals are combining their left without being seen rates with the AMA rates so over time, we may be incentivized to decrease AMA rates as well.  Additionally, there is growing literature that patients who leave AMA may not be as compliant with follow up or returning to the ED if they worsen.

My response: I appreciate that you’re worried about payment but my experience has been that insurance companies will cover you even if you leave AMA.  I think it’s in your best interest to stay, but it’s your decision. I cannot falsify the medical record. It is your choice to leave against medical advice and we have a formal way that we’re required to document that, including having you sign a form acknowledging your understanding of the risks.


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My occasional reality: We’re all aware of patients who leave AMA only to return hours later in cardiac arrest.  It definitely happens.  If a patient is refusing admission, I’ll sign them out AMA.  If they’re refusing a test like an LP (particularly when I think it very unlikely it will be abnormal), I will discharge them rather than have them sign out AMA. Patients should participate in their care and are allowed to make choices. I’ll document that the patient is refusing the test and understands the risks involved and I’ll include a similar phrase in the discharge instructions such as “You’re leaving without having a test (lumbar puncture/spinal tap) that could indicate a life threatening condition.   You did not want this test, but you can return anytime and we will reassess you and if you need this test at that time.  By not having this test, you understand you’re limiting my ability to diagnose a life threatening condition and you may leave the ED, get worse, and even die.” Whether the patient leaves AMA or I discharge them, I always provide them with discharge instructions, appropriate prescriptions, and follow up and return guidelines.

Patient Statement: I don’t want to pay for the ambulance to transfer me to the other hospital.  Why can’t I just drive myself?

Backstory: Patient transfers are an EMTALA issue so all of the ins and outs of EMTALA apply.  When transferring patients, requirements include using “qualified personnel with the appropriate equipment.”

My response: I appreciate your desire to save money and time, but unfortunately, transferring patients falls under a very rigid Federal regulation and we’re required to appropriately monitor (you/the patient/your child, etc). Driving yourself/your child is not allowed.


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My occasional reality: I can’t count the number of times I’ve had a parent want to drive their child to a psychiatric hospital for admission rather than wait for an ambulance and my answer is always no.  We need to follow the rules on this one. It’s in the best interest of the patient, the hospital and you.

Patient statement: I need to be admitted.  My Medicare won’t cover observation.  Why won’t you just “admit” me?

Backstory: Observation status (less than two midnights typically and also for specific diagnoses) is considered outpatient care by Medicare and this potentially leaves the Medicare patient footing a large bill compared to patients who are admitted where Medicare will pick up most of the tab.  Some of the fear that patients have about their bill may have been built on sensationalized media stories.  Recent studies by the Office of the Inspector General found that out of pocket patient costs for the majority of Medicare patients was less for observation patients than short-stay inpatient counterparts.  Unfortunately, there are pretty strict guidelines developed by CMS and insurance companies about what criteria need to be met for inpatient status and even if we tell the patient we’ll “admit” them, if they don’t meet the criteria, it will be switched to observation status in due course.

My response: My role as your emergency physician is to decide if you need further care in the hospital or if you’re safe to go home.  Billing categories such as admission versus observation status is dictated by your insurance company based on strict criteria. At this time, you do not appear to meet inpatient criteria, which is a good thing when it comes to your overall health. Research indicates that out of pocket expenses are usually lower with observation than with inpatient stays.  You can certainly talk to our case managers to discuss this further.

My reality: There’s very little wiggle room here.  You can talk to the hospitalist or case managers to get their input.  A three-day admission is required for eligibility prior to placement in a Skilled Nursing Facility, so that may help the case manager allow an admission. I’ve also had patients want to leave AMA instead of staying for observation, and this usually leads to the discussion of their risk of dying and isn’t their life and health worth the cost of observation.

Patient statement: My doctor wants me to have these labs done.  So while I’m here, can you just do them now for me?

My response (after I review the ordered tests): Some of these tests (typically the CBC and CMP) will get done today and I can give you the results.  I’m sorry, but the other tests are not part of the emergency department evaluation, won’t come back in a timely fashion, and more importantly, won’t be sent to your doctor. It’s still important that you get these tests for your doctor.  You’ll just need to do it as an outpatient.

Patient statement: I came here because my doctor wants me to have an MRI.  Can’t you just do it?

Backstory: Unless you work in a magical hospital that doesn’t care about your discharge length of stay, appropriate test utilization, AND has open and available slots for ED MRIs (whether they’re stat or not), then you probably don’t want to do this MRI.  It’s obviously very important to understand the background behind the MRI request as there is a difference between a patient sent from the neurosurgeons’ office for a stat MRI than a patient who shows up requesting a lumbar MRI because they couldn’t get an outpatient appointment this week.

My response (after a thorough history and physical): I’m glad you came here today so we could examine you.  MRI is usually an outpatient test unless you’re at risk of needing emergency surgery.  At this point, based on my history and physical exam, it does not appear that you are at risk of needing emergency surgery so you can safely have your MRI done as an outpatient.

Patient statement: I can’t believe I had to wait so long…

Backstory: There’s always going to be waits in the ED.  This is particularly true if you’re in a single provider ED and you’ve spent the last hour caring for a critically ill patient.

My response: I’m really sorry you had to wait.  I’m here to take care of you now.  How can I help you?

My reality: I generally keep it simple.  I apologize and move on.  Occasionally, I’ll let them know I had a really critical patient that required a lot of time to save their life.  Most patients appreciate that, but some just don’t care so I try to read into that situation a bit.  If they’re so self-centered that they don’t care that someone was sicker or even dying, I’m not going to change their view or their personality, so that’s on them. Through the years, I’ve come to appreciate that outside of the first couple of weeks of flu season, most patients don’t want to hear that it’s a “zoo tonight” as they’re thinking that we should just have more staff to handle it.  The last thing I want to do is get into a staffing discussion with a patient, so that’s why I usually just apologize for the wait, and let them know that I’m here for them now (sit down, try to appear as if you have the time for them).

Patient Complaint: I came in for a concussion. The doctor only spent a few minutes with me, but my bill was for $600.  That’s insane!

Backstory: I know healthcare is expensive and sometimes the bill to the patient seems excessive, but this type of complaint is preventable.  There are a variety of patient encounters where we are in and out of the room in one trip.  The trick is to make sure the patient understands all that is occurring while we’re in the room.  There is tremendous value in explaining what you’re doing/looking for on the physical exam, and/or why they don’t need tests that aren’t indicated (in other words make sure patients understand the value in what you’re doing).

My response: I’ve written other columns on managing patient complaints but my brief talking points include: thank you for bringing this to my attention; how are you feeling (was the diagnosis correct?); apologies for the cost of healthcare and the lack of communication; provide feedback to the provider with tips for preventing this type of complaint in the future.

My reality: This complaint should not have happened and can be preempted by the provider spending a little extra time talking to the patient. I tend to verbalize all my findings on the neuro exam and explain to the patient how important it is that their exam is normal, and while I can tell from their symptoms that they definitely have a concussion (which doesn’t show up on any type of scan), the good news is that I don’t see any signs to make me worried about a broken bone in their skull or bleeding around the brain, which are the only things that a scan looks for, so no need to expose them to radiation. I’ll often walk them through a shared decision making algorithm that we keep so they can understand and agree with the logic in not getting a CT scan. Validating that the patient did the right thing by coming to the ED can go a long way.  Using wording such as, “it’s a good thing that you came here today so that we could…” or even at the beginning “you came to the right place” let’s the patient know you’re taking their injury seriously.  Then take the time to explain their diagnosis and what to expect during their recovery.

Conclusion:

Residency prepares docs really well for the medicine. But what often trips them up is when they come across something controversial where they don’t understand all of the issues and have a hard time explaining the “why” to the patient. I think scripting is important, but I am more of a fan of giving my team talking points than making sure everyone uses the exact same wording.  While we do create scripts for our team, I also am happy to have people use their own wording so they’re comfortable giving the response.  It’s important for our provider team to have basic fluency in EMTALA, AMA, and financial topics like observation status and try to communicate clearly to our patients while being compassionate and empathetic.

 

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

1 Comment

  1. Thanks for sharing this Dr Silverman. This is a challenge we all face, and the article helps us navigate these difficult often daily conversations. I’ve shared it with my docs as well.

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