Crash Cart: Patient discrimination, medicaid coverage, ghost peppers, and Cubs fans in the ED

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This week: EPs dealing with patient discrimination. Plus, will Chicago ED visits spike during the World Series? Join in as our editors discuss the week’s headlines.

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How do you deal with patient discrimination?

One study looks at physicians who have reported discrimination and offers strategies to use in a tense situation. Original Article by Kaiser Health News

E. Paul DeKoning, MD, MS: This is a tough one. I think there can sometimes be an unspoken rule that we need to just “take it” when patients are rude, inappropriate, or offensive to us or other staff. The article states that the doc almost confronted the patient on the trainee’s behalf, but the situation sorted itself out. As a relatively conflict-avoidant person, I know I could have used training here–not just in how to eat it, but in making sure patients know what is and isn’t appropriate behavior and how to call them on it when they step over the line. I’ve had to learn how to navigate these issues on the job and I know I haven’t always done it well.

William Sullivan, DO, JD: Sorry, but if a patient refuses treatment from a physician because of religion, gender, skin color, or any other superficial reason, they’re free to leave. I agree that conflict resolution is an important part of medical training, but if a patient’s biases run deep enough that they have the gonads to request another physician for some inane discriminatory reason, then I think there is little chance that the relationship would be salvageable. The patients will be less likely to follow the advice of someone toward whom they have an animus and if the end result is a bad outcome, the patient would be more likely to blame it on the physician they didn’t want treating them to begin with. The thing that I noticed about this survey was that there seems to be an *expectation* that physicians just take the abuse and shrug it off – which will just encourage bad patients to behave similarly in the future. “The group also advised providers to set expectations early in medical training by communicating that discrimination can happen to anyone.” If physicians acted in a discriminatory manner toward patients, they’d be fired and probably have a licensure action taken against them. Patients and families just get a pass? More than a quarter of the physicians in the survey didn’t think that the hospital would have their backs if a patient or patient’s family member mistreated/acted in a discriminating toward them. How sad is that? Wonder why there is growing physician apathy and dissatisfaction with the medical profession? “Expectations” like this are one clue, Columbo.

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Numbers of ED visitors continues to rise due to medicaid expansion

The Oregon Health Insurance Experiment reports increased visits to the ED after insurance lottery. Original Article by Medscape // Accompanying Study by NEJM

E. Paul DeKoning, MD, MS: Please add this to the list of reasons why we will always have jobs: “…we found no evidence that the increase in ED use due to Medicaid coverage is driven by pent-up demand that dissipates over time.” “We thus found no evidence that Medicaid coverage makes use of the physician’s office and use of the ED more suitable for one another…if anything, the results suggest that it makes them complementary.” Even if primary care physicians increase the convenience of same-day appointments, as the article suggests, we will still be needed. With the ever-increasing time and productivity pressures, you can’t really work up a patient in the clinic effectively. So send them to the ED. We’ll take care of it.

William Sullivan, DO, JD: This is another one of those studies that is intuitive to anyone working in an emergency department. Patients can’t get into see primary care physicians or the appointments are months away so they come to the ED to get care (had two such patients last night alone). So the study shows that Medicaid patients are higher ED utilizers but that the higher utilization doesn’t translate into better outcomes. Since they’re “insured,” the hospitals now purportedly get *some* reimbursement for the care – even though in Illinois, the reimbursement is less than the cost of providing care and it doesn’t show up for months, or in some cases even years. So is Medicaid expansion a net positive or net negative? The answer may depend upon who you ask. I know how I’d vote.

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Hold the hot peppers

Ghost pepper ruptures patient’s esophagus during eating contest. Original Article by Live Science

E. Paul DeKoning, MD, MS: Somewhat of a misleading title. As the article says (way down there at the bottom), the perforation was from the patient’s violent vomiting. I first ran across the Scoville Scale of hotness (peppers) while reading my 5 year old son’s “bedtime math” book. Yes, a strange thing to read right before bed, but he (and I) actually learned something that night. Now, I have a follow-up for him when we work on the principle of cause and effect: if you eat peppers that score high on the Scoville Scale, you just might actually explode on the inside. Good to know.

William Sullivan, DO, JD: How many times do we treat patients whose last words prior to coming to the emergency department were “Hey, watch this!” After this case, add one to the tally. I like spicy foods, but when eating spicy food becomes a challenge more than a taste preference, someone who is not intoxicated and has more than a median IQ really needs to step in. Then again, as Paul said. Stories like this are the sweet sound of job security. Imagine using ghost pepper extract in a defensive pepper spray – the attacker’s face would melt.

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ED near Wrigley steps up to the plate as crowds rush in

The Oregon Health Insurance Experiment reports increased visits to the ED after insurance lottery. Original Article by Sports Illustrated

E. Paul DeKoning, MD, MS: Seems like a good idea. I had an organic chemistry professor in college who, after virtually the entire class bombed an exam, told us he was a Cubs fan because had a special place in his heart for second chances. We all got a redo. If they actually win the Series, the ED better be ready!

William Sullivan, DO, JD: Amusing that the story was in Sports Illustrated. Real phenomenon, though. Used to work at a trauma center near an outdoor concert venue. Certain concerts such as Jimmy Buffet and OzzFest always increased ED volumes by about 25%. Nice thing about it was that the venue owners would come and drop off stacks of free concert tickets for the ED and surgery staff. Not thinking that the Illinois Masonic crew got the same courtesy from the Cubs. Wonder how the ED volumes will be affected if the Cubbies choke…

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1 Comment

  1. I would like to respectfully offer a counter perspective to that expressed by Dr. Sullivan regarding abuse from patients. I acknowledge that my perspective is based more on rude and discourteous patients in general, than discriminatory patients in particular. I would like to start with an example:

    One week ago, during my shift, I picked up the chart of a colon cancer patient with recent mets to his liver and his biliary tree. He was jaundiced and had a fever two days after biliary stent placement and was diagnosed with ascending cholangitis. Long story short, the cancer he had been battling for two years was winning and he and his wife’s life revolved around his misery. They, and especially she, were at their wit’s end–depressed, angry, exhausted. In addition, they felt like physicians caused a delay in his diagnosis and sealed his fate. They loathed the very profession they now found themselves dependent upon. They were know it alls and wanted to tell me how to proceed with evaluation and management. They were sarcastic and nasty from the get go. They screamed at my staff, from the registrar to the nurses trying to put in the line–which, of course, took 6 attempts. Several nurses and several techs complained to me about how nasty this couple was and how they could “go fuck themselves”. Several refused to go back into the room. Despite the patient’s nastiness, I tried to keep my cool. It seemed I could do nothing right as I promptly made the correct diagnosis, started antibiotics, and arranged for transfer. They were not just nasty, they were high maintenance nasty. After two hours of evaluation, and with the transfer pending, the patient’s wife brought yet another specialist’s phone number to me requesting that I fax yet another copy of the chart. You know the type: every one of their many specialists needed to be brought up to speed immediately. And then it happened–unexpectedly, while still standing across from me, the wife regained my attention and asked me if I would please forgive her for her attitude and nastiness ( her words). She began rapidly rambling a series of excuses and explanations. I interrupted these explanations midstream by standing up, and then I hugged the patient’s wife. She sobbed in my arms for five minutes without stopping. When she finished, she told me she could not cry in front of her husband and she did not want him to know she had been crying. I took her around the long way to a bathroom where she could compose herself and freshen up and blow her nose before returning to her husband and resuming the performance of her life time.

    I went into medicine to be a healer. I chose emergency medicine so that I could have the chance to treat any problem anytime. I do not find this family member encounter to be an exception to my mission. Every patient and every family member provides us an opportunity to minister and each one may need something different from us. If I get two nosebleeds at 4 AM, I treat two nosebleeds at 4 AM. If I get an angry stressed out spouse, I treat an angry stressed out spouse. This special moment meant as much to me and my professional satisfaction as my last emergency pericardiocentesis. I made a caregiver that felt hopeless, lost, out of control and unsupported feel understood and supported and by serving as her punching bag, I believe I gave her a temporary sense of control. I provided healing. When no one else in the department, perhaps no one on the planet, wanted anything to do with this family I provided care for this woman. Isn’t that a buzzphrase mantra in emergency medicine these days? We take pride in the fact that we will treat all comers–the addicted, the homeless, the uninsured, the degenerate – – and how about the asshole? None of this is easy. Not everyone can be an emergency physician.

    Depending on my own resiliency bank I may or may not always live up to this standard; but as a role model, and one who leads by example, I try to learn from my failures and be this patient as much of the time as I can. Importantly, I have learned to forgive myself when I fall short of this ideal. In addition, I also believe some patients or family members truly do need tough love. The differential diagnosis for a patient or family of assholes does include congenital asshole syndrome, but also includes overwhelming grief, overwhelming fear or panic, current abuse, a lifetime of abuse, self-preservation, hopelessness, lack of self esteem and shame among others.

    Now, just like a chronic migraine, I realize the suffering, the stress and the anger of this spouse will certainly be back tomorrow–I provided more of a Band-Aid than a cure–and when it does I will be ready– ready to apply one of my favorite scriptures: ” A gentle answer turns away wrath but a harsh word stirs up anger”.

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