More Satisfied Customers

63 Comments

As our hospital administrator emphasizes the importance of high patient satisfaction scores and “pleasing every patient every time,” I’m really becoming disenchanted with emergency medicine. He’s getting his directives from the hospital board and being pressured by statistics on some web site that only administrators look at, so it’s tough to blame him, but this medical system is really heading the wrong way fast.

Patient #1:
A 18 year old female is brought in by her mother complaining of lower abdominal pain. She’s doubled over while she’s walking. After the nurse gets the history, she hands the patient a gown and tells her that she needs to get undressed for the exam.
“I’m not getting undressed for you. You’re all stupid here.”
“We’ll if you want the doctor to try to help you, you need to get undressed and put the gown on.”
Then the patient’s mother says “Honey, why don’t we start by putting the gown on?”
The patient replies “Why don’t we start by you shutting your f***ing face?”
Then she whips open the door and leaves.

Patient #2:
A 22 year old female also complaining of lower abdominal pain. She is accompanied by her sideways-hat-wearing pants-on-the-floor boyfriend. Urinalysis was normal, so I explained to her that we needed to perform a pelvic exam to look for other causes of the pain.
Boyfriend immediately chimes in “Yo! Ain’t nobody looking at my woman’s s*** but ME!”
I looked at the patient. “Do you want me to do the exam?”
She shrugged her shoulders and said “I guess so.”
Then I told boyfriend that he needed to wait outside. He pulled his pants up, puffed out his chest, and left.
The patient was ultimately discharged with diagnosis of an ovarian cyst.
Following day, the nurse manager finds me and says that boyfriend came back to her office and wanted to know my name because he was going to sue me for raping his girlfriend.

Patient #3:
Drunk guy brought in by police after beating up his girlfriend. He was fighting with police, so he was cuffed and escorted by a couple of officers. When he got to the ED, he was still fighting and threatening the staff, so he was put in 4 point restraints. Then he started in on one of the officers.
“You won’t be able to keep me in these things forever, you know. I’ll get out. When I get out, I’m going to find you, throw you up against your police car and [sodomize you].” The term that he used was too vulgar to post.
He could see that he was getting on the officer’s nerves, so he kept it up.
“Yeah, maybe I’ll even let your chief watch. I’ll enjoy every minute of it hearing you scream like a b***h, too.”
All the while the officer just stood there until he was secured in restraints. I don’t know that I could have stood there with this guy talking like that to me and not done anything.

There were other similar encounters. They all took place within two days. All of these patients will receive patient satisfaction surveys. I doubt any of them will be “pleased” as our administration desires.

Treat a judge like this and you get thrown in jail for contempt of court.
Treat an employee this way and you get sued for harassment or sexual discrimination.
Treat an average person on the street like this and you get a fist in your mouth.

When people can come to your place of employment and treat you like a piece of toilet paper – yet your continued employment depends on pleasing “each one of them every time,” it’s time to think about whether to continue practicing medicine.

63 Comments

  1. My last AMA ended up involving almost getting hit including having a phone thrown at me ( I ducked) 2 cops, 2 security officers, 3 maintenance guys (just to have some more muscle available) and a host of other people. We should have been selling some beer and brats they were so many people in the hallway. The jacked up family members came to get him and accused of us stealing when we returned 18 vicodin and he claimed he came into the hospital with 153. I seriously was expecting a call from my CNO about what I could have done to “prevented” this.
    Very sad indeed.

  2. My family member is a police Sgt. They take abuse of this nature on a daily basis. I don’t know how they maintain their composure.

  3. Mark Twain made a comment once that there are some individuals, if they can find nothing else to complain about, gripe that there are too many prehistoric toads in their coal. Administrators must never meet these individuals. Personally I think that if a doctor or nurse is assaulted and the patient is not demented or psychiatrically incapacitated, assault charges should be filed. I think the reason it often isn’t done is the fear that that action might trigger a future bullshit malpractice suit or some other complaint, and the hassle isn’t worth it.

  4. Unfortunately, people also get away with personal abuse if they’re the customer and you work in retail. Only advantage: it doesn’t usually involve 4-point restraints unless they’re trying to steal the merchandise, in which case management will pat your back.

    Medicine is NOT retail, though, and hospital administrations need to get over that idea.

    • Came to basically say that. And you’ll get harassed/assaulted by your employer if you’re poor enough to need the job more than your rights.

  5. Man, you are hitting it right on the head. On my last shift, three of us attendings had this exact talk that on a street, in a store, or wherever, we would never let someone talk and treat us the way some of the patients do. But we put on our doctor hat, enter the ER, and we must absorb such abuse in the name of professionalism. Hats off to all of you that sustain this behavior, too.

    Have a great day…

    • It’s not just patients in the ED. Even in physician offices, my coworkers and I face the same/similar treatment from patients. It’s even to the point that we remember who the really nice regular patients are–as at times they seem to be so few and far between.

  6. Patient #2 seems like she’s trapped in a bad relationship with a controlling abusive asshat.

    Hell, I’ve told my husband EXACTLY what happens during my yearly PAP smear (digital exam and everything) and he barely bats an eye…

  7. I don’t know how to fix bad people or administrations, but I can tell you a few of the reasons to continue in medicine. There was the time my migraine went into the third day and the pain became bad even by migraine standards. The staff at the ER was so considerate that they even talked in low voices and kept the lights off to ease my discomfort while they worked on me. The shot they gave me took away the bulk of the pain so I could sleep. There was the time I busted my foot, and the ER staff kept me as comfortable as they could until they could set the bone. I know you don’t get much feedback from the folks who actually needed the ER and don’t abuse the staff, but we do appreciate everything you do. Y’all have made my life better. Thank you.

    • Thanks to you as well.
      It’s pearls like you that keep the practice of medicine rewarding.
      Unfortunately, people like you are getting harder and harder to find.

  8. Soronel Haetir on

    Remember, you don’t actually need *good* scores, you only need to be better than the next poor slob. And since everyone gets their share of these turkeys it should all even out.

  9. [The following post is very cynical. Please do not read if you suffer from low self esteem, depression, hypertension, aneurysms, erectile dysfunction or are a lawyer]

    Like lawyers, the people who work in the carpeted section are disconnected from the real world. In the carpeted section they seem to sit around at large mahogany tables and try to organize chaos with optimal nurse to patient ratios, patient hour to staff hour calculations, patient satisfaction score to staffing ratios and some such. All the while listening to the light jazz over the streaming internet. It’s all about numbers, dollars policies and procedures. Human resources (I love the term) are replaceable and interchangeable. (I once worked at a hospital that tried to staff the ED with Nursing assistants, because it was cheaper).

    Meanwhile, in the place where the emesis hits the floor, also known as Learned Helplessness central we see situation after situation that we are seemingly powerless to resolve. We have to navigate around senseless rules and regulation, policies and procedures. Then superimpose something as ridiculous as satisfaction scores (“Did you receive you pain medications in a timely fashion?” .. “Was the staff warm and personable?” … real questions on our survey… really!). Beware if your scores are low… your job is at risk. Beware if the scores are too high.. you are overstaffed. If a patient complains, nobody has your back. If a patient sues… don’t talk about the case. It’s seemingly endless.

    Your feelings are normal. This is why we burn out.

    I have finally learned a few truths about the ED (both Docs and Nurses):

    1)) My job is paperwork, with a little patient care on the side.
    2)) I am a sin eater. Part of my job is to eat the sins of everybody who wants to make decisions without taking responsibility.
    3) if you ain’t pissing off 10% of your patients, you ain’t doing your job. The word “no” is part of my lexicon.
    4) Everybody remembers the name of the next Nurse/Doctor they meet (upstairs). Unless something very bad or very good happens.
    5) The hospital guide to hiring security staff …rule of 70’s … weight = age = reflex time (in seconds) = 70.
    6) The ED guide to police procedure concerning incarcerated patients…. “It’s your problem now. Bwahahahahahah…”
    (in defense for the police… they have it worse so you can understand their attitude)
    7) Kaka falls out of buckets but praise is filtered through charcoal fitters and is largely stolen by administration.
    8 ) Administrations are somewhat educable, but call it “refactoring and streamlining the process” instead.
    9) Administrations that hire PR consultants are completely uneducable. Don’t try.
    10) You are elite. You are smart. You can do anything. You can succeed inside medicine, and thrive outside medicine if it comes to that. Do not let anyone tell you different.
    11) You are smarter than Matt. OK.. that was snarky. Sorry Matt.

  10. I realize some of the above post is a vent, but also, WELCOME TO THE FREE MARKET that you were begging for. Patient satisfaction matters to the hospital not just so they can’t use it to beat you down, but because happy customers mean $$$.

    • Matt, your comment shows that you just don’t get it.
      The physician-patient interaction in the emergency department is not a “free market.” Someone could threaten to kill me and point a gun at my head. Federal laws still require that the patient get a screening exam and stabilizing treatment.
      In a free market, I refuse to enter into the physician-patient relationship with any patient that is obnoxious to me or my staff.
      Whether or not I work in a hospital is a free market decision. That’s why I’m deciding whether to stay in that position.
      Demand for emergency care goes up with newly “insured” patients who can’t find primary care physicians, supply of emergency physicians goes down.
      Wait and see how the market handles that scenario.

      • So you’re not going to treat drunks with devastating injuries because they might be rude to you?

        Or when you start treating someone if they turn on you you’re going to stop?

        I think your comment illustrates that YOU don’t get it. I don’t see how the ED ever becomes part of the “free market”. Can you see such a way? In reality that is, not in your pie in the sky world where the government gives you complete freedom to act while it pays your bills but also complete freedom from liability for your actions?

        I’m not too worried about all these physicians disappearing. One, the public hears that threat all the time. Two, the reality of how most people, including physicians, live will keep that from happening.

      • I don’t think anyone here is actually going to turn away someone seriously injured just because they’re a little foul mouthed. When people are hurt/scared, they often lash out. We know and accept that.

        It is more difficult to accept the obvious opioid abusing patients. This website is full of examples but I’ll reiterate a few of them. A patient with 12 visits in last 3 months for dental issue, fills lortab every time but doesn’t fill antibiotics at all; or, patients that are allergic to all analgesics except “the one that starts with a D” and the ones with intractable back pain that only responds to the D drug, yet when you refuse to give it to them they storm out of the hospital just like you or I would (ie no back pain apparent in their gait).

        What about patients who just don’t care… until they do. What about the same guy who shows up in your CP unit 6 times, and admits that it only happens after he does coke, and won’t stop doing coke? What about the women who come to the ED for a pregnancy test when they are available at the dollar store? What about the homeless guy who checks into the hospital every single night (my hospital has 3 of them, everyone knows them by sight, even the medical students)?

        Those are the patients that we often object to treating. Its not just that they waste our time, or that they’re abusive, or that they don’t ever even intend to pay (and yet still get satisfaction surveys). They also keep us from treating other patients who we can actually help, whether it is a serious problem or just one that happened at an inconvenient hour.

        C’mon man, you’ve been around here long enough to get some of this. I’m not going to get into the free market issue (I don’t know enough), but at least try and see where we’re coming from here.

      • I completely get where you’re coming from. That’s why I said I realize that most of the above is just a vent. I really, really sympathize with you – to a point.

        But is that all you’re doing – just venting? If so, that’s cool. But I see physicians like WC piss and moan that they want the “free market”. Yet they never explain how they would implement that, and even more pertinent, do nothing legislatively to move us toward that.

        I WANT you to be able to charge what you’re worth. I WANT you to be free of all these restrictions you dislike. But I see nothing from physicians, the people who are complaining constantly, that shows they want to be free of the government yoke. No ACTION. In fact, the only real legislative action is to get government MORE involved in your lives.

        You guys think I dislike your profession or don’t respect it. Totally untrue. I don’t like your attempts to screw those injured by malpractice, true. But I think we as a society and me as a patient would benefit significantly if you were freed from the third party payment model. And I think if you were treated more like professionals and less like conduits to tests we would all be better off. But I don’t see physicians making steps to do so. I just hear the same old vague threats of disappearing doctors.

      • Well we’re well known as not being organized politically. That might start changing, but I doubt it.

        Many of the things we bitch about, especially EPs like whitecoat, are things that will never get changed. Can you imagine what would happen if we pushed to completely get rid of EMTALA? Politicians, commentators and the lay public would all accuse us of being greedy heartless bastards who would let little Timmy die because he’s poor or refuse to provide all of the care they desire on their 99 year old demented mother with an EF of <10% and ESRD who is "still with it" despite failing every dementia test we have.

        EMTALA might be less objectionable if we have 2 little fixes. First, require some form of payment. I know most people without insurance can't afford ED level care, especially if something is actually wrong with them. How about $25 up front if its not an immediate life-or-death situation? How about requiring a patient to at least make some kind of monthly payment? We can even use a sliding scale. I don't think asking for $20 a month for their medical care is unreasonable.

        Second, do something about the lawsuits. One of the problems with EMTALA is that it provides no protection of any kind. There are many examples of patients who abuse the ED by coming in frequently to score drugs/free meals/warm bed/attention that are given a full work up for months on end. They complain of the exact same thing every time (usually chest pain or suicidal thoughts). How many times/year do you work up the same man who comes in for CP 2-3X/week before you can stop spending the $3,500 (what a 24 hour eval in our CP unit costs) and just tell him to go home? As things are now, never. He could have the EXACT same symptoms 99 times in a row in 6 months, but that 100th time when he actually does have an MI and dies will likely result in a lawsuit.

        I've read about 2 cases where a homeless patient died in the hospital because of exactly that scenario and all of a sudden these huge numbers of family members come out of the woodwork demanding money because "daddy deserved better than this". A) Boy Who Cried Wolf anyone? B) If they cared so much, why was "daddy" living on the streets? At some point, we need to be able to say enough is enough. I don't want to sound callous, but continually spending all this time and effort on our frequent fliers is expensive and slows down the ED for people who are actually sick.

        No one has a good solution to the second problem that both sides can agree upon. I'm not even sure there is one, but we can at least try a few minor things to help out. Even a little leniency from you legal folks would make a big difference in cases like those generalized ones I mentioned.

      • “Drunks with devastating injuries” are usually comatose on the beds, not up “being rude to [me]”. Another example of how you comment on things about which you have no knowledge.

        If someone “turns on me” you’re damn right I’ll stop treating them. I have a whole room full of patients to take care of. If someone attacks and incapacitates me, who’s going to take care of the next person rolling in with a heart attack? You? Gerry Spence? Know anything about triage? Know how medical providers are categorized in triage? Of course not. You don’t get it. Maybe you do get it and you’re purposely throwing out statements that make no sense.

        We’re going to have to add the “government paying for your bills” and “running to the government for immunity” to your unsubstantiated repertoire of inane arguments. The government covers less than half the cost of caring for patients in many circumstances and Medicare doesn’t cover the cost of caring for primary care patients – that’s why so many physicians don’t take Medicaid and are increasingly dropping Medicare. I have never “run to the government for immunity.” I have proposed on this blog – and also proposed to lobbyists, state lawmakers and one federal lawmaker that partial immunity for EMTALA care would increase the availability of emergency medical care. Whether they choose to investigate that assertion as a means to increase access to care is their decision.

        True emergency care will never become part of a free market. Patients may be able to choose their hospital in an emergency, but they can’t choose their provider. Many rural EDs are staffing nurse practitioners and family physicians as the sole emergency medical providers full time, now. As reimbursement shrinks, look for more and more systems to do the same. That’s how the current market will try to survive. Paying for less qualified care is the wrong way to go about things. We don’t see NPs or physician assistants doing open heart surgery, spine surgery, or reading pathology slides, do we?

        Regarding non-emergency care, free market is already here and it will be spreading. Go to a rural area and try to find a dentist that takes Medicaid “insurance.” Try to find a family practitioner in many rural areas that takes Medicaid “insurance.” If you don’t have an emergency, more and more hospitals are requiring some form of payment in advance or you don’t get treatment. I think lawyers call that a “retainer”. As hospitals struggle to keep their doors open, see how this concept catches hold.
        Of course, these statements are coming from someone who has seen all of this happening first hand and who has tried to help patients navigate the medical system when it does happen. I’m sure that your vast experience dealing with uninsured patients trying to find medical care trumps my ideas.

        Want to show me a link to any statutes saying that state penal codes no longer apply once a patient is in the emergency department? Assault is assault whether it occurs on the street, in a shopping mall, in a courtroom, in the emergency department or in your law office (if you have one).
        If a drunk patient spits on the floor of a courtroom, tells the judge he is going to kill him, and then urinates in a corner, does the judge put him in a chair, provide him with a tissue to wipe his mouth, a urinal just in case he has to relieve himself, and a litigant satisfaction survey? Of course not. Instead, a few guys with guns subdue the person and he ends up spending hard time in county lockup.
        Court systems don’t stand for such actions in the courtroom and everyone knows it. Guess what … you almost never hear of people doing these things in courtrooms. Happens every day in emergency departments across the country.
        Kind of scary that it’s a newsworthy event when hospitals take action against people that behave this way.

        You can make all the unsubstantiated “Mattuendos” and “Mattisms” that you want about disappearing medical care.
        By the end of this decade when Baby Boomers are getting sicker and sicker, we’ll be short 1 million nurses (.pdf file). As workloads increase, the remaining nurses will be so overwhelmed that they will get frustrated and will retire early or leave practice as well.
        One third of doctors stated that they planned to retire early or quit the profession if health care reform was passed.
        Can you link to any numbers projecting a physician and nursing surplus in the coming years? Didn’t think so.
        Your reality and everyone elses’ reality are just a little different, that’s all.

      • ” One of the problems with EMTALA is that it provides no protection of any kind.”

        Why should it? Why should people who can’t afford to pay not expect that you will treat them according to the appropriate standard of care? Just because they’re poor?

        “that 100th time when he actually does have an MI and dies will likely result in a lawsuit.”

        I’m not sure how you define “likely”, because given that the ratio of negligence to claims (not lawsuits) file is nearly 8-1 according to an article WC cited just the other day. And since you’re talking about someone who probably has minimal damages, I have a hard time seeing how that is “likely” that he files suit. Particularly if it’s not even a close question as to the negligence.

      • “We’re going to have to add the “government paying for your bills” and “running to the government for immunity” to your unsubstantiated repertoire of inane arguments”

        I think you have a different dictionary than everyone else. Government pays 50% of all healthcare expenditures, and that number is only increasing. If you don’t think government pays your bills, then you’re a fool. What’s more, not only do they pay most of them, the other third party payors key their pricing off the government’s.

        As to running to the government for immunity, that’s just a fact. Sorry you don’t like it, Captain Free Market.

        “I have proposed on this blog – and also proposed to lobbyists, state lawmakers and one federal lawmaker that partial immunity for EMTALA care would increase the availability of emergency medical care.”

        So you ARE running to the government for immunity. Not only do you contradict yourself, but you do it in the same post.

        But tell me, why should people who can’t afford to pay you not expect you to treat them with the appropriate standard of care? Because you make $200,000 a year and they don’t? Justice? You KNEW that EMTALA was part of the deal when you chose your profession, you know it when you sign the contracts with the hospital. Now you want to change the rules to benefit yourself even further? How much do you need?

        “True emergency care will never become part of a free market”

        Then quit whining for it.

        ” I’m sure that your vast experience dealing with uninsured patients trying to find medical care trumps my ideas.”

        It’s funny that you say that because I actually do have quite a bit of experience doing just that. Trying to get providers to take patients based on medical liens, for example; helping patients find physicians who will take payment plans, or fill out applications for charity care, so they can get the treatment they need while their case is pending. So yeah, I have a little experience in it.

        But I think you’re wrong, because I think you’ll see the government do a wholesale takeover before the scenario you predict happens. Government increases, it doesn’t recede.

        “Assault is assault whether it occurs on the street, in a shopping mall, in a courtroom, in the emergency department or in your law office (if you have one).”

        Got a couple, actually, but thanks for asking. I’d like to get rid of the overhead, though. You’re absolutely right. But if the police refuse to enforce, that’s a beef you have with the cops. Or your employer who is not providing adequate security. I think you should have that protection.

        “Guess what … you almost never hear of people doing these things in courtrooms.”

        “You can make all the unsubstantiated “Mattuendos” and “Mattisms” that you want about disappearing medical care”

        I hadn’t thought about naming them, but I like what you did there. But they aren’t unsubstantiated. You guys cry “no more access” about everything, from tort reform to Medicare cuts to whatever. You do it yourself. And yet as long as an area has money, it is overserved with physicians. And if it doesn’t, it’s underserved. That’s the sole driver.

        We may be short of physicians because of baby boomers, which is not due to physicians leaving, but rather more population needing care. The reality is physicians, like most people, can’t just up and quit. They’ve got mortgages, kids in college, car payments, etc. And there is no other job they can jump right into that pays anywhere near the same as what they make as physicians and what they’ve grown accustomed to living on.

        I’m sure you can find all kinds of physician surveys saying they’ll quit if they don’t get this or that, or they’d save us money if we passed this or that. But it never pans out. That’s the reality, my friend. The facts remain – if you have money – you’ll have all the physicians you need. If you don’t, you’ll not have enough no matter how many the medical schools put out. Again, them’s the facts. Sorry you don’t like them.

        You must not know many people who work in courtrooms where they do a lot of domestic relations work.

      • “I’ve read about 2 cases ”

        VA, whenever I see that I have to stop. Was this family member’s threatening? Or actual suits filed? And really, if the care was negligent, why shouldn’t there be a claim? Maybe the damages are lower, but just because the person was poor and even had no family, should that matter?

        WC once said there are about 1 billion patient-physician interactions each year. And I’ve asked him a number of times how many suits there are each year and how many he would expect there to be but he keeps neglecting to find the time to answer. So maybe you know?

        You ask lawyers to “lay off”. The facts are that most negligence never sees even a claim file, much less a lawsuit. When it does, your insurer fights tooth and nail regardless of merit generally. How much more laying off do you want?

  11. Don’t quit, just find a new joint.

    Or, better yet, invite the Board (seriously) to come and spend Saturday night in the ED, dressed as Volunteers. It could help, couldn’t hurt from where you are now.

  12. Patients 1 and 2 both sound like sorority chicks…ya’ know…bitchy, dumb, et al. Maybe you should try relating to them by disguising yourself as a frat boy…slip right under their radar and earn some positive reviews!

  13. I work in a Canadian ER which is obviously somewhat different in terms of admin system and litigation risk. I am occasionally telling patients that their behaviour has made it impossible to provide care for them and therefore their behaviour is putting their health in jeopardy.
    When I have kicked these folks out of the emerg (generally they are well people with trivial problems no mental illness and highly physically and verbally abusive) I have carefully documented that they do not appear to be suffering from psychiatric illness or intoxication and that because of their dangerous actions I was unable to do the history and physical needed to reach any treatment decision and the patient was asked to leave.
    I have had a little bit of push back from admin about this, but no administrators who would outright insist in writing that I need to put my own health at risk to see well appearing and dangerous patients. I also ask them to take down all of the signs around our department that say it is a violence free workplace when they confront me about this, since they are endorsing the appropriatness of patient violence.
    In my view a large part of the problem is that we tolerate this, and until we are informing patients and admin that this is unacceptable on every occasion that abusive behaviour happens in the ED we can not really hope for the situation to change…

  14. yep. press ganey thrives at my place of employment as well. it is laughable that lay people think this brings us into “the free market.” consider that the beancounters send surveys to “customers” that take our services without paying for it, and to those that belong to government programs that reimburse for less than the cost of providing the care. i’m pretty sure in other “free markets” these people are called “shoplifters.” should shoplifters routinely get customer satisfaction surveys?

    consider that these surveys are only given to ED patients that are sent home. no patient who is sick enough to get hospitalized receives a survey. i was told that studies showed patients weren’t clever enough to break down their hospital stay into ED and inpatient portions, so the admitted ones just get one survey for their inpatient experience. so the ED staff are only judged on the satisfaction of the least sick (and generally most demanding and quickest to complain about trivial things) patients.

    consider that more and more places are starting to have these survey results affect physician pay. at my hospital, 5 of my colleagues had raises witheld last year because they did not meet a certain score cutoff (no mention of this in our contracts, by the way). i pointed out to the administrator that these 5 guys are the 4 nights-only docs and 1 fast track-only doc. isn’t it possible that they see a patient population that is more likely to give bad scores? does he really think we coincidentally have our 4 least clinically skilled docs on nights? and if we drive them out of nights by making the shift less desirable, won’t we all be stuck working more nights? it fell on deaf ears.

    consider that these surveys ask questions to gauge the customers’ perception of their physician’s clinical skills. if someone comes in for a cold demanding antibiotics and can’t be convinced that viral illnesses aren’t treated with antibiotics, will they report that their doc, who didn’t give them what they wanted, is a “bad doctor?” if someone comes in because they’re hoping to score some percocets to then abuse or sell on the street, but the doc calls them out on it and throws them out the door, will they report that their doc is a “bad doctor?” if a patient comes in demanding unnecessary x-rays or ct scans and can’t be convinced otherwise? do you practice good medicine and withhold the tests? or do you put your own salary first and screw the consequences of radiation exposure? not to mention the contribution to escalating health care costs?

    look, i think having happy patients is a good thing. but some times, doing the right thing as a doctor and “satisfying your customers” are at odds and we are being incentivized to choose the latter.

    okay, i think i’ve said enough for now. clearly, the press-ganey issue is one of my buttons. in fact i would say this is the second most bothersome thing about my job.

  15. Wow. This ex-academic feels your pain. One main reason I left was the abuse of student satisfaction surveys. That was monumentally stupid, but doing this with ERs is even more stupid.

    And yes, at one of my institutions, the survey invited the student to estimate how well I knew my stuff. Yeeeargh.

    • Graduate student here, I feel your pain. Never been threatened with violence, but having students propose “favors” for grades is nearly as disturbing when 1 in 3 students on campus has herpes. The cover your ass paperwork for that would put Kafka to shame.

  16. There have been a few instances in my hospital where the chief of staff has talked with patients who have been abusive to nurses and has informed them that such behavior is unacceptable and will not be tolerated. If administrators would back up the hospital employees like this more often it would help. Maybe give the ER staff “patient” satisfaction surveys, and if a patient flunks because of abusive behavior sending him/her a letter asking them to seek care elsewhere.
    We actually have patients in my system where when they arrive, security is automatically notified notified and security officers are present when they are seen.

  17. WC, I know how important facts are to you rather than innuendo, so before you start claiming disappearing docs again, you might want to check out this:

    http://www.kevinmd.com/blog/2010/04/physician-supply-trends-primary-care-doctors-specialists.html

    “In summary, the recent trend in physician supply in the U.S. shows significant growth over the general population rate. Primary care physician numbers are also growing faster than other specialties.”

    That seems to be a different reality than what you’re saying. At least according to that physician.

  18. Look at the American Journal of Medicine website to see lots of discussion about the primary care problems the country is facing. There may not be a problem in some communities but there certainly is in mine.

    If you step back a minute and look at this discussion, a few things are obvious. First, I think most physicians would agree that their salaries compared to the rest of society’s are substantial (you can argue about whether it is commensurate with their worth, but that’s another issue.) Despite this, job satisfaction is low. This blog deals with a lot of the reasons – excessive administrative hassle and paperwork (“my job is paperwork with a little patient care on the side”), fear of lawsuits (and though studies show that many injuries do not go to trial, they also show that many suits are groundless and the care was proper), and having to deal with clueless administrators, third party payors and abusive patients. I quoted Mark Twain earlier. He also commented that “If you pick up a starving dog and make him prosperous he will not bite you. This is the principle difference between dogs and humans”. No one knows this more than doctors and nurses. We are, after all, there to help patients and have made and make considerable personal sacrifice to do so (and you can and probably will scoff about this, Matt, but it’s true. You make good money but at the cost of enormous workweek hours, lots of worry about whether you’re doing the right thing, nights, holidays, weekends and missed meals, sleep and family activities. After a while you have to wonder whether the personal cost and shit you have to put up with from some patients are worth it).
    We have to remember that 90% of our patients appreciate our efforts. This particular blog deals with the 10% who aren’t.

    • I don’t know why you think I’d scoff. I very much respect any professional because of the sacrifices involved and the responsibility all professions take on. The duty to the public is in many ways what sets a profession apart from a job.

      However, I don’t believe the personal sacrifice of the medical profession is as unique as you think. Many professionals endure just as much for less remuneration. The nature of their problems may be different but the weight is just as heavy. And they complain far less.

      • I actually do think medical and police/fire/first responder professionals are unique. Because 1) we cannot refuse to do our job if the patient/”customer” is abusive – we are legally required to (i.e., when was the last time another profession couldn’t walk away when bitten by a customer?) and 2) lives depend on it. The two together are what makes these professions different from others. Not either one apart. Unless you are one of these professionals, you don’t understand. Period.

      • Lives depend on everything everyone does. Don’t get melodramatic. Lives depend on 18 wheeler drivers doing their jobs properly. So I guess unless you’ve got a CDL you can’t understand. Period.

      • DensityDuck on

        Yes, my heart just breaks every time I think of all those lawyers sitting at their desk until long past six PM, dithering over the difference between “enter” and “return”.

        I mean, if only you JUST had to deal with people smashing up your workplace and threatening violence against you and your coworkers. Those docs have got it EASY.

    • “I do think a little humility wouldn’t hurt though.”
      shud tell this to people who come in to ED and start abusing the staff
      seems like a good idea!!!

  19. “Lives depend on everything everyone does. Don’t get melodramatic. Lives depend on 18 wheeler drivers doing their jobs properly. So I guess unless you’ve got a CDL you can’t understand. Period.”

    Matt this is one of the most ignorant of MANY ignorant statements I’ve seen you make on this blog. So I suppose the fact that any idiot can get a driver’s license (not talking about 18 wheelers here, but based on your analogy this also holds true) and drive a vehicle which could kill someone means that lives depend on them not hitting another vehicle or a pedestrian. Since lives depend on this, it’s not that much different than medicine. That’s basically your insinuation. “Lives depend on everything, so don’t get too full of yourselves there, doctors..”

    Well Matt I think most of us actually do have humility. I think you’re missing that entirely. This line of work will bring that out in you. Builds you up at times, and breaks you down at others. Over and over.

    I follow this blog periodically and I’ve commented on this before and I’ll say it again: I just don’t get your fascination with and antagonism with this blog and medicine in general. Part of me suspects you envy us and wish you’d chosen different with your life.

    One thing I can guarantee you: I don’t waste my time on attorney blogs and I read this one because it pertains to my career. I genuinely feel sorry for you, if as an outsider you have nothing better to do than visit this blog, argue, and stir the pot.

  20. I have been on extended canoe trips with two policemen (you get to know people real well when you share a canoe with them for several weeks), and have a nephew who is a fireman. These are the professions whose personal sacrifices most resemble medicine (show me the last engineer or lawyer who was awake working at 3 am on Christmas morning). All these individuals were eligible for full retirement after 20 years and although they worked odd shifts they were mostly regulated hours – not many long days followed by long nights and then another long day, as all physicians have had to do. My nephew is accorded enormous respect, especially since 911, much more than any doctor I know. There aren’t many people out there like Matt constantly demeaning the firefighting profession. The police friends took a certain amount of abuse but could always just arrest the idiot who was dishing it out. Granted, they do put their lives on the line more often than doctors and suffer from the retrospecoscope just as we do, and policemen do tolerate a lot of crap.
    Matt is an example of the general disrespect a lot of individuals have who believe the stereotypes of doctors portrayed in the mass media. I personally know very few doctors who are truly arrogant. You have to act confident even in the midst of a code – that doesn’t mean you’re not nervous on the inside, and sharp behavior from doctors usually occurs when thing are going badly, there’s a lot of stress, and the doctor feels exactly the opposite of arrogant.
    As far as him endlessly generating demeaning and antagonistic comments, on a blog mainly read by doctors, you really do have to wonder what kind of person gets his kicks by doing that.

    Actually, you don’t have to wonder.

  21. “I don’t waste my time on attorney blogs and I read this one because it pertains to my career. I genuinely feel sorry for you, if as an outsider you have nothing better to do than visit this blog, argue, and stir the pot.”

    Thanks for the sympathy. Even when not needed I can always use it.

    But I’m not here just to stir the pot, unless encouraging you to change your payment system constitutes that. As a patient, I think it’s better for me and all us patients. So really, this does pertain to me.

    I don’t much care for your desire to be immune from your mistakes because some of your customers are poor, that’s true. That doesn’t pertain to me per se, since I have disability coverage and health insurance, but as a member of society, I still prefer not to further tilt the scales of justice in favor of the wealthy and their insurers. That’s more of a personal thing, though.

  22. “Matt is an example of the general disrespect a lot of individuals have who believe the stereotypes of doctors portrayed in the mass media.”

    Actually, my position is based on personal experience, having dealt with physicians at length as a patient, as their attorney, and being adverse to them. There are some humble ones, but by and large there’s a lot of arrogance. Not to say that attorneys are immune from that, of course.

    “These are the professions whose personal sacrifices most resemble medicine (show me the last engineer or lawyer who was awake working at 3 am on Christmas morning.”

    Show me the podiatrist awake at 3 am Christmas morning. Or the dermatologist. And if a fireman or a policeman is not on shift at the time, they’re asleep as well. Thanks for illustrating the arrogance I was talking about. You have no real concept of what an attorney or engineer does, but you’re quite certain it’s nowhere near as demanding as what you do (presumably from the mass media). THAT is why people think you’re arrogant. Your certainty in the face of a complete lack of facts.

    I’m not demeaning your profession. You should read closer – I have enormous respect for what you do, I’m just not deifying you like you want. Nor do I think simply because you’re a physician you are blessed with infallibility in all areas. The fact that you take any disagreement with you as “demeaning your profession” only further illustrates the arrogance point.

    • A podiatrist didn’t go to medical school. A dermatologist, is well, a dermatologist. I was an engineer before I went to medical school. I come from a family of lawyers. Matt has some deep seated pathology that has distorted his prism.

  23. Incidentally, it’s especially ironic hearing you complain about being “demeaned” given what most medical practitioners will routinely say about attorneys at the drop of a hat. “Greedy” is the most charitable, which is particularly ironic.

  24. Actually, Matt, I think it would be wonderful if people’s expectations of what doctors can do were much more realistic. Where do you get the idea doctors want to be “deified”? I NEVER identify myself as a doctor outside the workplace. I welcome it when people ask me if they can get a second opinion – it decreases my liability. As far as speaking in complete ignorance about this subject, I do know what personal sacrifices doctors make, far more than you do, and have relatives who are teachers, firefighters, engineers, and accountants, and friends who are psychologists, police officers and lawyers, and I have an idea what sacrifices they make. The teachers (brother and niece) take a lot of guff from parents and students but aren’t physically threatened. Everyone I know puts in a lot of hours, but only the fireman and policemen routinely work nights, holidays and weekends. None of them worry as much. But, if you want to believe otherwise, fine. The point, which you have so clearly demonstrated, is that the personal sacrifices that doctors make are not appreciated, making the financial rewards of the job assume greater importance and contributing to job dissatisfation. Unfortunate, in my opinion. Having a person whom you are trying to help threaten or assault you doesn’t help either.

    • “The point, which you have so clearly demonstrated, is that the personal sacrifices that doctors make are not appreciated, making the financial rewards of the job assume greater importance and contributing to job dissatisfation.”

      Dave, US physicians the highest paid profession in the world. I’m not sure what other “appreciation” you want? “atta boys” from every third person you pass on the street?

      And really, you don’t value your own skills, at least as individuals. You’re all priced pretty much the same, you bill pretty much by the procedure rather than for your knowledge and time, which is what you’re really selling. Why should the public value you differently than you value yourselves? You’ve essentially said in your payment model that as long as I’m in the same specialty, one guy is as good as the next when it comes to doctors. The better one certainly isn’t getting paid any more for the quality of his work.

      As for knowing what people do, I know lots of people in all different walks of life. But until you’ve done the work, you have no clue. I’m sure you work hard and would never think anything else. But you really have no clue until you’ve done it. The work of a public defender may involve far more sacrifice than that of a dermatologist, for all I know. And for all you know – neither of us do those jobs. I have an uncle who is a fireman – he routinely works nights and weekends – for three days on and then four off. He’ll tell you the best thing about his job is the schedule.

  25. How frustrating for everyone subjected to this rudeness and threatened violence and sometimes violence.

    WC – if you leave they are losing a good doc and that is too bad for all the good patients, the hospital and even the bad pts that would benefit from your expertise and compassion.

    One of my favorite posts you’ve written was the one in which the transport crew and staff blew the patient off as a nasty old man or something like that. But you didn’t go into his room ..prejudging him. You went in and saw an elderly man ..who maybe was not himself, who needed your help and perhaps some respect and compassion. you befriended him by offering to fix his glasses and you even took the time to clean them. The result was that you both connected and you were able to do the exam. Forgive me that I don’t remember the exact circumstances ..but that was such a beautiful example of a positive difference you made for one of your patients. Not to mention all the lives you do save and the pain you relieve and the smiles and appreciation you receive from the good patients ..even if they don’t fill out the press ganeys.

    I am just so sorry that so many people seem to be trashy, etc. It’s not just in medicine. What is wrong with our society that these behaviors are on the increase?

    I think there should be consequences.

    Administration should back you up.

    I think it should be a prerequisite that administration does time in the ED.

    Is there anyway ..that the Your group can present the facts in a meeting. You deserve respect.

    The future you paint with dwindling medical professionals is disturbing. Baby boomers are getting up there.

    How can it be fixed?

  26. Pattie, RN on

    W.C., please do us all a favor and stick to your usual excellent insights and observations without jousting with a drunk frat boy like Matt. He hasn’t been the same since he found out that despite his Daddy’s money and contacts, a 2.19 GPA in Liberal Arts will not get him into Med School. If someone of his superior fiber can’t get to be a physician, it is clearly because all doctors are morons. That settles it in his mind.

    So the next time he shows up, tell him he is, as usual, 100% correct, and that he should go do several shots of Jagermeister to celebrate.

    And when he leaves, the adults can resume our conversation.

    • My parents were bitterly divorced, sadly, and dad’s money was rare in coming. And he was a small town insurance salesman, so his contacts were pretty limited. At one time I did like Jager, but quickly lost my taste for it. Tequila, though, I still love. So I guess one out of three isn’t bad. Apparently qualifies you to be a nurse.

      And no one said physicians were morons. Except you. They’re actually quite intelligent people as it relates to their field.

  27. I, like Dave, wonder why Matt believes we want to be “deified”. I think the issue Matt may be your perception of how we think of ourselves. You may also want to keep in mind that reading a blog, which is mostly read by MD’s, and covers hot button issues, is going to get our feathers ruffled a little bit.

    You might be just shocked to find out that in general, away from work most of us are *gasp* normal people who do NOT want to be deified—just respected. Nothing less, nothing more. Your comments after my previous post really illustrate some of YOUR personal issues, which seem to attract you to this blog.

    I’ll say it again: I seriously doubt that ANY physician is spending a significant amount of time on attorney blogs. I suggest you don’t have a life and in fact have some major psychological issues with physicians. Either than or you’re merely here in an effort to “sway the public opinion” in favor of med mal attorneys in some small way. Whatever the case, I feel genuine sympathy for you.

    • So don’t read my posts if you think I’m nuts. Who’s crazier, the person you think is crazy or doesn’t have a life in writing the posts, or the one who continually reads and continually replies “you’re crazy”? Seriously, my feelings won’t be hurt if you don’t read or reply.

    • Thanks, hon, but my nap is 11:30-1. So I’m up until I get dinner and then tucked in at 8. Appreciate you checking in though.

  28. One thing I don’t get is why you guys are so angry at any disagreement. After all, I fully support you getting paid what you’re worth, being freed from the yoke of the third party payment model, and remaining independent professionals rather than continuing down the road we’re headed with the present versions of health care “reform”. And I’ve said those things repeatedly.

    Simply because I don’t want to further screw over those injured by malpractice and further tilt the scales in favor of your liability carriers you are terribly irate. And another odd thing many of you make these very disparaging statements about other professions all the time, but whenever anyone dares to question the perceived sanctity of your own you get completely bent out of shape.

    Again, I WANT you to be successful, I WANT you to maximize your income, I WANT you to have more freedom in your practice, and I WANT you to maximize your free time. I SUPPORT you in that. I mean that sincerely. Don’t lose sight of that when you’re ramping up the personal attacks in response to some minor disagreement on another issue.

  29. There are some things you do repeat that are insulting, Matt. You have continually implied that if doctors want the same liability protection EMT’s have, it implies we think poor people do not deserve the same standard of care other people have. In fact, most doctors practice to the best of their ability regardless of the financial status of the patient and regardless of the malpractice risk. Do you think most people in Europe or Australia get worse care because the malpractice climate is less onerous? You do the best you can because it’s the right thing to do. To imply that we do otherwise otherwise is an insult. Similarly, with your blowing off the charity care doctors give, which is substantial when you consider medicaid, which is basically charity work. Whatever the “contract” is, in reality doctors do it because of a sense professional responsibility at an economic loss (I’m not talking mainly about emtala patients here, I’m referring to all the physicians who see these folks when they don’t have to). This is altruism, it’s a good thing, and in our society it’s the only way some people get care. It rankles me, who has spent many days and nights caring for people I knew I wouldn’t get a dime from, see you blow this away so cavalierly, and I’m sure other readers of this blog who have done the same feel the same way. This probably leads to some of the rancor.

    • That’s all well and good, but the question remains-why should you get immunity from negligence just because the patient may not be able to pay?

      I’m sure all the other things you said ARE true.

      What EMT protection are you talking about? If you want to be treated like an EMT can we pay you like one?

      I’m not blowing off your true charity care but I don’t know why it should entitle you to immunity.

  30. Howling Dog on

    I agree,with the original poster, this subjective, patient satisfaction stuff can be completely absurd. Our ED director, who otherwise is a great boss, takes these very seriously. The problem is, medicine is not a “have it your way” or “the customer is always right” business. If you get high patient satisfaction ratings by handing out boatloads of narcotics to drug seekers, does that mean you are providing better care? I wish we were free to speak our minds sometimes. “The reason you have chronic back pain is that you are 100 lbs overweight and sedentary.” Do you think telling the patient that would get you a high Press Ganey score? “That rude doctor insulted me.” I’m sure every job has its share of rude assholes to deal with. I can’t imagine, for example, being the poor employee at the airline ticketing desk having to keep a smile on my face while dealing with irate travelers whose flights have been cancelled, as if it’s that employee’s fault. Part of it is just that what used to be called common courtesy, like common sense, is a dying practice anymore. I like a lot of the older patients I see because they are generally polite and respectful. People my age and younger are often such spoiled brats, it makes me despair for the future of our country. Of course there are exceptions on both sides. (And BTW, have you ever noticed, when sober, the more badly hurt or ill the patient is, the less whiny and demanding they are?)
    One last thing: I think a great idea would be to have an up-front copay inversely proportional to illness severity. Acute MI or multitrauma? No copay. The sniffles for two weeks? $250 or go see your doctor. If you want a refill of your chronic pain medications? You have to pay for the visit and the medication right then and there. Post a fee schedule in the waiting room.
    OK, end of rant. I enjoy your blog, whitecoat. You often say what I am thinking.

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