Agraphia Medical Tragicomedy


(I Can’t Get No) Satisfaction

My resident told me today that he was planning on giving antibiotics to a kid with a fever. I asked him where the fever was coming from - he said he didn't see anything on the exam, but the parents were pretty insistent that the kid needed antibiotics, and he was tired of arguing. "Plus," he added, "it's good for patient satisfaction scores."

Bringing up patient satisfaction scores as justification for unwarranted treatment is a great way to earn my disapproval as an attending.

I popped into the room and saw a happy, healthy, smiling 5 year old pulling all the paper towels from the dispenser. He ran over to the door, gave me a high-five/low-five/fist bump combo, and then asked me when he was able to go home and watch cartoons. I did an exam which revealed absolutely nothing abnormal. The mom looked at me askance as I began to explain that her kid did not, in fact, need antibiotics.

"But he's got a fever," she said, "every time he has a fever my pediatrician puts him on antibiotics. My child needs antibiotics!"

Over the years, I've gotten very good at having this conversation with parents. Usually they leave the ER happy and reassured that their child looks healthy and well, with the understanding that antibiotics will make no difference - and in fact, may cause harm, predisposing their child to vomiting, diarrhea, allergic reactions, and resistant bacterial infections. In this case, mom was having none of it. There was no way she was leaving happy without antibiotics.

And so, in the end, she left - but unhappy, and without antibiotics.

I had a sit-down discussion with the resident afterward. Patient satisfaction scores have become increasingly important in recent years. Physician compensation is often directly tied to percentile ranking on these scoring systems. At one hospital I worked in, the patient satisfaction score was a 20% "bonus" to the yearly salary. Put in other terms - I could be personally at risk at losing $20,000 for every $100,000 I'm supposed to make.

If you think this doesn't change physician behavior, you're wrong. Emergency Physicians have something of a gallows humor about the whole idea - we have addicts that come in, needing their fix... and when we don't give it to them, our "satisfaction scores" go down. The same, however, is broadly generalizable to a vast swath of ER patients who want something. Sure, the easiest example is the drug seeker, but people come to the ER seeking just about anything; from antibiotics, to sandwiches, to MRI's. One famous patient last year used to come to the ER on a weekly basis asking for a male physician to perform a pelvic exam.

In the end, I feel very strongly that it is my duty as a physician to take care of my patients, and to me it supersedes my salary. It has become somewhat of a mantra for me and the residents lately, "Give your patients what they need, not what they want." I've spent tens of thousands of hours studying medicine and seeing patients. I've seen countless kids with fevers, including ones that are truly sick. Just because mom's doddering old pediatrician hands out pre-printed, pre-signed Amoxicillin prescriptions at the slightest hint of a fever... well, it doesn't mean I will.

This is an Emergency Department, not a Convenience Department. As an aside, my patient satisfaction scores are excellent. I'm chalking this mom up as an outlier.

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  1. Interesting post Zac. Well timed as this is precisely what I have been mulling over for the past few weeks. I saw a patient a few weeks ago with ‘headache and neck pain’. The resident saw her, accurately eyeballed that there was no emergency going on, and really struggled with a dispo for her because the patient was giving the stink eye. So I go to the bedside to, you know, ‘improve the patient’s satisfaction’ and spend 30 minutes (30!!) explaining in depth why I’m confident she doesn’t have an aneurysm or meningitis or a tumor. The patient had basically slept on her neck wrong or carried a messenger bag too much or taken on too much stress or I don’t know.

    So I explain all the different things she could do to get relief. I feel like I’m really getting through to her. Until she says, “Well I just don’t want to be discharged until you can tell me what’s wrong with me”. And ultimately I discharge her still giving me the stink eye. Why bother.

    JESUS! You want me to tell you what is wrong with you?!? Well, life is hard I want to say, and sometimes painful and oh, my neck hurts too and will you give me a massage. Good think you don’t have something bad.

    Patient satisfaction I’m sure has a place somewhere out there. When I go to my elective colonoscopy at age 50 I sure hope the guy gets me real sedate and puts the scope up my butt gently and tells me in plain English afterwards about my results and what to do next, and I hope I get cutesy reminder cards when I’m overdue for my next invasion.

    But in the Emergency Department, our job and the patient’s expectations are so often completely mismatched. I’m here to make sure you don’t have (insert life/limb threatening disease) and you want an explanation for your symptoms. Or an MRI. Or a refill. Or antibiotics. Or even just a work excuse or attention or pick your flavor. And if you don’t get that you’re not satisfied? What a setup Emergency doctors are put in. I wish Press-Ganey would stay the hell away from our ED’s. From my view, as you’ve eloquently described, targeting patient satisfaction leads to overtreatment, overtesting, and misuse of the ED.

    Now if only the hospital administrators would agree with me…

  2. Great post! I must say that I had no idea that doctors were judged by such ludicrous standards. I know that may sound a little harsh on the system but I guess that’s the way I feel. You would think that a doctors quality score would come from someone that’s qualified to give it, and letting the patient be the one that determines the quality score seems a little backwards. Hopefully sometime soon the powers to be will see the error in this system and implement something better or at least something that makes sense.

  3. I ended up seeing your blog by mistake while I was doing research so I want to tell you my story.
    7 years ago I tried to kill myself. I slit both my wrists (78 stitches – allot of surgery to repair/ I also overdosed on valium) I live in a small town, and since I almost died- it was town news. The doctor who treated me called me (as he thought I was sleeping,” piece of trash, she should die.” exact words. I was sent up to there mental ward and put on so many drugs I did not know who I was.
    ON MY OWN – I went through 5 years of cognitive behavioral therapy and refused to take and do not take any meds. I am now an engineer for the Department of Defense.

    1 year ago I became extremely ill. High fever, worst headache I had ever had in my life.

    Because of my past and the fact I got the same doctor- he told me I was looking for drugs, I was a junkie (although there was no scripts listed in my name- NONE) He told me it was in my head – I had the flu. Go home take aspirin.

    Is that what you would tell me? You revel in your blog about telling people like me that?

    I went on a work trip and became worse, in a hotel on the floor so sick I couldn’t get up out of bed. Terrified to go to the ER because of past experience I road it out.

    When I got home, I was so ill- it was 1AM and my boyfriend insisted we go back to my home town ER

    He walked in – no triage nothing- stormed out came in and gave me two shots in my ASS and not nicely I might add and then said “Go home you got your fix” I asked him what he had given me? He sneered back exactly what you came here looking for.
    Dilaudid and valium.
    I never asked for that at any time. I was in tears and asked him to please just tell me what was happening to me, I was so sick.

    At this point my boyfriend brought me to the car and was terrified he drove me to the next state to the ER (its only 20 minutes away) Told them everything.
    They immediately rushed me in-
    My heart was failing. My fever was well over 102 and my blood pressure was at stroke level.
    I had some rare virus that caused a meningitis. But worse than that my cerebellum was herniated and diseased. Whatever the virus was that had attacked my body basically ate away at my brain.
    In the last year I have lost most of my vision, I have vertigo so bad I can’t drive, my left side is weak. I have memory issues.

    All of this because some doctor got jaded and burned out? I had a record of having one misfortunate accident?

    Why practice medicine?

    I have a 15 year old daughter. What would you say to her?
    I will not recover from this, I will die a miserable death, because i was judged.

    I think its just sad -all I have read. Just sad

    • Heart Sick –

      So sorry to hear you had such a bad experience at the Emergency Department. Having worked in big academic ER’s and also in small rural ER’s, I know that the entire system is not without issue.

      You misread the blog and I don’t expect you to understand it, not being in practice yourself. Knowing the author, I can assure you that a patient like yourself is nothing like the issue that he describes here. What you had, sorry to say, is a crappy ER visit, and based upon what you say, a crew that lacked compassion. I’m sorry you had acute pain and it was discounted. For those of us trying to be compassionate doctors, we try really hard to make sure that kind of thing doesn’t happen. I just really think you don’t understand the issue that is being discussed here because the only experience you have is your own. Please don’t project fault on the author.

  4. I have a question. Isn’t it general practice for a patient’s primary care doctor to write an excuse note to be off from work – especially if it will be a period of two weeks off or more, instead of an emergency room doctor? I read an excuse note from an emergency room doctor that went like this: “So and so was seen in the emergency room such and such date, please excuse them from work for two weeks.” No detail on the reason why the person was in the emergency room. The note was not on official looking hospital stationery. It only had the name of the hospital (with no address or phone number) and the name and signature of a doctor (with no contact phone). Leads me to believe that the note was not legitimate. Are there legitimate circumstances where an emergency room doctor will write an excuse note for a patient to be off from work for an extended period of time? For instance, the patient I refer to in the note I read, went to the emergency room complaining of minor chest pain while breathing, and a blood pressure reading of 160/70. What makes it suspicious is that this person was talking prior to this about putting in a worker’s compensation claim for a fall (that was not witnessed) and after that, came back with a note that said minor contusion on hip.

  5. I don’t study medicine and I’m not an American, but I wanted to let you know I love your blog. Greetings from the other side of the pond!

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