Agraphia Medical Tragicomedy


The Patient Satisfaction Dilemma

I saw an exceptionally malignant patient with back pain a few days ago.  Readers who work in an ER know exactly what I mean just from that statement; for my lay readers, let me try to paint a picture.  He was a 50-something, shabbily dressed guy in somewhat of a constant state of disrepair.  There was a musty odor of tobacco about him, and when the nurse entered the room he sneered "Oh, there you are.  So there IS someone actually attending patient needs today.  Get me a damn soda, I'm thirsty."  He had been triaged, registered, and taken to a room within 25 minutes of arrival.  His wife piped in, "Make it a Coke for him and a Mountain Dew for me.  We don't do Diet."

I walked in the room to a hostile environment.   His wife was tapping her foot on the floor impatiently, lips pursed, and apparently we were fresh out of Mountain Dew.  He had his arms crossed and began to lay into me before I could say a word.

"I want an MRI.  I hurt my back lifting something a couple hours ago, I've had a bulging disk before, and I've been waiting now for the better part of 30 minutes to see ANYBODY who is competent around here."

I took a mental breath, calmed the raging inner demons, and introduced myself.  I apologized for not seeing him earlier as I had been performing CPR in another room and broke away just as soon as I was free.

I'll cut the story short here and get to the chase.  He left the ER with a diagnosis of back sprain sans MRI, shouting at staff, extremely angry... but it was clear from our first interaction that this was inevitable.  Interestingly, he didn't come to the ER for pain control - he came because he wanted an MRI, and was livid that I wouldn't give him what he wanted.

This gets to the crux of the matter at hand.  There has been a rising emphasis on patient autonomy in medicine, a deliberate shift from the paternalistic attitudes of physicians of old.  It is one of the four central "pillars" of medical ethics; Autonomy, Beneficence, Non-Maleficence, and Justice.  Most of the time, it is a good thing.  I involve patients and family members on their medical decision making as often as possible.  If I'm waffling about admitting a patient to the hospital, I'll ask them, "do you feel comfortable going home tonight?  We can try home therapy first and you can always come back if you aren't doing well."  I am often surprised by how adept patients are about making these decisions for themselves.

There is, however, a group of patients we'll call Generation WebMD, who think that 5 minutes of Googling has given them a provisional electronic doctorate.  This guy got it into his head that he wanted - no, needed - an MRI to diagnose his back sprain and wouldn't take no for an answer.

A scenario like this plays out every minute of every day in every ER across the country.  I have had furious mothers physically escorted from the premises by security guards over whether or not their child should get antibiotics for a cold.  Drug seekers have thumbed their switchblades at me when I inform them I will not be providing them with their fix.  One of our regular COPD patients has a strict "only three breathing treatments per day" policy to prevent him from overstaying his welcome, happily puffing on albuterol while lighting cigarettes and tampering with the smoke detector.

It's a huge issue.  Physician reimbursement nowadays is often linked to patient satisfaction scores.  Physicians at a neighboring ER, for example, have 25% of their entire salary directly tied to phone surveys.  That's a huge incentive to make sure people are happy - and people are happy when they get what they want.  Unfortunately, what people want when they come into a medical setting is often not what they need.

Here's the thing.  If all you do is constantly acquiesce to patient demands to make them happy... well, you aren't really a doctor, are you?  You're just a puppet medical license with a DEA number for hire.

I got into a huge argument with a woman a few weeks ago about antibiotics for two days of sinus pain.  She started screaming so loudly at me that a police officer walking down the hall peeked his head in.  She finally asked me a simple question, "JESUS, doc, why are you being so damn obstructionist about this?  All I want is some fucking AMOXICILLIN for my sinusitis!  It has worked EVERY OTHER TIME. It's not like I'm asking for a prescription for medical marijuana!  WHAT IS THE HARM?"

I've thought a lot about her in the past few weeks.   Every single patient I have seen dying of multidrug resistant bacteria, every news article I see about superbug TB, every case of clostridia difficile colitis - I have mentally told her, "This.  This is the harm.  The harm comes in physicians prescribing things that aren't needed, doing tests that aren't indicated, giving therapy just to say we did.  One day we will look back from the brink and realize we should have been more careful."

I could go on, but I've made my point.  It is so easy to roll over and give people what they want.  I fight this temptation every single shift.  Mom wants amoxicillin for her kid's "ear infection".  Guy wants Vicodin for back pain.  Family wants me to "do everything" for the 95 year old demented nursing patient.

With a click of a button I can easily do all these things, even when I know I shouldn't.  And I'll get paid more.  And I'll avoid lawsuits.  And my patient interactions will be far more pleasant.  I suppose in the end, I try to do the right thing instead of the easy thing because I firmly believe that my duty is to take care of my patients.

And sometimes, despite violent opposition, that means simply saying no.


Playing With Fire

He looked pretty comfortable on the stretcher - unconcerned, even.

32 years old, already with bilateral toe amputations from massively uncontrolled diabetes.  He had already had bone infections, a condition known as osteomyelitis, and he had been through a few months worth of IV antibiotics through a PICC line.  Somehow he still managed to be completely noncompliant with every and all medical therapy suggested for him.

"Evening, sir, my name is Dr. Zac.  What brought you in tonight?"

"I think I got the bone infection again, and I want my Dilaudid," he said, casually, "I'm allergic to morphine and Vicodin, all I take is Percocet and Dilaudid now.  Also, I would like Phenergan and Benadryl with it."

I paused.  There are few things that bother me more than a patient requesting Dilaudid, Benadryl, and Phenergan in the very first sentence.  That particular cocktail of drugs is well known among ER physicians for being an incredibly potent high, and the immediate request for that triumvirate somehow belies a concern of illness from the patient. Most patients come in worried about what is causing the pain, and want an answer - the pain control comes second.

In this particular case, though, he was really quite sick.  He had a fever, his heart was racing at about 120 beats per minute, and his foot looked infected - and the infection was spreading up his leg.

Turns out he hadn't been bothering to check his blood sugars - routine for him, upon reviewing his chart - and his blood sugar was also around 350, which is great for hungry, thriving bacteria.

I started an IV on him, drew cultures of his blood, started potent IV antibiotics, and immediately called the admitting physician.  I begrudgingly gave him a small dose of Dilaudid - he had put our other pain medications on his "allergy" list, a common gambit among patients who want their physicians locked in to giving them the stronger medications only.

The nurse came to get me 30 minutes later.  "Room 5 says he's leaving.  He's got stuff to do at home."

I was floored, so I went and had a long talk with him.  I'm a firm believer that fear-based talks don't do anything for people and that positive reinforcement is more useful.

Still, I tried both.

"I can't force you to stay, and I know you don't like checking your sugars.  Listen, I'm not the diabetic, I never have been.  I have no idea how difficult it is to check sugars and dose insulin all day, every day.  What I do know is that from what I'm seeing here, you're probably about to lose your leg, just like you lost both toes.  I don't know, maybe the infection will even spread throughout your body this time and kill you."

"I can help you if you stay. I can get your sugars down, I can get antibiotics in you, we can try to figure out a way to make your diabetes control work for you before you become crippled."

"Tonight is one of those turning points in your life.  Stay, and we have a fighting shot at stopping this.  Go, and you'll always regret not staying, right here, right now, when you lose your leg."

Nothing I said stopped him from going.  He said he'd come back in the morning, but he never showed.  It's not often I feel like I've failed someone, but I feel like I failed him.  Then again, if I couldn't convince him to stay despite my best efforts?  Well.

I guess some people just like to play with fire.


Fitting the Stereotype

I treated a guy a few days ago for the "worst lower back pain of his life". This is a surprisingly common occurrence for emergency doctors, and I must admit that I immediately wrote him off. Mohawk, neonazi tattoos, bad teeth, nasty attitude.

I went through the song and dance, pretending to care about his "back pain after twisting it the wrong way". I've heard this story so many times, from so many drug seekers, that is has competely lost its luster. Immediately I informed him that I was not comfortable prescribing narcotic medications.

"But I'm allergic to tylenol, aspirin, and advil!" he decried, "Please, doctor, it hurts so bad. Can't you give me something else? Nobody can help me but you..."

Even a couple of years into hearing these complaints I still cringe a little on the inside while I put on the hard, callous exterior. "I'm not going to prescribe you any narcotics today, sir."

But what if I'm wrong? What if he's truly in pain and I'm just being stubborn? He was barely able to sit up from the bed without wincing in pain when I examined him. Every small touch sent him into paroxysms of agony. I discharged him with an anti-inflammatory I hoped he wouldn't recognize the name of.

Two days later I was walking back from the cafeteria and saw him strutting down the hall towards the urgent care with a heavy backpack on, no evidence of the "extreme pain" he had 2 days earlier. The doctor covering urgent care called me when he came in 10 minutes later for an inability to walk.

Nobody likes to be made a fool of, which I suspect is part of the reason Emergency Physicians undertreat pain. I follow up many of my patients in the hospital (did my suspected heart attack actually have one?), but I never follow up on suspected drug seekers. Why? Because I don't want to turn cynical earlier than I have to.