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.
As I am wont to do lately, I've been thinking an awful lot about prescription drug abuse. My last shift, I saw a guy who got in two car wrecks in the space of a few hours while taking his 2mg prescription Xanax "bars" six times a day as prescribed. I saw a woman with over 300 prescriptions (each of which contained 30-120 individual pills) for opiates and benzos in the past 3 years from around 40 different doctors. Another woman lamented that she ran out of pain meds just in time for the weekend, and her primary doctor wasn't going to give her "Roxi 30's like I asked for" - street slang for oxycodone 30mg, the highest-value street drug currently on the market.
I've said it before, and I'll say it again. Prescription drug abuse in this country is a massive issue. There were over 16,000 fatal overdoses in 2010 and the number continues to rise. More people are dying from overdose than from car wrecks in some states. While I care about alcohol abuse and illicit substances to a lesser degree, I'm fixated on prescription abuse because it is preventable. One source states that the USA uses 80% of the world's opiate supply and 99% of the world's hydrocodone.
There are several issues at play. One is that no physician wants to be confrontational if they don't have to. I think ER docs do it by necessity, but primary care doctors can't afford to antagonize their patients - and thus, jeopardize their revenue stream. When someone comes in and has been on Xanax three times a day for the last 10 years, you throw up your hands and write the script plus refills.
This particular behavior needs to stop. We ER docs see the overflow from the primary care physicians, the psychiatrists, and the dentists who turn into unwilling pill mills. As long as there is no oversight, this will continue. Aside from the nebulous concept of "doing the right thing", there is no reason for any individual provider to wean patients off these meds. In fact, the opposite is true - patients would simply leave your practice and go to another provider who will give them their fix.
I believe the solution lies with the state medical licensing board. Here's my plan.
- The state board sends all physicians an alert "Your license may be in jeopardy! Statewide, physicians must come up with a plan to wean all of their patients off prescription opiate medications and benzodiazepines, unless there is a documented and valid reason to keep doing so. You have 1 year to comply."
- At the six month mark, remind physicians that they are coming up on the deadline. Give them a progress report.
- At the year, patients on chronic Xanax, Klonopin, Ativan, Valium, Percocet, Oxycodone, Vicodin etc have all had this discussion with their primary doctor "The government is cracking down on physician controlled substance licenses. Neither myself nor other physicians can prescribe controlled substances on a recurrent basis any more."
- Any physicians not playing ball get 3 notices, then lose their controlled substance license.
- The end goal is to have meds prescribed as intended, with short courses written for acutely painful or stressful episodes. Long-term opiate management would be tightly restricted to the setting of cancer, fractures, and a few other conditions. Long-term benzo use should be flat outlawed.
I'd love to hear your thoughts. Soon here I'm thinking of marching on Capitol Hill.
One of my favorite things is when patients rip up a prescription - it's just such an unnecessary, childish action. Usually it goes something like this:
Patient: "I need purpleset tens for my back pain. My doctor is out of town."
Me: "That's Percocet, and the fact that you abbreviate the dose 10/325 as 'tens' makes me concerned that you're far too familiar with this medication. We're going to give you some Tylenol today."
Patient: "I can't take Tylenol."
Me: "You know there is Tylenol in Percocet, right? That's the 325. It stands for 325 milligrams of Tylenol."
Patient: "Its a different kind of Tylenol. You don't understand."
Me (sighing): "I know. These medical degrees, they hand them out like flyers these days, don't they? Doctors just don't understand medications like they used to."
I routinely write prescriptions for Motrin and Tylenol for patients. I'm not trying to be snarky or insulting - I truly want them to take those medications on a scheduled basis for their pain. They may not be prescription-only, but countless studies have shown that they are effective and are an integral part of therapy. I also write Sudafed prescriptions for sinusitis and otitis, and Prilosec prescriptions for heartburn. Both of those medications are over the counter, but patients may not know when and how to use them appropriately.
For this patient, though, there is one thing he wants from his ER visit - opiates. His body has gotten completely hooked on that sweet candy, and when he runs out and start jonesing badly enough... he comes to me.
What drug seekers want is multifactorial. I've sat down and talked to these guys occasionally and asked them what their gain is. They hate coming to the ER for the small 12 pill score they might get from us if lucky. What they really want is to find someone who is going to fund the habit; hopefully a doddering old primary care doc who is loose with his script pads. From him they can score 120 oxycontins with another 120 morphine sulfate tabs - doses that DWARF what we give from the ER. We're merely the safety net when their score doesn't come through.
And so, my little Tylenol script tends to make them upset. I've seen more of these ripped up, thrown on the ground, and stomped on in a pique of rage than I care to. One guy even accidentally ripped up a prescription for Vicodin along with the Motrin prescription I gave him. This will come as a shock, dear readers... but I did not reprint the script for Vicodin.
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.
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.
"Hey, brotha. I need help. Look, I'm not gonna shit you, I'm an alcoholic. I'm homeless. I've got back pain. You can help me, you're a doctor. I need Ativan so I don't go into DT's and some Percocet for my pain. Please, brotha, I lay myself at your feet."
Before me lies an emaciated husk of a man, frost-bitten, his bleach-blonde hair pulled into dirty dreadlocks. The room reeks of alcohol, the tang of shitty beer lying uncomfortably in the air. His bloodshot eyes track me as I walk over to examine him.
This was my first introduction to our resident frequent flier. He's famous; every ER doc in the city has treated him for everything from alcohol withdrawal to blood infections. Among other things, he's an asshole, a florid alcoholic, and an abuser of the system (a news article estimated his ambulance rides, ER visits, and ICU stays costing the taxpayer more than $10 million).
Unsurprisingly, my exam is unremarkable. It's freezing out, and the ER is a refuge for a few hours from the biting cold and the unforgiving streets. I prepare myself for his discharge, and give him his papers.
"Your exam is normal today. I can't find a reason that your back hurts. I'm sending you home."
"Fuck you, man. I can already tell, I can't change your mind. I know your type. Yea, I'll fuckin' go. You know how cold it is outside? Yea, I'll fuckin' go. I'll go, you privileged sumbitch. You have no idea what it's like to be homeless."
He leaves without much fuss. A nurse claps me on the back for handling him well. She thinks my no-nonsense attitude approach will serve me well as an ER doc. All the same, a small voice in the back of my head wonders if I should have been more compassionate.
The rest of the shift goes uneventfully, and as I drive home, I notice it's cold out, cold enough to freeze the windshield on my car. I run inside my heated house and crack a beer. Life is good.
"You have no idea..."
Out of guilt, I throw on a sweater and my overcoat, and shuffle outside. It is bitingly cold; I start shivering instantly. The stars are frigid, beautiful, and unforgiving, the moon austere behind a single veil of cloud. He was only wearing a sweater and some thin pants when I discharged him. He must be freezing right now. I last all of 5 minutes; my teeth chatter so hard I fear I'll break the enamel. I rush inside, the warmth enveloping me like an old friend.
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.