Agraphia Medical Tragicomedy

11Aug/13Off

(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.