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.
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.
When you get ready to examine a patient, there are a few clues you can use beforehand to determine how sick they are. There are some quick ones, such as how many visits they've had in the past 30 days for the same back pain, or whether or not they have any vital sign abnormalities. Sometimes you're in luck and labs or xrays have already been performed.
But all of these methods pale in comparison to Dr. Zac's Rule of Twofers. Now, I don't mean to talk myself up, but this formula is genius. Allow me to demonstrate:
Where the total sickness of your patient is equal to a coefficient (δ) times the total possible sickness of any given patient divided by the number of patients in the room. Please note, there is a separate but directly related theorem when multiple people from one family check into different rooms in the ER.
You may ask yourself, "What exactly is δ, Dr. Zac?" Quite simple. It's the Coefficient of Chief Complaint, goes from 1-10, and it is used to scale the importance of certain chief complaints. Usually it equals 1, but if the chief complaint is, say, "horrific car wreck on the interstate," it allows us to overpower the denominator.
A few examples:
- Mom checks in her four children at the same time, all who have "Fever x 1 Day" listed as a chief complaint. Fever has a δ coefficient of 1. Thus, the maximal sickness per patient is divided by four, leaving us with an essentially social visit. Make your pleasantries, crack a joke or two, look in the kids' ears, no antibiotics necessary.
- Dad, drunk, lights the house on fire. He and his 8 illegitimate children are brought in as well as his mistress. "House Was On Fire," naturally, carries a δ of 10. Thus, 10 divided by 10 patients gives us 1, leaving us with a maximal potential sick value equivalent to that of any other patient in the ER.
- A friend sitting in the room with your patient mentions offhandedly that she coughed once earlier today. Unfortunately, all the sick in the room has already been used up by your patient, leaving the friend with a δ = 0. This is a special case, also known as the "convenience coefficient" and occurs when someone is so far from being sick they couldn't even be bothered to check in at triage.
There you have it, folks. Dr. Zac's Rule Of Twofers. It's bulletproof.
Lady, it's 4:17AM. Why are you bringing your child in for a "fever" of 99.2 degrees without any symptoms whatsoever? "Just to get him checked out" is not a good enough explanation.
Here are some possible reasons I came up with:
- Me and my boyfriend were up partying all night with blow and ecstasy and we decided to keep the party going all up in this hospital.
- I work at 5:30AM and this is the only time I could find to bring my kid in.
- The kids were up partying all night with ketamine and poppers, so I figured I'd get them checked out since they were still awake.
- We set our clocks ahead by three hours at my house so we're never late for anything.
- Something is horribly wrong with my child and I noticed it when he woke up from sleep at 4AM.
Since you've made it clear that #5 is not the answer, I guess I'll go with #1. Also, ma'am, contrary to what you may think, being seen in the ER is not free. Giving our registration people a fake phone number isn't going to get you out of paying the bill.