From the Editor’s Desk: A Test, a Shot, and a Prescription

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EACH EMERGENCY PHYSICIAN HAS TO DEVELOP THEIR OWN STYLE AND SET OF COMMUNICATION SKILLS TO DEAL WITH THE DILEMMA BETWEEN PRACTICING EVIDENCE-BASED MEDICINE AND “GIVING THE CUSTOMER WHAT THEY WANT.”

A Test, a Shot, and a Prescription

Andy Mayer, MD FAAEM — Editor, Common Sense

Each emergency physician needs to develop a strategy to deal with the numerous patient and personalty types which we can encounter in the average shift. There are of course the chronic pain patients, the worried mother, the anxious overly concerned son, the histrionic patient, the medically savvy (at least in their mind) patient, and this list goes on and on. Successfully dealing with each of these types of patients requires patience and interpersonal skills, which can be difficult to successfully master. Each of us has a weak point and a type of difficult patient, which is especially challenging for us to handle. All of us come to the practice of emergency medicine with a unique skill set and a set of biases due to past experiences. Learning a process which you can use to deal with our patients especially with the type of patient which you feel is “worst of the worst” is crucial for each of us. A failure or limited ability in mastering these skills needed to handle these patients can lead to significant frustration for the practicing emergency physician resulting in burnout.

The problems related to dealing with these patients can come to the forefront when an individual emergency physician’s patient satisfaction scores are reported. Every emergency physician now has to deal with whatever patient satisfaction tool, which your hospital uses. There are some good reasons to try and measure patient satisfaction and useful information can be obtained from them if the methodology allows for statistically significant results. Many of these survey tools do not offer such utility and simply meet the hospitals needed data requirements even if the data is worse than useless. Bad data drives bad results and conclusions, which can injure the parties involved. This fact is why these patient satisfaction tools often lead to significant deterioration in the satisfaction of the emergency physicians with their careers. This can lead to worsening of their wellness and their ability to provide empathetic and effective care to their patients. Physicians can develop unhealthy and wasteful practices as they develop their own unique method of dealing with these patients. I do not judge the tired emergency physician who towards the end of a long late shift, ends up bargaining with the manipulative patient who senses weakness in their quest for the narcotic du jour. Each of us has high and low points in our individual ability to remain strong and true to our principles. These incidents can be reflected directly in your hospital’s satisfaction tool.

Many of these satisfaction surveying devices offer the patient the opportunity to write in comments. Reading all of these is one aspect of my role as a medical director. Certainly, there are many fine comments commending the wonderful and compassionate care, which the patients received, and everyone enjoys reading those. However, this same forum can lead to offensive and soul-sucking experiences as the comments are turned into “incidents” by your quality department. These probably well intentioned quality and safety individuals want answers and solutions to every possible reported issue. They were not at the bedside at 2:00am but awoke fresh for their weekday shift to review what you did on the nights, weekends, and holidays while they were home with their families. Dealing with the often-ridiculous sounding complaints can be wellness killers for anyone involved. One of my least favorite aspects of being a medical director is having to share some of these patient satisfaction survey responses with my partners. Certainly, all emergency physicians can have a bad day or simply have a patient with whom they cannot connect with generating a complaint. We all on occasion receive valid negative comments associated with poor outcomes, delayed diagnosis, interpersonal interactions, etc. Using this feedback to learn and grow as a doctor can be a useful tool through which we can learn to become better physicians. However, many of us find that the criticism which we receive can really be unjustified particularly when it relates to not given pain medication, not treating a virus with an antibiotic, or otherwise trying to properly and cost-efficiently care for our patients.

Taking the time required to reassure an anxious mother of a child with a bump on the head is a great example of this paradox. Using properly learned assessment techniques and our

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clinical experience we often and properly decide that the three-year-old should not have a head CT. Trying to relate this information and convincing someone else that your judgement and clinical decision making skills are accurate can be difficult. Taking the time needed to do this can be frustrating to all and lead to a poor patient satisfaction score and a withering of the involved physician’s spirit when they read the comment from this same mother that the “doctor didn’t do anything for us.” You know that you are right in that you properly did not expose the child to needless dangerous radiation, improved throughput in your department, saved resources and provided excellent and proper care. What is one to do? Learning to negotiate between doing what you know is right and “the customer is always right” mentality is one key to your professional contentment.

Thirty years ago, when I finished my emergency medicine residency I entered a group which had an assortment of physicians. Most had been trained in other specialties and had “grandfathered” into emergency medicine and were board certified and were solid doctors. A couple of the older members who were founding members of the group had never bothered to go through the board certification process. These same more senior physicians clearly shied away from the sicker patients and wanted to focus on the easier “fast track” class of arrivals. This was okay with me as of course, I wanted to demonstrate my new emergency medicine training and enjoyed being able to see all of the sickest of the arrivals. As every young emergency physician should do, I watched the more senior members of my group and tried to learn from them. Working with physicians with decades of experience is a great way to see both good and bad techniques in dealing with patients.

The senior physicians in my group seemed to be able to “satisfy” their patients despite the fact that many of their practice habits seemed to me to be wasteful and not science based. However, they seemed to understand patient satisfaction and how to make a satisfied customer much more than I did when I was handed my shiny new certificate denoting residency completion. They had developed their toolbox to make patients happy. Of course, I tried to use my training to practice quality evidence-based emergency medicine. I tried to explain that Amoxicillin does not cure viruses and that the Ottawa ankle rule allowed me to confidently say that the patient did not need an ankle X-ray. The old veterans would simply shake their head and smile and try to explain how to make patients happy. One of them quietly told me that if I followed a simple rule that life would be easier. I of course asked what was the rule as the insight and wisdom of someone who had been working for years in a busy suburban emergency department I assumed would be useful. I imagined that his advice would be on target and might be a game changer for me. He explained that if you simply did three things for every patient that they would be satisfied, believe that you cared about them and also believe that you wanted them to get better. These three things to do for every patient were “a test, a shot, and a prescription.” He asserted that if you provided these three things the patient seldom complained. Of course, I explained my shock that many patients did not need any of these and that his rule simply increased the cost of health care for limited if no benefit. He smiled and shook his head again telling me that I “would learn” about medicine. Certainly, physicians who practice this way significantly contributed to the explosive cost of health care in America. Sadly, these practices continue. Do any of you not hear from patients that the nurse practitioner who saw them at the local Urgent Care “always” gave them a flu test, a steroid shot, and a prescription for an antibiotic when they have a cold?

Each emergency physician has to develop their own style and set of communication skills to deal with the dilemma between practicing evidence-based medicine and “giving the customer what they want.” This paradox is often at the root of many of our patient satisfaction issues and also our own personal wellness issues. Seeing excellent and caring physicians distraught about patient complaints when they believe they did the right thing for the patient by not giving them what they ask for is painful. We each need to develop the interpersonal skills to be able to navigate these treacherous waters. There is no single right answer or strategy which will work for everyone and this is why this issue is so difficult to master. Again, it is hard to judge too harshly a physician who “gave in” to a particular patient’s demand for a specific test, medication, or admission. The key is mastering a way to have the patient believe that you validated their need to come to the emergency department in the first place, that you took their complaint seriously, that you performed the necessary testing to support your expert opinion, and that you provided the best treatment for their problem. In a significant number of patient presentations all of these criteria can be accomplished by simply talking to a patient and not spending money on testing and medications. This of course is a real skill and also having the insight of knowing when to pick your battles is crucial.

Consider watching other members of your group and also other physicians who come through your department as consultants. You can learn a great deal by watching the skills and techniques, which they use to satisfy their patients. You already know the physicians who the nurses want to work with and the patients want to see. You will quickly be able to see that some are popular with patients because they simply avoid all confrontation and do not fight doing tests, giving narcotics, or admitting problem patients. You will see others who practice excellent medicine but always seem to be generating complaints while actually being the better doctor. The key is to find the right approach between these two extremes which will work for you. Try and watch small interactions and see what methods you think might work for you and try them. The people who walk or roll into your emergency department are not just customers. They are our patients and we are their doctor. We cannot afford to lose this sacred relationship. Giving the patient what they want is not a good idea as it often is not the correct action. American health care costs are ridiculously high and ordering the tenth CT scan of the year for a headache patient or similar activity will only lead to a deeper hole of health care spending. Please work on your toolbox so you do not feel the need to waste money by giving every patient the abovementioned test, shot, and prescription. 