Monday, June 14, 2010

Entitled Entitlement Patients

I made an interesting, and not so surprising observation last week.

Within the span of 30 minutes, I had:

-5 people arrive from a major MVA (car accident):

-one with a broken neck and multiple broken ribs (flail chest);
-a pregnant woman with a horrible hand injury that had to go to the OR;
-3 others with significant cuts & bruises and believable neck & back pain (not
the ["my neck hurts when I twist it all around & my lawyer (the one with
the funny hat, pink suit & the boa constrictor told me I needed X-rays
an MRI, a neck brace and a copy of the ER record"] kind post MVA neck pain)
-a child who had drowned (successfully resuscitated)
-and an Acute MI

Over the span of that same hour, I collected 8 patients on the "minor" side of the ER. In looking at the complaints of these patients, I was pretty certain that one of the patients (a 4 year) had the viral meningitis of which we've been seeing a butt-load of cases.

It took me almost 2 hours to get to the patients in the minor hallway. Two had left after throwing their sheets & blankets on the floor. I apologized to each patient and explained why it had taken me so long to get to their rooms.

Four were very polite and stated that they completely understood. After the encounter, they thanked me several times (including the parents of the child who did have meningitis). Two were very rude (one stating "well, it's about d**n time). They remained rude despite my explanations and apologies.

When I looked up all 8 patients later, I discovered that the 4 polite patients had private insurance. The 4 who either left, or were extremely rude were all "self pay" (translation "no pay").

Also of the 4 with New Orleans New England Insurance (NONE), their complaints were all non-emergent & nonsense complaints. 3 of the 4 insured patients needed to be in the ER.

And people wonder why ER doctors become jaded!



  1. Patient satisfaction is very important. All of us know about AIDET but perhaps we should be using GETOUTED instead.

    Greet - Say Howdy and eye every person in the room to see if they have any weapons. Don’t let anyone get around behind you or restrict your flight of escape!
    Expectations - The difference between expectation and reality is a reason for low scores. Be sure to set expectations exceptionally low so that you can thrill the patient and significant other (or not) when they have a better experience than expected. Example: State, “I'll be the doctor taking care of you today. I hope to become board certified if I ever pass the examination. I’ve just worked in emergency rooms for the last few months, but I’ve been doing a lot of reading. I feel confident that I won’t make any serious errors today!"
    Time and Duration - Describe the testing, IVs, meds, etc. and how painful it all will be. Give the patient a chance to change their story to avoid the tests at every opportunity. Overestimate enormously the length of time that this all will take so that once again, the patient and family will be thrilled when they don't spend all day and night in a bed listening to the drunk next bed pray to his spiritual advisor Commode!
    Observations - Explain the results of all the tests, and what happened based on the results of these very expensive tests. This is a terrific time to "manage up" your team especially the nurse ("I see your nurse today is Missy. You are very lucky. She's the best that we could hire for the money. She’s just gotten out of rehab and is doing very well on her new medication! Please let me know if you notice her doing anything just a little strange!")
    Understanding - Make sure the patient and family and generally the person through the curtain next door understand the diagnosis and treatment plan. Be remarkably specific in a loud and easily understood voice, about all of the bodily functions that you want the patient to control through various meditational techniques and positions.
    Thank the patient - during your disposition conversation for choosing our ED. You appreciate the loyalty that they displayed when passing right by at least three “For Profit” hospitals on the way to your “Free Hospital”.
    Encourage questions - and give all drunks the personal cell phone number of your local rehab center manager. This is the manager that refers many of his clients to the ER to have their blood pressure taken and a check up!
    Drugs and alcohol - Make sure to do smoking, alcohol and drug cessation counseling. You may do this by stating: “I know that you cannot afford to buy the prescription that I have given you, please consider reviewing your drug investment portfolio!”
    In conclusion: Our nurses and nurse managers should be using GETOUTED as well. We should also be reminding each other to GETOUTED. The administration has requested that compliance with GETOUTED be added to the annual physician and mid-level provider evaluation form. The top performer in using this technique will be eligible to receive a free high colonic at Quidos’ Hinny Center.

  2. I don't know who you are stranger(Anon738) but I like the cut of your jib..

    2 free ED visits to those who can name the movie from which the above quote was taken..OF

  3. it's from the simpson's 1998...

    [before setting sail on a submarine]
    Captain Tenille: Any questions?
    Homer: Is a poop deck what I think it is?
    Captain Tenille: [laughing] I like the cut of your jib.
    Homer: What's a jib?
    Captain Tenille: Promote that man at once.

    visit number one... i need three months of oxycontin for my fibro...

    visit number two... xanax is the only thing that works for my seizures and i'm going to africa for three years and my neurologist just died.

  4. 911 you are a phuking idiot! Just when do you think I watched the Simpsons? sheep dip...Good Grief!

  5. Oldfart,

    your presenile dementia may have got you thinking that the quote is from Caddyshack, but it's not... you can read the whole script in ten minutes on the net... excerpt follows...

    Caddymaster (CM): Carl Lipbaum died last week in summer school from a severe anxiety attack.

    Unknown extra (UE): I heard he swallowed his vomit during a test.

    CM: However it happened, he was a good caddy
    and a good kid.

    UE: He was a brownnose, Lou... You hated him!

    CM: Shut up! That means the caddy scholarship is available again. Anyone who's interested
    should go see Judge Smails.

    UE: And kiss his ass!

    CM: That would help. Let's move out. We've got golfers waiting. You! Pick up that blood.

  6. and '85,

    love the new orleans- new england insurance observation. i think it's true, in part, because when you are getting a bunch of shit fo free you probably feel the need to act like you deserve it... i.e. like a freaking DIVA.

  7. 9-11, do you know all that Caddyshack dialog by heart or do you have to look it up on IMDB like I do??

  8. What I fail to grasp is WHY these non-emergent, non-insured, vacuum-brained money suckers would want to park their backsides in ER for hours on end for a headache? Do they have nothing better to do?

  9. the 'why' is a good question...

    1. often, no, they do not have anything better to do.
    2. often, they are seeking documentation to support a claim, case, or unexcused absence from work. since they pay nothing, why not use the ER this way?
    3. often, they get what they want... a prescription for something valuable on the street and they can then make money.
    4. and, VERY often, they come to the ER with a real medical problem that has been festering for days or weeks because while they would have had to pay to see a primary care physician, ER visits are 'free' with their state or federal 'insurance'... free for them, expensive for us.
    5. they saw something on tv and wanted to make sure they didn't have it... what was that thing again?
    6. they are lonely.
    7. they are treated well and they are safe.
    8. did i mention they don't have to pay for it themselves?
    9. there is television in the waiting room.

    there are lots more reasons but it's starting to get me sick in my stomach...

  10. I think it is important to absolutely fail in meeting the expectations of these patients who are overtly abusing the emergency room.
    Fail to give them a narcotic Rx (yes I know your PMD is away but I can't do it, I just can't so it), fail to give them a diagnosis even if you know the diagnosis (it doesn't seem to be an emergency condition so it must be something that I can't diagnose since I am an emergency doctor), fail to give them documentation of pretend injuries (a discharge diagnosis of 'well patient' is my preference), fail to give them a sandwich, and fail to give them a place to hang out (yes, see these frequent fliers ASAP when they show up, do absolutely nothing that is non-emergent for them and discharge them).
    Eventually these patients give up on you (ie. they are successfully re-programmed as to the purpose of the emergency dept.).
    For anyone who is thinking of writing a 'you-don't-even-care!' reply to this, stop....I do care, I care about your Dad who is in the bed next to these time wasting people and having a heart attack. I want to treat his heart attack in time and these drug-attention seeking folks are jeopardizing it!

  11. dr j,

    i feel ya bro! one of the reasons i'm leaving the game is that the last arrow left in my quiver is this response... it's all we have left, passive-agggressive dodging and slow-downs. i do it too. i hate it. and then some ninny with a clipboard comes and dings us all for not adequately treating pain or for a 'customer' complaint they just received from a 'customer' who didn't pay a dime. it is one of the end results of politically correct thought/rules... the prohibition of straight talk, and, in particular, the prohibition of 'no'.

  12. Why We Burn Out!
    The major gist of the conversation was; the EM physicians must tailor their requests for days off, shifts to work and personal issues so that the COMPUTER PROGRAM can effectively develop the EM Shift Schedule. I am sure that all EM Physicians have been slammed to the floor and disrespected with this dictum in the past!
    What is wrong with this picture? The EM Physician MUST accommodate the computer instead of the computer accommodating the physician. That is JUST WRONG on so many levels that it is not possible to enumerate them without RALPHING!
    Having made EM Shift schedules for many years I know of what I speak. To make an effective schedule that maximizes the physicians’ satisfaction the scheduler MUST know the Physicians wants, needs and preferences. When were you, as a physician, last asked about your satisfaction? We must be satisfied and valued in our role to provide the best care.
    The person that makes the schedule should:
    • Ask each physician what their preferences are. All of us are different.
    • The scheduler must accommodate the physicians and not the computer
    • If the scheduler does not wish to take the time to make a great schedule they should give the responsibility to someone who does
    • Get the computer ‘THE HELL OUT’ of the schedule. It will NEVER fill the needs of the physician. It just does not ‘GIVE A DAMN’.
    • If the schedule will not accommodate all of the requests then speak to the individuals involved and have the physician rank the importance of their requests. There are times when every person cannot be given their first choice. That is when a chit is made and the next time there is an issue that person will be given first choice.
    Hell, when I first started as a scheduler I did it all on poster board with grease pencils. Without exception all physicians were given what they wanted! Don’t tell me it can’t be done. Maybe you just don’t have the capacity to do it!
    EM Physicians are the most disrespected physicians in most hospitals. The saying that it takes 3 weeks to fire a nurse and 3 minutes to fire a EM physician is demonstrated daily. I have never yet seen a physician group stand up to their oppressors. We just step over the body and get back on our hamster wheel.

  13. i've found that the vast majority of patients with medicaid or the uninsured WITHOUT assets come in with absolute nonsense, people with medicare or "good" commercial insurance come in with a mix of bs and non-bs, and the uninsured WITH assets tend to wait until they're on death's door to come in.

  14. Every system is perfectly designed to function exactly the way that it does!