Night Shift
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She stopped pouring, confused.  “How’s that?”
 
“It was slow,” I explained.  “After about two in the morning everything kind of dwindled down to a trickle. I only saw a handful of patients all night. We couldn’t move anybody into the rooms anyway because they were all full with patients being held from day shift for admission.”

“So you had an easy night,” she said cheerily.  “You should be thankful.”

“Not really,” I said, cradling my mug. “First, it’s painful just sitting there at three in the morning watching the clerk’s hair grow. And second, nights like that kill my RVU average.”

“What’s RVU?”

“How long have we been married and you don’t know what an RVU is?”

“How much longer do you want to be married?” she countered. As she reached over to refill my cup she paused, coffee pot suspended over my lap. “More coffee, Sweetie?” she said with a saccharine smile.

“Relative Value Unit,” I said, making a strategic retreat. “I get a base pay, but if I don’t see enough patients then I don’t get my share of the bonus money that’s based on my RVU average.  And my RVUs are based on how complex the cases are. If the problems are simple, the RVU is low. And my RVU average for the month tanks.”

“That doesn’t seem quite right,” she said sounding sympathetic again. “You can’t make patients come in can you?”
 
“Well, that’s supposed to be the other part of the incentive, my patient satisfaction scores.  The idea is that the doctors who are the nicest to the patients should get paid more because the patients will come back. But we get hammered on both ends on nights. The patients have to wait forever for the few beds we have, so they’re angry before I ever see them.”
 
“But do you really want the patients to come back?”

“In theory, no, but if I want to get paid, yes. I know it sounds strange, but I only make money when really bad things happen to people. Or when I really suck up to people.”

“Wouldn’t it be better if you were paid to be available, but hoped that no one got sick.”

“That makes too much sense.”
 
“So what’s the answer?”
 
“I guess we feed the bears.”
 
“What?”
 
“You’ve seen those signs at Yellowstone.  ‘Don’t feed the bears’. If you don’t give them what they want they won’t come back. We do just the opposite. We give them anything they want expressly so that they will come back.  You know, ‘The customer is always right,’ that sort of thing.”

“What’s the problem in that? ‘It’s never wrong to treat people right.’ Isn’t that what they say?”
 
“I don’t mind ‘treating people right’” I said defensively.  “I mean, I try to do all those things they tell you to do. I introduce myself. I tell them how many years they are going to wait for their tests to come back.  All that stuff. It’s just sometimes they want things that I won’t give.”
 
“Why not?”

“Sometimes people ask for stupid stuff,” I said. “You wouldn’t believe it. I had this guy who had indigestion. Real indigestion, you know, GERD. He didn’t have chest pain masquerading as  indigestion. He had a burning sensation in his throat every time he ate Mexican food, and no other time. He just had plain-old-indigestion.  But you know what? He wanted an X-ray. He thought that an X-ray would cure him. So sure, I could have done a whole chest pain work-up, including an X-ray. And maybe somebody else would have. He would have been happy. The hospital would have been happy. But the truth of the matter was that he just didn’t need it. All he needed was some Maalox and
reassurance. We got an EKG just on the chance that he is the one in a gazillion that has reproducible angina whenever he eats jalapeno peppers. But that only made him complain louder that he needed an X-ray.”
 
“So why didn’t you just give him what he wanted? What’s it going to hurt to give him one little X-ray?”
 
“You don’t get it,” I huffed. “He didn’t need it. Have you seen our medical insurance bill lately? The reason insurance costs so much is it has to pay for all those tests and medicines that doctors order just to satisfy patients or cover every conceivable base where they might get sued.”
 
“What difference does it make for you to try to take on the whole system? Just go with the flow. Make the system work for you instead of beating your head against the rocks.”
 
I paused, surprised. “I’ve never heard you so cynical about the system.”
 
“I’m not cynical, just realistic,” she said with a shrug. “The fact of the matter is that the guys that order all the tests and give patients what they want make more money and get sued less, right?”
 
I sank deeper into my chair, eyebrows furrowed.  “You are correct. But it doesn’t make it right”.
 
“Besides, who’s to say that doing all those tests and giving the patients what they want doesn’t do some good. Haven’t you said that sometimes you get surprised by patients with the strangest complaints that turn out to be something serious?” Our whole married life we have argued over every possible thing, taking turns climbing on the moral soap box.  This morning it was my turn.
 
“Don’t you see the harm that is done?” The pitch of my voice was starting to rise and I began to wave my hands. “If everyone does every conceivable test for the slightest little complaint, the next thing you know, doing the test is the standard of care. Then the poor schmuck who is just trying to practice good, cost-effective medicine gets sued when some crazy patient has a poor outcome. And he gets nailed by some prostituting ‘expert’ who says that doing some esoteric test was the standard of care.”
 
“And that ‘poor schmuck’ would be you, right?”
 
“Yeah,” I whined.
 
“Hey, that’s fine. Just remember, if you decide to take on the world, don’t bet the house, OK, Rocky?”
 
“Adrian,” I moaned dramatically. “I got my ass kicked.” She shook her head, then rolled her eyes.
 
Mark Plaster, MD, the founder/editor-in-chief of Emergency Physicians Monthly, practices emergency medicine in Baltimore. This email address is being protected from spambots. You need JavaScript enabled to view it.

Comments   

# ED PhysicianWilliam Hardman, MD 2007-09-10 01:43
I loved Feeding the Bears. We all know it is wrong, and expensive, and teaches patients to expect unnecessary and expensive tests and medications. When will we consider ourselves professionals and do the morally correct thing and just do what is medically indicated, instead of that which is better for our own financial bottom line?
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# RNDaphne 2007-09-19 20:49
I agree with Dr. Hardman, and would like to see physicians stand up for themselves against big insurance and the legal system. I see this problem every time I work and feel sorry for physicians like Dr. Plaster but surely your profession is large and powerful enough to face this problem head on.
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