Comments on: Reader Poll

By: Aesop

Aesop — Sat, 30 Mar 2013 13:05:46 +0000

Sorry, I’ve got other patients, and so do you, Doc. Most of them actually sick.
The first thing I do is enforce the 1 visitor policy at my facility. I let them rock/paper/scissors that decision, then go from there.
If, after 2 minutes, the one left can’t articulate a 15 words or less reason-for-visit, I send them outside until they can collectively come up with one. I encourage them to try a shout out on their cellphones to someone with a clue.
And yes, Press Ganey be damned, I have suggested to them out loud that if necessary they contact the Psychic Friends Hotline, because the waiting room is usually 20 deep, and we need the bed. I have explained to them that if they don’t know why they’re here, neither do we. In the meantime, I go back to other patients.

And if a 12 lead, urine dip, CBC and Chem 7 along with vital signs come back normal, they’ll be taking gramps out the door the same way they came in, about an hour later.

By: Aaron Billin

Aaron Billin — Thu, 28 Feb 2013 17:17:59 +0000

Amen

By: Aaron Billin

Aaron Billin — Thu, 28 Feb 2013 17:10:46 +0000

We all have had these encounters.

When the patient and/or family are vague, I ask, “what would you like me to do for you?”. If they persist in being vague, I realize that pressing them for more information will only aggravate them. At this point I document the lack of history, do a detailed physical examination, and order a basic work up (usually CBC, CMP, UA, TSH; but tailored to the situation). I avoid expensive work ups. Remember the radiologist has to have a complaint that supports the CXR or CT you ordered. “Mama doesn’t look right” doesn’t cut it. Calling it “weakness” when the patient and/or family never verbalized or demonstrated weakness is dishonest (yes, even fraud). Pressing most vague patients/families for more information is like extracting a worthless ROS from a drunk just so you can bill at a certain level. Document that the ROS is unobtainable and move on.

If I find something on the physical examination or basic work up that justifies admission, then I admit the patient. If I find nothing that justifies admission, then I explain to the patient and/or family that the criteria for admission to the hospital have not been met and I then discharge them to home to follow up with their primary care physician.

Vagueness often indicates an unspoken motive that the patient and/or family don’t even recognize. With the elderly it is usually caregiver fatigue and they want the patient admitted. I am concerned about how many respond to just admit the patient and let the hospitalist/PCP figure it out. They came to see me for me to figure it out. In my hospital I have to meet Interqual criteria for admission. Admitting the patient when they have not met criteria for admission takes more of my time, reduces patient satisfaction scores when they are discharged without the “problem” being solved, and sets the patient and/or family up for this to happen over and over again. Do the right thing for the right reasons (while protecting yourself and your hospital at the same time).

By: John

John — Thu, 28 Feb 2013 12:53:37 +0000

When the family says “he just doesn’t look right” (JDLR), it means they’ve made the best evaluation they can without any medical training. “JDLR” is a valid observation, but without the skills to expand on it they’re frustrated by their inability to vocalize what they think is wrong.

It’s time to do labs, an ECG and an eval for the “dwindles”. Does he have a primary? Does medical records have a Hx? You’re not done yet!

By: Charles J. Neilson MD

Charles J. Neilson MD — Thu, 28 Feb 2013 06:55:08 +0000

Telling the family that the HISTORY is the most important aspect in getting the diagnosis seems to give one a few more questions before these idiot families go bonkers again. They will hold a grudge because you asked “too many questions” anyway. Their answers are typically like this example…..eg “it’s been going on for a while”……when asked what the diagnosis was in the recent evaluation elsewhere…..”don’t know”. You know you have really people really interested in the welfare of the patient when they make themselves the center of attention and then want to leave with the patient. I believe asking everyone to leave the room but the patient or one parent if a child is a good recommendation.

By: Alan lewis

Alan lewis — Thu, 28 Feb 2013 03:22:36 +0000

The first law of the house of god…

“The patient is the one with the disease”

It’s not you, it’s them.

By: jon Hager

jon Hager — Thu, 28 Feb 2013 00:01:54 +0000

We all get these difficult families from time to time. ist thing is to have a policy of not allowing more than 2 family members at a time into the exam room. Try to joke a little with the patient and/or family members…a little humor goes a long way to get them to relax. Ask the patient if he is a veteran. Most enjoy the recognition and those who are will appreciate being recognized as such. The rest is to use your experience to ferret out as much info as possible, then a thorough PE and approriate studies. Can’t please everyone, though, and personally, I don’t give a rat’s ass about PG scores

By: Doc Letz Roc

Doc Letz Roc — Wed, 27 Feb 2013 20:29:34 +0000

I am no longer an EP. I now am a FP. I did that gig for 13 years and finally said ,”ENOUGH” This family you described of which I have seen my share were complete idiots and was one of the big reasons I left EM. We live in a world now were idiots are no longer considered idiots they are considered “socially disadvanteged” and whatever “rabbit hole” they are jumping down, all responsible parties are supposed to jump down the rabbit hole with them. Because if you don’t your not compassionate, or your not communicating or your not whatever. But just remember when you go down the hole with them your just another PC asskissing whore that basically gives the paying customer whatever they want. By definition that’s a whore. When you stop being rational and become irrational to make some idiot happy with your care what else can you call yourself. In family medicine I deal with some of that but when it gets to the level that crosses the magic line from just stupid to complete idiot , I send them packing. Why you ask? Because I can, it is my show and my rules because I own the bussiness. I practice medicine the best I know how and try to stay in the real world and make decisions with real facts as clearly as I can get at them. My practice is full. I feel bad for you guys and gals because you are in a tough positions in EM. It is a thankless job. I do miss occasionally participating in a miracle but the sacrafice is worth it. God’s Speed Friends. Your Friend Dr G.

By: ADIII

ADIII — Wed, 27 Feb 2013 18:22:36 +0000

I think you asked too many questions. When it became clear that Grampa “doesn’t look right” and you sense hostility, it behooves you to go to plan B. You say, “Let’s do Grampa’s physical exam,” and do that. That probably will show a frail elderly person with no obvious cause for his visit. You say, “We are going to carefully test Grampa to see what’s wrong.” Then you order your weakness workup. Mine is a CBC, chem profile, urinalysis, EKG and chest x-ray. It can be added to, depending on what your exam suggested, perhaps with cardiac enzymes, or D-dimer, or TSH, or head CT–whatever. Order it all as a package, not piecemeal. You say, “This will take about two hours (or however long it might take) to accomplish, because testing takes time.” Then you can leave the room, cool off, check to see if he has old records (can be extraordinarily helpful at times), and determine if he has a primary care physician to whom he can be admitted. The family is left with the notion that something is happening, so they may (or may not) be mollified. Then you can see several more patients, and come back to this one when all the tests are done. You then tell the family what the tests showed. I find it helpful to print the results and hand them to the most annoying family member. Then they can’t tell the hospital CEO that “He didn’t do nothing.” After all, a workup was done and the results were presented to the patient and his family. Then I call the PCP or hospitalist to admit the patient, because your workup will probably have revealed a reason to admit Grampa. The key is to not get embroiled in the family’s distress, but rather to have a plan to evaluate the patient and get him admitted.

By: Liana Bittner

Liana Bittner — Wed, 27 Feb 2013 17:49:19 +0000

I m an ER physician and have had many such encounters. Recently a VA nurse practitioner brought her mother in with similar symptoms. I work these cases of the elderly as I would the babies. Babies can’t tell you what’s wrong and parents just sat there’s something wrong. They’re not acting right. I go through my ROS and do the full cardiac work up. If there’s a major abnormality in the labs/X-rays I admit and let the PCP sort it out. The PCPs have better repore with the patient/family than the ER doc. You’re right the family just wants their loved one admitted. Whether there’s truly something wrong or just guilt for not being there for their loved one in the past. My primary concern as an ER physician is first to save lives. Then I need to make the family happy and prevent writeups that I have to answer to, which wastes my time. I see my job as customer service. These people want to be made happy. If you ask too many questions they get angry. They get angry if you make it seem like they’re not taking care of their loved one. So I only ask what they perceive the problem to be, the ROS, and do labs. I then put it in the PCPs lap. That way I spend less time in the room arguing with family and everyone is happy. If the family wants the pt. admitted and they perceive you don’t they’ll get angry with you and not the PCP.