|Image Credit: Flickr|
AAEM/RSA President '15-'16
Originally Published: Common Sense March/April 2016
Patient satisfaction. It feels like sometimes the concept is overemphasized, yet another addition to the countless expectations and constraints placed on doctors. I have felt this way at times, but recently my thinking has shifted. Instead of trying to meet arbitrary Press Ganey requirements, I have focused on trying to understand patients' wants and needs in order to better connect with them.
I recently had a shift with what seemed an unusually high number of patients with difficult personalities and “supratentorial pathology.”At times it was exceptionally frustrating, and although I started the shift feeling positive, by midway through the morning I could feel my spirits sinking. People had psychosomatic complaints. Some were drug-seeking and negotiating for narcotics. Some were demanding inappropriate care or tests. Some acted entitled and were rude to staff. I took this as a challenge, and tried to reframe my mind to see it as a learning experience in how to deal with difficult patients.
First, I decided to shift my perspective from my own objectives and workflow concerns to the point of view of patients. What do these people really want? Why are they in the emergency department? One of our faculty once wisely stated that people come to the emergency department because they are in pain or because they are afraid. Although it is impossible to like everyone, I tried to see parts of their experience through a different lens, as if they were a friend or family member or as if I were the patient.
For instance, one patient had a vascular malformation of the brain with recurrent episodes of bleeding. She presented with mild and somewhat vague neurologic symptoms that she feared were due to more bleeding, and asked for an MRI. In addition, her husband was somewhat aggressive in asking for the MRI. Although their demeanor initially bothered me, I realized they were afraid. I put myself in the shoes of the patient and her spouse and tried to imagine how I would feel if I had a ticking time bomb inside my head. How do you know what to seek care for? When is it“the big one”? I realized that if I were in her shoes, I would not want to be in the ED and would want to return to my normal life as soon as possible. Rather than explaining that the test she was requesting was unnecessary and telling her what we were going to do, I instead asked her why she wanted the MRI and what she was hoping we could do to help her. I listened, and told her that I heard what she was saying and understood her frustrations.
When we got to the bottom line, they were in the ED for reassurance and because of poor discharge planning and unclear follow-up. They weren't sure what the signs of a recurrent bleed were, and she was afraid of a serious bleed if she stayed home. They said they would have waited, but didn't have an appointment with their specialist for another week. We did a CT, coordinated care with her specialists, and made sure she had a clear follow-up plan and a better understanding of return precautions. They left happy with their care and feeling better than when they came in to the ED.
Another patient was a morbidly obese man in his 20s with vague chest pain. After appropriate testing, including a normal EKG, we reassured him that his pain was likely musculoskeletal and were planning to send him home. Sometimes we tend to brush these patients off as anxious or as inappropriately using the healthcare system. However, I decided to spend some extra time talking with the patient. I told him that although we weren't concerned about anything life-threatening today, this was an opportunity to talk about his health and preventing heart disease in the future. We talked about his weight and his lifestyle – he opened up and told me he wanted to lose weight but didn't know where to start. He mentioned that he had a problem with sweets and had been to a fast-food chain earlier, where he ordered a supersized coffee drink with extra shots of chocolate and whipped cream. In the end, we made plans for him to make a few simple changes and to follow up with his primary care doctor to make additional plans to help get him on track.
People mourn the“lost”doctor-patient relationship in an era of incredible litigiousness and increasing pressures on our time and resources. We consider ourselves master diagnosticians, but we also have a chance to have an impact on the difficult or non-emergent patients we see. These encounters are opportunities for emergency physicians to help patients in ways other physicians may have overlooked. On the shift I described, I didn't do anything glamorous, didn't do any major procedures, didn't make any difficult diagnoses, and didn't make any great saves. What I did was provide reassurance, comfort, and patient education. These conversations took only a few minutes more of my time, but I believe more good was accomplished in them than in any amount of expensive lab tests and imaging I could have tossed at these problems. Sometimes the answer really is to spend more time talking with the patient. I left my shift feeling re-energized, feeling that I had taken a further step towards becoming a more compassionate and accepting physician.