Patient Satisfaction and the Emergency Department: An Elusive Goal

I've been practicing emergency medicine exclusively for almost 19 years now, with the exception of my overseas deployments in Iraq (2008-2009) and Afghanistan (2014-2015), where the practice was a combination of emergency/urgent care, occupational medicine and some primary care.  During this time, I estimate that I've seen somewhere around 70,000+ patients in this time, and have not gotten many patient complaints.  If fact, I could count the number of written patient complaints that I have received with the digits on my hands.

When I think about those complaints, and about the experiences I have had in treating 70-thousand-plus patients, I am surprised that I haven't received more.  Don't get me wrong...I am not an ogre or something, but everyone does have an "off" day now and again.  In fact, I'm a pretty out-going and friendly guy, and I enjoy my work.  I also generally like people, which I suppose is one reason that I decided to practice medicine for a living for the past couple of decades.

Hospitals are working hard to improve patient satisfaction.  The reasons are clearly tied to increased income for the hospital, although on very solid ground I can say that this was a really stupid idea. For this reason, we started seeing the guest / patient services-type of people being introduced twenty-something years back.  Then TVs started showing up in the ER.  Then paper and eventually tablet-based patient satisfaction surveys became the norm.  Patients are now being categorized as clients or customers.  There are issues with that, particularly in the emergency department, where the purpose and environment of care are vastly different from other out-patient and departments and inpatient units.

The Emergency Department exist to treat emergency medical cases.  That's why they call it the "emergency" department.  The emergency department does not exist because you want your knee MRI today, rather than have your doctor schedule it.  The emergency department does not exist to refill your chronic medications, and certainly not to function as your pain management clinic.  Americans, by and large, are uninformed, unrealistic consumers of health care services.  Patients seem to liken the ER to a medical convenience store,  Americans want what they want, preferably want to get it for free, and they want it right now, and they expect it to be completely error-free.  In short, they have unrealistic expectations of what they can get from the E.D. and many have no idea of what should even constitute a legitimate reason for coming to the E.D. is the first place. Just because you want it now, does not make it an emergency.

Girl comes into the E.D. because she missed a period and thinks that she could be pregnant.  She has absolutely no symptoms (nausea, vomiting, bleeding, abdominal pain, etc.).  I have difficulty with this because, "I want a pregnancy test," is not a valid reason to seek attention in the E.D.  In general, I'll advise the patient to either; 1) go to the health department for a free test, or 2) go to any pharmacy or store and buy a pregnancy test.

Similarly, I have had girls come to the E.D. because they decided to have unprotected sex the night before and "just want to get the morning-after pill."  Not to champion the cause of rank stupidity in American society, I'll advise the patient to go to a pharmacy and ask the pharmacist for "Plan B."

An obese patient comes into the emergency department with chronic knee pain.  It's worse when the patient walks. there has been no trauma / injury, and there are no significant exam findings.  The patient expects an Xray of the knee(s) and some magic pill to pop that will magically cure the fact that the human knee is simply wearing down due to years of supporting weight that the joints of their 5'3" frame were never designed to support.  The proper treatment in this case would be weight-loss and exercise, with likely OTC analgesics.  No matter how you phrase it, the patient's complaint will say something like, "he said my knees hurt because I'm too fat."  There's no way you're going to get a good satisfaction score here, or in any of a dozen examples that I could give you.  However, despite that fact, the medical care was appropriate and sound.

I have provided some very sick patients with very good care, only to have a relative make a complaint for some vagary, often not even related to care provided.  If the patient was a conscious, competent adult, I generally ignore these complaints altogether.  If a complaint comes from someone associated with a competent adult patient (a second-hand complaint, if you will), I'll generally just toss it in the nearest waste receptacle.  If the actual patient has an issue, I am happy to address it.  If the complainant isn't the patient, then it's simply a waste my time.

Many years ago, I learned that "you can make some of the people happy, some of the time, but you can never make all of the people happy all of the time."  True words then, and the since an increasing number of Americans have gone the way of the "people of Walmart," it is even truer today.

A few helpful tips I can offer on satisfaction, with a degree of confidence from managing to have so few complaints over the course of my career, are as follows:

1. Be nice from the outset.  Both to the patient and to the family.  During the time you do have with them, get to know something of them other than just the medical facts.  Find a commonality. Use their name.  I like being on a first name basis with my patients.
2. Let them know who you are, what you do, and if opportunity permits, how long you have done it.  Let them see what you do and have the opportunity to experience you as a professional.
3. Keep them informed of their progress, and especially of any unusually long delays in their care and disposition.
4. Involve them in the decision-making process and be sure to explain any procedures you are doing.  Talk with them while performing procedures.
5. Give them realistic expectations, without dashing hope.
6. Be empathetic to their situation and allow them to feel that from you.  It doesn't make you weak or unprofessional, just human.  It never hurts to hold someone's hand.
7. Honor their requests, when appropriate.  They may ask you to call their doctor.  Even if they're not on staff, it's just a phone call.
8. A touch of humor doesn't hurt...just remember your audience.
9. Do the best job that you can do, and finally...
10. Don't worry about the scores.

Plaintiff Vs. Dr. Jon's Urgent Care, Martinsville, VA

* Skip to the bottom for an Update

Almost a couple of years ago, I was contacted by an attorney with a request to review some medical records and for my opinion about the medical care she had received at Dr. Jon's Urgent Care in Martinsville VA.  The attorney that contacted me had found an article I had published in 2001 while I was completing my Masters in PA Studies that was appropriate to the cause of death in this case.

In seems that a young woman had received a trauma to her right lower leg when she was inadvertently hit by a crate of heavy photographic equipment.  On the day of the injury, she was seen at a clinic on the site of the injury and followed up the next day.  The young woman had a significant blow the the right calf, and was pain, even though she was still able to ambulate on the leg.  (Now, any clinician with any diagnostic and prognostic ability worth squat already should have an idea of what happened in this case, so just write it done now so there will be surprise at the end.)

She rode an hour from the site of the injury to Atlanta, took a relatively short flight to Charlotte, and then a 2+ hour car trip to Martinsville, VA.  During the next several days, she sent text messages to her friends and relatives around her leg, still being in significant pain, despite taking elevating her leg and taking Tramadol.  Eight days after the injury, she was seen again in follow-up at another work-site clinic where it was documented that her symptoms were not improving and referred her to Dr. Jon's Urgent Care clinic, where she was seen the same day.

The complaint was right foot and ankle pain with history of the injury as noted above.  She was seen by the attending PA, an exam was performed and it was noted that the patient had bruising and moderate pain in the calf with tenderness on palpation.  (If you still don't now what happened, you might consider going back to school).   An Xray was performed and closely scrutinized until  a possible small avulsion fracture of the talus was diagnosed, but apparently all the soft-tissue trauma and swelling to the injured calf readily apparent on the Xray was overlooked entirely.  So she was splinted, placed on crutches and suffered a fatal pulmonary embolism less than 72 hours later.

In my review of the patient's visit to Dr. Jon's Urgent Care, it was my opinion that the patient way at high risk for DVT and tha she should have been referred to the ER for further evaluation (i.e. an ultrasound of the affected limb).  I don't like being in the posiiton of being critical of a colleague's care, but if I said that consideration of of the possibility of a DVT was not reasonable in this case, then I would have been intellectually dishonest.  Not only was it possible, but it was very high on the list.  That it wasn't even considered at all, is incomprehensible to me.

A suit was brought on behalf of her estate by her mother, and I participated in the proceedings as an expert witness for the plaintiff.  The defense contention is that they never considered the possibility of this patient having a DVT, despite having the obvious risk factor of a serious trauma to a lower extremity, with continuing pain for 8 days that was "not improving," according to the work-site clinic that saw her earlier the same day.  An employee Jon's as well as the evaluating PA claimed that the patient has insisted that only her ankle was hurting and that she didn't want her calf examined (how likely is that since she was sent there because her leg was "not improving" and despite her multiple text messages about her leg pain though-out the week, despite being on Tramadol.  Did I neglected to mention that she was on NuvaRing.  Of course none of this was recorded in Dr. Jon's medical record of the patient's care and has all being asserted post-mortem.

I will admit that the defense attorney leading the case is smart and skillful.  Her attempts to excuse the oversight of the significance of the patient's injury and the failure of the clinician involved were based on trying to confuse the jury.  The inferences were that if the patient didn't have  a coagulapthy, cancer, CHF, age over 60 or any of a litany of established risks, then the clinician had no reason to suspect a DVT.   However, the  patient has a lower extremity trauma, the pain is persisting, she has a bruised, swollen and tender calf, and she's on NuvaRing, a contraceptive that has a higher-than-average association with DVT that traditional oral contraceptives. This, to me literally screams DVT. However, jurors are not well-versed in medicine, have no understanding of how the practice of medicine is conducted, and they are easily misled by a bright attorney being well-paid to misdirect them.

Only this evening, I was informed that the verdict was returned in favor of Dr. Jon's Urgent Care. I should not be surprised by this for the reasons I stated above, but I can also say with all honestly that I am not completely surprised.  These same people that complain about a long wait, or the fact that they were not given water in a timely manner or that they're lab work is taking too long...the one's that don't understand and are easily misled, are the same people that, 75% of the time, will give a provider a free-pass for missing  a condition that ultimately resulted in an untimely and clearly preventable death.  I suppose that should give providers some re-assurance that, if we make a similar mistake, we can also get the same free pass that Dr. Jon's Urgent Care got in this decision.

My sympathies to the family in this case.

Update:  I was informed by the Plaintiff's attorney that the court had vacated the defense verdict and that the case will be re-tired.  Hopefully, the new jury will make a more informed decision.  When sloppy or incompetent medicine contributes to the death of a healthy young life, someone needs to be held accountable.