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Emergency Medicine News:
doi: 10.1097/01.EEM.0000435018.28576.89
Viewpoint

Viewpoint: The Oath is ‘First, Do No Harm’ (Not First, Do Not Disappoint)

Horana, Lasanta S. MD

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Dr. Horana is the assistant medical director of emergency services at Robert Wood Johnson University Hospital in Hamilton, NJ.

Patient satisfaction has been such a focal point of conversation that everyone from administrators to physicians to consultation firms have made careers and livings from it. A wide disparity of opinions about the place satisfaction has in medicine exists even within our own field. Proponents believe it drives change; opponents believe it forces physicians to retire early. The reality is that policymakers believe in it, and it is here to stay.

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Once upon a time, no one cared about the patient's opinion, and he had little ability to negotiate his physician encounter. What the physician said was near-absolute, and the patient had no recourse. And so the patient bill of rights was born.

That was taken a step further when we didn't just empower the patient but asked, is he satisfied? This innocent question made the pendulum swing completely to the opposite direction. Now, as an emergency physician, I stand with no recourse and await the day when the physician's bill of rights comes out. When will someone empower physicians?

The pendulum has swung so far that it is plausible for a patient to come into the ED, and speak to the physicians and staff as he chooses; he can even be derogatory or threatening. A patient who is not satisfied now has the ability through a wide array of media to access a direct channel to the CEO of the hospital to complain about the atrocious treatment he received. Many websites also allow patients to rate their doctors publicly and describe in detail what monsters they are. These complaints do not fall on deaf ears. Administrators and medical leadership have their job security tied to the satisfaction of the patient because dissatisfied patients are seen as losing paying customers. Generate a few dissatisfied customers, and you will be terminated or asked to find employment elsewhere. If you don't think this happens, take a survey of how many physicians have changed jobs because of patient satisfaction. You might be surprised.

So what is the physician's recourse? He has little to none. We can't complain about the patient. No one cares except our spouses and peers. There is no website for reporting an angry, rude, and confrontational patient. There is no place we can rate patients on what a joy or nightmare it was to take care of them. There is no America's most-wanted list with mugshots of these patients. We can't even generate a complaint. We can't complain to a CEO. We can't choose to have them not come back again and again and again (often these patients are our most frequent users).

EMTALA forces us to treat these patients every time. We have to listen to the insults, field the threats, put our lives and staff in danger, and take abuse and frank disrespect. Forget thinking of you actually standing up for yourself or breaking your professionalism. You might as well call a lawyer now to represent you in front of the state medical board. This is the state of affairs on a nightly basis in emergency departments across the country.

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The problem as I see it is that we mislabeled the process as patient satisfaction. The problem is inherent in the term. It implies that our job is to satisfy the patient. If a patient was not satisfied, we failed. This is quite contrary to our training in emergency medicine.

Many ED visits are not satisfying for the patient no matter how much we try. There is nothing satisfactory about the patient not being placed on a Versed drip that he requested for his chronic back pain. There is no satisfaction in my not being able to magically find the cause of abdominal pain a patient has had for eight years and that has befuddled 19 previous emergency physicians.

A parent “can't get no satisfaction,” as the Rolling Stones famously sang, when the source of his child's nine complaints are all viral and antibiotics are not indicated. There is no satisfaction in not getting a work note for three days (including Labor Day) for an atraumatic foot sprain. No satisfaction in hearing that your mother will not be hospitalized for the weekend because her dementia got worse, and she could not remember little Johnny's nickname.

It is not satisfactory to hear that the tingling in your fingertips and around your lips is not an embolic stroke but a panic attack and hyperventilation syndrome. No satisfaction in knowing that I was not empathetic and appeared to be indifferent to you collecting disability at age 27 as a result of a herniated disc on chronic pain management. I can't satisfy you when the plastic surgeon you requested for your facial laceration laughed and hung up on me because you did not have insurance. The list goes on and on. No matter how nice, respectful, and timely I am, a certain proportion of ED patients will not be satisfied. I will not meet their expectations so let's not ask them if they are satisfied.

Satisfaction is an obligation or even a promise we make that means we will deliver satisfaction. This is not realistic when we consider all the moving parts that go into one ED encounter. This is not Disney, and I am not selling vacuum cleaners. No matter how much the patient satisfaction guru wants us to adopt the customer service model of Disney, the ED is not Magic Kingdom. We should label these surveys “Patient Feedback Surveys.” Feedback does not imply a pre-expectation; it implies a process that already occurred and now seeks constructive criticism or suggestions for improvement, not a rant about how I never should have been licensed to practice medicine.

We need our leaders in emergency medicine to advocate for the physicians, and the Emergency Nurses Association should do the same for the nurses. We need to draft a bill of rights that is supported by hospital administration saying that we will not tolerate frank disrespect, foul language, or threats! Once in a while, it would be nice if administration and medical leadership actually sided with us and defended us. Once in a while, it's OK to say that someone was out of line, that this kind of behavior will not be tolerated. Our job security is not based on three complaints and disregard for the other 397 patients I served and satisfied this month. Let's get some perspective that two of my 15 surveys were negative, making me fall out of the 95% patient satisfaction expectation although my other 350 satisfied patients failed to fill out a survey. Let's change the surveys. Empower me, give me some recourse, and defend me! After all, the oath that I took was first, do no harm, not first, do not disappoint.

© 2013 by Lippincott Williams & Wilkins

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