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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Wednesday, June 11, 2014
Life in the Emergency Department: Not What You Expected?
This is what you signed up for, right? A career where you are a multitasking, highly-skilled medical practitioner in a fast-paced emergency department. This place is predictably unpredictable, but you are saving lives, and it feels good! The problem is, you cannot help feeling unappreciated, underpaid, overwhelmed, and exhausted. You are finally living the dream, but the dream consists of working weekends, double-call, and every other holiday. You miss lunch while still gaining a few pounds. You gain incredible insight into a very broken care system. Feeling more like a nightmare? It’s certainly not what you expected.
 
Now you have to deal with demanding patients who expect customer service perks. The patients who say, “Do more tests,” and insist on instant gratification. The audacity! You are frustrated that your clientele is telling you how to do your job. The degree behind your name means nothing because Google has allowed your patient to complete a self-diagnosis. This place is for emergencies, not primary care. These complaints are not emergent at all.
 
You feel justified by your disdain because you are not alone. Your colleagues exchange glances when a patient demands a head CT, or you hear a deep sigh from a co-worker when a patient asks for a stat MRI for back pain he has had for eight years. The nurses agree that your narcotic-seeking patient is simply that, and needs security to escort him out. Mr. Jones is back again for a refill of his blood pressure medication. Now you see one more person just signed in with a stubbed toe.
 
This is not what you signed up for at all. Breathe. Stop for a minute and regroup. Now, slap yourself. Maybe you need to slap yourself twice. This is what you signed up for! The ED is not just for emergent concerns. It is a care center where people know there are doctors and nurses. It is not just for emergencies like strokes, MIs, and blunt trauma! It is for patient care, in general, and their satisfaction. Until you realize patient satisfaction is part of the care plan, then you are going to continue to live a miserable existence in your department. Let us explain.
 
Back when organized medicine was — wait a second — has it ever been organized? No. Never. There are buildings with roofs, medications, tools, and machines that help you make decisions, but it’s not exactly organized. The ED is full of chaos. What about resources — or lack thereof? Your local resources exist, but most of the time they are almost impossible to utilize. Now, add the following fun facts: Your patient may not be able to read or write or speak English. He might be elderly or broke. When these types of patients ask you for a helping hand, why do you act so annoyed? We all know your badge doesn’t say S. Smith, Waiter. It doesn’t say J. Jerk, either.
 
Your badge says Emergency Physician or Nurse or Physician Assistant or Nurse Practitioner. This role is more than knowing how to diagnose and treat heart failure or catch early sepsis. This role is about providing total patient care and making people feel better, even the ones who don’t quite get it. It is about making people happy and motivated to play an active role in their own health care. After all, a happy patient trusts you, and isn’t that what this is all about?
Recent personal opinion columns scold and mock our demanding patients and hospitals that stress concern about patient satisfaction scores. Most of these rants reiterate the same themes about non-emergent patients demanding non-emergent testing or treatment. Many ED providers complain that patients don’t understand our overwhelming jobs, and visit us with complaints that should be seen somewhere else. Well, the ED is that somewhere else.
 
Providers whine that nonsensical satisfaction scores should not be part of our job evaluation. The patient’s opinion should not be a factor or used as an evaluation tool. Nonurgent patients should understand we are busy with other emergencies, and they need to wait. This may be true, but we don’t need to broadcast to them that maybe they are not as important. We also don’t get to say their patient satisfaction scores simply don’t matter, that only the admissions’ and critical patients’ scores are read.
It’s controversial. Patient satisfaction, however, is important in the ED and so are the scores — to an extent. What people think about your care should matter to you and your facility. It should be measured and monitored. You should want to change your practice based on negative feedback.
 
Also important are refills, toe pain, dental pain, and well checkups. The ED is not just for emergencies, and it will always be that way. It doesn’t matter what a patient’s needs are; you must provide aid. The challenge is not the difficult intubation or rushing a stroke patient to the CT scanner within the window. Those steps are easy for you because they define your job. The real challenge is to accept that the ED will never be what you want it to be or operate the way you see fit.
 
It is also a challenge of your character. Patients are going to remember you, and their opinion matters regardless of who they are and what their complaint is. Their opinion should also matter to you because this also defines your job. This should not be seen as a chore but as a job that you want to master. You may yearn to explain to people what constitutes a true emergency. In the end, though, whatever brought them to the ED is an emergency to them, and they need your help. Your definition doesn’t matter.
 
As ED providers, we prioritize. Most days, we make a difference and people appreciate our efforts. Other days, we see demanding patients who are not as privileged with our educated minds or who do not have the financial solution to their health care needs. We must accept that the ED is a mixing bowl of complicated cases and part of our job is to find a recipe that works for each patient. The ED is a place for compassion and creativeness, not for complaining, personal bias, or judgment.
 
No, we do not have to prescribe antibiotics for every cough or runny nose to boost our scores. Not every patient gets a CT or an x-ray just because he asks for it. Providers seem so annoyed by the requests. Find a middle ground with alternative options if you can. Considering patient satisfaction as a goal is not giving in to Press Ganey. It is important to reexamine how you practice and how you treat people, even the incredibly ill-advised ones. As providers, we are still allowed to exercise our clinical judgment to make a decision about patient care and not get irritated at patients when they ask for or demand things. Do not lose sight of creating a relationship through communication, trust, and ultimately, kind rapport. Don’t fall into the I’m-the-provider-and-I-know-best mentality. We can explain our thought process to patients and reassure them about our decisions whether to do testing.
 
Our jobs as ED providers include saving lives, but they also include considering patient satisfaction. These scores should not be exempt just because we make life-or-death decisions. Our profession should be respected and some patients need to wait, but being callous is never justified. Maybe we can look past the initial insults of certain patient complaints and find a deeper meaning. Not all of the scores are accurate or reflect the total picture of who we are as providers. No one is perfect, and we should accept that there is always room for growth and change.
 
We have a privileged job, but it does not mean we are allowed to be pompous. Patient satisfaction, courtesy callbacks, answering questions, and going the extra mile not only make a difference to our patients, they define our role as care providers. Rolling our eyes at our regulars will not make them stop coming. The next time you feel yourself wanting to say, “That is not my job in the ED,” think again. It is your job, and it is going to keep being your job. Consider patient feedback realistically. Treat everyone with compassion and courtesy, and I guarantee the rewards will not be what you expected.
 
How important is patient feedback to you?
7/24/2014
alex antalis MD said:
The problem with patient satisfaction surveys is not they they exist, but that most providers are judged using markedly nonscientific, statistically insignificant data. In our institution, the survey "n number" is 40 patients every three months in a department that sees 15,000 patients. We are at the 100 percentile for one-quarter and at 50 percentile for the next quarter. We would need about 400 responses, not 40, to be near any statistical significance but our system already pays out more than $1 million annually over all departments, so there is no interest in more accuracy. My opinion is that the hospitals survey just enough to say they do it, and use them as they see fit to justify criticism of provider behavior. I ignore both positive and negative results; they are equally statistically inaccurate. Alex Antalis, MD
About the Author

James R. Roberts, MD & Martha Roberts, ACNP, CEN

James R. Roberts, MD, is the chairman of emergency medicine and the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine and toxicology at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, CEN, is an acute care nurse practitioner at Inova Fairfax Hospital Emergency Department in Falls Church, VA, and is Dr. Roberts’ daughter.

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