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Curbside Consult with Dr. Jayne 12/19/16

December 19, 2016 Dr. Jayne 3 Comments

Winter roared across much of the US this week, reminding many people that no matter how good we think our technology might be, mother nature sometimes has the last laugh. Our region’s weather went way beyond what forecasters expected, bringing the transportation infrastructure of several metropolitan areas to a complete stop. Conditions went from bad to worse right before the evening rush hour, stranding people in their cars for hours. It was bad enough throughout the weekend that fire trucks were skidding off the road and airplanes were sliding off the runways.

Unfortunately, that kind of weather doesn’t stop those of us in healthcare who are responsible for manning the patient care trenches and for supporting the systems that make our work easier. Sometimes that means getting up an hour earlier than usual to make sure that the car is defrosted and there is plenty of extra time to get to the hospital or office. Other times it means staying late to make sure everyone is taken care of, regardless of what might be going on in our own lives.

I was seeing patients this weekend and we had several rushes, seeing nearly 50 patients in the first few hours we were open. One of my staff was uncharacteristically attached to her cell phone, as she worried about her son heading home on the icy roads from his first semester at college.

In patient care, though, we’re expected to be “on” all the time. We don’t necessarily get a break to check in with our kids or family and make sure they’re OK, especially when we have dozens of needy patients in front of us. And in this era of consumer-driven healthcare, there doesn’t seem to be much room for the caregivers to be human.

Normally our center delivers high-quality care in an efficient manner, but this weekend we were just swamped, as were the rest of the centers in our group. Normally we have some providers who float between the locations, but there was no room for that as patients tried to be seen between the freezing rain and the impending snow. Patients were calling from location to location checking out the wait times. My scribe and I scurried from room to room as fast as we could, with him literally finishing one patient’s visit documentation as I started our introductions in the next exam room. Despite our efforts, there was still an hour wait at one point, with a couple of patients leaving without being seen.

Regardless of the wait, we’re still significantly faster than the emergency department. This was confirmed by the patients who arrived in our waiting room after giving up elsewhere first. At least at our practice, patients generally wait in their own private space, with cable TV and comfortable chairs.

As a physician, I feel awful when patients leave without being seen, whatever the reason. It means that we missed an opportunity to treat an illness or maybe to just provide reassurance. Sometimes those missed opportunities can have life or death consequences, and that possibility is always on our mind even if most of what we’re seeing is colds or sniffles. I’m glad my patient who had an acute appendicitis decided to brave the weather and come in and to take me up on the CT scan I offered to confirm it. For a while, he had debated not seeking care, which could have been disastrous.

Due to the ice, we saw a fair number of people who slipped and fell, sometimes hitting their heads. Especially with elderly patients or those on blood thinners, we have to be vigilant about evaluating them since the margin for head injuries can be small. I know the weather created chaos in many people’s schedules, but I don’t think I’ve seen as many patients trying to talk me out of an appropriate workup as I saw this weekend. On the other hand, there were quite a few patients trying to talk me into treatments they didn’t need, such as antibiotics for their viral illnesses or the illnesses they are afraid of catching.

No amount of embedded clinical decision support in my EHR is going to help me through those conversations. I can give the patient an antibiotic and lower my clinical quality metrics, but raise my patient satisfactions scores. Or I can hold the line against antibiotic resistance and risk bad reviews. Despite a patient mix that was similar to my last few shifts, my patient satisfaction scores were lower than usual. Comparing them to the patient wait times, though, showed a trend – regardless of the care, patients who waited longer gave lower scores.

When I first got into informatics, I worked on projects that involved preventable harms and straightforward, evidence-based medicine. The data often helped identify situations where a change in behavior could improve patient outcomes and where the interventions needed were clear. Those were my bread and butter, and I have to admit I feel completely unprepared to deal with the kind of data that is now in front of me. It’s not just the data in our system that I have to address with our providers, but the public-facing reviews. When potential patients see the low scores and negative reviews for today on Yelp, they’re not going to know that it was in the context of a major ice storm and below-zero temperatures.

Patient engagement is supposed to be a good thing, but sometimes it’s a double-edged sword. There’s enough to learn in medical school and residency already, and adding the need to learn how to manage social media and online patient reviews is something that feels foreign to many clinicians. Add the stresses of managing EHRs that can be less than cooperative, the usual staffing and office dramas, insurance headaches, and more, and you have a recipe for burnout.

I’ve been keeping my eyes peeled for continuing education courses or informatics presentations that discuss dealing with this situation. I know that good rapport with the patient along with empathy, discussing the situation, etc. can help avoid low patient satisfaction scores when we err on the side of clinical quality. But in the pressure cooker of most care delivery organizations, those discussions can be hard to execute.

I’m hoping some of my CMIO and CMO readers will have some suggestions because I’m somewhat at a loss here. I know I’ve written about this before, but it is definitely weighing heavier on me after this weekend. Although being at the forefront of a new specialty’s growth can be exciting, it’s sometimes maddening especially when you’re not connected to an academic center. As clinicians, we’re focused on getting to the root cause and trying to fix things. When we don’t have the answers, we tend to dig in and keep investigating until we find them, or at least something we can test drive.

How do you react to low or decreasing patient satisfaction scores, especially around events out of your control? Email me.

Email Dr. Jayne.

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Currently there are "3 comments" on this Article:

  1. Since 80% of the tons of antibiotics produced each year go to animal feed, your role in “hold[ing] the line against antibiotic resistance” is smaller than you might have been led to believe.

  2. Best advice.
    Ignore ALL patient satisfaction scores. Its like teacher satisfaction scores from students. Meaningless.

    I also always say be wary of the 5 star physician. They are usually giving patients what they want (antibiotics, narcotics, etc) and not what they need.

    Do your very best to NEVER look at them.

  3. Jayne
    Another insightful and forward thinking piece. This is precisely the conundrum many of us face; although it IS possible to have hi quality care (avoiding unnecessary antibiotics) as well as hi patient satisfaction scores, it is nearly impossible to do that AND have hi productivity or throughput numbers, especially in near-crisis situations. Having a scribe, as you do, is a potential partial solution that allows more face to face conversation between doctor and patient, but it doesn’t ‘fix’ the consumer-driven pressure to give in to inappropriate requests for futile care. This scenario is well written and thoughtful, and something for which we should definitely discuss and develop solutions.







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