Randapanda II

Actual Patient Encounter:

“I’m really, really annoyed.”

“Really? Why?

“I’ve been sitting here for an hour and you just now walked in.”

“I’m sorry. We’re pretty busy tonight.”

“Well, I’m still annoyed.”

“How annoyed?”

“Like, a 10 out of 10.”

“You know, my Great-grandmother was driven from her home in Asia Minor by the Turks and had to walk two hundred miles to get to Smyrna where she took a ship to Athens. Several of her children died along the way and the Turks wouldn’t even let her stop to bury their bodies. When she arrived in Athens what was left of her family had nothing but the clothes on their backs. As far as being annoyed, to me that’s a ’10 out of 10.'”

“OK, maybe it’s a 9.5 out of 10.”

Speaking of…

Speaking of wait times, the typical non-emergent patient encounter in a busy and understaffed Emergency Department proceeds in a predictable manner full of emotional highs and lows. First comes the interminable ordeal in the crowded, smelly waiting room relieved at last by the hopeful flurry of activity with the triage nurse. Determining however that you are going to live, she sends you back to the waiting room for another stint with the cross-section of the city who have nothing better to do at 2AM. There you stew until, at last being called to “to the back,” you are treated to another optimistic spurt of activity as your nurse asks you all kinds of interesting questions, hooks you up to the lights and whistles, and even draws some blood for some standard lab work associated with your complaint.

Unfortunately you will now have to wait again, rapidly becoming bored with the novelty of your room the type of which you have probably seen many times before. The flat screen television is nice but since you don’t really like The Fresh Prince of Bel-Air, by the time your doctor decides to finish his coffee break, chatting with the nurses, or whatever it is he does to pass the time on his ridiculously easy job you are now at the limits of your patience and wondering to yourself if it wouldn’t be easier making an appointment with your own doctor. Just when your boredom starts to turn to despair however, the doctor walks in and everything seems now to be headed in the right direction. He is professional, calm, listens intently to your complaints, asks probing questions, lays his hands on you like you were his prom date, and finally gives you a learned opinion on what he thinks and what he’s going to do to elucidate and treat the source your problems.

And then the bastard disappears. You are vaguely aware of some frenzied activity in the big mysterious rooms that you passed on your way to your own and your babydaddy (or cousin or friend or whomever came with you) angrily reports that all your doctor is doing is standing at the nurse’s station talking on the phone. In his good time he saunters in, reports that all the tests have been negative, and confirms that not only are you not going to die but the horrific disease that brought you in would be best managed by your own doctor or worse yet, would respond quickly to smoking cessation, weight loss, or a little bit of rest and patience. So long, nice meeting you, and don’t let the door hit you on the ass on your way out.

I mention this because my hospital is making a tremendous effort to decrease wait times. I am completely in favor of this, both because I want my patients to be happy and because a shift is a lot nicer if people are seen, evaluated and admitted or discharged quickly. And as I am currently negotiating a contract where part of my bonus is going to depend on patient satisfaction scores, not only am I going to have pre-printed prescriptions for percocet with my address and pager number in case the patient’s dog eats the pills, but I can see how happy patients are going to be good for my bottom line. On the other hand I work at a busy and completely understaffed hospital and I can only see so many patients per shift. I try to work quickly but we cannot just run the patients in and out like cattle as this would jeopardize their safety. I am also still a resident so every patient I see has to be discussed with an attending, herself fairly busy, before admission or discharge which further slows patient disposition.
Not to mention that despite a waiting room jam-packed with mostly non-urgent complaints, we occasionally get a really bad trauma (or two or three from the same accident) or a critical patient that sucks up a lot of time. It’s not like I’m just standing around. I think every Emergency Medicine resident who reads my blog can attest that, although our hours are good and we get lots of time off, when we are at work we are usually working at a frenzied pace that sometimes precludes even taking a break to eat or urinate.

So although I am as appalled as the next guy that people occasionally wait an hour or two in their rooms to be seen by a doctor, it’s not my fault and I’ll get to them when I get to them. Additionally, the stream of nurses, patient representatives, and various bureaucrats exhorting me to move my lazy ass will forgive me for not panicking and dropping everything to see the non-emergent patient cooling his heels because I am oh-so-obviously taking my sweet time dealing with the eight patients I am already working on. I suppose I could work a little faster but there is very little incentive to do it. I won’t make a dime more for sprinting from room to room instead of walking and the hospital is already getting a lot of work for the twelve bucks an hour they’re paying me. The expectation that I’ll struggle to justify their poor staffing decisions is asking for a little too much sugar for their dime, even from a resident who is used to being taken advantage of.

Not to mention that the other day when I allowed myself to be browbeaten into dropping everything to see a patient who had been waiting long enough to make Press-Ganey feel a disturbance in the Force, when I asked him how long his back had been hurting he said, “Since high school.”

Piling On

Several readers have commented that it’s time to lay off of chiropractors and other purveyors of Complementary and Alternative Medicine because I have apparently said everything about the subject that needs to be said. While it is true that there are only a limited number of ways to demonstrate the ridiculousness of things like Reiki or acupuncture, I get the same enjoyment from doing it as I get from other equally useless activities such as poking a dead ‘possum with a stick.

As a good Southern boy I have poked plenty of dead ‘possums (and even et me a couple or three) but like poking the glassy-eyed corpus of Complementary and Alternative Medicine, the novelty never wears off. Those things are weird and they don’t usually lay still long enough to be inspected. In fact, I only got a brief glimpse of the last live ‘possum I saw because he was charging at me making bone-chilling enraged ‘possum noises and my dog and I were running away for all we were worth. When we finally got clear of the creature my dog cocked her head, looked at me, and I’m sure she was saying, “Man, that was one crazy marsupial.” It says something about didelphis virginiana that a black lab, a dog that will chase anything that moves, instinctively knows to flee from it.

But I digress. Complementary and Alternative Medicine is incredibly retarded and people who believe in it are operating on the same intellectual plane as people who claim to have been sodomized by extra-terrestrials. The fact that ostensibly educated people like the totally ridiculous folks over at Duke Integrative Medicine embrace completely ridiculous therapies like Reiki and homeopathy only goes to show that on many levels academia is a trailer park, as mired in ignorance and superstition as any collection of movable housing anywhere in America. They’re just a little thinner is all. The squalid academics living in their ivory single-wides can talk a good game of course, but the minute you start to believe in Reiki, a therapy that is nothing more than spiritual fire flowing from some greasy charlatan’s hands, you start to lose credibility rapidly. If the intelligentsia in this country believe in things as ridiculous as Reiki and homeopathy, in what else do they believe and why should I take them seriously?

10 thoughts on “Randapanda II

  1. Sigh, reading this blog never gets old.
    As usual, hats off to your patience and sense of humour…it is humour, isn’t it? 😉

    Take care

  2. Nice Post–I would love to hear more about what you think of tying pay to patient satisfaction surveys.

  3. Nice read. “The squalid academics ….” please tell me that took more than 10 minutes to write because it took me that long to read it.

    Regarding pay for satisfaction. Here’s the problem as I see it with the carrot-and-stick model that they’re going to pay you with. There is good research to show that most of the variation in a CSS (customer satisfaction survey) in healthcare comes from the tangilbles in a health care experience. Waiting, TV working, paint/decor, pain, etc… This happens because the expectations for quality of care are largely unknown whereas there are many expectations re tangibles. The interactions are important but the 10min that you, the doctor, spends with them out of a 1-3hour process is not likely to cause significant variation.

    Therefore, if they propose to pay you based on th CSS they have to give you control of the other tangilbles that the patient will experience. That includes staffing to minimize wait times. In England they’ve started to pay health districts based on CSS and they’re a silly clause in the contract that basically says “provide care to the best of you’re ability”.

    The way I read you’re post the hospital is willing to trade quality for access (and the two are always a trade off). Because CSS are affected much more by access than quality.

  4. Funny stuff as usual. My own university has an assistant dean for complementary and alternative medicine. Her lectures usually consist of making snide remarks against Western medicine and claiming that our pills are produced by profit-driven corporations who don’t care about the side effects of their poisons. During one lecture, I busted her for three outright lies about the way the FDA works. Eventually, she stopped trying to convince us that homeopathy and acupuncture would cure everyone.

  5. Twelve bucks an hour huh? That’s robbery and we all know it. You make it look like us homeboys chillin in pharmacy don’t have a care in the world.

  6. you ever mention to your patients that you’re getting $12 an hour when they assume you’re a rich-ass doctor driving a Benz?

  7. To TheProwler – I once stopped in at a Stewarts (our local version of 7-Eleven) after class with my med student ID on. While my purchases were rung up, I winced at the price. The cashier saw my ID and said “It’s OK, you’re a rich doctor.” I told him that I’m just a student, and I pay $40k of tuition for four years. He replied “Well, that’s still OK, because you’ll be a rich doctor when you graduate.” I said after I graduate I can look forward to working 80 hr weeks for 3 years, making less than he is now. The cashier shut up.

    Needless to say, I don’t wear my badge outside the hospital any more.

  8. Please never stop talking about CAM, where will I get my post-PBL session sanity check from? I just came from listening to one of my classmates go on for a good half hour about how American medicine sucks because we don’t use CAM as a first line approach and he had a bunch of sinus problems but then he got some treatment in Austria where he held onto a wire attached to vials with potential allergens and there was a machine recording electric signals and it diagnosed him with wheat allergies and now he’s all better. And then our group facilitator (a psychologist) nodded and said “well, that makes sense” (No, I’m pretty sure it doesn’t) and then the facilitator told us about how some nurse has shown that pumping aromatherapy into the air stops many nosocomial infections and oh God it was horrible.

    The good part is that isolating myself with my basic science textbooks for the rest of the day now sounds downright appealing.

  9. I am curious to know what Dr. Panda Bear thinks of the fMRI studies done on acupuncture. There is a classic point for visual problems that is located on the lateral side of the nail of the 5th toe. When needled, the occipital lobe showed activity, but when dummy points were needled (even 1-2 mm off the classical point) there was no such activity.

    Not that I don’t think that most of the alternative practitioners are scam artists but this shows some sort of scientific validity.

    (Admittedly, I was a quack. I quit and am suffering financially because I won’t go back into it. I turned down a very good job in another chiropractor’s office because I felt it was morally reprehensible to practice chiropractic now that I knew the truth. They don’t tell you about the quackery when you go in.)

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