Recently I was wondering if more difficult patients get better care.
We recently had a difficult patient. Every day, a doctor would have to spend over an hour talking to the patient about her many concerns. There were meetings about how everything needed to be carefully documented for this patient so that she would not throw a fit. Considering how much time we spent on this patient, it seems like she was getting better care than any other patient.
But is that really true?
I'd like to think that every patient we treat receives good care. Just because that care was being meticulously documented to avoid a lawsuit doesn't mean that the care was better. Just because the doctor spent time arguing and discussing the same issues with the patient over and over doesn't mean the care was better.
But I did notice that nurses and staff would avoid going into the patient's room if remotely possible, unless they absolutely had to. Nobody wanted to see that patient because they didn't want to get yelled at.
What do you think? Does the squeaky wheel gets the most grease or the least?
Its a good question, I wonder about this myself. Not only in healthcare. I try to be low maintenance for my kids' teachers, coaches, tutors. I am hoping that this way they don't avoid dealing with my children. But I see multiple parents whose children use the same teachers, and parents constantly on the phone with these teachers, ask multiple questions, micromanage, Skype teachers with videos of how their child plays this piano piece, and demand input before their scheduled lesson. I suspected at times that these kids get more out of the teacher. But I guess you really need teachers input. As far as doctors, I will quote my seasoned colleague. He said he personally wants to be treated by a country doctor, who does not have ego, and who does not know that the patient is a physician. He feels this situation will give him standard of care (read, best) treatment. With low key patients, he felt physicians are unbiased, more objective and ultimately most effective. I'll go with this wisdom. In my own experience whenever I tried to be demanding in my healthcare I got less.
ReplyDeleteAs a general rule, I think that the saying of "the squeaky wheel gets the grease" is true. But it's a bit different in medicine than in some other service-driven fields, because we're spending potentially a lot of time together and it's face-to-face.
ReplyDeleteLike you, I've observed nursing and other medical staff trying to avoid going into a difficult patient's room unless absolutely necessary. The demanding, threatening family may also get everything that they think they want in the form of radiology imaging and lab tests... but what are they getting, really? By threatening lawsuits and deciding the course of care, they're essentially wasting their time and money by shouting down the expertise that is around them. Additionally, given that the human connection has shown to be important in healing, the patient making threats is doing themselves a disservice. By comparison, there are some patients that are so pleasant, they're checked on and offered amenities probably more than average, as the staff begin to dote on them. Care should be standardized, sure, but just as patients are all unique individuals, so are the medical staff, and it's a very human process.
The only unfortunate thing to admit is that there are some medical staff who, whether due to personality or being busy, may not give patients the attention that should be given. No matter how nice or enticing a patient may be, nothing short of complaining or threatening a lawsuit will grant them more attention... and sometimes, it's attention that is legitimately needed.
I don't fault any patient (or their families) who comes in making threats. Making complaints has the best chances of getting things moving and affording special treatment (if available) in any industry, so it's not surprising when people try to use that methodology in medicine. Patients and families are usually scared and feel powerless; complaining and threatening to sue may be the only courses of action that they feel they can take, aside from being passive. And since it changes behaviors in the staff around them, they may feel that it's something they need to do to afford themselves the best care possible... even if they don't realize that the behaviors changed for the worse.
They may get more grease, but not the good grease. You can participate and advocate for yourself without being unpleasant.
ReplyDeleteI don't think it does the patient any favors when they are so disliked, the staff will avoid their room (or phone calls if outpatients) unless necessary. LIke Heidi said, there is a way to advocate and still be pleasant & kind. I'm sure those types of patients DO end up getting special treatment---getting appointments squeezed in, for example. You can be "squeaky" in a pleasant way---persistent, knowing what you want or need, and insisting you get it, yet not demeaning and antagonizing everyone.
ReplyDeleteIn order to sue, you have to have the money for the lawyers and such, so I assume the person had money.
ReplyDeleteOtherwise doctors can name the squeaker "crazy" and shut them up with "anti-psychotics" (tranquilizers).
Meh...If she had money, she should have been labeled "neurotic" and shut up with lithium.
DeleteI do think this would have been a good psych consult. Not to help the patient, but to help the team deal with things a little more effectively. Spending lots of time on petty complaints alternating with completely ignoring the patient isn't really helpful (think of parents who do that with small children).
Considering how much time we spent on this patient, it seems like she was getting better care than any other patient.
ReplyDeleteSSC Result 2015 BISE Peshawar Board
I would say they get the least grease. Even though we always try to do our best for every patient, I will tell you in pediatrics that pleasant families who are kind to their doctors/nurses will get much more attention for their child than those who scream at people every time they come in. I may spend more total time in a room explaining things to the "squeaky wheel" families (usually trying to convince them why their child would not benefit from a test or a continuous pulse ox, etc), but their attitudes put me on the defensive and make me want to avoid that room as much as possible. Also, parents/patients who are constantly screaming for pain medication make me leery to give them pain medication because I never feel like I know when they actually need it. Parents/patients who are pleasant and ask questions, I am much more likely to sit in their room and explain things thoroughly to them on my own volition because there's rapport there. They're the patients I peek in on throughout the day just to say hello. And I'm way more willing to believe them when they assert that they need something because I know they aren't the types to constantly demand things.
ReplyDeleteThis seems like a rhetorical question. Everybody in health care knows that patients we find "difficult" get worse care. Too bad patient's don't seem to.
ReplyDeleteI'm a doctor, and I can tell you that, while the squeaky wheel gets the grease, it's not necessarily the good kind. I don't argue with patients past a certain point, so a lot of them do end up getting extra unnecessary investigations and consults because I can't really manage to talk them out of it (e.g. CT heads for benign headaches, GI consults for benign abdo issues - for which they will get a scope, back x-rays for benign back pain - which has a lot of radiation. much more than a chest x-ray). Some people can be reasoned with, and this stuff can be avoided, but by definition not with 'difficult' patients. This is a high profile study from a couple of years ago that linked higher satisfaction scores to poorer outcomes.
ReplyDeletehttp://www.advisory.com/Daily-Briefing/2012/02/15/patient-satisfaction
Now, with a pleasant patient, particularly one with a legitimate medical issue, I'm much more likely to go above and beyond the call of duty (e.g. call someone on their behalf, write a letter for them free of charge, spend a bit of extra time explaining things so they feel comfortable, etc). Everyone gets the care they need, even unpleasant ones, but some people get a dash more - dependiing on whether or not you're pleasant, that care can be 'bad' or 'good'.
"a legitimate medical issue" to the patient , pain is a legitimate issue. Only an Xray or some such scientific test can show if the pain is physical or psychological.
DeleteThey get kicked out of the docs office for asking for care that follows medical research and the like. Or they catch the docs in more than one "whoops", etc.
ReplyDeleteI never threatened to sue any one. I just say I'll let others know about them. That's the best thing: just the facts. That's all I state. I tell people to ask questions.
"... that follows medical research..." There is research and there is research. A 'study' involving 500 patients is hardly more than anectodal. A study done by someone with an agenda can be interesting, but watch your source. I get so tired of hearing from people about something they read online, therefore, it must be true. No, it isn't. If you want you doctor to pay attention, start citing legitimate, peer-reviewed and accepted standards of care.
DeleteAnd to the other anonymous who said that the only way to prove that pain is psychological or physical is with an x-ray or a scientific test (whatever that is) ... not true, either. We take histories and perform physical examinations, which when done correctly, will lead the practitioner to the right diagnosis; the x-ray is just confirmation. Furthermore, neither x-rays nor any other scientific testing are 100% accurate in determining the cause of pain, especially. They also lead to over-diagnosing. For example, if you are over 35 years of age and have been upright most of your life, there will be "bulging discs" on your MRI. Bulging discs are not a diagnosis, they are a fact of life that do not require surgery or long-term narcotic pain management. But, patients always point to the MRI finding of bulging discs as some sort of Holy Grail that requires the doctor to treat. TCG