Are patients more appreciative out in private practice land?

[EC3]

Seems like most of the patients in our ED are overwhelmingly disgruntled and not too pleased before, during, or after treatment. Is this a residency thing or is this how it is out in the real world, too? I understand that waits are long and people are at their worst, etc. but seriously, it's depressing to work so hard to help someone only to have them not give two ****s about any of the workup you did.

Do PP docs find this to be the case as well?

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[southerndoc]

Depends. If they're waiting in the waiting room, they're usually pissed off.

In the community setting you'll find much more customer service. You'll spend more time with patients explaining test results, and in general, they are more demanding of your time.

Overall, I like community emergency medicine over academic. I had always said I would go back into academics, but I'm enjoying this so much that I doubt I will. I will probably do the toxicology fellowship, but doubt I'll work in academia full-time afterwards.

 

[EC3]

Depends. If they're waiting in the waiting room, they're usually pissed off.

In the community setting you'll find much more customer service. You'll spend more time with patients explaining test results, and in general, they are more demanding of your time.

Overall, I like community emergency medicine over academic. I had always said I would go back into academics, but I'm enjoying this so much that I doubt I will. I will probably do the toxicology fellowship, but doubt I'll work in academia full-time afterwards.

How do you guys end up dealing with drug seekers in regards to the customer serivce aspect? Do you just give them their fix or do you argue the need? And can they just file a complaint if you're not giving them what they want even if it's not indicated?

 

[southerndoc]

How do you guys end up dealing with drug seekers in regards to the customer serivce aspect? Do you just give them their fix or do you argue the need? And can they just file a complaint if you're not giving them what they want even if it's not indicated?

Give in to most of them, flag their chart eventually, then once that's done everyone usually takes a stand together.

 

[docB]

Are patients more appreciative out in private practice land?

No.

Better off people often are incredibly entitled. They want what they want and they are used to getting it. When they don't they get mad.

 

[VALSALVA]

No.

Better off people often are incredibly entitled. They want what they want and they are used to getting it. When they don't they get mad.

Interesting take. It's been my experience (so far) that the less someone has in life, the more selfish and less thankful they are in the ED. The few "thank-you's" I get usually come from the folks that clearly drove in from suburbia.

 

[SolidGold]

No.

Better off people often are incredibly entitled. They want what they want and they are used to getting it. When they don't they get mad.

I've done 1 month each at 2 community hospitals during residency so far and it's easy to tell which patients are well-off and entitled, but I've never had one get mad at me if I explained the rationale behind what I was doing even if they were expecting something more. Even then, they were thankful.

At the academic hospital, I could spend 20 minutes of my time setting up a primary care physician that will see uninsured patients that will charge very little money, give them an appointment, and still get an earful from a patient because I "didn't do nothing" for them despite working them up for 2 hours. I really take pride in helping those with less resources, but very few appreciate you bending backwards for them.

There is a big difference to me, and I'm considering changing my long term career goals because of it.

For people looking at programs now, consider your community EM experience because you want to experience it whether you end up liking it or not.

 

[docB]

Interesting take. It's been my experience (so far) that the less someone has in life, the more selfish and less thankful they are in the ED. The few "thank-you's" I get usually come from the folks that clearly drove in from suburbia.

I've done 1 month each at 2 community hospitals during residency so far and it's easy to tell which patients are well-off and entitled, but I've never had one get mad at me if I explained the rationale behind what I was doing even if they were expecting something more. Even then, they were thankful.

At the academic hospital, I could spend 20 minutes of my time setting up a primary care physician that will see uninsured patients that will charge very little money, give them an appointment, and still get an earful from a patient because I "didn't do nothing" for them despite working them up for 2 hours. I really take pride in helping those with less resources, but very few appreciate you bending backwards for them.

There is a big difference to me, and I'm considering changing my long term career goals because of it.

For people looking at programs now, consider your community EM experience because you want to experience it whether you end up liking it or not.

I was being a little glib. Since this is a serious thread let me explain my answer.

In my particular practice one of the hospitals I work at is in a very well off area. I find the patients at that place really tough to deal with. They demand unreasonably frequent updates or they get mad. They want their doctors called multiple times during the work up or they get mad (and call the doctor themselves). They are frequently not in the ED with a new problem but are there to get some test that the primary couldn't or just didn't get approved as an outpatient. If they can't get the test (ie. non-emergent MRI) or of other things have to be done prior to the test ("My doctor sent me for a CT scan of my chest. I don't want blood drawn (to check Cr) or an EKG. Just do my test!) they get mad.

I have found legitimate poor people to be grateful and easy to deal with. I agree that the real welfare crowd who are given everything don't care what you do for them. That will never change as long as they are entitled to all the stuff they are entitled to.

 

[Hallm_7]

If you want to see appreciative patients then go to rural America. I love getting transfers in from rural places because they are typically very appreciative, easy to get along with, will do what you ask of them (won't complain when you need to do a rectal or pelvic or some other uncomfortable exam or procedure). I grew up in rural America and there is an almost unshakeable respect that people there have for physicians. It's also amazing how these patients almost never ask for pain meds even though they really need them (I tendto trust their pain scales more too since not everything is 10/10). I had a rural transfer patient last week with a fractured rib, dislocated shoulder (already reduced), and open calcaneus fracture who only requested more pain medication when I specfically asked if he wanted any more since it has been a couple hours since he received his dilaudid.

And if anyone has never treated an Amish patient then you're really missing out. They always, without exception, leave me rejuvinated about becoming a physician.

 

[VALSALVA]

If you want to see appreciative patients then go to rural America. I love getting transfers in from rural places because they are typically very appreciative, easy to get along with, will do what you ask of them (won't complain when you need to do a rectal or pelvic or some other uncomfortable exam or procedure). I grew up in rural America and there is an almost unshakeable respect that people there have for physicians. It's also amazing how these patients almost never ask for pain meds even though they really need them (I tendto trust their pain scales more too since not everything is 10/10). I had a rural transfer patient last week with a fractured rib, dislocated shoulder (already reduced), and open calcaneus fracture who only requested more pain medication when I specfically asked if he wanted any more since it has been a couple hours since he received his dilaudid.

And if anyone has never treated an Amish patient then you're really missing out. They always, without exception, leave me rejuvinated about becoming a physician.

Great point about rural America. My program sends us out to a small town, for a month, that has a level II trauma center that serves a lot of square mileage! Those patient's, in general, were wonderful to deal with. It was like I was in a different country!

 

[southerndoc]

If they can't get the test (ie. non-emergent MRI) or of other things have to be done prior to the test ("My doctor sent me for a CT scan of my chest. I don't want blood drawn (to check Cr) or an EKG. Just do my test!) they get mad.

I had a similar patient one day. Sent in for a CT angiogram to rule out a PE. I told him we would draw blood to check his kidney function tests, cardiac enzymes, etc. He said "I was sent here for a CT scan, nothing else. You ER docs just want to order stuff to make more money." After telling him I didn't make money by ordering labs, I finally gave up.

I went outside, grabbed an AMA form, and returned telling him he had to sign it. "What's this for?" "This is a release of liability so when the IV contrast for your CT damages your kidney you can't sue me because I don't know how your kidneys are functioning without bloodwork." The guy gets pissed, then signs it out of machoism. Two minutes later his wife comes out and says he'll let us do whatever we want.

Guess what? His creatinine was 2! I canceled the CT scan, checked a d-dimer (elevated) and a lower extremity ultrasound (positive for DVT) and just went ahead and treated him for presumed PE. Had I done the CT scan, he wouldn't had nil for kidney function.

 

[docB]

I had a similar patient one day. Sent in for a CT angiogram to rule out a PE. I told him we would draw blood to check his kidney function tests, cardiac enzymes, etc. He said "I was sent here for a CT scan, nothing else. You ER docs just want to order stuff to make more money." After telling him I didn't make money by ordering labs, I finally gave up.

I had two patients last week who were coincidentally in adjoining rooms. I told one "Your tests are all normal so I'm going to discharge you and let you go home." She went off about how "You are just sending me home to save money by not treating me right (which in her opinion meant putting her on a Dilaudid drip)."

In the next room I told a guy with chest pain that I wanted to admit him for a rule out. He then told me "Nope. I'm going home. You are just trying to run up a big bill on me and I won't have it!"

I swear it was all I could do to not push both gurneys into one of the rooms and say "Ok. You two need to hash this out and decide if I'm screwing you over for money by admitting you or discharging you 'cause at least one of you is wrong."

 

[southerndoc]

OMG, nothing like people wanting a Vitamin D drip. Vitamin D in this case being Dilaudid.

 

[DrQuinn]

Interesting thread. I have been at a tertriary care center (Tampa General) for residency, and now inner city 80k visit Level 1 tertriary care in DC, since graduation. I will be moving to a sweet sweet community job of 35k in one month, I will let everyone know the difference.

That being said, I serve predominantly low to middle income African American patients, mostly working class. And they are a pleasure, an absolute pleasure, to deal with. I would say 98% of the patients are thankful, pleasant, honest, and nonconfrontational. I am sure I will be quite surprised how different it will be in the communtiy in Wisconsin.

But atleast I'm a wee bit closer to docB!!!!

Q

 

[EM2BE]

From what I've seen in limited experience -

Inner city - If entitled to welfare, the patient feels entitled to do with treatment as they want (i.e. I want pain killers for my pain but I don't want blood drawn today for the reason I'm here)

Rural - If entitled to welfare, you won't know unless you look at the chart or ask them for prescription purposes. They are often bashful about having welfare and don't want anyone in the area to know (because if one person knows, they all know). Also something to keep in mind when in the rural area and asking about insurance - keep the voice as quiet as possible so that the person in the room next to them can't hear. They have pride, but also needed financial help.

Rural - agree as above. Grateful as can be. Also can run into problems with stubbornness though. Elderly are used to the white male physician and have problems with change in any aspect of this. If a doctor retires and a younger doctor takes over and does things differently, the younger will hear about it and hear the whole "taking all my money" aspect. The patient will be grateful for being taken care of eventually, but it may take some convincing as to why things are different.

Suburban - I've seen grateful and entitled, pain 10 for paper cut or pain a 1 when missing a limb. However, the 10s quickly earn a reputation and you will know within a month. As stated above, the pain scales are often under-reported. Also, may not come in until things are the worst they can imagine - when you see them, do a full physical. Chances are they haven't seen a doctor for 10-15 years (because nothing was "that bad" but "I did sew up my own finger a few years ago - look at how I don't have much of a scar."

Edit: Yes, I did grow up in the suburban and rural area (too confusing to explain).

 

[SolidGold]

Regional location withing the US likely does have something to do with how patients tend to act. As a medical student at Tampa General and working quite a bit in the ED there, the patient's were appreciative and most of the people I interacted with are from similar socioeconomic backgrounds as the people I treat now.

I usually don't care if a patient is appreciative or not because I like doing the right thing and helping those with little resources get the care they need, but it's refreshing to work out in the community because a larger portion of the patients come in with real complaints that are legitimate ED cases.

 

[GeneralVeers]

Here's a simple breakdown based upon a complex mathematical formula:

Inner-city welfare types = Not-appreciative and always pissed off
Working-class poor = very appreciative
Blue collar middle class = very appreciative
Generic Middle class = Somewhat appreciative, but demanding
Rich Mofos = demanding and irritating.

 

[roja]

Having gone from the South to NYC to the west coast (and friends all over) I think you see that what this boils down to is how someone's mamma (daddy, granma, auntie, etc) raised them.

Bad manners and entitlement crosses all socioeconomic strata.

The more important question is: how are you going to deal with it when you encounter it?

You can try and minimize the frequency that you experience it but this is probably shooting in the dark. You might get lucky, you might not.

Try and figure out how you are going to deal with and how not to let it annoy the piss out of you.

 

[Jeff698]

I'm in community practice in a relatively well off area (North Austin suburbs with surrounding rural areas) and our population is pretty varied.

We have the same hypovicodinemic trolls as everyone (the only constant in EM) but we also have a lot of very nice, appreciative and understanding patients.

I find that the economic background of patients doesn't correlate well to their sense of entitlement. The social background, i.e. Roja's mamma factor, correlates very well.

For the trolls, I try to be sure there isn't really anything going on (it turns out that trolls can get sick, too....just to keep our lives interesting) and then cut my losses as quickly as possible. I usually give them the benefit of the doubt when it comes to ED treatment, am a little more skeptical about narcotic prescriptions but still pretty lenient unless they're repeat offenders or just plain piss me off.

Take care,
Jeff

 

[EM2BE]

Has anyone else seen an ED that had a book of drug seekers and all their aliases? I saw this in one ED and found it was used by all the physicians to double check and see if their suspicions are correct. This was in an ED without electronic records.

 

[GeneralVeers]

Has anyone else seen an ED that had a book of drug seekers and all their aliases? I saw this in one ED and found it was used by all the physicians to double check and see if their suspicions are correct. This was in an ED without electronic records.

SHHHHH.........technically it's illegal.

 

[Jeff698]

SHHHHH.........technically it's illegal.

And none of us would ever consider doing such a horrible thing.

Take care,
Jeff

 

[Jeff698]

BTW, Texas just had a new law go into effect that requires us to include both our DEA and Texas DPS registration number on all narcotic prescriptions.

As I looked into this law, there is a provision in it to create a databank of everyone who fills a narcotic prescription in the state, regardless of where it is filled. Physicians would be able to search this database to see how if our patient is frequently filling narcotic prescriptions.

While I'm all in favor of something like this, it sounds too good to be true.

Take care,
Jeff

 

[GeneralVeers]

BTW, Texas just had a new law go into effect that requires us to include both our DEA and Texas DPS registration number on all narcotic prescriptions.

As I looked into this law, there is a provision in it to create a databank of everyone who fills a narcotic prescription in the state, regardless of where it is filled. Physicians would be able to search this database to see how if our patient is frequently filling narcotic prescriptions.

While I'm all in favor of something like this, it sounds too good to be true.

Take care,
Jeff

I was in favor of it too, until I worked a shift there last month and couldn't remember my DPS number. I got several threatening notes from the hospital saying I would be "fined" if I didn't include it.

 

[tkim]

Although some states have an online database in where you can lookup patient's prescription filling habits. I'm still trying to figure out if NY has one.

 

[DrMom]

We have one in Oklahoma. It is extremely useful!

 

[Arch Guillotti]

Has anyone else seen an ED that had a book of drug seekers and all their aliases? I saw this in one ED and found it was used by all the physicians to double check and see if their suspicions are correct. This was in an ED without electronic records.

That would be a "turkey file".

 

[docB]

BTW, Texas just had a new law go into effect that requires us to include both our DEA and Texas DPS registration number on all narcotic prescriptions.

As I looked into this law, there is a provision in it to create a databank of everyone who fills a narcotic prescription in the state, regardless of where it is filled. Physicians would be able to search this database to see how if our patient is frequently filling narcotic prescriptions.

While I'm all in favor of something like this, it sounds too good to be true.

Take care,
Jeff

We have a website maintained by the state pharm board that will show you all the scheduled drug prescriptions filled by a person for the last year. It is really helpful when they lie and say they haven't gotten any narcs for months. It's not that helpful when they just come in complaining that their po meds don't work and they want a little "starts with D" holiday.

 

[PeepshowJohnny]

The interesting thing about the upper-middle class/upper class patients is that (in my very limited experience) they come in two big flavors.

The first is the stereotypical "I'm an important person and my complaints needed addressed HOURS ago" person. This can be even worse when it's the well to do parents bringing in their kid. They're demanding and a pain.

However, you do get the "social engineer" types ocassionally. This second group want special service as much as the first type, but they know how to get stuff done (probably how they got ahead in life.) They try to be your friend, compliment you, and basically make YOU feel guilty they have to wait because you like them.