The theatrics of care

[Angry Birds]

Patients, I realize, like to wait one hour. Greater than 1 hour and they start complaining. Less than an hour, though, and they also complain. I discharged a patient on sight from waiting room, was super nice to them and gave them the exact same care they’d get if they had been called back, but nope, they hated it.

They don’t like being treated in the waiting room and instead want to be brought in a room. The room has therapeutic effects.

They like tests, with results.

They like CT scans.

They like meds and prescriptions.

What else?

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[allantois]

A lot of medicine is pure theatrics

I will also add that often times there needs to be a value exchange - if the patient does not put any value into the exchange (which is usually monetary), they will often not appreciate the full benefit of their received care

 

[Mount Asclepius]

There are a large percentage of patients who value testing (specifically imaging) over physician expertise.

 

[Mount Asclepius]

Everyone gets a goody bag. Frequent Rx top prizes are Zofran, Bentyl, Ibuprofen 800 mg (this is very different than 4 tablets of OTC Ibuprofen 200 mg), Acetaminophen (because it’s Rx strength), Naproxen and Lidoderm patches.

A wise attending told me during my training that they just need something to occupy their time long enough until they forget about the whole ordeal.

 

[skougess]

Everyone gets a goody bag. Frequent Rx top prizes are Zofran, Bentyl, Ibuprofen 800 mg (this is very different than 4 tablets of OTC Ibuprofen 200 mg), Acetaminophen (because it’s Rx strength), Naproxen and Lidoderm patches.

A wise attending told me during my training that they just need something to occupy their time long enough until they forget about the whole ordeal.

Don’t forget rx Pepcid.

 

[WorkNoteEmergency]

Back and knee X-rays are big winners.

When I was a Navy doc, our clinic had a pharmacy right in the lobby. When they’d come in with a URI, they’d leave with a bag stuffed with decongestants, antihistamines, Motrin. Nothing says “I have a good doctor” like a brown bag full of cheap pills. No SIQ chits tho.

 

[GonnaBeADoc2222]

So in my current gig, I am not incentivised to care about any of this. I've gone the past handful of years not doing any kind of "customer care" type stuff and somehow my PG scores are average for the group.

The writing is on the wall however, and it's becoming apparent that "leadership" is starting to care more about it.

It's funny though because anyone with two neurons inclined towards ED operations would observe that the issue in this shop isn't physician driven, but process. After making the patient wait 5 hours in the WR, 4 hours for imaging, 3 hours for the nurse to get around to collecting urine and another 5 hours for a resident consultant, they somehow want the ED physician to play customer care specialist on the backend and salvage the PG score? Poppycock.

 

[CoolDoc1729]

Patients, I realize, like to wait one hour. Greater than 1 hour and they start complaining. Less than an hour, though, and they also complain. I discharged a patient on sight from waiting room, was super nice to them and gave them the exact same care they’d get if they had been called back, but nope, they hated it.

They don’t like being treated in the waiting room and instead want to be brought in a room. The room has therapeutic effects.

They like tests, with results.

They like CT scans.

They like meds and prescriptions.

What else?

We have maybe 10 young anxious patients who have gotten used to being treated in the waiting room because they come in frequently and for nonsense. Once in a while they get a room because we have rooms. Then they freak out because they think something must be finally wrong this time because they never get out in a room! pace for ten minutes in the doorway and then leave ama in a panic 🤦🏻‍♀️

 

[sloh]

Patients, I realize, like to wait one hour. Greater than 1 hour and they start complaining. Less than an hour, though, and they also complain

So essentially it doesn’t matter. They will complain regardless.

 

[HemorrhagicShock]

These are all great tips and I hope we have more coming!

What other "BS" Rx do you all use? How about showboat approaches with the angry daughter who's an MA and has a son who is in "medical school" to be a "radiologist" (actually studying to be a rad tech)

 

[skougess]

These are all great tips and I hope we have more coming!

What other "BS" Rx do you all use? How about showboat approaches with the angry daughter who's an MA and has a son who is in "medical school" to be a "radiologist" (actually studying to be a rad tech)

For young, non-diabetics, I throw short course prednisone around like candy.

I refuse to do the antibiotic thing that urgent care loves so much though.

 

[Fox800]

These are all great tips and I hope we have more coming!

What other "BS" Rx do you all use? How about showboat approaches with the angry daughter who's an MA and has a son who is in "medical school" to be a "radiologist" (actually studying to be a rad tech)

Benzonatate perles, Robitussin DM (generic).

Maalox Max (generic version) for GERD/epigastric whatever.

Acetaminophen 500, ibuprofen 400, loperamide scripts liberally. Patients appreciate it but don't recognize you can do the same OTC - whatever.

Lidocaine patches - 5%.

Albuterol if they complain about wheezing, whatever.

For the frequent flier cyclic vomiting/gastroparesis/HG patients that Zofran "doesn't work for" (i.e., they didn't take it before coming straight to the ED after vomiting twice) - promethazine suppositories, PO metoclopramide or prochlorperazine.

 

[Saddleshoes]

If you give Patients something to do it gives them a since of participation in their well-being. If you do it right they go out feeling like a member of the team. Examples would include....
----Tell them to eat more fruit.
----Tell them to drink more water.
----Have them walk up 3 flights of stairs Am and PM
----Brush their teeth 3 times a day
----ETC>

 

[Fox800]

Rename the ED "Tests 'n pills". That's what the people want.

"The American people have spoken, and they want...radiation." (CTs)

 

[HemorrhagicShock]

These are outstanding tips!

I've had to reframe my entire mindset to reverse burnout. As somebody mentioned above, SO much of the patient's satisfaction with their ED visit is completely out of our hands, and trying to spin my wheels to make everybody happy was destroying me.

I've completely shifted my approach and now I FULLY lean into being a waiter/customer service concierge "the patient knows best" kind of doctor and it's made my job a thousand times easier. It's fully on autopilot, I don't even think twice about it, and it makes my day a THOUSAND times easier.

It's zero sweat off my back to order a quick x-ray, or even do a bunch of BS labs. You REALLY want those antibiotics? Okay sure, have a work note with it. You want Mom to be admitted? Okay, let me order a million-dollar work-up, and dictate an easy Level 5 chart. Hospitalist refusing to admit? Not a problem, ally with the patient and family and show them how I'm "pulling favors" to try to get them admitted. Point towards the evil insurance companies as the reason ("I really want your Mom to be admitted too, but doctors no longer make those decisions anymore, let me see what I can do on the backend, I promise we're going to figure something out that works for everybody"), and then coach them up on what to say to the hospitalist when they come down to see the patient after they refuse and I tell them that they at least need to see them before refusing. Easy.

I saw a very helpful PandaBearMD post on Reddit recently (he posts there infrequently with the same classic sage advice) and it changed my perspective and has helped immensely.

Equanimity with the dumpster fire that is EM, stoicism on shift (always), and the One True God is leaving your shift on time. Nothing else is more important!

 

[Fox800]

These are outstanding tips!

I've had to reframe my entire mindset to reverse burnout. As somebody mentioned above, SO much of the patient's satisfaction with their ED visit is completely out of our hands, and trying to spin my wheels to make everybody happy was destroying me.

I've completely shifted my approach and now I FULLY lean into being a waiter/customer service concierge "the patient knows best" kind of doctor and it's made my job a thousand times easier. It's fully on autopilot, I don't even think twice about it, and it makes my day a THOUSAND times easier.

It's zero sweat off my back to order a quick x-ray, or even do a bunch of BS labs. You REALLY want those antibiotics? Okay sure, have a work note with it. You want Mom to be admitted? Okay, let me order a million-dollar work-up, and dictate an easy Level 5 chart. Hospitalist refusing to admit? Not a problem, ally with the patient and family and show them how I'm "pulling favors" to try to get them admitted. Point towards the evil insurance companies as the reason ("I really want your Mom to be admitted too, but doctors no longer make those decisions anymore, let me see what I can do on the backend, I promise we're going to figure something out that works for everybody"), and then coach them up on what to say to the hospitalist when they come down to see the patient after they refuse and I tell them that they at least need to see them before refusing. Easy.

I saw a very helpful PandaBearMD post on Reddit recently (he posts there infrequently with the same classic sage advice) and it changed my perspective and has helped immensely.

Equanimity with the dumpster fire that is EM, stoicism on shift (always), and the One True God is leaving your shift on time. Nothing else is more important!

I think it's time for an EM version of The House of God.

All hail the One True God (leaving work on-time).

 

[WorkNoteEmergency]

Yes the X-rays are actually a time saver. Patient can sit in a chair, you do other stuff and explaining a neg Xray or Xray with just degenerative stuff (which I what I tell older people to expect and then I’m the genius doc) is way quicker than talking someone down from a no diagnostic work up visit.

Cyclic vomiting and cannabis hyperemesis - once the frequent flyers have had 3-4 visits without lab abnormalities, they don’t get any more work up from me and sometimes (rarely) even get away with no IV.

I also would ask up front a lot, “you just need a work note?” and that saves everyone a lot of hassle.

 

[dozitgetchahi]

These are all great tips and I hope we have more coming!

What other "BS" Rx do you all use? How about showboat approaches with the angry daughter who's an MA and has a son who is in "medical school" to be a "radiologist" (actually studying to be a rad tech)

Tip from the rheumatology clinic:

Check a vitamin D level and if it’s low, start them on daily vitamin D (like 1000-2000IU)…that dose is unlikely to ever be excessive for someone, and if they have diffuse pain and the level is really low, it may even help reduce it. Plus it will be helpful for bone health etc.

One of my attendings in rheumatology fellowship always emphasized checking this in fibro patients. That way, you can look like you’re doing something specific and special for it.

 

[CajunMedic]

A wise attending told me during my training that they just need something to occupy their time long enough until they forget about the whole ordeal.

I'd always teach my residents "What's their prize for coming in?"

These are all great tips and I hope we have more coming!

What other "BS" Rx do you all use? How about showboat approaches with the angry daughter who's an MA and has a son who is in "medical school" to be a "radiologist" (actually studying to be a rad tech)

Back Pain: PO Toradol for 5 days, Robaxin (usually low-dose), and 5% Lidocaine patches
My tummy hurts and I'm not being brave about it: Zofran and Bentyl
Sniffles and relatively healthy: Short course prednisone, Tessalon Perles and +/- take home Albuterol Inhaler
Chest Wall pain w/Negative Work Up: Explanation of precordial catch, 125 of Solu-Medrol and short course of prednisone

Since I work on the border of the Midwest and the Northeast, my accent and last name are an anomaly. My accent tends to get thicker and more "down the bayou" later into a night shift anyway. I will pour on the cajun charm and my last name will sometimes start a conversation and defuse angry family members. Worked really well my last shift with an entire pissed off family

 

[CoolDoc1729]

For the frequent flier cyclic vomiting/gastroparesis/HG patients that Zofran "doesn't work for" (i.e., they didn't take it before coming straight to the ED after vomiting twice) - promethazine suppositories, PO metoclopramide or prochlorperazine.

I consider “zofran didn’t work for me” to be the equivalent of a positive cannabinoid UDS. It really seems like the cannabinoid hyperemesis patients need some d2 blocking action. We don’t have droperidol so I’m a compazine fan. I need the noise to stop lol

 

[BoardingDoc]

Yes the X-rays are actually a time saver. Patient can sit in a chair, you do other stuff and explaining a neg Xray or Xray with just degenerative stuff (which I what I tell older people to expect and then I’m the genius doc) is way quicker than talking someone down from a no diagnostic work up visit.

Cyclic vomiting and cannabis hyperemesis - once the frequent flyers have had 3-4 visits without lab abnormalities, they don’t get any more work up from me and sometimes (rarely) even get away with no IV.

I also would ask up front a lot, “you just need a work note?” and that saves everyone a lot of hassle.

Yeah, the cannabis puking frequent flyers don't get labs or an IV after visit 3. IM meds only.

 

[RustedFox]

I'd always teach my residents "What's their prize for coming in?"




Back Pain: PO Toradol for 5 days, Robaxin (usually low-dose), and 5% Lidocaine patches
My tummy hurts and I'm not being brave about it: Zofran and Bentyl
Sniffles and relatively healthy: Short course prednisone, Tessalon Perles and +/- take home Albuterol Inhaler
Chest Wall pain w/Negative Work Up: Explanation of precordial catch, 125 of Solu-Medrol and short course of prednisone

Since I work on the border of the Midwest and the Northeast, my accent and last name are an anomaly. My accent tends to get thicker and more "down the bayou" later into a night shift anyway. I will pour on the cajun charm and my last name will sometimes start a conversation and defuse angry family members. Worked really well my last shift with an entire pissed off family

I use this to my advantage as well as a PA boy working in FL.

Patient from the north? - "You know how we work, neighbor. We northeasterners know how to get things DONE."
Patient from the south? - "Listen, I wasn't born in the south, but I got here quick as I could. Y'all unnerstand?"

 

[Angry Birds]

So essentially it doesn’t matter. They will complain regardless.

No. You gotta hit them at the hour mark. Exactly. Haha

 

[Angry Birds]

Yes the X-rays are actually a time saver. Patient can sit in a chair, you do other stuff and explaining a neg Xray or Xray with just degenerative stuff (which I what I tell older people to expect and then I’m the genius doc) is way quicker than talking someone down from a no diagnostic work up visit.

Cyclic vomiting and cannabis hyperemesis - once the frequent flyers have had 3-4 visits without lab abnormalities, they don’t get any more work up from me and sometimes (rarely) even get away with no IV.

I also would ask up front a lot, “you just need a work note?” and that saves everyone a lot of hassle.

Dude. A thousand percent about X-rays. Patients love X-rays and it makes it so easy to just see them after their bullsh** X-ray. And I just order portables and call radiology tech to bang it out.

 

[Angry Birds]

These are all great tips and I hope we have more coming!

What other "BS" Rx do you all use? How about showboat approaches with the angry daughter who's an MA and has a son who is in "medical school" to be a "radiologist" (actually studying to be a rad tech)

I do reverse psychology here. I’ll say stuff like, “Oh wow, your daughter is a great resource here… blah blah blah.”

 

[Angry Birds]

we

If you give Patients something to do it gives them a since of participation in their well-being. If you do it right they go out feeling like a member of the team. Examples would include....
----Tell them to eat more fruit.
----Tell them to drink more water.
----Have them walk up 3 flights of stairs Am and PM
----Brush their teeth 3 times a day
----ETC>

I don’t know about this. I think they like meds. And meds that aren’t over the counter. That’s what they are coming for.

 

[CoolDoc1729]

If you give Patients something to do it gives them a since of participation in their well-being. If you do it right they go out feeling like a member of the team. Examples would include....
----Tell them to eat more fruit.
----Tell them to drink more water.
----Have them walk up 3 flights of stairs Am and PM
----Brush their teeth 3 times a day
----ETC>

I think about 1/3 of my patients would arrest if they walked up 3 flights of stairs. My area is comically poor and unhealthy. And if I mention fruit I’ll hear about “food deserts” even though I myself shop at the store 2 miles from the hospital on my way home. 🤦🏻‍♀️

 

[Tiger26]

Surprised nobody has mentioned the most basic and archaic theatrical standard of care--auscultation of the heart and lungs.

A test that gives me almost no clinical value in the era of imaging for all and invariably results in a complaint if not done.

 

[BoardingDoc]

Surprised nobody has mentioned the most basic and archaic theatrical standard of care--auscultation of the heart and lungs.

A test that gives me almost no clinical value in the era of imaging for all and invariably results in a complaint if not done.

I only use my stethoscope to detect wheezing or if I know I'm going to do literally nothing for a person who has a BS URI and has no need to be in the ER anyway.

 

[Tiger26]

I only use my stethoscope to detect wheezing or if I know I'm going to do literally nothing for a person who has a BS URI and has no need to be in the ER anyway.

Exactly--99% theatric. The occasional wheeze or to tell them their lungs sound viral.

 

[WorkNoteEmergency]

I consider “zofran didn’t work for me” to be the equivalent of a positive cannabinoid UDS. It really seems like the cannabinoid hyperemesis patients need some d2 blocking action. We don’t have droperidol so I’m a compazine fan. I need the noise to stop lol

I used Haldol quite a bit until we got droperidol back.

 

[thegenius]

we


I don’t know about this. I think they like meds. And meds that aren’t over the counter. That’s what they are coming for.

I agree, I wish there was a good Rx med for pediatric common colds or mild bronchiolitis. know any?

 

[thegenius]

Surprised nobody has mentioned the most basic and archaic theatrical standard of care--auscultation of the heart and lungs.

A test that gives me almost no clinical value in the era of imaging for all and invariably results in a complaint if not done.

lol

"your heart sounds strong sir" - patients love that more than anything else. it allays their chest pain fears

"your lungs are nice a quiet" - patients love that too but they don't know what "quiet" means...so I tell them that it means they aren't working hard at all. Do this all the time for pts aged 0 - 8.5 who come in with nonsense breathing complaints

 

[gutonc]

Exactly--99% theatric. The occasional wheeze or to tell them their lungs sound viral.

I even tell people it's performative and they still love it. I usually just talk to them through the whole process. 3 or 4 birds with one stone.

 

[Ghee Buttersnaps]

I try to reframe everything to present it that we are all on the same team even if I am trying to do the opposite of what they want. "Its great that you are worried about pneumonia, I was also worried about pneumonia when you told me how you are feeling so it seems like we are on the same page. I am so relieved that your X-Ray was clear and I didnt even hear any evidence of it when I listened to your lungs!"

Then a party favor of albuterol and tessalon perles

Then return precautions given with as much seriousness as possible to show how much I want to make sure the patient is getting better

Dude. A thousand percent about X-rays. Patients love X-rays and it makes it so easy to just see them after their bullsh** X-ray. And I just order portables and call radiology tech to bang it out.

And every now and then on a spine XR that has been ordered 5 hours ago in triage a kind radiologist will throw you a bone and say "XYZ finding can be seen in muscle spasm" or something great like that. How can a patient argue with it when it says it right there on the X-Ray!

 

[Tiger26]

I might even add ear tubes for kids as procedural theater. Basically, you as a parent brought your kid to the ER at midnight so frequently that they invariably were diagnosed with otitis often enough for you to get an ENT visit for what was essentially just the viral spectrum of toddlerhood.

If you ask ENTs, they'll tell you that they'll put ear tubes in for anything who gets sent to clinic.

 

[Fox800]

Exactly--99% theatric. The occasional wheeze or to tell them their lungs sound viral.

Same. We wear an in-ear radio headset so we only have one stethoscope earpiece in, can't hear anything on 99.9% of patients anyways unless it's super loud. It's all theatrics.

 

[Angry Birds]

For young, non-diabetics, I throw short course prednisone around like candy.

I refuse to do the antibiotic thing that urgent care loves so much though.

Prednisone blasts are probably just as bad. Not that I don’t do it though.

Same. We wear an in-ear radio headset so we only have one stethoscope earpiece in, can't hear anything on 99.9% of patients anyways unless it's super loud. It's all theatrics.

In-ear radio!? What in the world?

 

[Pudortu]

Same. We wear an in-ear radio headset so we only have one stethoscope earpiece in, can't hear anything on 99.9% of patients anyways unless it's super loud. It's all theatrics.

I bought a $300 stethoscope with audio amplification. No joke I caught a murmur on my first patient. Then I quit caring because it didn’t make a difference to me. Now I use it for wheeze or no wheeze.

 

[GonnaBeADoc2222]

This thread is sad. It shows the bastardization of our field.

It's amazing when I have rational patients that are happy with simple reassurance after a chest x-ray.

That being said, daddy needs his PG bonus so keep the pearls coming!!!

 

[WorkNoteEmergency]

Prednisone blasts are probably just as bad. Not that I don’t do it though.


In-ear radio!? What in the world?

I worked in a USACs joint that used them and pissed everyone off because I refused to wear it. Drove me bonkers trying to talk to a patient while some other people are kibbitizing on the radio. Dumbest thing ever but it was supposed to make a “quiet ER” . I lasted 9 months there.

 

[TooMuchResearch]

Surprised nobody has mentioned the most basic and archaic theatrical standard of care--auscultation of the heart and lungs.

A test that gives me almost no clinical value in the era of imaging for all and invariably results in a complaint if not done.

It fell out of favor for me for a few years there but I'm listening to hearts and lungs with a vengeance these days.

 

[RustedFox]

It fell out of favor for me for a few years there but I'm listening to hearts and lungs with a vengeance these days.

Bonus if you turn the stethoscope and use both the bell and the diaphragm.

Magic.

 

[Fox800]

I worked in a USACs joint that used them and pissed everyone off because I refused to wear it. Drove me bonkers trying to talk to a patient while some other people are kibbitizing on the radio. Dumbest thing ever but it was supposed to make a “quiet ER” . I lasted 9 months there.

It's great to get a hold of a nurse or tech instantly, if they are wearing their radio. It's annoying when they're telling jokes or whatever and won't shut up while I'm having to have a serious talk with patients/family.

We need a separate channel for docs only, or to reach the doc. No RN and tech chitchat allowed.

 

[HemorrhagicShock]

Because EM is mostly theatrics and acting (let's be real here - the medicine is less than 10% of the job), how do you apply these philosophies to consultants? Particularly the recalcitrant ones, or ones that typically push back on even the most standard and straight-forward admissions?

A tactic I rarely use, since most of our consultants and hospitalists are awesome, is effusive praise at the bedside in front of the patient.

The consultant that was a dillweed over the phone, that I had to force to come in? I will make sure that I either confront him in person when he sneaks into the ED and thank him profusely for the help (it's hard to be an a$$hole to somebody else's face, much easier over the phone), or I'll wait til he's in the patient's room, barge in, and sing praises about the consultant to the patient. "Oh, didn't mean to interrupt, good to see you Dr. ENT! He's going to take great care of you and we're going to come up with a good plan. I'll let you all finish and come back and reassess. Thank you everybody!"

I'll do it in the most TV doctor way, and the patients and families love it, and you KNOW the consultant is seething with rage inside, but he's now in front of the family and patient. I'd say 90%+ of the time the consultant will check back in with me about the case and be cordial and surprisingly appreciative, making the next handful of consults much easier.

Works wonders

 

[The Knife & Gun Club]

Everyone needs a door prize. It’s the participation trophy of our generation.

One of my favorite moves is printing a referal to a specialist on prescription paper for the patient.

We have an order for most outpatient referrals so I’ll put the order into cerner, type “please call 305-555-5555 (the hospitals main scheduling line) to schedule your appointment with Dr. Whoever or the first available provider” into the comments.

Then print the order like I’m printing a paper script.

Walk into the room and sign it with a dramatic flourish in front of the patient.

 

[Angry Birds]

Everyone needs a door prize. It’s the participation trophy of our generation.

One of my favorite moves is printing a referal to a specialist on prescription paper for the patient.

We have an order for most outpatient referrals so I’ll put the order into cerner, type “please call 305-555-5555 (the hospitals main scheduling line) to schedule your appointment with Dr. Whoever or the first available provider” into the comments.

Then print the order like I’m printing a paper script.

Walk into the room and sign it with a dramatic flourish in front of the patient.

Genius

 

[FrustratedFamDoc]

I’m primary care but the performance is the same. Full physical! Etc.

1. My opening line: ‘good to see you. How can I be helpful for you today.’ Bam, straight to business.

2. Don’t tell them it’s vistaril cause ‘maaan, that’s like water.’

Atarax. They’ve never heard of it. Sounds like Xanax. It’ll buy you time, at least until you see them again.

 

[BoardingDoc]

I’m primary care but the performance is the same. Full physical! Etc.

1. My opening line: ‘good to see you. How can I be helpful for you today.’ Bam, straight to business.

2. Don’t tell them it’s vistaril cause ‘maaan, that’s like water.’

Atarax. They’ve never heard of it. Sounds like Xanax. It’ll buy you time, at least until you see them again.

By the same token, you can always rx for dolobid as well. Also only works once.

 

[Fox800]

By the same token, you can always rx for dolobid as well. Also only works once.

Can also try this with Percogesic.