Sunday, March 7, 2010

Customer Service

A lady has pet duck. One morning she wakes up and finds the duck floating feet up in the backyard pond. She takes the duck out of the water and rushes the duck to the veterinarian.

The vet looks over the duck, shakes his head, and says sadly to the woman, “I’m sorry, but your duck is dead.”

“That can’t be!” cries the woman. “You need to do some tests!”

“Ma’am,” says the vet, “I know this is upsetting. But I’ve been working with animals for twenty five years, I and I can say with metaphysical certitude that your duck is dead.’

The lady crosses her arms, a look of defiance in her eyes. “Doctor, I don’t believe you. I don’t think you’ve checked thoroughly enough.”

The vet sighs. “Okay.” He goes out of the room and comes back with a cat. He puts the cat on the examining table. The cat walks around the duck, sniffs at it, and looks at the vet. The vet looks back at the cat.

The doctor takes the cat out of the room and returns with a Labrador retriever. The dog walks around the table, it’s nose in the air; it rears up on its hind legs and peers over the edge at the rapidly cooling bird. The dog looks at the vet. The vet looks back at the dog, his tail drooping with sorrow.

“Ma’am,” he says again, “your duck is dead. And I’ve done a CAT scan and a Lab test to be sure.”

(You saw that one coming, right? And a tip of the cap to John McLaughlin as well. That man can turn a phrase like nobody's business.)

There are lots of reasons health care costs are rising in this country. Defensive medicine. Increasing health insurance premiums. Technology costs. An emphasis on procedure instead of prevention. Fraud and abuse. Administrative overhead. Profit margins. And while very few of these factors are under the direct control of the physician, doctors are constantly being asked to be the “front line” defenders of the system in order to hold down overall costs.

But then there’s this thing called “Customer Service.”

Amy Zaguni is late 40’s-ish woman with chest pain. She’s had it before about six months ago. She had several cardiac risk factors noted at the time…a family history of heart disease, and she smoked a half pack of cigarettes each day…so she was admitted to the Chest Pain Center of our hospital for further evaluation. Serial blood tests revealed no evidence of a heart attack, and a stress test performed at that time was normal. She was diagnosed with chest pain due to anxiety, and had actually been seen by her cardiologist within the past several weeks and given a refill of her medicine for anxiety.

Today, her chest pain is back. She tells me the pain is sharp, knife-like, radiating from the front of the chest through to her back. The pain is not associated with any nausea, vomiting, sweating, or shortness of breath as would be classic for a heart attack. It’s been constant for a few days, and it gets worse when she coughs or takes a deep breath. Her lungs are clear, and her heart sounds fine. Her heart rate and rhythm on the monitor is normal. I can push at the joints between the breastbone and the ribs and bring back her pain, and her pain is also reproduced and made worse when I ask her to move her arms while I provide resistance to the movement. (The latter actions will tense the pectoralis muscles of the chest; pain to these maneuvers suggests that the insertions of the muscles on the chest wall are involved in some fashion.) The nurse had followed our chest pain protocol prior to my arrival in the room, and had obtained an electrocardiogram (EKG) which was perfectly normal.

I explained to her that everything about her history and exam suggested that this was probably chest wall pain, and most likely did not represent pain coming from the heart. I said we would get a chest x-ray to make sure we’re not missing something else going on, but if that looked good we could send her home with some medication for her discomfort and simple instructions for home care.

“So you’re saying it’s all in my head.”

“No, ma’am. What I’m saying is that I think your pain is coming from the wall of the chest and not from your heart or lungs. The EKG looks good, and we’ll get that chest x-ray too, but with a normal stress test six months ago I think it’s pretty safe to say it’s not your heart. A stress test may change over time, but we’re talking years, not months. So I really think we can get you on your way home in fairly short order.”

“But you need to get some blood tests.” (Sometimes I make the mistake of forgetting, in these days of patient empowerment, that many of them are full graduates of the Wikipedia School of Medicine.)

“No, ma’am. Based on the way you describe the pain and your examination it’s pretty clear what’s going on. I don’t think blood tests are going to be helpful here, and I hate to stick people with needles if I don’t have to.

“I want some blood tests done.”

One of the best lectures I’ve ever been to was called “Ten Things I’ve Done to Change My Practice.” It was delivered by Dr. Gregory Henry, who at the time was an emergency physician somewhere in Michigan. In his talk, he espoused the “Philosophy of Yes.” In the ED, there’s already enough stress on you. When patients make a demand of you, it’s just easier to give in than fight the good fight. You’ll spend less time disputing with the patient, they will like you for giving them what they ask for, and there will be a lot less nasty phone calls from administration. Besides, as most ED physicians get paid a straight salary the only way it affects your income is by losing your job because of patient complaints.

I’d like to think that a lot of what Dr. Henry said was hyperbole for the sake of making a point, but in many ways I’ve taken his thoughts to heart. So as long as I think that what the patient wants is not too invasive, not likely to cause them any harm, and not likely to violate any of my personal ethical beliefs, I’ll pretty much do whatever they want. Plus, I usually work on the “Baseball Rule.” I’ll explain things twice, and if the request is the same a third time I just figure I’m outta there.

“Sure, no problem.” I’m doing my best to smile. “You seem pretty aware of the medical system. Which blood tests would you like?”

“The ones you would usually do in a case like this.”

“Ma’am, as we talked about before, I would usually do no blood tests in a case like this. So if you ask me to order the tests I’d usually get, the answer is that I would get none, which is not what you want. So what tests would you like?”

This goes on for twenty more minutes, with the above conversation repeated, in its entirety and with much additive excruciating detail, three more times. Meanwhile, as I’ve been trying to negotiate the provision of cost-efficient and efficacious care, the Lords of Triage have just thrown three more patients into my box who need to be seen. This, of course, is my own fault…in the interest of customer satisfaction, I’ve just discharged three other patients rather than make them linger for no particular reason. If I hadn’t done so, the ED would be clogged up and I could actually decrease my stress level and my workload because there would be no further room at the inn. Silly work ethic...we’ll have to fix that.

There are lots of things we could talk about related to this story…what lab tests actually mean, how they should be used, how accurate they are; the benefits and risks of the popularization of medical knowledge and of patient empowerment; if the demands of patients upon their physicians and the health care system as a whole would be impacted by reform that insured all parties are liable in some way for the costs they incur; and what role tort reform would play in the willingness of physicians to aggressively engage in cost containment. As I sit at my computer and write, these are all truly fascinating areas of discussion and debate which can keep me entertained for hours on end. (Note: Beer and nachos help.) And I’ll be perfectly willing to admit that part of why I’m frustrated by this issue is that many of the patients we work so hard to satisfy are, in fact, not responsible for their own costs. Their care quite literally comes out of my own pocket, both in the taxes I pay and the professional fees I’ll never receive.

But for me, as a working ED doctor, this story is all about customer service. And in the medical setting customer service means meeting patient demands, pure and simple. If nothing else, it represents a professional survival strategy. The shame is that it’s not good medical care.

(Author’s Note: The way I write has very little order or structure to it at all. I’ll sit down and type out whatever comes to mind on the screen, going back to rewrite and edit at some later time. So I always find little random segments of thought scattered throughout the document files when I open them up. Following are the things I found appended to the draft of the larger piece above:

On the first day of Christmas
My true love said to me,
There’s no way I can be pregnant.

On the second day of Christmas
My true love said she had
Two beers last Sunday,
And there’s no way I’m having a kid.

On the third day of Christmas
My true love said she got
Three hives from Ultram,
Two beers last Sunday,
And I’m not sure the kid will be yours.

Nurse to patient: “When you tell me you take Lortab and Xanax for chronic pain, and your drug screen turns up negative, it means the sink is peeing for you.”

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