I went into medicine to help people. Emergency medicine gives me a lot of opportunities to do this and relieving pain is one of the most rewarding parts of my job. Usually, making pain go away makes patients happy.
Making patients happy is more and more an important part of medicine. Hospitals survey patients and track complaints in evaluating quality of care. Insurance companies and government agencies use patient satisfaction data to determine reimbursement rates. This information is also increasingly available on the Internet to consumers who want to pick providers with high satisfaction records. In a world of increasing competition, high satisfaction scores give hospitals and doctor groups an advantage in attracting and retaining patients. This puts a lot of stress on doctors to keep their patients happy. As a result, the practice of medicine is increasingly driven by the business philosophy, “The customer is always right.” If the doctor does what the patient wants, the patient is happy. The patient gives high satisfaction survey scores and never complains. The doctor, his group and the hospital all look good and are happy.
This is wonderful as long as patients want what is good for them. When patients demand care the doctor doesn’t feel is in their best interest, a conflict develops. If the doctor says “no” to patient demands, the doctor may be rated lower on patient satisfaction surveys or even have to respond to official patient complaints. Knowing this, the doctor has to decide whether to do what he or she thinks is best for patients or just give patients what they demand.
To illustrate how this engenders conflict, I will tell you about a situation where a patient complained about my care.
A middle-aged man came in complaining of abdominal pain. He had been seen in our emergency department many times over a few months for similar complaints. I had this in mind as I took a medical history and examined him, including pushing carefully on his abdomen. I then excused myself and went to look at the documentation of his many previous visits to the emergency department.
When I returned to the exam room, I reviewed with him his many emergency department visits of the prior year. Most of them had been for abdominal pain for which he had almost always been given intravenous opiates. I told him I had no way of knowing if he were or were not a drug addict. I told him that, if he continued to come to the ED for opiates, he certainly would become addicted. I also pointed out that, as much as he uses the ED, he had to expect our staff would probably treat him as if he were an addict. I counseled him to take stock of his life patterns and do everything he could do to work with his primary care physician to avoid coming to the ED for pain medicines.
I offered to run tests to make sure he had no serious medical condition causing his abdominal pain. I offered to give him something to help his pain but told him I felt it would not be in his best interest to give him intravenous opiates. He argued with me but, when he could tell he would not get intravenous opiates, he refused further care and walked out.
I was not at all surprised when, a few days later, I was contacted by the hospital’s Patient Services Department about a complaint they received from this patient about me.
I am sure he felt like I accused him of being a drug addict. He didn’t get the opiates he had grown accustomed to getting on previous visits to our ED. I am sure he was unhappy when I told him hard truths he didn’t want to hear. While all that may be true, I think I took good care of this patient. However, patient satisfaction data alone might suggest I am not a good doctor because I didn’t make my patient happy. You can see how unfair this is and why I am frequently conflicted over how to deal with this sort of a situation.