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.

We are expecting our first grandchild this fall. Here is a picture of our son, Philip and his prego wife, Elizabeth, with the diaper bag I made for “Genghis,” the best name they have been able to come up with so far.

This recipe is in a Pillsbury cookie cookbook I found at a thrift store. I used Granny Smith apples for crispness and tartness. I added a sprinkle of granola to the top of the dough before baking, which added a fun crunch and made them more interesting to look at. I used cinnamon, rather than nutmeg. Next time, I will try the nutmeg but would certainly put in less than the 1 teaspoon it calls for because that much nutmeg is just too much for my taste.

Recipe By:

Pillsbury

Ingredients:

1½ cups firmly packed brown sugar
½ cup butter, softened
¼ cup milk
1 tablespoon lemon juice
1 teaspoon grated lemon peel
1 egg
1½ cups all purpose flour
1 cup whole wheat flour
1 teaspoon baking soda
1 teaspoon cinnamon or nutmeg
¼ teaspoon salt
1½ cups finely chopped apples*
1 cup granola, plus more for topping**
1 cup powdered sugar***
¼ cup lemon juice

Directions:

1. Heat oven to 375°F.

2. In large bowl, combine brown sugar and butter. Beat until light and fluffy. Add milk, 1 tablespoon lemon juice, lemon peel and egg. Blend well.

3. Add all purpose flour, whole wheat flour, baking soda, cinnamon and salt. Mix well.

4. Stir in apples and 1 ½ cups granola.

5. Drop in 2 tablespoon balls about 2 inches apart onto ungreased cookie sheets. Sprinkle with additional granola and gently press into surface.** Bake 9 to 13 minutes or until light golden brown. Immediately remove from cookie sheets. Cool until completely cooled.

6. Meanwhile, in small bowl, combine powdered sugar and ¼ cup lemon juice
lemon juice, adding enough lemon juice for desired drizzling consistency. Drizzle over cooled cookies.***

Notes:

* I used Granny Smith

** I added the granola on the surface and it made them look a lot cooler and the crunch was really fun.

*** I used almost twice as much glaze as the recipe called for.

My patient was a 34-year-old man who was brought in by ambulance after having a seizure. He was confused and not able to tell us what had happened. A while later, the wife arrived and said the patient woke up in the middle of the night, as he was prone to doing lately. She said he was pacing around the house when she heard a thud on the floor. She found him having a grand mal seizure.

For the last several months, the wife said, the patient had been behaving abnormally, especially at night. She said he would get up several times during the night during which time he would stretch, groan, rub his hands over his hair, pound his chest then jump back into bed. Sometimes, he would wander aimlessly around the house before finally going back to sleep.

The patient and his wife had argued over this because the patient denied any knowledge of these spells and it was his belief that she was not telling the truth when she would describe them.

When the patient recovered from the seizure and was back to his normal self, he admitted to several other worrisome symptoms. For example, he might be driving down the freeway when he would get the feeling he needed to jump out of the car. His hands would come off the steering wheel and fall to his lap. He felt an intense internal conflict as he really wanted to jump out of the car but was completely unable to move. This would quickly pass and he was able to continue to drive normally. He also admitted to having frequent feelings of déjà vu. *

This is a very interesting case of what most certainly was a new diagnosis of temporal lobe epilepsy. **

Here is a case report I found in the medical literature that describes night behavior like my patient had. I paraphrase it here:

The patient is a 39-year-old man with no family history for epilepsy or sleepwalking. From age 6, the patient had episodes while asleep during which he suddenly woke up, screamed, and had complex and movements of his arms and legs. Sometimes he fell out of bed. In other episodes, he got out of bed and walked around the room with violent movements, screaming with a terrified expression. Lastly, he went back to bed. His parents thought that he seemed to be conscious throughout the seizure and that he was aware of it, though the patient denied this. These episodes lasted about one minute. www.journalsleep.org/Articles/250609

* http://en.wikipedia.org/wiki/Déjà_vu

** http://en.wikipedia.org/wiki/Temporal_lobe_epilepsy