The Customer is NEVER Right - A Nurse Practitioner's Perspective
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Patient complaints continue

Although the book has been written and in publishing, patient complaints continue to be frequent  and unrelenting. Not having anywhere to turn to share those stories, although sometimes I slip and unfairly mention them to my much better half, I will document them in this blog, where others may comment on the same but keep in mind patient confidentiality. Sharing the stories in the book was not about me complaining but instead to direct change by showing how ridiculous and redundant patient complaints are yet administrators side with patients/family every incident over those trusted to care for others. On top of that, the stories themselves scream to be told as they are so outrageous and documenting them alone is therapeutic. For all those reasons I will continue them here.

On that note, shortly after a parent and the teenage patient stormed out of the room I was seeing them in I was informed I had a telephone call on hold. After introducing myself to the person on the other side, a customer service administrator, I was asked if I recalled a patient I had seen two days prior. The answer was, “No,” as I rarely recall patients unless an exceptional case. After retrieving the mentioned patient’s chart the administrator and I went back and forth for a period clarifying the patient was not a child but instead a twenty year old adult. The confusion stemmed from the fact that it was not the adult patient who complained but instead the patient’s parent, who by the way was not present during the adult patient’s visit.

According to the administrator, the parent complained that I was rude and made the patient feel stupid and because of that they would not be returning. Although the administrator pressed me as to how or why the patient or the parent would come away with that conclusion all I could recall was the patient had a cold sore on her lip and chin.  However, I mentioned to the administrator my intent was not to be rude or make anyone feel stupid and that it was common for others to misinterpret my dispassionate and phlegmatic character in a negative manner.

During the same conversation the administrator mentioned another parent had just complained about not returning to the clinic because I was inappropriate and rude. That parent happen to be the parent and teenager that had just stormed out of the room before I picked up the telephone to speak with the administrator. Now that was an exchange I could not forget as it had just occurred.
The parent stormed out of the room followed by the teenage patient only because I declined to provide the patient a school note. I had seen the patient, with the parent present, two days earlier and the patient was diagnosed with a viral illness. As a consolation (a balloon-a metaphor discussed in the book), knowing there would be no benefit, I offered the parent Tamiflu as the parent was looking for something. However, the parent turned it down and instead requested a note for school, something I do not subscribe to as healthcare should not be proxy parents.

If a parent does not want to send their child to school for whatever reason that should be between the parent and the school and healthcare should not be the authority of that decision. It is one thing to keep infectious patients segregated from the masses but not wanting to go to school or work because I do not feel well should be an adult’s decision and not “My Doctor said so.” Especially when I could not find a reason to keep the patient out of school or work.

Sadly, to appease the parent, I wrote a note for school but declined to include the day before as the parent had requested. Two days after the initial visit and the day the school note expired the patient returned to the clinic. Although the parent mentioned the patient was not better and the patient mentioned he was nauseous the night before neither thought the patient was worse. On that note, and after the physical examination I said to the parent, the patient did not appear ill, just like two days before, and that he could return to school that morning.

As if I had been talking to the wall the parent said, “Are you not going to give him a note for school?” “No,” I said. “But he had fever this morning,” the parent injected. “What was the temperature?” I asked. “He felt hot. I do not have a thermometer. I have always touched his forehead and I know when he has a fever,” the parent said. “But he did not have fever when he checked in this morning,” I said looking at the chart. “Because I gave him Tylenol before we came in,” the parent snapped back. “And you should,” I said. Adding, “But, Ma’am, I cannot justify keeping your son out of school when he does not appear ill nor has a documented fever.” “Are you calling me a liar?” the parent snapped. “No Ma’am,” I replied, “I am not suggesting you are lying. Its that your son does not appear ill.”

Then out of nowhere the parent says, “What if I told you he had a temperature of 101?” After a short pause the parent added, “He had a temperature of 101 this morning.” Concerned of that comment I said to the parent, “Do you really want me to add that to the chart after you said you did not check him for fever with a thermometer?” The parent then became infuriated making statements I dismissed because she was angry and then they stormed out of the room.

I shared that with the customer service administrator on the telephone and her reply was, “You may want to change your way of addressing patients because [the organization] cannot afford patients not returning.” Holding back words I said to the administrator, “The issue was not that the patient was ill or not. The issue was the parent wanted a note for school for whatever reason.”

The administrator then questioned me if I were to see her as a patient, “Would you believe me that I was vomiting or would I have to bring in evidence of vomit?” At that point, I knew the administrator was taking the patient’s side but nonetheless I answered, “Vomit is objective. I do not need evidence if you vomit or have diarrhea. But saying you almost threw up or almost had a seizure or were almost run over by a truck was subjective. And if you say that for whatever reason, yet do not look ill or injured, it is hard to say if that is true or not.”

“I been working at this clinic (Locum) for less than one month and today was the third time I seen that child,” I said to the administrator. “Besides seeing him two days ago, I saw him before for an abdominal pain he has had intermittently for more than one year, and when I saw him the pain was gone but I believe the parent wanted a note for school that day too and I said, ‘No.’” By the way, the adult patient which prompted the customer service administrator’s telephone call, I had seen her twice in less than a month also. The administrator’s closing statement was I curb my demeanor and presentation with patients as the organization could not afford patients not returning to the clinic.
Interesting enough, the above conversation with the customer service administrator was not the first one while working at that clinic, as I had spoken with her weeks earlier about a different patient meltdown. However, during the first conversation I was being asked if the patient with the meltdown needed to be fired from the practice to which I answered, “I do not let or feel threatened by patients. However, if the clinic staff does feel threatened by the patient than yes you should fire that patient but that is something you need to ask your staff.”

That patient’s medical complaint was an infected toe nail according to the chart. However, after introducing myself the patient went into a diatribe that he was there to check on who was the healthcare provider denying his friends their medicines. To which I took issue with and said, “Sir, I am not going to discuss treatment of other patients with you nor am I going to justify my practice.” I then asked him to climb on the examination table to look at his toe. Once on the examination table, the patient returned to his tirade and I stopped him again, “Sir, you will not talk to me or anyone at his clinic in that manner. I am here to provide a service.” “Then service me!” he snapped back. After taking a deep breath I inspected his toe, which was not infected, but the patient continued with his profanity and inappropriate behavior and without saying another word I walked out of the room, the patient following behind but into the waiting area.

That incident was reported by the clinic supervisor, as it was their policies to report such patient outburst. Because as for me, and as I mentioned to the clinic supervisor and the customer service administrator, “I do not have a problem seeing those patients. However, I will only see them as long as they behave appropriately. Otherwise, I will walk out the room leaving the patients talking to themselves.”

Not that it mattered, but I believe the toe nail patient’s tirade was because I had declined a number of patients refills for narcotics and instead referred them all to Pain Management and most of them objected. One in particular, and who I thought the toe nail patient was advocating for, telling me in a fury, “Go back to whatever country you came from.” A comment hard not to explode after. A comment, the family, who accompanied the patient and who was just as upset they were told to follow up with Pain Management, apologized for but I was not convinced the gesture was genuine and I walked away. The patient later calling the clinic to apologize also, I was told by the clinic staff.

Nonetheless, after the conversation with the customer service administrator about the school note and the adult patient with cold sores I went back to seeing patients. Ironically, the next patient did follow up with Pain Management at my referral. However, when I asked the patient how things went; in a nutshell the patient stated it was a complete failure and a big waste of time and she was only back in the clinic because it was almost thirty days and time for her narcotic refill.

The patient, in her mid 70’s was accompanied by her son who had a different concern than what the patient was there for. The son wanted to know if I had asked the patient, his mother, if she knew the street value of the narcotics she had requested at the initial visit. It was likely I had asked the patient that question after her request was for hydrocodone 10mg four times a day. That was 120 pills and each pill has a street value of $10-$20. So I may have asked her. But not because I thought she was selling the pills but because a report I had seen recently on TV and I was curious if the 70+ year old patient I had just met knew that. Nonetheless, the innocent query was no more than curiosity, although maybe after brought to my attention inappropriate, but never was the intent indicting or malice.

And although then and more so after the fact not justifiable that I asked the patient the street value of narcotics, meeting a 70+ year old patient for the first time who when asked why she was in the clinic she requested I refill her pain medication rather than her stating her condition I was caught off guard and was concerned. Some may say my concern was no more than semantics. However, I had to question the patient as to why she was taking the narcotics as she did not recall and to me that is disturbing and more so after she said, “That was neither here or there. I have been taking this medicine for a long time and I can not function without it because the pain was to much.” But she could not recall what pain it was she was prescribed the medicine for and the fact the dose was increased over time was disturbing to me.

Furthermore, although the patient was fragile she did not look to be in any discomfort and much less when I told her I would not be writing for hydrocodone 10mg as she almost became unglued. Making matters more upsetting for me, the patient also asked for a refill of  her colace (a stool softener for her constipation from opiate use). I just could not believe someone put this patient on a narcotic for whatever reason and rather than weaning her off it, the narcotic was increased to the current dose which pharmacologically was not doing anything for her pain but made her constipated.

So when I entered the room and the patient mentioned that Pain Management was a waste of time and after hanging up with an administrator who hinted I curb my interactions with patients to avoid them leaving the practice I wrote the 70+ year old a prescription for hydrocodone 10mg 4x/day Qty #120. However, when I asked if there was anything else the son insisted I explain myself and maybe even apologize for inappropriately asking his mother the cost of narcotics on the street.
Instead I told the son, “My intent was never malice. My intent is to take care of patients.” The son then added that if that were true why would I send his mother to have a steroid injection knowing the side effects of those medicines. Of course I held back, but my desire was to ask the son if he was then okay with the side effects and social damage narcotics have on patients.

After asking if there was anything else, to which the answer was no but I could tell the son was not satisfied, I walked out of the room. Thinking of the customer service administrator’s words, I thought to myself, one would think a family concerned I asked about the street cost of a drug would complain, but nope, I was never told that patient or family complained. The moment I sat down in the office chair I got up and went looking for the 70+ year old patient and her son, only to find them outside; the patient getting into their car and the son assisting his mother. I stepped outside and said to the son, “Can I share one more thing with you?” But the son indicated he was not interested. Regardless I said to the son , “Today is my last day here. So do not let me working here keep you from coming back. As next week you will have a permanent healthcare provider.” The son did not comment and seemed disinterest on whether I would be there or not.

At the end of the shift and on the drive home I thought of why or how the adult patient with the cold sores concluded I was rude and made her feel stupid. All I could come up with was, after the assessment and diagnosis of a cold sore I said to the patient, “This is caused by a virus and likely will clear up on its own. Do not pick at it to keep it from getting infected and forming a scar on your chin.” To which the patient immediately mentioned, “My family always needs medicines for viral illnesses.” That made no sense to me and while reviewing the patient’s chart I remarked, “Viral illnesses are not hereditary and although for some viral illnesses antiviral medicines my be helpful this was not one of them.” However, in the chart was a note for a similar episode and the patient was prescribed an anti-viral so I did the same and asked the patient if there was anything else and when she said no we both walked out of the room.

As mentioned, that was the second time I saw that patient where she was a patient in the four weeks I worked at that clinic. I wondered what the first interaction was like, as I was the same person, and she had returned. Nonetheless, neither of the above customers were right either but unfortunately it is likely I will not be invited to work for that organization again either.
The Customer is NEVER Right!

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