The Customer is NEVER Right - A Nurse Practitioner's Perspective
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Another HUGE melt down, this time, a 35 year-old female with dental pain and the enabling administration.

The patient’s medical complaint was a long convoluted history of dental pain for more than a month and why she was in the emergency department versus seeing a dentist, blah, blah, blah, blah, blah. On exam, not that it mattered, because as mentioned many times, over and over and over, these dissatisfaction complaints have nothing to do with healthcare but everything to do with EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS. Nonetheless, the physical exam revealed a number of teeth missing and the rest of them had cavities, erosions, fractures and/or all of the above. Overall, just very poor dental hygiene, to critics, that is NOT being judgmental but a diagnosis and even more reason why the medical complaint was not an emergency, not that dental pain is an emergency ever.

“Here are your discharge instructions,” I said to the patient, which included follow up with a dentist and Pen VK (antibiotic).

“What am I getting for pain?” the patient asked.

“A dental block, which will last 2-4 hours, and also take ibuprofen or naproxen as needed for the pain,” I said, which she had agreed to when I saw her initially. However, by the time I put her discharge together, gathered the necessary equipment for a dental block and returned to perform the dental block and discharge her the patient had changed her mind.

“Are you kidding me?” the patient fired back.

“Ah, no,” I answered. Did I mention the patient was crying the entire time about how bad the pain was during the history of present illness, review of systems, physical exam and the discussion of treatment, follow up and why to return to the emergency department? She was. And maybe that was why she agreed to the dental block initially as I doubt she did not hear me mention the dental block. Anyhow, then I suddenly had her attention as her crying had come to a sudden halt. However, it seemed, if not obvious, that she had not heard anything I had said. Although I believe it was selective listening, as I was not convinced her lack of hearing my instructions was because she had cried the entire time when I initially saw her. As I found it ironic that when she did not hear what she sought all the crying stopped.

“I want to see someone else who is going to give me something for my pain,” she yelled, again, no longer crying.

“Sure you can. You can see a dentist. Or, you can check in again,” I replied.

“I want to see someone NOW(!) who is going to give me something for my pain,” she yelled back, again, no longer crying.

“I am going to do a dental block to take of your pain away right now. That will help with the pain and will last for 2-4 hours. Then take acetaminophen, ibuprofen or naproxen, as needed, for the pain. Because what is going to help your dental infection are antibiotics and not pain medicine,” I added.

“I know my patient rights. I want to see someone else,” she yelled back.

“I agree. You need to see a dentist. Or, you can check back in after I discharge you,” I said.

“NO!” she yelled at the top of her lungs. “I want to see someone who is going to give me pain medicine NOW!” she yelled at the top of her lungs some more.

“No ma’am. That is not how any of this works. You are discharged and you need to follow up with a dentist or you can check back into the emergency department,” I said.

“NNNOOOO!!!” she continued to yell at the top of her lungs and I walked away.

In the past, when patients asked for another provider or “a second opinion”, as their patient rights dictate, I would tell them that was what the follow up was for, to make sure they were doing better and/or a second opinion. Sadly, healthcare administrators did not like my answer stating I had misunderstood the patient’s request at that moment as it was a customer service issue and not about follow up or about “a second opinion”. Oh, really? Sounds like placating and NOT healthcare to me. Therefore, in order to keep my job, I decided not to get involved with patients seeing some else or a “second opinion” at those moments. Consequently, when a patient says they want to be seen by someone else I just tell them to go check in again. It bottlenecks the already overcrowded healthcare system, but again, customer satisfaction is NOT about healthcare and instead solely about customer retention and profits. Not to mention, it is not fair to add to other providers’ census JUST because a patient did NOT get what they wanted. So, if administrators do not care about overwhelmed systems then sending one more to the waiting area to check in, again, will not matter.

At the nurse’s station I asked the clerk to call security to have the patient escorted out. Oh. Did I mention it was 5:30am and the dental clinic on campus opened at 7:00am?

Yes, every weekday, the dental clinic takes the first 20 patients as walk-ins and the line starts to form at about 6:00am. Did I also mention this dental pain with the long convoluted history had been going on for more than a month? Yes, more than a month. And, and, the unconvincing part of the physical exam was that when the patient was distracted the dental and intraoral exam was unremarkable other than poor dental hygiene and multiple chronic dental issues but nothing that looked acute. Yet, I had to fix it now and why I offered her a dental block. But NNnnnoooooo!

Of course the charge nurse then got involved after all of the screaming down the hall. Unfortunately, the charge nurse wanted to point out that the patient had an opioid contract. Although I understand the administrative “position” of opioid contracts and I know the charge nurse was on my side I shared with the charge nurse, “It does not matter to me if the patient has an opioid contract or not. She [patient] does not need opioids for her dental pain. And, even if she didn’t have an opioid contract she still does not need opioids.”

“But if she has an opioid contract we can tell her we are not supposed to give her opioids,” the charge nurse replied.

“I understand,” I said, “but the issue is not that I am ‘not supposed to give her opioids’ because of her so-called contract. The issue is she does not need opioids for dental pain. Thus not that I am ‘not supposed to give her opioids’ but that I am NOT going to give her opioids. Not to mention, what would be your argument then if she did not have an opioid contract and she insisted on opioids when I cannot find reason to prescribe them? Whether her or anyone else.”

That said, again, knowing the charge nurse was on my side, although not what I was looking for as when these incidents occur it is not the moment to seek out companions and why I always take full ownership of these moments and try not to involve others. I also knew the charge nurse was not suggesting that opioids are ONLY for patients without opioid contracts. With that said, I do NOT entertain opioid contracts. DO NOT. DO NOT. DO NOT. And I do not for a number of reasons but here are a few:

-Providers create opioid contracts because they are incapable of telling patients, NO! That is not I. I do not and will not hide behind opioid contracts to tell patients no. The answer is no not because you have an opioid contract thus I “cannot” prescribe them to you. The answer is no because I, me, I, do NOT find a reason to prescribe you an opioid. Of course, some will say why not pick your battles. This being a battle someone else has already battled for you and all you have to do is point to the pain contract as to the reason why you “cannot” prescribe them opioids. No, that is not I. When I say NO it is because I said NO and not because your mother said NO. I take ownership of my decisions rather let others do that for me.

-Administrators support opioid contracts so those patients can be written off as problematic without affecting the organization’s satisfaction scores if the patient complains. That is not I. Not to mention, bad stuff happens to bad people too. Even a drug-seeking patient may have a condition in which they may need a narcotic temporarily. Is it still denied because of their pain contract? Pain contracts are nothing about doing the right thing but instead are a slippery slope.

-The ONLY thing opioid contracts do is LABEL people. My narcotic prescribing habits are limited and why I NEVER get caught up in those issues and NEVER have reason to look up patients in prescription banks. How is that possible? NEVER have I seen a drug-seeking patient whose pain complaint was for anything I would consider an opioid for, like a fracture. Instead, drug-seeking patients, more common than not, have medical complaints for which I do NOT prescribe opioids, like headaches, dental pain, abdominal pain or musculoskeletal and joint pain being the most common. I do NOT prescribe narcotics for any of those thus I never have those issues with drug-seeking patients. Drug-seeking patients might get upset but I do not get caught up in the drama of having to look up patients in prescription banks to influence me on whether or not to prescribe narcotics.

Those being a few of my reasons as to why I shared with the charge nurse, “It does not matter to me if she [patient] has an opioid contract or not she is discharged.”

The charge nurse, again, who I know was on my side, went to inform the patient of her [patient] disposition. However, now security, with their impotent conflict resolution and aggression management policies, had become the patient’s shining armor advocate telling the charge nurse the patient “only” wants to be seen by someone else. The charge nurse then comes and repeats the patient’s request to me.

“I know already. She told me. And why I told her to go check in, either with the dentist or in the emergency department again,” is what I shared with the charge nurse. Unfortunately, by then I had an agitated tone as security got involved in what is not in their job description, to undermine the nursing and/or medical staff.

However, to everyone’s disbelief the patient does not really “only” want to be seen by someone else. Instead, the patient “only” wants what she wants and who she sees for that does not matter at all to her. And to get what she wants the patient is manipulative and because her strategy did not convince me now she is laying it on, and laying it on thick, I must add, to anyone that will listen. Because, to the patient, it does not matter if it were the security guard who gave her narcotic or housekeeping for that matter, as either would suffice the patient’s drug-seeking behavior if either were possible. On that note, maybe I should have given security the patient’s chart so that security could evaluate, diagnose, treat and disposition the patient. As if that was all the patient really wanted, to “only” be seen by someone else. What a missed opportunity?

Because if so that this patients “only” wanted to see someone else I would be willing to prove my point—that they are not interested in seeing anyone for that matter and instead just want what they want and who they get it from do NOT matter to them. To prove that point I would put a bowl of opioids in the waiting area, along with a stack of work absence notes (the notes being for a different complaining demographic—but that is another story), from where those seeking those items could just grab a fistful and go about their business without seeing anyone as it would keep them from bottlenecking the healthcare system. Because if those complaining, or better yet, yelling, drug-seeking patients wanted to be seen by someone, anyone, not a single opioid would be missing from where they were placed.

And by the way, to critics, drug seeking behavior is an actual ICD-10 diagnosis and not about being “quick to judge” or judgmental. But that too is another story.

Did I mention, after security interviewed the patient the officer came to ask me what had gone “down”? Does it really matter? Why do we waste resources on these patients? Security and I have other things to do rather wasting our time, money and effort on patients with EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS. For me, that includes seeing patients who value, trust and appreciate us for the care we give. For security, I was not aware hospital security was Scotland Yard or Columbo for that matter. This is not about us versus patients. This is about a patient abusing the healthcare system. And not any system or industry but a system and industry that is genuinely dedicated to looking out for their well being.

But NOOooo! Now I have to answer to security as to why the patient is complaining. Are you FREAKING kidding me!?! I DO NOT know why the patient is complaining. Go ask the patient complaining as to why she is complaining. My job is to evaluate, diagnose, treat and disposition patients and NOT to figure out why they are complaining. That’s the job of administrators who side with patients and why I leave that placating to administrators and I move on to the next patient.

But now, I guess, it is the job of security too, to placate to complaining patients.

My stand, although it has been my Achilles’ tendon, has been and continues to be to dismiss those who annoy us. Dismiss the rude, the entitled, the abusive, the demanding and outsiders who have taken us down the wrong tracks. Why? Because by dismissing those who annoy us it frees us to focus on those who value, trust and appreciate us for the care we give. However, although difficult for others, as it is not worth the risk of losing their jobs, on this we must stand in solidarity and not waiver. Otherwise those who annoy us will not change their behavior as long as they can find tolerance elsewhere. Thus why when security and administrators placate to those who complain the cycle continues.

As for security, am I above them? ABSOLUTELY NOT! NEVER have I believed or suggested that. Not above security, not above the charge nurse or advocating nurse, and not above complaining patients either. Actually, I am not above anyone for any matter. However, do I really have to rehash the entire exchange with security? Not to mention, some administrator will be by shortly who will want me to tell them what happened as well. But for those who want my answer this is it: I saw the patient. I evaluated the patient. I made a diagnosis. And, most significant I formulated a treatment, follow up and discharge plan. Unfortunately, unlike 99% of patients I see, this patient, this ONE patient, did not agree with those plans. Because of that, and only because of that, the patient wants to see someone else. But not “only” someone else but instead someone else that will agree with whatever the patient’s EXAGGERATED UNREALIST EMOTIONAL EXPECTATIONS are. Expectations, I must add, that have nothing to do with healthcare. Note, the patient is NOT complaining about my evaluation, diagnosis, follow-up or discharge. The patient is ONLY complaining about my choice of analgesic. Not to mention, when encouraged to check in to the emergency department again the patient balks. Why? I have no idea. However, what about these reasons, all speculation, but bear with me as I point out some of the obvious.

-The patient agrees with everything except my choice of analgesic, a dental block and NSAIDs.

-The patient does not want to see a dentist for whatever number of reason.

-The patient does not want to go through the waiting again.

-The patient does not want to take a change that who ever picks up the chart next might have the same prescriptive practice as I of no opioids for dental pain.

I am sure there are many more reason or not as to why the patient will not see the dentist or check into the emergency department again. But whatever those are those interested in the reasoning, as I am not, must ask the patient.

Nonetheless, security wants details. “Read the chart!” I didn’t say that, as I know security cannot read the chart as that would be a HIPPA breach for the patient but damn.

Anyhow, now security is not an ally of mine but of the patient and I am okay with that as everyone wants to be the patient’s advocate because I guess I am NOT.

However, I will say this, and for no reason other than to point out the ridiculousness of such position of other. It is appalling that I am trusted to care for the ill and injured, men, women, child, infant and the unborn. Yet, when I dismiss those who tread on us I am no longer trusted but a monster. A monster enablers have determined is inappropriate and why enablers feel compelled to coddle those who tread on us. Sadly, the enables do not stop there but they also seek others to do the same for them under the membership card of advocacy.
My position as to when others suggest, or better yet tells me, to pick my battles. Picking your battles is NOT only the mantra of those who have NOT fought battles but more so it is a position of convenience. Because anyone who has fought any battle will tell you how inconvenient that is and it is that inconvenience and sacrifice which gives worth to the battle.
On that note, I never solicit anyone’s support, although it would be very much appreciated. I do not solicit anyone’s support as I am well aware of the wrath, which includes losing everything as I have so many times, from being on the “wrong” side, as defined by others, of these skirmishes. That being something I never wish onto others nor will I put them in such jeopardy.
If what is meant by “a monster” or “rude” is that I am conceited, standoffish and confrontational because I do not allow others to define me, push me around or walk all over me than I will wear that label proudly. Because as long as anyone is a welcome mat who defends and coddles those who are inappropriate those who are inappropriate will not only walk all over you. The inappropriate will also wipe their shit-caked feet on you as well. Because of that I always stand in solidarity with those I share a shift with, even those who are undermining, as I will not allow outsiders to divide us.

Nonetheless, the endpoint to this debacle was to just have the patient check in again. But NOOOoooo!

Now security, the dissatisfied patient’s “NEW” advocate, involves the nursing supervisor, an administrator. Why? Because the patient does not want to hear it from the charge nurse either after the charge nurse informed the patient she was discharged. So now security, the patient’s “NEW” and supreme advocate, dismisses the charge nurse as well in what security must believe is in the patient’s best interest. Really?

Now the nursing supervisor asks the attending physician to see the patient. I, of course, or at least of course in my mind, came unglued telling the nursing supervisor, “There is no reason why the attending needs to see that patient.”

It’s not like the attending sees patients who are in agreement when I discharge, transfer or admit them. This is not a pulmonary emboli I am negligently discharging. This is not a misdiagnosed necrotizing fasciitis I am negligently discharging. This is not an abdominal patient I have overdosed with opioids and despite the patient’s respirations are six per minute I intend to discharge after given the patient a single dose of narcan. This is not a patient with a penicillin allergy I intend to give Bicillin IM to after consenting the patient to the risk of anaphylaxis shock and potential death.

Nor is it because of my incompetence or breach of duty. Nor is it because I might cause injury, disability or death to the patient. Nor is it because of my prejudice, alcohol or drug addiction. Nor is it because I am unreliable or cannot be trusted. Nor is it because I undermine those I work with.

It is none of those. Instead, this big brouhaha and the reason the attending is being asked to get involved is ONLY because the patient complained. And for the same reason, or lack there of, an alliance has formed to advocate for the patient over my desire to discharge her to follow up with a dentist.

Having said all that, one would hope intervention was solicited for any of the negligent other reasons listed above but it was not. Not that the intent here is to point fingers but instead to point out, that the above-mentioned conditioned have been discharged by others, both physicians and non-physicians, only for those patients to return with significant complications. Complications that could have been prevented if “so-called” patient advocates were looking out for outcomes and the safety of healthcare workers and patients rather concerned about dissatisfied customers. However, to those misfortunate cases the administration simply says, “Those incidents were system failures and are being handled.” Oh really? System failure? Yet, when patients or families complaint about healthcare workers because that healthcare worker did not cater to EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS those incidents are not system failures but the individual healthcare worker’s character flaws. On top of that, those complaints from patients and/or family are taken at face value as to whatever those who complain make up is the truth and no reason for those incidents to be thoroughly investigated.

However, as I shared with the current director, as long as those negligent healthcare workers are not on the customer complaint radar those providing poor care are not dismissed. A comment the director did not appear too comfortable with yet did not dismiss. Nonetheless, this dental pain patient is not a sentinel event about to happen or even one of 40,000 annual medical errors in healthcare about to happen either. So then why does the attending have to get involved with this patient? Why!?!

Oh, for the sake of saving an unsatisfied “customer”. Got it. It’s called “customer recovery”.

“Why can’t the patient just go line up at the dental clinic or check in again [in the emergency department] if that is what she wants, to be seen again,” I ask the nursing supervisor.

The nursing supervisor firing back, “You no longer matter.”

WHAT!?! I no longer matter. Really? That was the answer from the administration. I no longer matter. Really? Aww! My ego. I no longer matter. Maybe I should go home then. I thought.

I “NO longer matter”. That is an interesting one. Never heard that before. Not to mention, when the patient seeks litigation against me, do I still NOT matter? How interesting! A “NEW” paradigm. If you want to matter you have to stay off the patient complaint radar. Oh! Okay! Got it!

More interesting is the fact that despite the number of these melt downs and ALL the drama they involve at every place I have worked at nothing ever changes as the end result is the same as well, me being fired or being asked to resign.

Strangely enough, despite me knowing the administration will side with patients and families I am still amazed that administrators continue to side with petulant, unreasonable, angry and demanding patients over those of us who are not only vetted extensively but more so are permitted to provide care to the masses, the ones who do not complain. More ironic is the fact that of ALL the masses seen it is those with EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS who remind me as to how expendable we are. Expendable not because of a bad patient outcome as those healthcare workers are given the benefit of the doubt and a risk versus benefit assessment is conducted and rarely are those healthcare workers dismissed. Yet, we are expendable, without discussion I will add, because we will not bow or cater to the whims of others. That comment not to play the victim card but to point out that it makes NO sense, at least to me. And even worse that administrators would say, “you no longer matter” to those caring for the masses who did not complain. I am sure any satisfied patient would agree that those who do not bow do matter.

If I recall correctly, that same shift I admitted three patients and transferred another two or three and discharged a number of them all of which were appreciative and satisfied yet the administration says I “no longer matter”. Huh!?!

Nonetheless, after the nursing supervisor’s plea to the attending to see the complaining patient I had discharged the attending asked the nursing supervisor to have the patient check into the emergency department, if the patient’s desire was to be seen in the emergency department again.

Oh, wait, where did I hear that before? That a rhetorical question as I have no expectations of attending physicians in supporting me for any reason as we work independently and neither of us owes the other anything. However, it is a breath of fresh air when someone supports you in that manner. Having said that, I do not find it appropriate that my patient load is being thrown onto the attending physician’s lap as the attending has their own patients to see. I also do not appreciate it when the attending is asked to pick up patients I have already seen as I feel that I have let the attending down.
It is obvious that I “no longer matter” because when I made the suggestion 30 minutes prior it was inappropriate. Yet, the attending says the same thing and the nursing supervisor leaves with her tail tucked between her legs to tell the patient the choices were to either check into the emergency department or follow up the dental clinic. The same patient the charge nurse and I told the same thing to, to check in again or follow up in the dental clinic more than 30 minutes before. But NNNNOOOOOOooooo! So now it was the nursing supervisor telling the patient to check in if she wants to be seen again and it was fine. Huh?

Although never been the case, not that I am aware, I am just curious what the administration says when the patient declines to be seen by the attending. Oh wait, that is a story from the book. A patient who demanded I find her a surgeon after I called her surgeon and her surgeon declined to see her before her scheduled appointment. I, of course, said, “No” to the patient’s request that I find her another surgeon. However, at the patient’s insistence and because of her inappropriate behavior the attending physician in the emergency department at the time called the hospital’s medical director, a surgeon, who accepted and catered to the patient’s demands. Thus the patient was admitted, as she had demanded.

Nonetheless, with regard to the dental patient, now the dynamics had changed. Somehow, during the same shift, I went from seeing patients and dispositioning them on my own, to include admissions, transfers and discharges, to “no longer matter”, to what I said more than 30 minutes earlier, in the patient’s best interest, he-he (that’s a laughing he-he), and now back to being able to see the next patient. To top it all off, now the administration was okay with the patient checking in, again, for the same medical complaint. However, again, as well, the administration had no qualms with the patient bottlenecking the system.  Not to mention, just a moment ago according to security and the administration, it was I who was being bombastic and inappropriate when I asked the patient to sign in again. Huh?

WHY? What had changed? NOTHING!

Oh, wait a minute, there was a difference, the nurse practitioner “no longer matter[ed]” but the nursing supervisor could not say the same to the attending. Not an issue of mine but an issue of the nursing supervisor as I do not get caught up in the politics of administrators as patients seek help from healthcare workers and not administrators. But, whatever!

So the patient checks in again and without any additional drama, I must add. Despite I said the same to the patient more than 30 minutes before, to check in again. But at the time the patient yelled, “NOOooo!” and demanded to be seen by someone else as if I were a monster and should not be allowed to make such suggestions to patients.

That’s okay, it was obvious security and the nursing supervisor thought the same as the patient, that I am a monster and should not be allowed to make those suggestions to patients. But now it was attending who made such bombastic and inappropriate suggestion and no one thought the attending was a monster. Not the administrator and not the security officers. So now the same words, check in again, MUST be okay. Oh. Okay. Once again I am reminded where I stand in the line of things.

So the patient checks in and is seen again, not by me and not by the attending, but by the fresh provider who just came in at 6:00am and who immediately discharged the patient without any pushing back. Why? Anyone?


Yes, the patient was given a prescription for opioids for her dental pain. Whatever! Again, had security or the administrator done the same, just given the patient some opioids, the patient would have been out the door a long time ago.

Just to be clear, my issue is not with drug-seeking patients but about the difference between appropriate healthcare and accommodating the EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS of the few.

I am okay with patients complaining that their EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATION were not met rather bowing to poor healthcare because of placating.

I hope the security officer and the nursing supervisor are not patients some night, not because I would dismiss them, but because that will be very awkward, considering I “no longer matter” to them yet I am the one seeing them. Although, they may request to be seen by someone else and if so I will discharge them as well after telling them to check in, again.

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