The Customer is NEVER Right - A Nurse Practitioner's Perspective
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I saw this story back in 2009, when it originally made headlines, and dismissed it because although I can relate based on my experience in the emergency department my plight with regard to the customer experience is not about where my taxes goes. Not that I do not have a beef with wasting tax money, because I do, it’s just that is not my issue with patients or families who complain. My frustration, instead, and the book’s theme, is that patients, whether the well off or not so well off, insured or not insured, and adorned or not adorned, push back against those of us looking out for their best interest and, worse, that healthcare administrators side with them.

If dismissed then why mention now? Because since the mentioned article our nation has become even more divisive and the political theme this election seems to be between the haves and the have nots. When instead the underlining theme is more of the same, as in elections past, fraud, waste, and abuse that somehow gets lost by claiming divisiveness.

In the book I too mention fraud, waste and abuse, as it cannot go without mention, however, it is only mentioned in the book on how it relates to healthcare. My experience, and only my experience, after working at more than 30, yes, more than 30 different healthcare organizations, which include urban, suburban and rural, and in the communities of the haves, the have nots, and the more common potpourri of everything in between, has taught me that how a patient adorns themselves, their habits, or what insurance or lack of insurance they have does not predict anything. It does not predict their health consciousness. It does not predict their compliance. And much less does it predict their sense of exaggerated unrealistic emotional expectations or entitlements either. None of it is predictable.

To that, although I cannot list, as they are too many to list, the number of times those with more expect special treatment and to who I say, “No.” My reasoning, if its not available for those who have less I will not considerate it for those who have more regardless their blue-blood claims or their deep pockets. Having said that, I agree that if they have the means and can afford “xyz” then they should get “xyz” and that is fine with me as long as they pay for it from their own pockets and not from taxpayers or healthcare insurance. Case in point, and I have many, a well off patient in the emergency department requests a plastic surgeon for a facial laceration repair. “Tomorrow, on your own, you can go find a plastic surgeon that can do a better job,” is what I say. Why? A plastic surgeon is not an emergent need. If the organization consults plastics for all laceration, to include on weekends, holidays, and the wee-wee hours of the night or morning, then fine. If not but only does so for those with the means then that is not an organization I want to work at. If the patient insists on a plastic surgeon then I will discharge them to call their private plastic surgeon to come repair the laceration, as long as their plastic surgeon is credentialed at the organization. Having said that, that is not to say that if a laceration is too complex and needs plastics or another specialty I will not consult that specialty, because I will.

Having said that, just because you have insurance does not mean your insurance should pay for unnecessary diagnostics or treatments either as that unnecessary cost is passed on to others. Case in point, again I have many of these entitlement examples as well, a young man wanted an MRI of his back because of back pain. That is not how any of this works I shared with the young man citing it was not the standard of care. And when the patient reminded me he had insurance my answer was I will order it but will document the order is by the patient’s request and not clinically indicated. That being an order his insurance likely will not pay for thus he would have to pay for it himself. Again, if you have the means to pay for it have at it but I will not run up the bill just because you have insurance.

On that note, those on Medicaid, adorned or not, are not the only ones who smoke “costly” cigarettes or participate in other unhealthy behaviors, like tattoos or abuse of alcohol and/or drugs to mention a few vises. As the well off partake in those too. Not to mention, what if those shiny teeth, tattoos, expensive shoes and/or new cellphone are how the patient was paid for instead of with money for whatever it is s/he does for a living, whatever that may be. Why? Because I do not make judgments I make diagnoses.

In the book I mention that I do not fall for the all too common, “You don’t know me” victim card either. So this is not a soapbox moment of scolding those who judge others as that is their issue and not mine. Instead what I tell those who pull out that card of “Don’t judge me” is, “Who you were does not matter. What matters is who you are now.” Meaning, which differs from what “life coaches” (whatever that is) tell their clients, how you are behaving this moment is what matters because who or what you are has no weight with me.

On top of that, these points of view or labels of “the haves” and “have nots” are only divisive and accomplish nothing but pin us against one another and puts blinders on us as to the real problems in healthcare.

Another example, but first a disclaimer—very few have the extreme view against illegal immigration that I do, to include Donald Trump who I would call a “Mini Me” when it comes to illegal immigration. With that said, illegal immigrants do not, again, DO NOT, suck up healthcare. Instead, the award of the most parasitic healthcare consumer goes to our nation’s citizens, those insured or uninsured alike, who think every sneeze is swine flu, every headache a tumor, every cough cancer and any stomach pain is Ebola.
That includes illegal immigrants who have waited so long before seeking medical attention that their conditions are now so critical that their care becomes so costly, which although a burden they are not the parasitic ones. But that is another topic and has nothing to do with healthcare but instead has everything to do with the underworld of illegal immigration and those who defend and profit from it claiming they are advocates, but, again, a totally different topic.

All that to say this about the mentioned posted comments from a healthcare worker in 2009. Yes, I CONCUR, we have a “crisis of culture”. However, and where I differ, although the adorned on Medicaid are part of the problem they are not the only ones to blame. Because although not able to cite the source it is a well-known fact that 50% of our nation’s healthcare cost is consumed by 5% of our nation’s population. A cost that is mostly concentrated on the top ten most expensive medical conditions: heart conditions, cancer, trauma, mental health, arthritis, COPD/asthma, diabetes, hypertension, normal birth and hyperlipidemia. None of which can be solely contributed to the “have nots” as “the haves” also contribute to the “crisis of culture” with regard to healthcare and in general society as well, but the latter also a separate theme not for here. Again, nothing to support my two sense [sic] other than my experience of working for 30-plus years in healthcare and at more than 30 very different healthcare organizations.

Nonetheless, the point is to see patients as patients and not how they are adorned or the lack there of. The same goes for seeing them as patients, ill or injured, rather than seeing them as consumers, customers, clients, or guest.

Now, in Dr. Jones defense, his comments were as a taxpayer and not as a healthcare worker as he never mentioned he did not treat that patient despite his objection to her adornment and/or habits. Again. NO Shoes. NO Shirt. NO Service. Homeless or Bill Gates. The Pope or a child molester. Clean underwear or not. Neither are policies in healthcare and a significant distinction from other industries I must add.

The political point is this one, disagreement is not a hate crime or a crime at all. To those who suggest Dr. Jones seek another profession, disagreement is it a lack of compassion or of caring either. Who of us is absent of disagreement with those we love most? Yet, those disagreements are not the end of those relationships.

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