The Customer is NEVER Right - A Nurse Practitioner's Perspective
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Letter to Dr. Kelli Ward
Healthcare's "few indeed bad apples". WHAT!?!
They called it, “Violence in nursing”: I call it, “Healthcare Directed Violence”
Patient satisfaction = Nurse satisfaction, NOT!
What just HAPPENED!?!

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I am neither a pessimist or an optimist. I am a REALIST!















































I have now worked fourteen shifts thus far at the current job and I ALREADY see the writing is on the wall. That is not a self-fulling prophesy, a phrase I cannot stand, but simply a fact instead. I have seen this movie a number of times already.
 
Interestingly, however, during one SAME 10-hour shift customer satisfaction went from one extreme to the other and, luckily, back. This being an argument I made in the book, how is it possible that when the only changing variable is the patient that someone else, other than the patient, is at fault? Given everything else is the SAME, except for the patient, how is it possible the patient and/or family is NOT at fault? The same shift. The same day. The same staff. The same EVERYTHING! The ONLY different variable is the PATIENT! Yet, HOW!?!
 
I've been asked MANY times if I have ever considered myself the common denominator of these dissatisfied encounters. My answer, “NO!”

Here is an example, one of MANY, if nurse Bruno allows “X” inappropriate behavior from patients and/or families than nurse Megan should allow “X” inappropriate behavior as well. However, if nurse Megan DOES NOT allow “X” than it is nurse Megan who IS the problem according to healthcare’s submissive, altruistic and accommodating or junior-high school culture. Healthcare pointing to nurse Megan as the common denominator as these incidents ONLY occur with nurse Megan, thus nurse Megan clearly is the problem and NOT the person who is inappropriate. Those same persons, labelling nurse Megan as the common denominator, accepting the inappropriate behavior from patients/families as benign or as part of their job and tagging nurse Megan as being either too thin-skinned, too serious, the problem, or the latest social GARGABE—she lacks the emotional intelligence, just to name a few of the name-calling.
 
What if Megan is NOT the common denominator but instead the uncommon numerator. Semantics? If you like. The difference, the inappropriate behavior everyone tolerates and ignores is instead the common denominator. I get it, such tolerance is the path of least resistance and how we get to keep our jobs and/or stay safe. Believe me, no one I gets it better than I. But DON’T excoriate those who push back.
 
On the other hand, the uncommon numerator, like nurse Megan, are those who dismisses the ones who annoy US. NOT just those who annoy nurse Megan but those who annoy ALL of US! ALL OF US! As these inappropriate behaviors towards healthcare workers are NOT nurse Megan’s alone or even new but are common to us ALL and been around FOREVER!
 
Healthcare workplace violence is an underreported, ubiquitous, and persistent problem that has been tolerated and largely ignored.”
 
Those who do not push back BOWING because they DO NOT have nurse Megan’s testicular fortitude to dismiss those who annoy us. Again, not only annoy nurse Megan but annoy us ALL! I get it, nurse Megan is risking not only being labeled but worse being unemployed and NO ONE wants to be unemployed. IT SUCKS! I get it! After 30+ jobs I know being unemployed and having to find another job SUCKS! I know it very well! However, complacency with the status quo for whatever reason, lack of testicular fortitude or NOT wanting to be labeled or unemployed is NOT nurse Megan’s fault or reason for her to be labeled or excommunicated by others in healthcare. Whatever happened to, “All for one and one for all”? Oh, everywhere else but healthcare. GOT IT!
 
Adding insult to injury, healthcare administrator’s sacrosanct and ALL to common idiot-ology [sic] that conflict between healthcare workers and patients risks the administration’s goal of customer retention for profits, by any means necessary and at the risk of so much, to include disregard for expendable healthcare workers.
 
By nurse Megan dismissing those who annoy us, again, who annoy ALL of us, the rude, the entitled, the abusive, the demanding, and those who have taken us down the wrong tracks, outsiders and administrators as well, nurse Megan immediately deescalates any situation. How? The dismissal of any inappropriate behavior instantaneously takes away the thunder and attention those being inappropriate so desperately seek. More important, dismissing those who annoy us frees us to focus on those who value, trust and appreciate us for the care we give. Not to mention, it is NOT the job of healthcare workers to confront ANYONE who is inappropriate in any manner. That is the job of administrators or those the authority is delegated to, i.e. security. The job of healthcare workers is healthcare and NOT ANY KIND OF DRAMA, NONE!
 
The myth that businesses lose money or close because of those being dismissed told friends and families is hogwash. Businesses close for many reasons but NOT because of those who were inappropriate were dismissed. Sure, businesses might lose the ones who were inappropriate and that is fine as those businesses should focus on those who value, trust, and appreciate us for the care we give. And those, by far, are in the majority. If anything, dismissing those who annoy us will cause those who are inappropriate to change their behavior as they will eventually realize it is they who are the common denominator and they gained nothing with being inappropriate and why they were dismissed. The dismissal causing them personal conflict regarding their attention seeking behavior.
 
This tolerated and largely ignored silent national crisis, that is inappropriate behavior toward healthcare workers and healthcare directed violence of any scale, is ONLY because healthcare administrators and pundits DO NOT want to offend patients or families, as it jeopardizes their goal of customer retention for profits. Customer retention for profits being the driving force in healthcare and the reason why healthcare administrators side with customers over their very own and extensively vetted loyal employees. By doing such healthcare administrators also risk the safety of employees.
 
The following stories altered to maintain the patients’ privacy while maintaining the gist of the interactions and why any similarity is purely coincidental. However, of course those who complain could find these stories to be about them, as the song says, and if so they should notify the author for the story in question to be removed as cited in the site’s disclaimer page.
 
Again, the following stories occurred on the SAME shift of the SAME day with the SAME staff and even the SAME room temperature just to control ALL variable, except the patient. These stories occurring one after the other as well, I kid you NOT. One after the other in the presented sequence below. I CANNOT make this stuff up even if I got paid to do so.
 
A 72-year-old with chronic lower back pain. Those familiar with the theme of this blog likely, already, reaching the conclusion this story doesn’t turn out well and why it is here. Especially since the patient has already been seen by primary care (PCP), had x-rays done and scheduled to follow up next week to discuss the x-ray findings. Her PCP—someone the patient has been seeing for “years” the patient shares with me. Her back pain—she has been having for months, MONTHS, “maybe even years,” the patient added. Back pain that more common than not gets better with acetaminophen. Yet, her last dose, wait for it, wait for it, two days before I saw the patient. Imagine if she had taken the acetaminophen as needed until seeing her PCP in another week. But NNNOOOooo! Other than her back pain the history of present illness was unremarkable. No fever. No rash. No saddle paresthesia. No incontinence. No trauma/injury. NOTHING but CHRONIC back pain. However, the patient’s age—greater than 50 years old, a GINORMOUS BIG RED FLAG anywhere!
 
Again, the only concern is the patient’s age thus the standard work up—a lumbar x-ray series and urinalysis. And of course, a physical exam. As mentioned in the book, the physical examination is NOT a free estimate but the foundation of our decision making.
 
The x-ray revealing lumbar scoliosis, otherwise unremarkable, along with the urinalysis and physical exams that were unremarkable and the patient was discharged to follow up with her PCP. Easy peasy! Right? The story being shared for a reason.
 
After an extensive discussion with the patient, the family and nurse present, the patient asks if I have a local practice where she could follow up instead of her PCP, again, a PCP she has been seeing for “years”. Nonetheless, my answer, “No. I only work in the emergency department.” The patient mentioning how much she appreciated my attention and thoroughness with my physical exam and explanation of findings, treatment plan and expectations. The patient adding how her PCP, of so many years, “just ordered the x-rays without as much as a physical exam and much less an explanation,” her words.
 
My rehearsed answer to those comments, “I cannot tell you what others do or not do. I can only tell you what I do.” And off I went to see the next patient.
 
Not the next patient but two or three patients later during the SAME shift.
 
A 45-year-old with chronic knee pain who was scheduled to see her orthopedic surgeon regarding a recent MRA of the same knee just days before I saw her in the emergency department. The patient in the emergency department that day because of knee pain after a misstep while descending steps without a fall or other injury. Ooookayyyy.
 
But that’s not it. The patient is in the emergency department because the patient is incapacitated after the misstep, I guess. However, other than limited active range of motion of her knee because of pain the knee appears unremarkable to me. Other than the patient CANNOT bend or straighten her knee from where I found it, flexed at about 15 degrees. Otherwise, no deformity. No swelling. No bruising. No redness. NOTHING! But what do I know? That said, and something mentioned in the book as well, NOT only in “The Customer is NEVER Right” but in every book in medicine, PAIN DISPROPORTIONATE TO CLINICAL FINDINGS IS ALWAYS(!), ALWAYS(!), SIGNIFICANT UNTIL PROVEN OTHERWISE.
 
Otherwise commonly MEANING admission! That is the law of healthcare ANYWHERE and EVERYWHERE on this PLANET, EXCLAMATION POINT!
 
Of course, I always ask, “How did you get here?”
 
And they always say, “By wheelchair.”
 
And I always ask, “Do you use a wheelchair at home?”
 
“No,” they most commonly reply.
 
So, then I ask, “How did you get to the hospital if you don’t use a wheelchair at home?”
 
That is where the creativity begins, “I hopped.”
 
Really? “You weight 300lbs and stand 5 feet and you HOPPED? From where I stand you haven’t hopped in a VERY VERY LONG time. And that isn’t passing judgement but a diagnosis. Anyhow, today, despite the excruciating pain, you hopped. Okay.” Those words NOT spoken but thoughts that might have, okay, DID cross my brain.
 
Fine. On to the physical exam and the entire knee joint hurts. The knee hurts so bad the patient grabs my hand, which I cannot stand. When patients grab my hand during a physical exam I immediately stop and let them know my intent is not to hurt them. But instead that I must do an exam and that without an exam I am not able to reach a conclusive diagnosis. I then ask them if it is okay to continue with the exam, as I do NOT want to also be charged with battery aside their complain to administrators.
 
Sometimes patients push my hands away and that I cannot stand at all. Yet, despite I take their forceful contact as inappropriate, unnecessary and offensive, to those patients too I also tell I must do a physical exam and ask if it is okay to continue. However, I say the latter only after sharing with them first, “DO NOT push my hand away.” Sometimes they apologize. NOT that I am looking for them to apologize but when they DON’T more common than not there is a hidden agenda that eventually comes to a head, sometimes sooner than later.
 
If the patient insists that I NOT touch them I let them know I cannot do a physical exam without touch. And if they insist on NOT being touched they get the rehearsed answer when patients decline, “Your condition could worsen, cause permanent disability and/or death,” in this instance due to I am not able to reach a specific diagnosis or treatment plan without a completed evaluation, which includes touch. If, after that information of risks versus benefits, the patient continues to decline the physical exam I simply move on and document that the patient declined a complete evaluation after the patient verbalized understanding of the risks related with an incomplete evaluation, to include the absence of a diagnosis. After which, the patient will be discharged against medical advice.
 
However, with this patient that was not the case and after finishing the physical exam, I shared with the patient, family present, my diagnosis. Not enough. Of course, NOT! And why the story is here.
 
The patient wanting to know about x-rays that were taken prior to my assessment. X-rays I DID NOT order and would NOT have ordered as the x-rays were NOT clinically indicated, which I shared with the patient, the family present. Now some patients appreciate that information, decision and reasoning of not subjecting them to unnecessary diagnostics, in this case unnecessary radiation, and the unnecessary bill.
 
That, of course, was NOT the case with this patient and family. Both becoming unhinged, argumentative and inappropriate. The catalyst of their EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATION unknown, not that it matters as that is the patient’s issue, which then is catered to by the administration.
 
However, it being my first week I thought I would try to make this better somehow within my tolerance as I WILL NOT compromise my integrity for others, PERIOD. That said despite the issue, ONCE AGAIN, was NOT mine but ONCE AGAIN EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS. Nonetheless, I went and looked at the x-ray someone else had ordered. The x-ray—unremarkable. Imagine that. The knee actually looked like it had NEVER been used—the lines were nice and smooth without evidence of arthritis, effusion or any other finding. But I knew the bones and the joint were not the problem and why I would not have ordered an x-ray that would not help with the diagnosis. This pain was ligament pain simply from the history of present injury and mechanism alone, if any pain at all but that is another issue, and the clinical exam confirming it was NOT bone related pain. Nonetheless, I went back to share with the patient, “The x-rays look fine.” I ALSO might have said as well, but I do not recall although sometimes I do say, “Actually, the knee looks like it’s NEVER been used.” Unfortunately, a statement this patient may have taken offence to if I was right—that the knee may have NEVER been used.
 
Interestingly, when I returned to share the unnecessary x-ray findings the patient was NOW sitting on the edge of the bed, both her knees flexed at ninety degrees (normal) with her feet dangling and in NO distress. When, NOT more than two-minutes ago she could NOT flex the knee or tolerate me touching it. But somehow, while I was gone the patient manage to sit up and appeared to be ready to go. Another miracle wonder I guess. I CANNOT make this stuff up.
 
“If the x-rays are fine what is causing the pain then?” the patient asked.
 
Despite I had already mentioned it, AND I DO NOT LIKE REPEATING MYSELF in my private life or at work, I said it again, as I am trying to stay employed, “This is a ligament injury for which you are seeing an orthopedic surgeon and likely you have injured it some more.”
 
“But you don’t know that,” the patient fired back and the family as well although a bit later in the conversation, which I also DO NOT appreciate. I got it the first time, I DO NOT need you OR anyone else to repeat it.
 
What? I just told you the bones and knee joint look normal. You already know you have a ligament injury in that knee. You saw an orthopedic surgeon for it. You had a MRI of that knee. And for some reason, despite ALL you already know YOU came to the emergency department for my expertise and you think I have it wrong. WHAT!?!
 
Fine! “What am I going to take for the pain?” the patient asked.
 
“Rest, ice, keep it elevated and ibuprofen or naproxen,” I said.
 
NOPE! That did not go well. “BLAH, BLAH, BLAH, BLAH…” the patient said.
 
The spouse then injecting in, “Dude.” Which I DO NOT mind called by friends but I cannot stand being called by patients and/or families and it NEVER goes well when I ask them to refrain and they just repeat themselves, “Dude.” Thus, I walked out of the room.
 
The patient adding, “You act like your shit doesn’t stink.” Not sure what that means but I can assure you my shit does stink, some episodes more than others but it stinks.
 
Discharged instruction posted I went to see the next patient. When I return the nurse mentions the patient wants to complain. Okay. Sound the alarm!
 
From there the untrustworthy [pun intended] pattern throughout healthcare, the submissive, altruistic and accommodating culture, takes over and the customer recovery-obsessed administration protocol is initiate and they ALL showed up. First, the charge nurse who is someone annoyed with having to defuse a situation “someone else” caused with the first question, “What happened?”
 
Normally I say, “You will have to ask the patient (or whoever).” However, I been at the job a week and would like to make it through the month. Not to mention, no one here knows me, as if it matters and another story. But more important, again, I want to stay employed. So, I share a succinct version of the story with the charge nurse, which the patient WILL refute and their version will be the one taken at face-value thus why I DO NOT participate in those berating exercises. A movie whose ending I have seen a number of times and NEVER ends well. Nonetheless, the charge nurse gets what was asked and leaves, never to be seen again. Which is fine. Except…
 
Next, the Emergency Department Director shows up. The director just happened to be working during the same shift. The director sees the patient and shares with me a few points about interacting with patients and why I say the writing is on the wall.
 
In particular, the director mentioned that we are at the mercy of the screeners thus I should not throw them under the bus. The screeners—those ordering the initial diagnostics from when the patient first arrives to the emergency department, protocol that is very common across the nation emergency departments thus NOT unique to this one. However, the director’s pearl being related to my comment to the patient about not needing an x-ray to reach my diagnosis. The expected script, instead, I was told by the director, “The x-rays did not provide much information toward the diagnosis.” Oh. Okay. Which is similar to what I said EXCEPT I mentioned it with the emphasis before rather than after the fact and I also added, “I would NOT have ordered it.” Which I take to signify, “I am looking out for you.” DAMN! Once again, I was too forth sighted, I guess. Another bad quality I picked up somewhere and was not aware of. Oh well!
 
The director also adding, “I gave her something for the pain.” Oh! Okay! I guess. Maybe I should just go home.
 
My first chat with the director and what is it about a patient complaint. Again, a new job, and I am batting zero for three with this ONE patient. Not only did the patient complain. NO BUENO! But I also told the patient there wasn’t a need for x-rays. Which was true and the director agreed but nonetheless, NO BUENO! And I also did NOT cater to the patient’s request for “something for the pain” other than ibuprofen or naproxen. Again, NO BUENO! Wait? I thought three strikes was an OUT! Maybe it’s three patient complaints and you’re OUT! Nonetheless, I cannot imagine the director sees me a star. While being a star is NOT the intent or interest it DOES NOT help to be on the boss’s shit list within the first month at a new job. That I know from my extensive criminal [a Freudian slip] record and recovery from there is slim to none.
 
I get it, healthcare is a business. However, that is NOT how it is sold to patients. Believe me, if healthcare were sold as a business and we were transparent about running up the bill I would NOT have a problem with it. But that is NOT how it is sold thus for me running up the bill equals fraud, waste and abuse. Can running up the bill be justified? ABSOLUTELY! And why medical screeners have become the norm in emergency departments across the nation as is giving in to patients’ EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS the norm throughout healthcare as well.
 
The same with catering to customers, in any industry, the idiot-ology [sic] is more about creating new industries rather fixing any problems. That being the reason I say, “Healthcare is NOT broke but as intended, customer retention for profits.” No more and no less. And that is fine if that is the case but it’s NOT being share with those paying the bill.
 
The belief that businesses will lose customers, thus money, has been debated for decades, across ALL industries with the same findings. Businesses DO NOT close because of poor customer service, they DO NOT. Some customer service subject matter experts even pointing out that customer service, to include the new and improved version customer experience, is a SCAM!
 
That said, NO one wants to provide poor customer service or be known for poor customer service.
 
However, businesses who push back against inappropriate customer will only lose the customers who are inappropriate and not customers who are appropriate. If anything, those businesses should be grateful of such loss as more common than not inappropriate customer are needy and toxic. Because of that losing inappropriate customers will ONLY save those businesses the time, effort and money to spend with customers who genuinely value, trust and appreciate the business over inappropriate customers with their hidden agendas. Not to mention, businesses who dismiss inappropriate customers will dodge many unnecessary headaches to say the least.
 
Sure, those who are inappropriate will badmouth the business and tell 10-100 of their family and friends. Today, maybe, even millions more within their social media networks. However, and what businesses take for granted, those who appreciate us, regardless industry, are loyal and that is who we should seek over those who annoy us.
 
If businesses dismissed those who annoyed us rather cater to them, those who annoy us would realize they achieved NOTHING by being inappropriate. Not to mention, at some point those who annoy us will learn it is they who are the common denominator no one wants to do business with them. However, for that to happen businesses, especially healthcare, must stand in solidarity and dismiss those who annoy us for change to happen. If not, those who annoy us will simply find refuge where the inappropriate behavior is tolerated as the comportment of any organization is the behavior which is tolerated.
 
Unfortunately, because of the fear of being badmouth for dismissing those who annoy us or of losing ONE customer to the competition businesses have become complacent with the status quo of catering to the dissatisfied and balk rather push back.
 
I get it, it’s a business and businesses make their money from customers and without customers there is no money. Got it! However, and my argument, you must have confidence in your employees as it is their expertise that customers seek rather go elsewhere. Nowhere is that expertise more desired and appreciated than in healthcare and from healthcare workers. The phenomena of returning customers in healthcare is largely based on expertise sought versus service. That ought to be reason enough for healthcare employers to side with the employees they vetted and who are loyal to the organization rather side with customers who are inappropriate. Business will survive without those who are inappropriate. Businesses will not survive if they lack expertise. Here is the litmus test, if the inappropriate behavior is behavior you would NOT accept at home than you should NOT accept it at your business and much less ask your employees to accept such inappropriate behavior.
 
The time of small thinking over the status quo must end, in ALL industries but especially in healthcare where our lone desire is to help others. Unfortunately, for healthcare, that will NOT change until healthcare changes its submissive, altruistic and accommodating culture—a HUGE paradigm shift.
 
I get it, the director is running a business and I DO NOT have a problem with such, after all it’s how I get paid. But at what cost? The director mentioned about being thrown under the bus. WOW! I cannot wait until I see that patient and/or family again and I will see them, as they fit the “frequent flier” profile. Again, not judgement but a diagnosis. Something tells me we will meet again but with the NEW paradigm established by the director the patient will decline to be seen by me and likely will ask for the director directly, no pun intended. And, of course, I will discharge the patient to be seen by someone else. The patient only delaying their when wanting to be seen by someone else as I will move on to the next patient. The next patient, who, likely will value, trust and appreciate my desire to help others.
 
Incidentally, and I cannot make this stuff up, the next patient was just that patient. A patient who valued, trusted and appreciated my desire to help other. Despite the next patient was a two-year old. A two-year old brought in by her parent due to the patient had a fever and runny nose. After assessing the history of present illness, a review of systems and a physical exam I had an extensive discussion with the parent related to findings, treatment plan, follow up and reasons to return to the emergency department. The parent verbalizing understanding and agreement. But it was the patient, a 2-year-old, yes, a 2-year-old, who extended her hand to me giving me the colorings she had done while waiting to be seen (that coloring is the picture at the top of this post). The patient offering it to me to keep as if she could tell I was having a bad shift or maybe, just maybe, a 2-year old was appreciative of what healthcare workers do for others and she, a TWO-YEAR old, was sharing that with me.
 
I would like to think the child’s gift was because of the latter as I try to not bring to the next patient the negativity of others, even if it was just one patient ago.
 
Those three patients during the same shift almost one after the other and the difference of their interactions with me was them, the patients were the ONLY different variable. As the shift was the same, even moments from one another. The staff was the same. And I was the same. The ONLY different variable were the patients and despite two of the three patients had good experiences the one bad experience was the one who was given the most attention. Ironic how that happens!
 
That said, they were NOT the only patients worth mentioning. The week prior, I saw a 37-year-old with abdominal pain. The patient had been seen some twelve hours prior to my evaluation for the same symptoms but was back as instructed by his discharge instructions, which included to return to emergency department if symptoms were worse. During the prior visit, the patient had an extensive evaluation just twelve hours prior that included blood diagnostics and CT Abdomen and Pelvis ALL which were essentially unremarkable.
 
My common abdominal pain question, “When did you eat last?”
 
“After I [patient] left the ER this morning,” the patient replied.
 
“What did you eat after leaving the ER this morning?” I asked.
 
“I [patient] had a chicken burrito,” the patient said.
 
“You had a chicken burrito, this morning, after you left the emergency department for abdominal pain and you wonder why you are having abdominal pain now?” I thought to myself without sharing. I mean, come on man work with me here. Really? A chicken burrito moments later after complaining of abdominal pain and being seen in the emergency department for it. Knowing that questioning would not go well I asked instead, “Was the pain right after eating?”
 
“No, it was later,” the patient said and added, “What does it matter what I [patient] ate?”
 
“Did anyone tell you not to eat fried, greasy, fatty, caffeine, or alcohol containing foods?” I asked.
 
“No!” the patient fired back.
 
“If I had seen you this morning for the abdominal pain I would have told you not to eat fried, greasy, fatty, caffeine, or alcohol containing foods,” I replied.
 
Now upset, the patient fired back, “That’s not what they told me. They told me if the pain gets worse I should come back. And none of the medicine they gave me is helping the pain.”
 
Other than upset I found the patient to be in no distress and most definitely not ill or toxic appearing. The abdominal exam was essentially benign except for some discomfort in the left lower quadrant with palpation without guarding, rebound, rigidity, distention or mass. The patient becoming more agitated when I instructed him to continue the medications prescribed that morning and keep gastrointestinal rest by avoiding the foods mentioned until at least 48 hours without abdominal discomfort. But essentially just another dissatisfied customer who, I guess, was hoping for a catastrophic diagnosis that just was NOT there.
 
The patient firing back, “What if it’s my appendix?”
 
“Not your appendix, Sir. Your appendix is on the other side and although rarely it could be on the left side that was NOT the case according to the Cat Scan this morning, which mentioned your appendix was in the right lower quadrant and unremarkable,” I replied.
 
Whether the patient complained or not I have NO idea as I DO NOT follow patients.
 
Another patient seen in the first fourteen weeks was for a rash that was sporadic for some 11+ years, YES, 11+ years. A rash the patient was self-medicating with a prescribed medication which the patient took as needed and which the patient stated was the prescription, despite it made no sense to me. The patient also stated she applied over-the-counter topical ointment with inconsistent improvement over the years.
 
Ookkkaaaayyyyy. “What was different today?” Another common question of mine that I asked.
 
Different that day was that the patient had a second rash in a different location for a least ten days without treatment. The patient adding, her visit to the emergency department was after seen at an Urgent Care Center (UCC) where the patient was instructed to be seen by a dermatologist. When unable to obtain an appointment with a dermatologist the patient decided to be seen in the emergency department with the EXAGGERATED UNREALISTIC EMOTIONAL EXPECTION of finding a dermatologist. Ah, NO! I DON’T recall ever working at an emergency department that had dermatology on-call but I could be wrong. Nonetheless, at this emergency department, on that day, there was NO dermatology on call but even if there were there was ABSOLUTELY no justification I could phantom to consult a dermatologist. Instead, I gave the patient a diagnosis and a treatment plan, which the patient agreed with. I wrote up the patient’s discharge instructions and prescription. DONE!
 
NOPE! If done we wouldn’t be detailing this story now would we? Instead, the nurse comes back and says to me, “The patient wants to be seen by someone else and said she is not leaving until she sees someone else. What do you [NP J. Torres (new kid on the block)] want to do?”
 
“I do not get caught up with patients who express discontent. I do healthcare not customer service. For customer service, you will have to ask administrators,” I said.
 
“Do you mind if [another provider] sees her [the patient]?” the nurse asked.
 
“Nope. Again, that is not an issue of mine. I am done. I discharged the patient and have moved on. The patient’s discontent is for the administration to manage,” I shared with the nurse.
 
The patient was seen by another provider and discharged with the same diagnosis and treatment plan I had come up with, imagine that. Later I shared with the nurse my customer satisfaction record. However, I am not sure my record caught the nurse’s attention. That said, I am think it was a good thing the nurse was not moved by my record as that too is my Achilles.
 
Was a formal complaint submitted by the patient? I have NO idea or moved to find out as those incidents have NEVER resulted in my favor regardless the endpoint. Anyhow. NEXT!
 
Another memorable patient during the first fourteen days at the new job was a 24-year-old patient who sustained a head injury almost two weeks before I saw her. According to the patient, during her interview, the patient stated she was seen hours from the injury at another emergency department from which the patient left against medical advice because she did NOT want to be transferred to a facility of higher care. Days later the patient returned to that same initial emergency department and was then transferred to a facility of higher care as initially intended, as the services needed by the patient were NOT available at the hospital she had been initially seen at.
 
Interestingly, after transferred the hospital the patient agreed to sheleft that hospital against medical advice. The patient firing back that she had left against medical advice because “the nurse there…” when I asked the patient, “Why would you leave a hospital that is trying to help you?”
 
Nonetheless, two days later, after leaving against medical advice from the hospital she was transferred to, the patient then sought medical attention at the emergency department I was working at, again, two-weeks from her initial injury, and how I got involved. When I walked into the room I found the patient sleeping but easily aroused. During the interview the patient was histrionic, short with me, using inappropriate words and when asked to change her behavior by me the patient fired back, “Who are you?”
 
I DO NOT like repeating myself but trying to keep my job I replied, “My name is Jose. I am a Nurse Practitioner.”
 
“I want to see someone else,” the patient fired back.
 
“Not one of the choices,” I replied. Adding, “Your choices are: You can be seen by me. You can be discharged and go sign back in to be seen by someone else. Or, you can leave against medical advice, as you have so many times already.”
 
“I [patient] don’t want to be transferred [to another city] because I have a warrant for my arrest [at the city the patient would be transferred to],” the patient added after agreeing to be seen by me.
 
“Well, you likely will need to be transferred [to the city which worried the patient] as we do not have the services you need here,” I replied.
 
“I am going to leave then,” the patient fired back.
 
“Okay,” I said.
 
I know that bad stuff happens to bad people and why I am NOT dismissive of those who are inappropriate and why I ask them to change their inappropriate behavior hoping they will, even though I know some will NOT change their behavior. However, when appropriate, why invest time, energy, and effort when the patient is NOT willing to participate in their own care UNLESS the care is to their EXAGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS, which in this case was negligence and malpractice. Again, I have NO idea or interested in what happened to the patient. What I do know it the patient declined the treatment plan and left against medical advice after an extensive discussion related to the risks of her decision to leave against medical advice. My desire to help others is unconditional, except, patients MUST be appropriate and willing to participate in their care within the treatment plan. When that is NOT the case those patients have to be let go as they are a risk to healthcare workers and other patients. The DUTY of healthcare workers is to help others. That said, it is NOT the duty of healthcare workers to deescalate or recover hostile patients or families just for the sake of customer retention. That is the job of administrators and NOT the job of healthcare workers. NEXT!
 
Interestingly, although an unrelated story but worth sharing, the parent of a different pediatric patient than the one mentioned above asked me if the device everyone, yes everyone, wears on our person was a camera. Because wearing this device was a first in 30+ years of working in healthcare at first I did not understand the question. However, when the parent pointed to the device I was wearing on my shirt I realized what he was asking about. My answer, “No. It’s a hands-free voice-activated communication system. For a lack of a better example it’s like Siri on the iPhone, when we state predetermined verbal commands it allows us to communicate with anyone or everyone on the net, hands-free. It’s helpful. But not a camera.”
 
A story worth sharing as I am NOT an advocate of body-cams in healthcare, even if they would be beneficial in exposing EXAGGGERATED UNREALISTIC EMOTIONAL EXPECTATIONS. Instead, I find these “duct-tape” fixes to be no more than what I have labeled as “new industries that DO NOT fix healthcare’s problems”. As healthcare’s problems have ONLY to do with healthcare’s altruistic, submissive and accommodating culture which is the root cause that keeps healthcare from fixing healthcare’s problems. Problems which NO one else has to fix but healthcare. Not to mention, these “new industries” are NOT intended to fix healthcare’s problems but are just another industry taking advantage of healthcare for profits. Thus, PURPOSELY, why these “new industries” fall short as to fixing healthcare’s problem. In NO matter do I object to the idea of “new industries”, as capitalism is the foundation of our great nation. However, healthcare has been a sucker to other industries for long enough and worse at the cost of healthcare, healthcare workers, and patients.

Again, not a pessimistic or optimistic but a realist. And why I see the writing on the wall. DARN!

Once again, we have become so complacent with the status quo, like the comment, “at the mercy of the screener”. And, unfortunately, those annoyed with being complacent fear pushing back so no one dares to ask for change. But I AM! As the time of small thinking, like, “being at the mercy of the screener” among many, must end for us to take healthcare back and MAKE HEALTHCARE GREAT AGAIN! Otherwise, nothing will change, which is the expectation of some.

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