6 ms·

The whole idea of having patients rate ERs is, to put it nicely, laughable. And, to put it bluntly, it is a slap in the face of healthcare professionals who wor

by jlg23 11y ago

The whole idea of having patients rate ERs is, to put it nicely, laughable. And, to put it bluntly, it is a slap in the face of healthcare professionals who work in one of the most stressful hospital environments. * How friendly the staff is is absolutely irrelevant when you have a medical emergency. In normal hospital settings, in most countries, what buys you "friendly staff" is paying a premium that allows the staff to actually have enough time to pity you. A nurse who only tends 3 patients can do that, a nurse who has to tend 30 cannot. * Wait times in ERs depend on the severity of your condition in relation to what other patients have to deal with. Most urgent comes first. A broken leg hurts but it won't kill you no matter how much you moan. The unconscious guy with rapid blood loss would be dead if they prioritized patients according to some fifo or loudest moaner first scheme. * I'd always chose the bigger ER over a smaller one: The more people they treat, the more experienced they are. Same is true for non-emergency hospitalizations. The Spudd recently had a great comment on "educated" patients: http://thespudd.com/hospital-to-replace-doctors-with-parents-who-have-done-their-research/ http://thespudd.com/hospital-to-replace-doctors-with-parents...

tertius 11y ago
To be fair, ERs are being rated, not doctors. They are generally independent of each other. " How friendly the staff is is absolutely irrelevant when you have a medical emergency. " I disagree, delving into the negative spectrum of interpersonal communication could cause unwarranted stress which could exacerbate many conditions. I agree that staff shouldn't be expected to bend over backwards, but there's no need for negative treatment. And I don't consider saying "no" to a low priority case as negative treatment. And if as an ER employee you can't handle the stress of the ER you may need to change departments or get some training. " I'd always chose the bigger ER over a smaller one " Which requires research, which most people don't have time for in an emergency. But I agree completely with this. I live in one of the largest medical centers in the world and I know where to go.
- kom107 11y ago
  Many empirical studies point out that in fact, the 'friendlier' the staff is (meaning higher 'patient satisfaction scores') the poorer the actual clinical outcomes are at that facility. See: https://www.advisory.com/daily-briefing/2012/02/15/patient-satisfaction https://www.advisory.com/daily-briefing/2012/02/15/patient-s... Longread but excellent: http://www.theatlantic.com/health/archive/2015/04/the-problem-with-satisfied-patients/390684/ http://www.theatlantic.com/health/archive/2015/04/the-proble... As someone who works in healthcare (formerly at the bedside), and who's partner is a current ED nurse, this infuriates me. Department budgets are related to patient satisfaction scores, the EDs generally tend to have low scores because, yes, sorry you've been here for 3 hours, but we had 4 other patients come in (and HIPPA prevents me from telling you that they were level 1 gunshot wounds) and we can't tend to your constipation right at this second. If someone actually were to check Yelp for wait times and then have to wait longer...scores go even lower, reimbursements decrease, staff have higher patient ratios, lather, rinse, repeat. I assure you, I have seen many, MANY patients complain and file greivances with the Department of Health, Joint Commission, etc, that their toothache, or even general wellness physical, should take prescedence over cardiac arrests. This is in a top 10 hospital in the United States, and we generally score above average with patient satsifaction. The public has no clue and this is not helping.
  - tertius 11y ago
    "(meaning higher 'patient satisfaction scores')" I was not addressing this at all. Patient satisfaction scores are a lot more broad than "staff was friendly, check". I even state the following "And I don't consider saying 'no' to a low priority case as negative treatment." I have family and friends that are ER physicians (and have done it in multiple countries), and they can handle the stress of stressed patients without needing to resort to stress induced interaction themselves. This is all that I was referring to. I do not tolerate rude medical staff, and no one should. Again, if you can't handle the stress, get training or change departments.
    - kom107 11y ago
      I appreciate and understand that they are significantly more broad than the friendly staff metric. However, patients who feel the staff were friendly tend to give higher overall ratings. And I know that you stated that you don't consider saying no to a low priority case as negative treatment, but again, I promise you, PLENTY of people do. I got it at least once a shift, if not more frequently. I have literally had patients come up to me in another patient's room WHILE WE WERE DOING COMPRESSIONS and complain that we weren't getting them ice fast enough. I'm sure being an ER physician can handle the stress, because they aren't interacting with the patients like the nurses and techs interact with the patients. Have they ever had someone hit them because they didn't get their turkey sandwich fast enough? Spit in their face because they were made NPO? Pee on them on purpose? I sincerely doubt it. The scope of practice is entirely different. I think the nurses and techs do an incredible job of keeping it together and maintaining a friendly demeanor towards patients when they have to put up with these things. It's easy for you to say 'If you can't handle the stress, get training or change departments'. That's exactly the response that causes nursing to have such a high turnover and burnout rate. No one is advocating for staff to be rude, I'm advocating, however, for better ratios for the nursing staff and more patient education on the other side of healthcare. And frankly, I think that sometimes, it should be okay for healthcare workers to interact with a patient like they are an asshole because THEY ARE. You'll get the same standard of care, but I'll be damned if I'm going to go to another floor to search for some ice cream for you after you called me every name in the book and pulled out your IV for the third time in the past 4 hours because you didn't like that I still won't give you another dose of dilauded...and you're in the hospital because you're diabetic and morbidly obese.
mrits 11y ago
I have no problem slapping faces of healthcare professionals. "The more people they treat, the more experienced they are." - I've been playing golf for 20+ years and often get beat by 15 year olds
- jlg23 11y ago
  Except for, a healthcare professional playing golf cannot cause nearly as much harm as a golf player playing healthcare professional.
Asbostos 11y ago
If they have time to be friendly, perhaps they aren't so overworked and can really treat you more effectively. It sounds like an indicator of better treatment. If doctors are always rushed off their feet, that's probably not an ideal hospital to be in. It sounds like mismanagement. We wouldn't accept it in most other industries.
- kom107 11y ago
  It's not mismanagement. It's a matter of applying business concepts of productivity to the healthcare setting. Ex: In business, if Joe the factory worker can make 100 widgets in an hour, and Mike can make 150 in an hour, with the same number of defects, Mike is more productive than Joe. So now let's apply this to the ED: If Joe the nurse can discharge or admit 10 patients in an hour, and Mike can admit or discharge 15 in an hour, Mike is more productive, right? Well, no, because maybe Mike had patients that were triaged as low priority, but Joe was working Level 1 trauma side. Or you have patients presenting with the same things, but one is a healthy 30 year old and another is 80-something with multiple comorbidities. I've seen Baumol's Cost Disease used to explain why we see the healthcare industry grappling with rapidly increasing costs, especially wage costs: because we can't measure productivity. I'd argue, from what I've seen, that in fact, that's not true. I even came up with a formula to measure nursing staff productivity relative to patient acuity levels, but never had any buyers. Why? You start getting into questions about actual patients that no one wants to answer, because they're uncomfortable ethical questions, and reimbursements will drop regardless of the answers. Being treated effectively at this point is being treated as a human, and either bringing the disease under control, or getting rid of the disease. We need to undersand that although these healthcare workers are in caring professions, their work is being increasingly shifted from what we all think effective treatement should be, to what the business thinks effective treatment should be (read: profitable). You do accept this kind of rushing in other industries, because you believe in productivity. And that's fine. It's also fine to believe in productivity in healthcare (I do), but not in the patients/hour concept. As a country, we need to change this model. I'd encourage you to advocate for safer staffing ratios, at a minimum, for nurses and doctors.
mikeash 11y ago
These are good points, but I feel like #1 and #2 contradict each other a bit. Yes, you don't give the slightest shit how friendly the ER staff is when you're having a heart attack or a stroke. And yes, if you come in with a broken leg, that's not nearly as urgent, so you shouldn't complain at waiting three hours because people with heart attacks and strokes are being seen first. But on the other hand, the same thing that means you can wait three hours for a broken leg means that the friendliness of the staff becomes more important, and more feasible. If they're not treating you right away then they should at least be nice to you while you wait, possibly in agony. Really, I think this illustrates that "the ER" is a little too general. There's good reason for that, of course. You want to have a one-stop shop available when something important happens. I think the proliferation of "urgent care" facilities is a response to this. People there will be less distracted by emergencies where seconds count, and be more able to give you better, or at least nicer, care for your broken leg.
- kom107 11y ago
  And that is indeed, the goal--Urgent Care unless you are actually having a heart attack or some such (or it's after hours). Emergency room is just that--for Emergencies. It's going to take a massive public education campaign for this to switch--with the passage of EMTALA back in the 80s, people started treating the EDs as their PCPs, and somehow 'Emergency' became synonymous with 'Fast' care. I don't forsee the government undertaking this, nor do I see the payers (insurance companies) undertaking this, and providers don't necessarily have the time. This also assumes the public is receptive to this kind of education. The healthcare delivery system is incredibly ripe for disruption.
  - mikeash 11y ago
    Why wouldn't the insurance companies do it? Surely getting more of their customers into urgent care instead of ERs would reduce their costs.
    - bigchewy 11y ago
      why would the insurance companies want that? Lower costs means lower revenue over the long term. Given that they are effectively capped at a maximum profit margin, they can't make up for this with increased profitability. It's part of why healthcare operates so differently from everytihng else.
neurotech1 11y ago
Try landing on a carrier, the pilots get graded on every single landing, in one of the most stressful environments out there. They have Landing Signal Officers who make sure the pilot is safely on the glidepath, and in difficult conditions "sweet talk" the pilot with instructions [0] If the LSO & Air Boss (in charge of the flight deck) and staff don't do their job, and a jet runs out of gas in the pattern they will have some major explaining to do. The officers involved will be called before a mishap board. If a hospital ED patient flow was actually ran like the Air Boss runs the carrier deck, then things would go a lot smoother. An F/A-18 at landing weight ends up in the water if they have to wait more than about 30-45 minutes, unless refueled in the air. The other thing to remember is that in major hospitals, the Trauma service and the Emergency Department have a separate patient flow. If someone is having a heart attack or serious injury, they will be handled by the trauma service. The nurses handling the ED are not treating immediately critical patients, except perhaps on initial triage. Also, a "broken leg" can easily end up critical from puncturing the femoral artery if its not stabilized and/or the patient will go into shock, if not given appropriate pain meds. I personally think that ED staff should be graded for QA of treatment and "Patient Interaction". Neither of which requires lengthy interaction with the patient, only maintaining standards. I'm not sure I'd apply the typically subjective Yelp standards to ED evaluation either. [0] https://www.youtube.com/watch?v=sD_mUwzpUs4 https://www.youtube.com/watch?v=sD_mUwzpUs4
- jlg23 11y ago
  I don't think that comparison is valid. * On a carrier 100% of the people are well trained professionals. Not so in a hospital, were patients have never been trained to be good patients. * Not only are people not trained to be patients, they are, especially in situations of distress, usually not helpful at all. As a rule, you do not trust a diagnosis provided by a patient (even if a doctor!) because the person might exhibit an acute stress reaction (https://en.wikipedia.org/wiki/Acute_stress_reaction https://en.wikipedia.org/wiki/Acute_stress_reaction) - avoiding this state by prior exposition is one of the reasons why pilots train emergency situations in flight simulators. * Managing "hospital ED patient flow" is something that has improved a lot (see your example of direct transfer to trauma units), but it still is the attempt to manage the inherently unmanageable: On a carrier you know how many jets you have in the air and how long their fuel lasts and thus you can coordinate, in an ED you can only, if such a system exists in your region, have incoming ambulances diverted to other hospitals. But you still have no idea who will stumble through your door the next moment, brought by friends or taxis. I am all for collecting data and applying metrics to make a process better, but there are some areas where the collection and evaluation should be done by professionals who understand what they are grading, not by amateurs who either entered that area involuntarily (actual emergencies) or who just try play the system for their own advantage (getting prescriptions).

by jlg23 11y ago

tertius 11y ago

To be fair, ERs are being rated, not doctors. They are generally independent of each other. " How friendly the staff is is absolutely irrelevant when you have a medical emergency. " I disagree, delving into the negative spectrum of interpersonal communication could cause unwarranted stress which could exacerbate many conditions. I agree that staff shouldn't be expected to bend over backwards, but there's no need for negative treatment. And I don't consider saying "no" to a low priority case as negative treatment. And if as an ER employee you can't handle the stress of the ER you may need to change departments or get some training. " I'd always chose the bigger ER over a smaller one " Which requires research, which most people don't have time for in an emergency. But I agree completely with this. I live in one of the largest medical centers in the world and I know where to go.

kom107 11y ago
Many empirical studies point out that in fact, the 'friendlier' the staff is (meaning higher 'patient satisfaction scores') the poorer the actual clinical outcomes are at that facility. See: https://www.advisory.com/daily-briefing/2012/02/15/patient-satisfaction https://www.advisory.com/daily-briefing/2012/02/15/patient-s... Longread but excellent: http://www.theatlantic.com/health/archive/2015/04/the-problem-with-satisfied-patients/390684/ http://www.theatlantic.com/health/archive/2015/04/the-proble... As someone who works in healthcare (formerly at the bedside), and who's partner is a current ED nurse, this infuriates me. Department budgets are related to patient satisfaction scores, the EDs generally tend to have low scores because, yes, sorry you've been here for 3 hours, but we had 4 other patients come in (and HIPPA prevents me from telling you that they were level 1 gunshot wounds) and we can't tend to your constipation right at this second. If someone actually were to check Yelp for wait times and then have to wait longer...scores go even lower, reimbursements decrease, staff have higher patient ratios, lather, rinse, repeat. I assure you, I have seen many, MANY patients complain and file greivances with the Department of Health, Joint Commission, etc, that their toothache, or even general wellness physical, should take prescedence over cardiac arrests. This is in a top 10 hospital in the United States, and we generally score above average with patient satsifaction. The public has no clue and this is not helping.
- tertius 11y ago
  "(meaning higher 'patient satisfaction scores')" I was not addressing this at all. Patient satisfaction scores are a lot more broad than "staff was friendly, check". I even state the following "And I don't consider saying 'no' to a low priority case as negative treatment." I have family and friends that are ER physicians (and have done it in multiple countries), and they can handle the stress of stressed patients without needing to resort to stress induced interaction themselves. This is all that I was referring to. I do not tolerate rude medical staff, and no one should. Again, if you can't handle the stress, get training or change departments.
  - kom107 11y ago
    I appreciate and understand that they are significantly more broad than the friendly staff metric. However, patients who feel the staff were friendly tend to give higher overall ratings. And I know that you stated that you don't consider saying no to a low priority case as negative treatment, but again, I promise you, PLENTY of people do. I got it at least once a shift, if not more frequently. I have literally had patients come up to me in another patient's room WHILE WE WERE DOING COMPRESSIONS and complain that we weren't getting them ice fast enough. I'm sure being an ER physician can handle the stress, because they aren't interacting with the patients like the nurses and techs interact with the patients. Have they ever had someone hit them because they didn't get their turkey sandwich fast enough? Spit in their face because they were made NPO? Pee on them on purpose? I sincerely doubt it. The scope of practice is entirely different. I think the nurses and techs do an incredible job of keeping it together and maintaining a friendly demeanor towards patients when they have to put up with these things. It's easy for you to say 'If you can't handle the stress, get training or change departments'. That's exactly the response that causes nursing to have such a high turnover and burnout rate. No one is advocating for staff to be rude, I'm advocating, however, for better ratios for the nursing staff and more patient education on the other side of healthcare. And frankly, I think that sometimes, it should be okay for healthcare workers to interact with a patient like they are an asshole because THEY ARE. You'll get the same standard of care, but I'll be damned if I'm going to go to another floor to search for some ice cream for you after you called me every name in the book and pulled out your IV for the third time in the past 4 hours because you didn't like that I still won't give you another dose of dilauded...and you're in the hospital because you're diabetic and morbidly obese.

mrits 11y ago

I have no problem slapping faces of healthcare professionals. "The more people they treat, the more experienced they are." - I've been playing golf for 20+ years and often get beat by 15 year olds

jlg23 11y ago
Except for, a healthcare professional playing golf cannot cause nearly as much harm as a golf player playing healthcare professional.

Asbostos 11y ago

If they have time to be friendly, perhaps they aren't so overworked and can really treat you more effectively. It sounds like an indicator of better treatment. If doctors are always rushed off their feet, that's probably not an ideal hospital to be in. It sounds like mismanagement. We wouldn't accept it in most other industries.

kom107 11y ago
It's not mismanagement. It's a matter of applying business concepts of productivity to the healthcare setting. Ex: In business, if Joe the factory worker can make 100 widgets in an hour, and Mike can make 150 in an hour, with the same number of defects, Mike is more productive than Joe. So now let's apply this to the ED: If Joe the nurse can discharge or admit 10 patients in an hour, and Mike can admit or discharge 15 in an hour, Mike is more productive, right? Well, no, because maybe Mike had patients that were triaged as low priority, but Joe was working Level 1 trauma side. Or you have patients presenting with the same things, but one is a healthy 30 year old and another is 80-something with multiple comorbidities. I've seen Baumol's Cost Disease used to explain why we see the healthcare industry grappling with rapidly increasing costs, especially wage costs: because we can't measure productivity. I'd argue, from what I've seen, that in fact, that's not true. I even came up with a formula to measure nursing staff productivity relative to patient acuity levels, but never had any buyers. Why? You start getting into questions about actual patients that no one wants to answer, because they're uncomfortable ethical questions, and reimbursements will drop regardless of the answers. Being treated effectively at this point is being treated as a human, and either bringing the disease under control, or getting rid of the disease. We need to undersand that although these healthcare workers are in caring professions, their work is being increasingly shifted from what we all think effective treatement should be, to what the business thinks effective treatment should be (read: profitable). You do accept this kind of rushing in other industries, because you believe in productivity. And that's fine. It's also fine to believe in productivity in healthcare (I do), but not in the patients/hour concept. As a country, we need to change this model. I'd encourage you to advocate for safer staffing ratios, at a minimum, for nurses and doctors.

mikeash 11y ago

These are good points, but I feel like #1 and #2 contradict each other a bit. Yes, you don't give the slightest shit how friendly the ER staff is when you're having a heart attack or a stroke. And yes, if you come in with a broken leg, that's not nearly as urgent, so you shouldn't complain at waiting three hours because people with heart attacks and strokes are being seen first. But on the other hand, the same thing that means you can wait three hours for a broken leg means that the friendliness of the staff becomes more important, and more feasible. If they're not treating you right away then they should at least be nice to you while you wait, possibly in agony. Really, I think this illustrates that "the ER" is a little too general. There's good reason for that, of course. You want to have a one-stop shop available when something important happens. I think the proliferation of "urgent care" facilities is a response to this. People there will be less distracted by emergencies where seconds count, and be more able to give you better, or at least nicer, care for your broken leg.

kom107 11y ago
And that is indeed, the goal--Urgent Care unless you are actually having a heart attack or some such (or it's after hours). Emergency room is just that--for Emergencies. It's going to take a massive public education campaign for this to switch--with the passage of EMTALA back in the 80s, people started treating the EDs as their PCPs, and somehow 'Emergency' became synonymous with 'Fast' care. I don't forsee the government undertaking this, nor do I see the payers (insurance companies) undertaking this, and providers don't necessarily have the time. This also assumes the public is receptive to this kind of education. The healthcare delivery system is incredibly ripe for disruption.
- mikeash 11y ago
  Why wouldn't the insurance companies do it? Surely getting more of their customers into urgent care instead of ERs would reduce their costs.
  - bigchewy 11y ago
    why would the insurance companies want that? Lower costs means lower revenue over the long term. Given that they are effectively capped at a maximum profit margin, they can't make up for this with increased profitability. It's part of why healthcare operates so differently from everytihng else.

neurotech1 11y ago

Try landing on a carrier, the pilots get graded on every single landing, in one of the most stressful environments out there. They have Landing Signal Officers who make sure the pilot is safely on the glidepath, and in difficult conditions "sweet talk" the pilot with instructions [0] If the LSO & Air Boss (in charge of the flight deck) and staff don't do their job, and a jet runs out of gas in the pattern they will have some major explaining to do. The officers involved will be called before a mishap board. If a hospital ED patient flow was actually ran like the Air Boss runs the carrier deck, then things would go a lot smoother. An F/A-18 at landing weight ends up in the water if they have to wait more than about 30-45 minutes, unless refueled in the air. The other thing to remember is that in major hospitals, the Trauma service and the Emergency Department have a separate patient flow. If someone is having a heart attack or serious injury, they will be handled by the trauma service. The nurses handling the ED are not treating immediately critical patients, except perhaps on initial triage. Also, a "broken leg" can easily end up critical from puncturing the femoral artery if its not stabilized and/or the patient will go into shock, if not given appropriate pain meds. I personally think that ED staff should be graded for QA of treatment and "Patient Interaction". Neither of which requires lengthy interaction with the patient, only maintaining standards. I'm not sure I'd apply the typically subjective Yelp standards to ED evaluation either. [0] https://www.youtube.com/watch?v=sD_mUwzpUs4 https://www.youtube.com/watch?v=sD_mUwzpUs4

jlg23 11y ago
I don't think that comparison is valid. * On a carrier 100% of the people are well trained professionals. Not so in a hospital, were patients have never been trained to be good patients. * Not only are people not trained to be patients, they are, especially in situations of distress, usually not helpful at all. As a rule, you do not trust a diagnosis provided by a patient (even if a doctor!) because the person might exhibit an acute stress reaction (https://en.wikipedia.org/wiki/Acute_stress_reaction https://en.wikipedia.org/wiki/Acute_stress_reaction) - avoiding this state by prior exposition is one of the reasons why pilots train emergency situations in flight simulators. * Managing "hospital ED patient flow" is something that has improved a lot (see your example of direct transfer to trauma units), but it still is the attempt to manage the inherently unmanageable: On a carrier you know how many jets you have in the air and how long their fuel lasts and thus you can coordinate, in an ED you can only, if such a system exists in your region, have incoming ambulances diverted to other hospitals. But you still have no idea who will stumble through your door the next moment, brought by friends or taxis. I am all for collecting data and applying metrics to make a process better, but there are some areas where the collection and evaluation should be done by professionals who understand what they are grading, not by amateurs who either entered that area involuntarily (actual emergencies) or who just try play the system for their own advantage (getting prescriptions).