Patient satisfaction vs. Unnecessary testing—Who wins?

“You have chronic back pain, sir. You had a back x-ray in this ED 2 months ago for this and have not had any new trauma. In fact, you have had a MRI 6 months ago to look at your back. You do not need an x-ray today.”

“Ma’am, you have been here 8 times for your dental pain and you have yet to see a dentist as we have recommended. I cannot keep giving you Percocet prescriptions as they are addictive and you really just need to get your tooth fixed.” 

“Your child has a virus. I know you tell me he has been sick for two months but he looks fine today and his vitals are all normal. He does not need an antibiotic. Follow up with your doctor in 2-3 days.”

“I know your son bumped his head but his exam is normal, he is acting normal and he did not lose consciousness. He is eating Cheetos and drinking Mountain Dew. He does not need a CT scan of his head today.”

We have all had variations on these conversations daily. I have often considered keeping a log of patients that really do not need to be in the emergency department but that would be a lot of work. Actually, I am occasionally handed a list of these patients in the form of an insurance denial list. This is a list of patients that do not truly have a diagnosis that required an emergency visit. The problem is, because of EMTALA I must see these patients for a medical screening exam. When the diagnosis is constipation without any fever, abdominal pain or vomiting, the patient’s insurance will likely not pay for that visit. In reality, the patient could have scheduled a visit at their primary physician.

The patient then becomes irate that their insurance did not cover the visit and sometimes go as far as asking the documentation to be changed to support the need for the ED visit, or they ask for the bill to be written off. When the patient comes in for what they think will be some testing and a prescription and then in reality only need an exam and instructions, they do not perceive that they received value for their $50 co-pay.

I have been guilty of ordering that test or prescribing that antibiotic to the demanding patient on occasion. We all try to avoid doing this but sometimes it just seems impossible. Why? It is a combination of factors but often patient satisfaction is to blame. As in any business, it is very important to keep your customer happy. If they have another emergency, you would like to be their provider of choice and be able to meet their needs. Patient satisfaction is examined, reported, studied and worried about by all hospital and ED group administrators. We all try to make the patient experience as pleasant as possible in what is usually a very stressful time in someone’s life. I do believe this is important.

Patients have many reasons for using the emergency department: true emergencies, sent by their primary physician, convenience, lack of access to primary care, and worry to name a few. The insured patients often feel that they are entitled to that unnecessary x-ray because they pay for the insurance. I hear that quite a bit. Those without insurance will try to get the outpatient work up done in the ER since they cannot access healthcare. Many patients want the immediate answer or even the “second opinion” in the ER as their primary doctor “can’t find what is wrong with them.”

It is impossible to avoid all complaints in the emergency department. The patient with the dental pain who did not get Percocet may write a rambling letter to the hospital CEO or even the local newspaper. The child whom you did not prescribe antibiotics will go to the pediatrician’s office in 2 days where the doctor will promptly write for the unnecessary antibiotic thus making the mother think the emergency department was in error in not prescribing them. (The pediatrician is probably even more sensitive to keeping the mother happy as he is running his private practice.)

Unnecessary testing leads to increased healthcare costs to all in the form of higher insurance premiums, leading to the inability to afford insurance for many. Untoward events occur as well, including a cellulitis to an arm from a blood draw that was not necessary, a complication from a central line that had to be placed for poor venous access in a patient that only presented to get narcotics, increased cancer risk from the multiple abdominal CT scans, and increasing antibiotic resistance on a global scale. The potential complications are many.

I have yet to see a good estimate on the cost of these unnecessary tests due to patient satisfaction. It would be difficult to measure yet I think it is significant. How then do we minimize unnecessary testing? How then do we tell a patient something that they may not want to hear? How do we avoid the potential and unwarranted complaint?

I believe by being consistent and following a set process, you can minimize complaints as much as possible. First, always treat the patient with respect. Remember the Golden Rule? Introduce yourself to everyone in the exam room. Second, always try to update the patient and inform them if the testing is taking longer than expected. Patients understand delays when informed, but if you just ignore them for 3 hours without any update, they do tend to get upset. Always go back and explain results in common terms. Ask if they have any questions. Explain the follow up plan and for what reasons they need to return to the ED. Explain to the patient why you did not order the test that they really hoped to get. This takes extra time but may help them understand why it was not necessary. Lastly, document your chart well. When the complaint comes, you can lean on your documentation to explain why the test was not necessary and that you explained this to the patient.

It is very important as an emergency physician to find out why the patient is in your ER. I don’t mean the diagnosis, although that is obviously important. Each person has their own reason which must be determined, the mother that worries that a fever of 105 will damage her child. The 40-year old with chest pain because a friend of his died 2 weeks ago from a heart attack and now he is worried. The daughter of an elderly patient that is visiting from out of town and is concerned about her mother living alone and just wants her “checked out” while she is in town. You need to find the back story. You need to be able to address the immediate concern, and provide reassurance to the patient or family. If you can do this well, treat others with respect and communicate effectively you will minimize those complaints while doing the right thing.