Had a job interview....2nd time I have been asked this:

[cbrsmurf]

Just Rx erythromycin 1g TID and they'll be pooping so bad they'll never want another abx ever again

[GetMeOuttaThisMess]

I would estimate that 99% of what people come in for don't need antibiotics at all. Bronchitis, pharyngitis, even UTI's.

Huh? 99%? Really?

[rev ronin]

So to redirect the debate a bit, what is the best way for us, as conscientious, evidence-based medical providers, to push back against the management-driven emphasis to "give 'em what they want!"?

* Legislation eliminating customer satisfaction surveys in medicine?

* Provider unionization?

* FSMB penalizing providers who behave poorly?

* Federal regulations?

 

We all agree it's a problem... now how do we fix it?

[Reality Check 2]

I like unionization.

The state boards would be overwhelmed and unable to handle all the complaints...

Unions could try to force corporate medicine to abandon satisfaction surveys.

We could across the board random chart checks for all levels of providers to have charts reviewed for decision making process.

 

Patients could be given realistic expectations of medicine, disease and the human body.....

[Katera]

I like unionization.

The state boards would be overwhelmed and unable to handle all the complaints...

Unions could try to force corporate medicine to abandon satisfaction surveys.

We could across the board random chart checks for all levels of providers to have charts reviewed for decision making process.

 

Patients could be given realistic expectations of medicine, disease and the human body.....

 

^^^

This is a start.

 

Otherwise I don't have any real advice on a fix.  As long as medicine remains for profit in this country and corporate overlords are placed in direct supervision (hiring/firing) of providers, this is only going to get worse.  A lot worse.

[HMtoPA]

The bigger issue is that this reinforces patient entitlement and people's lack of tolerance for any sort of discomfort, when they can just go to the local clinic and get their feel-better pills, because "it's the only thing that works". This is happening at my job, where we place "patient access" above all else and will see anyone and everyone for any complaint, same-day if at all possible. Half my day is devoted to 2-day sore throats, 1-day coughs, and foot pain without injury for 36 hours.

 

 

Yup. I'm so sick of hearing the word "access" at my current job, and I've only been here 2+ months. I think it's important to reserve some same-day appointments for acute concerns (especially in my rural area with limited ED coverage) but the reality is that most of these appointments go to people with such minor illnesses or injuries that I'm astonished they even bothered to call for an appointment and take the time to come in. 

 

I guess growing up without health insurance gave me and my family a certain DIY mentality when it comes to our health care, but I have to wonder how so many people go through life without a working understanding of basic OTC pharmacology and first aid skills, not to mention the resilience to "suck it up" a little bit. I mean, I don't mind people seeking out my expertise if they truly don't have the health literacy to know any better, but it's just that so much of this garden-variety stuff is self-limiting and benign, and would resolve on it's own if these patients were made to wait a few days for an appointment - but instead they show up right away to my FP clinic, and I end up having to just provide reassurance and prescribe symptomatic treatment that is usually available OTC. "Mommy medicine," I call it.

 

At the same time I hesitate to be such a prima donna that I scoff at every patient that dares to cross the threshold of my exam rooms, but there is definitely some frustration there.

[Reality Check 2]

My family was medical and military and the whole bleeding out the eyes, limb hanging thing wasn't a joke.

 

If you barfed, rinse mouth, go to bed, ice chips graduating to jello and broth.

If you had diarrhea - wash hands, go to bed, ice chips, decaf tea and then BRAT.

 

I had horrific tonsils and they got yanked as a toddler but everything else was common sense and tincture of time. Maybe some benadryl but it was rx back then.

 

We seem to have lost the idea that not every illness is an episode of Grey's Anatomy (never seen it) and some sort of crisis.

 

I get folks in for a UTI and find glucose in the urine but they don't want to hear about that.

Never mind the A1c was 8.5 A YEAR AGO and they never followed up.

Astounds me sometimes.

 

We just HAVE TO put patient responsibility back into life and medicine or we are doomed as humanity.

 

We can sue McDonalds for hot coffee when we ordered hot coffee and we sue for stupidity - don't light a roman candle in your mouth..... At some point folks have to be put back in charge of their own well being.

[sk732]

...I have to wonder how so many people go through life without a working understanding of basic OTC pharmacology and first aid skills, not to mention the resilience to "suck it up" a little bit.

 

 

The sucking it up bit in particular - we have unfortunately given rise to a generation of wusses I'm afraid, when it comes to some things and people expect a quick fix to everything.  When I joined the Army 30 odd years ago, we didn't go on sick parade unless our limbs were hanging off, and even then, we would be ridiculed a bit for that.  I had to rip a young trooper's face off a few years back for not only giving my lip in front of my subordinates, but also because he gave me lip because I wouldn't give him any time off for a measly, non-thrombosed, hemorrhoid.  The words I used were to the effect of "it's pretty obvious to me that you have no concept of dealing with even minor physical discomfort and my guess is you'd be the whiny (add your own demeaning descriptor) who call a CASEVAC in for a cold in Afghanistan". 

 

Of course, then there are the people that jump over the fine line between hard and stupid...but that's another post in itself.

 

SK

[ventana]

I like unionization.

The state boards would be overwhelmed and unable to handle all the complaints...

Unions could try to force corporate medicine to abandon satisfaction surveys.

We could across the board random chart checks for all levels of providers to have charts reviewed for decision making process.

 

Patients could be given realistic expectations of medicine, disease and the human body.....

 

 

So to redirect the debate a bit, what is the best way for us, as conscientious, evidence-based medical providers, to push back against the management-driven emphasis to "give 'em what they want!"?

 

* Legislation eliminating customer satisfaction surveys in medicine?

* Provider unionization?

* FSMB penalizing providers who behave poorly?

* Federal regulations?

 

We all agree it's a problem... now how do we fix it?

 

 

Historically I have thought unions were far to powerful, and had the system rigged - think UAW who got the automakers to pay something like 90% of the wages of a laid off worker for the first year - that was just insane..... 

 

BUT

 

Now that "big industry" has moved in and set up shop I see no real other way then joining together for a united voice.  One PA, NP Doc can be fired and nothing is lose - but if we stand together and make GOOD MEDICAL decisions - well administration be darned...  

 

Tired of feeling like a commodity..... 

[AMD]

Job is with an Urgent Care chain (corporate owned like most)

 

Pleasantries out of the way, their medical director said she only had one question....

 

Doc: "If a patient comes in with a virus that you know is a virus (i.e. URI), and asks for a Z-pack because that's all that works, what do you do?"

 

Now...I know the answer she is looking for, but it shocks and saddens me that I am being asked this by an M.D. I respond something to the fact that every case is different and each needs to be evaluated on it's own...etc etc etc.

 

Doc: "Well I just wanted to make sure that you will give them what they want, because here at (redacted) we are *VERY* sensitive to negative Yelp and Google reviews. We just can't have them. (Doc continues): I get some APP's who say they will never give an antibiotic for a virus to keep the patient happy because of resistance, etc" (I swear she said that word for word), and I just need to make sure that you understand your roll here. To keep patients happy".

 

Me: <blank state>

 

This is the 2nd time I have been asked this exact question by an Urgent Care corporate chain. The 1st was by the admin interviewing me, but this was by the medical director, an M.D.

 

I guess after all these years of practicing medicine, I am just crushed to see what we have become as providers. Literally whoring ourselves out to corporations who have Zero interest in practicing decent medicine.

 

At the end of the day, these are the jobs in my field that are available. I like many others with a family and responsibilities, have to work. It's easy to sit on a message board and take the high and righteous road by saying..."I would turn them down just on principle!". Principle does not put food on the table or put my kids through college.

 

Dunno, just sad over the whole thing.....

I'd tell the interviewer what they want to hear, all the while knowing that having integrity, ethics, and empathy gets higher yelp ratings every time!

 

"I understand that the Z pak ALWAYS works for you. But, no I'm not gonna give you an abx rx for a virus, because when you actually have bacterial pneumonia that will be the one time the Zpak won't work and you'll end up a lot sicker. So take this OTC, and give it another 3 to 5 days"

 

Sent from my SAMSUNG-SM-G900A using Tapatalk

[sk732]

Guess they'd get upset about me pulling this one out:  http://www.newswire.ca/news-releases/as-part-of-the-choosing-wisely-canada-campaign-the-canadian-association-of-emergency-physicians-releases-a-list-of-commonly-used-tests-and-treatments-to-question-595621741.html

 

SK

[Reality Check 2]

Guess they'd get upset about me pulling this one out:  http://www.newswire.ca/news-releases/as-part-of-the-choosing-wisely-canada-campaign-the-canadian-association-of-emergency-physicians-releases-a-list-of-commonly-used-tests-and-treatments-to-question-595621741.html

 

SK

 

Dang you for bringing actual evidence and medical practice into their patient satisfaction scores..... :))

[sk732]

They'd just look at me a say "What do you know, you're a Canadian?"...and I'd have to answer something along the line of "The country that brought you insulin, brain mapping, WIlliam Osler, some transfusion medicine advances, delivery methods for biochemical warfare agents (courtesy of the dude that brought you inuslin incidentally), the Role 3 surgical centre in Khandahar when we were still there, the dude that made the longest sniper shot in history, some of the arsonists that burnt down the original White House in the War of 1812, and most importantly, socialized medicine that allows me to not give a serious crap about what some dolt on WhinyPatient.ca wrote about me."

 

Now the fun bit - I'm thinking of posting that web page up in every exam room tomorrow when I start my shift :-D.

 

SK

[Reality Check 2]

Thanks for the Funny, SK.

I needed that today.

 

Currently working through a narcotic seeking transient metal worker with nondescript pain complaints.......................

[sk732]

Ahh, yes...the "I'm just sore really...can I have a fentanyl patch for that?" sort of dude.

 

SK

[Reality Check 2]

I have determined today that my current FAVORITE part of my job is ------

 

NO PRESS GANEY and no suits counting beans and metrics.

 

I am still accountable for my service to patients but through good MEDICINE, not scales of happy

 

My second favorite today - cute kids who get flu shots

[SHU-CH]

So to redirect the debate a bit, what is the best way for us, as conscientious, evidence-based medical providers, to push back against the management-driven emphasis to "give 'em what they want!"?

 

* Legislation eliminating customer satisfaction surveys in medicine?

* Provider unionization?

* FSMB penalizing providers who behave poorly?

* Federal regulations?

 

We all agree it's a problem... now how do we fix it?

 

If providers cannot take some responsibility soon, I can see antibiotics winding up as controlled as narcs someday. Everyone will cry about the loss of control and autonomy, but we are bringing it upon ourselves.

[quietmedic]

Knowing precisely what you are talking about, I wouldn't necessarily turn down the job... A lot of urgent cares are like this, it's just the nature of the game today. But what you say in the interview doesn't necessarily have to be what you do in real life. sure, I have given the fact that patient she didn't need it... But at the end of the day, after I explained very carefully the differences between bacterial and viral infections, explain to them that theydidn't need it, and all that... And they still say they have a big week coming up and they really would like to knock it out with a zpack, I saand prescribe it to them... Look, if you don't give it to them, they will go across the street to the other urgent care, and get it from them. if I prescribe it, I do question them and say give it a few days and if there is no change, then take the medication. I have had patients who were in fact not necessarily relieved to not need antibiotics, but were pleasantly surprised to learn that almost all of these are viral, and didn't push the issue. but then I have patients who know exactly what they came in for, and it wouldn't matter much what I say. like I said, they're going to go across the street and get it anyway, so I feel like if I give it, at least I can give full perspective on it to them in person. and I would answer something similar on a job interview... Say, I would do my best to educate the patient that is not necessary, but at the end of the day if they insist, it's the lesser of two evils.

[Reality Check 2]

It is not good practice to practice bad medicine.

DON'T GIVE PEOPLE ANTIBIOTICS WHO DON'T NEED THEM.

 

There is no gain here.

 

We are going to end up with superbugs that don't respond to everything.

 

And, we are perpetuating the myth that EVERYTHING needs a prescription.

 

We need to go back to common sense and tincture of time.

[quietmedic]

I agree, in an ideal world... But in the market where I practice, they can go to half-a-dozen Urgent Cares literally around the corner, where they WILL get what they want, (probably from a Moonlighting non-PA practitioner who just doesn't give a damn). Perhaps it will take making antibiotics a controlled substance, to make people understand the severity of this, because when I explain it to them they just don't get it. And unless practitioners start worrying about ethics violations on their licenses, they will keep giving it, I think. Hell, I like that controlled substance idea...

 

P.S. I wish they made sugar pills that look like a z-pack. I would prescribe it without hesitation!

[GetMeOuttaThisMess]

Adults: 30% chance of bacterial etiology. ENT: abx if sx w/o noted source after seven days. Give abx access, have written sheet expressing these facts, and notate these instructions were given. RSS are not that accurate in spite of what others might have one believe and if you're in a setting w/o lab (culture) capability you could be more culpable than if you don't provide treatment access.