Seven years ago, I vividly recalled a patient saying, “It needs to be as easy to schedule with you as OpenTable.” For most health care systems, this request is now a reality. Yet, how far has the restaurant metaphor moved into patient expectations? Recently on a closed Facebook physician group, a post discussed how to convince patients they do not benefit from antibiotics when they have a respiratory virus. One theme of many comments prompted this article: “We need to prescribe antibiotics to not receive poor customer service star ratings.” In the age of online star ratings and system incentives aligned with those ratings, are physicians to become the new “medical waiter” for our patients, even when the “order” is not in the patients’ best health interest? Or, are physicians, especially those in ambulatory primary care, to remain as we are trained, as health care advisors, coaches, consultants, and coordinators for our patients’ medical concerns? Recently, several days after a patient was seen by one of our NPs for her viral bronchitis, I received a portal message insisting on opioid cough syrup. I prescribed benzonatate capsules. She responded with both an angry phone call and portal message to the office. I reminded her how I had helped guide her through her recent breast cancer care, for which she is very pleased, and that I always have her best health in mind. The next day, after the benzonatate had worked well, she had slept and was rested, she sent an apology portal message. Another newer patient requested to have her labs drawn for a repeat thyroid level due to a recent decrease in her thyroid dosage based on very low TSH. I placed the TSH order. She then insisted that I order an extensive panel of free T4, free T3, total T3, etc. After observing that she would not be dissuaded and hoping to avoid an unpleasant confrontation, I placed her “order” for the more extensive thyroid panel. Results were all normal, except her TSH remained very low. I recommended we continue to lower her thyroid dose. Again, she sent several negative portal messages, stating I was out of date, she knows her body, she is hypothyroid and needs a thyroid medication increase, rather than a decrease. I volunteered to speak with her by phone to deescalate the situation. I used my integrative medicine reflective listening skills for 15 minutes, then advised her that I would not be able to increase her thyroid dosage due to her very low TSH and offered to refer her to a holistic endocrinologist. She hung up on me. Filling her first “order” did not alter the outcome of dissatisfaction. We have all experienced the demanding patients, whether looking for opioids, antibiotics, sleep medications, hormone therapy, imaging, or referrals. The patient is convinced that they are more informed in what they need for their health than what our training, experience, and evidence-based medicine would recommend. With the advent of EHR patient messaging, we now receive online portal “orders” from patients for these services without a medical assessment other than the patients’ self-diagnosis. What has changed since most of us were trained, is that now, not promptly filling the “patients’ order” can result in negative online reviews. As an internist, I find myself debating the values of patient satisfaction and shared decision making versus values of evidence-based medicine and our duty to reduce unnecessary health care costs. For our annual reviews, in my large academic health care system, we can receive up to 12 points for meeting benchmarks in health care quality indicators of hypertension, diabetes, and preventive screening. We receive two points if we are in the top 5 percent of patient ratings for the general internal medicine division and one point for the top 20 percent. There are no points allotted for cost containment, such as limiting unnecessary referrals or imaging, antibiotic, opioid, or other controlled substance prescribing stewardship or evidence-based care in managing common conditions other than hypertension and diabetes. In this final decade of my now 35-year career as an internist, I am grateful that I experience a “good tired” after the 12-14 hour day required to see patients and complete the electronic in-basket. Part of my “good tired” comes from the satisfaction that I feel content with my work that day; I have lived my values of helping patients, caring for them and confident the patients are receiving excellent medical care from our clinic, whether online portal messaging, telemedicine visits, phone calls or face-to-face visits. I am pleased I have been able to adapt to all of the changes in health care over my career and can still work hard. My “good tired” would be lost if I became a “waiter,” spending my day filling “orders” from patients that may not help and potentially harm them. My 4.75/5.0 rating did not qualify for any “points” for my annual review, and yet I find the patient comments to be supportive and meaningful. I will remain a health care investment advisor for my patients, in a shared decision-making model, with the hope that, over time, they will find the increasing trust that this is for their best health. Annie Moore is an internal medicine physician. Source
