Comes to ER, told to follow up, doesn't, comes back, gets angry

  1. Some patients come to ER for an ongoing problem, for example, abdominal/ bowel problems. They get a workup. In this example, the patient is told to follow up with GI. A colonoscopy would be the next step.

    Months later they return to the ER with the same problem, having failed to follow up as instructed. Do they expect an emergency colonoscopy?

    The doctor runs some basic tests, then instructs the patient that they must follow up, that a colonoscopy is the next step.

    Pts gets mad and is going to file a complaint against the doctor, storms out of room.

    I feel that the health classes in school need to educate our young on how to navigate the medical system.
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    About Emergent, RN

    Joined: Dec '13; Posts: 2,364; Likes: 17,298

    13 Comments

  3. by   beekee
    My guess is that they can't afford follow up care and are frustrated that their condition hasn't changed.
  4. by   KatieMI
    While I cannot deny that education is a good thing, I feel that health care providers should also start to speak the language their patients speak and deliver information the way it would be clearly understood. The current "professional" and "politically correct" medical language just doesn't do the job. All those "might help", "you may want" and "you've got little bit of problems" give lay people impression that 1) their problems are not serious enough, and 2) that they have wiggle room while they don't.

    I heard many times that direct and honest communications are not what most people expect and "it is important to tell them what they want to hear". It was one of my breaking points between medicine and nursing because I just refuse to lie to my patients. So I tried to speak with my patients about, well, undeniable facts of life after I establish trust and good contact with them, and I can tell that most of them appreciate it.

    I can add that during my long way as a nano-premee's mom, there were only 3 (three) providers who spoke with me with complete honesty and openness, and two of them were neonatal NPs.
  5. by   traumaRUs
    Moved to ER Nursing
  6. by   JKL33
    Quote from KatieMI
    While I cannot deny that education is a good thing, I feel that health care providers should also start to speak the language their patients speak and deliver information the way it would be clearly understood. The current "professional" and "politically correct" medical language just doesn't do the job. All those "might help", "you may want" and "you've got little bit of problems" give lay people impression that 1) their problems are not serious enough, and 2) that they have wiggle room while they don't.

    I heard many times that direct and honest communications are not what most people expect and "it is important to tell them what they want to hear". It was one of my breaking points between medicine and nursing because I just refuse to lie to my patients. So I tried to speak with my patients about, well, undeniable facts of life after I establish trust and good contact with them, and I can tell that most of them appreciate it.

    I can add that during my long way as a nano-premee's mom, there were only 3 (three) providers who spoke with me with complete honesty and openness, and two of them were neonatal NPs.
    This is good to think about. One of the things I've actually seen a huge improvement in (while everything else seems to be going down the toilet) is the way ED providers are interacting with patients these days. They sit down and talk to patients a good amount of the time, especially in situations where follow-up is important.

    We don't send anyone out without follow-up instructions, regardless how minor their condition.

    I think it helps to have conversations about the ED's role - but those can't be undertaken willy-nilly. They have to be respectful and informative, not based upon chastising people. Patients truly don't understand our convoluted healthcare system, and honestly common sense is not helping too much of the time, either. If you have chest pain and have a work-up and are told to schedule an outpatient stress test but instead of doing that you come back 2 weeks later saying that "the pain is back" and then get mad that the previous ED course is going to be repeated, that is a failure of both understanding and common sense (how would we know whether you're having an MI today based on studies that were done two weeks ago??) - - but, patients don't know that. I try to preempt their anger all the time by telling them, "Well, I know you had these things done two weeks ago but now you're having new symptoms, so the tests that we did when you were here last time can't be relied upon to tell us what's going on today..." - - it usually works (as far as having them not get angry), but doesn't fail to surprise me that they didn't know that until someone tells them.

    When discharging patients I sometimes have conversations about the role/capability of the ED - it helps if I have confidence in the rapport I've established with them. I say something along the lines of, "I'm sorry, I am sure it is very frustrating to have put up with this for so long and then when you come to the ED we are not able to tell you exactly what is causing it. Unfortunately sometimes the role of the emergency department doesn't work that way - - our primary task is to look for emergent or urgent serious conditions that might be associated with ______ (abdominal pain). We have checked out those things out today, and your normal CT scan gives us some confidence that you don't have a condition that needs emergency surgery, for example. But it's very important that you take the next step and see [GS, GI] because they may have suggestions for additional studies that can't be done in the emergency department, like a colonoscopy......Here is the phone number for Dr. X - and our recommendation is that you call the office in the morning and an set up an appointment.

    I also talk to them about how they are encouraged to return to the ED if anything changes and I review the information about that, but I ususally do reiterate that we have done what we can do to evaluate the kind of symptoms you're having today, and if these continue, our only options really would be to repeat what has been done already (if appropriate) so it's VERY important that you take the next step and meet Dr. X.
  7. by   Emergent
    I think we need a public service campaign to help educate the public on how to most effectively manage their healthcare and navigate the system as it is. Sadly, in the United States it's a disorganized mess in many respects. PCPs are under so much pressure, the system is confusing to even me, a healthcare professional.

    Add to that a public that is used to instant gratification, and patients who are surveyed after every ER visit, and you'll see people throwing tantrums and threatening to take their business elsewhere.
  8. by   ruby_jane
    [QUOTE=Emergent;9689309]I think we need a public service campaign to help educate the public on how to most effectively manage their healthcare and navigate the system as it is. Sadly, in the United States it's a disorganized mess in many respects. PCPs are under so much pressure, the system is confusing to even me, a healthcare professional. QUOTE]

    I don't disagree (and I chuckled at "emergency colonoscopy"). Even four decades after EMTLA, there is a perception (by some) that all the health care needs will be met in the ED. Do y'all have a social worker that could help with referrals? Is there even a low-cost/sliding fee clinic (like a FQHC) nearby that the patient could be referred to?
  9. by   kbrn2002
    Quote from beekee
    My guess is that they can't afford follow up care and are frustrated that their condition hasn't changed.
    This very well might be the case. Insurance [or lack thereof] can stink. At an ER a patient is at least guaranteed to be seen by somebody that can at least put the proverbial bandaid on. Then they leave the ER and either can't afford to see a primary provider much less a specialist or even if they have somewhat decent insurance they can't get an appointment anytime soon and the symptoms return before they can be seen.
  10. by   MelEpiRN
    And they very much do not understand an "MD" does not mean that particular MD can prescribe just any medication.
    I got SCREAMED at for over an hour one time by a lady who was so mad her family member was not prescribed methadone. It was explained in detail that to get methadone, the family member would have to go to the methadone clinic to establish care. They truly couldn't comprehend that we couldn't just write a script for it. (Law in this state).
  11. by   ERnursebyday
    Unfortunately the problem is the patient will, most likely, have the same tests completed again with the same results. Many patients think the ER is a one stop shop and it's quite the opposite. Focused acute care.
  12. by   JKL33
    Quote from kbrn2002
    This very well might be the case. Insurance [or lack thereof] can stink. At an ER a patient is at least guaranteed to be seen by somebody that can at least put the proverbial bandaid on. Then they leave the ER and either can't afford to see a primary provider much less a specialist or even if they have somewhat decent insurance they can't get an appointment anytime soon and the symptoms return before they can be seen.
    I agree with you and with beekee, too. The problem is, none of those (very likely) issues change one thing about what happens in the ED or what the ED can do to help; I'm speaking on a fundamental level, of course: We can (and do) put in extra effort making phone calls to specialists trying to get appointments and to various agencies that might be able to help and to social work for their input. But in the end if the patient can't or doesn't follow through we still don't magically become the person/place who can do the colonoscopy on the next ED visit. Please know I'm not trying to be sarcastic here; I know we all know these things, but sometimes I truly think patients don't. Sometimes it very much seems like they believe that if they just make enough fuss or return to the ED enough times, something different will happen or they will see a different doctor who will suddenly say, "You need a colonoscopy and since you feel so bad we're going to get it done right now." I do think there is a knowledge deficit there.
  13. by   liathA
    Is there a possibility of providing patient education here? If the patient doesn't have insurance or a primary care provider, is there one or more low-cost/sliding fee clinics in your area that can be recommended so that they can start to build a relationship with a primary care provider? Maybe as part of screening - "Do you have insurance? Do you have a primary care provider?" and if the answers are no, you can inform them about local services? Maybe something to talk over with your supervisor(s)?

    In my area there's a primary care clinic that provides financial assistance services, including sliding scale as well as assisting low-income patients with applying for medicaid, etc., if they're eligible. They also work closely with a free specialty clinic (requires a referral from primary care in addition to financial eligibility) that is staffed entirely by volunteer clinicians. If people are relying on emergency services as their primary health point of contact because of a lack of funds and/or a lack of knowledge about the other options available to them, then I'd want to share that information with them. Whether or not they make use of the information is a separate issue, but at least they'll know.
  14. by   Munch
    Due to an array of health issues I've suffered over the years(both acute and chronic) I've been to the ED many times. From the patient point of view when you are told to follow up with your GI or primary or whoever doctor it can be frustrating because you are hurting NOW and having to wait until you get an appointment with the respective doctor could mean days of waiting in pain(or dealing with whatever symptom that was bothersome enough to warrant a trip to the ED).

    Add to the problem many people not fortunate enough to have insurance and that's that..they aren't going to make a follow up appointment they simply can't afford it.

    I am not saying using the ED for every little problem is ideal but what is the alternative? Patient comes in and they aren't sick enough for an admission to the hospital for these tests(my hospital does perform GI tests to inpatients where the case is emergent enough I actually had an upper endoscopy done because I was throwing up blood) but they don't have the resources to follow up with a specialist on an outpatient basis so the patient is in a kind of medical purgatory not knowing what else to do..so what do they do? Its a sad state of affairs and I don't have a good solution or answer for those patients that can't and don't follow up.

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