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Comment by tertius | Hacker News Reader

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.

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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-s...

Longread but excellent: 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.

"(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.

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.

> 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.

Irritability is a part of suffering.

I get and appreciate that, but I really don't think it's appropriate to hit someone over a turkey sandwich. If you're able to eat that and walk around on your own and watch the ball game, pretty sure your suffering isn't sufficient to warrant punching a nurse in the chest.

The appropriate response to assault is getting police involved.

Fundamentally I believe non-consensual violence is the result of suffering. I think isolating violent people and protecting yourself is much better than meting out arbitrary punishments. Consider that someone willing to punch a nurse in the chest over a turkey sandwich very likely has some kind of mental health issues. If the assault is actually a problem on the level of a crime, then call the police.

Agreed with Ectoplasm here. My mother was a psych nurse and this was par for the course. She did not enjoy this part of the job.

"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."

And I'm on the practitioner's side here. And yes I can see that this influences ratings. My quick one liner about evaluation of facility vs. independent doctor may be confusing in that the rest was not addressing evaluation but rather treatment of 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."

Yes and worse. But given that, I can certainly see that this is the status quo for nurses/techs and not for doctors so I can certainly sympathize. I'm not defending these actions.

"'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."

Yes, it is easy for me to say, but my ease by no means releases someone from their responsibility to control their emotions under stress. And I'd like to hear more about that being the reason for high turnover.

"I'm advocating ... more patient education on the other side of healthcare."

Ha! In the U.S. this is a lost cause. I do agree with you completely, but the system is set up in such a way that medical knowledge is abstracted away from normal life/people to a ridiculous degree. And both parties, the lay and the physicians, seem to prefer this. Incredible!

"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' used in the third person below)

If that means reacting in kind then I disagree. If you're rude to a rude person then you're a rude person. If you decide that somehow a rude person deserves a lesser degree of care then you should get reacquainted with medical ethics.

You did add "You'll get the same standard of care." So the above is a general comment and not 'aimed' at you personally.

Assault = police.

I'd guess that patient ratings (of doctors, maybe not ER rooms) correlate with the doctor's willingness to prescribe all the drugs if asked, which could be what we're seeing here.

My personal experience leads me to hypothesize that it's just simply how fast patient requests are fulfilled and how well their questions are answered. A LOT of that comes down to nursing. The doctor may explain things incredibly well, but frequently patients turn and ask the nurse questions after the doctors leave the room, because they didn't quite understand what was being said. Also, it's the nursing staff that's toileting patients, getting and administering their meds, walking with them, talking with them about their condition, etc.

Pain management comes into it as well, but I also think that's something that could be added to improved patient education in this country (per my commentary below). For example, when people talk about their family members being in the hospital, and how their pain is bad, I ask why they don't get palliative care involved. 9/10, I get 'well they're not at end of life, so why would I do that?' Pallitive care focuses on quality of life at any point, and a large part of that is pain management. Most people don't know that, however, and the system is unfortunately set up such that patients and their family members often hold this (incorrect) belief on what palliative care does.

> patients turn and ask the nurse questions after the doctors leave the room, because they didn't quite understand what was being said.

This makes me extremely curious as to how hospitals in the US work. Why does the doctor leave the room and leave the patient there? What's the doctor doing elsewhere? What's the patient doing in there?

So the way inpatient (hospital) settings work here in the US is that patients have their own rooms (occasionally shared rooms, with one or maybe two other people, but by and large patients have a private room). Usually the doctors round in the morning, meaning they stop in to the room, talk with and examine the patient, and then update the plan of care as necessary. The nurses then execute the plan of care--the nurses administer medications, explain processes, etc. The nurses cannot diagnose a disease (officially), nor can they prescribe medications (officially). Typically, conversations patients and nurses have result in the nurse suggesting a doctor look at a specific cluster of symptoms or test for a specific diagnosis, and/or prescribe given things. Nurses are supposed to be advocates for patients. Doctors plan the care. Excepting surgeons, doctors rarely actually administer the care.

The inpatient system works this way because it is easier to scale--our nurses often have bachelors degrees, with an emphasis on biosciences: pharmacology, pathophysiology, anatomy and physiology, etc. The providers (doctors, hospitals) are reimbursed based on what is prescribed (the procedures) and (this is key) how many people they see. So, it makes the most sense, financially, to have the doctors see each patient for, say, 10-15 minutes only, and then have the nurses carry out the plan of care. If you have a good working relationship between the doctor and the nurse, the doctors will often rely on what the nurse thinks to decide on what tests to order and/or what meds to prescribe. How does it work in your country?

Huh, that's quite interesting, thanks for the thorough explanation.

I live in Argentina, and it works quite differently. Patients wait outside the doctor's office, the doctor will call them in, examine, and prescribe any study, treatment or medication necessary. The patient leaves and the doctor remains in the room.

If the patient needed some study (eg: some scan, blood test, etc), they'll need to head to the hospital's lab with the order and get it done there (or you can go to another hospital if you prefer, though I don't think this is common at all). If there's a medicine prescription, then the patient will have to go to a pharmacist and get it himself, again, with that order.

Private hospitals are paid by each patient they see (and studies are paid separately), either by the patient or their health plan. Public hospitals are free, though they may charge some studies/supplies. Some public hospitals won't attend you for free if you have a health plan and will instead force you to use it instead.

I'm not sure which system is faster, but there's no nurse involved in general when just seeing the doctor, which must make a difference (eg: less personnel), and it's the patients who move around instead of the employees.

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