Parental Satisfaction

 

Just a Virus

In Annals of Emergency Medicine this month is an article about Parental Satisfaction (Byczkowski TL, et al. A Comprehensive View of Parental Satisfaction With Pediatric Emergency Department Visits. Annals of EM. Oct 2013; 62(4): pp.340-350). The pressures of “patient satisfaction” / “parental satisfaction” scores are now becoming more prominent throughout our medical practices.  This article attempts to delve into the factors that may influence the parental satisfaction in our Ped EDs and notes that, in addition to pain management and wait times, other influential factors are 1) perceived physician and nurse teamwork/coordination, 2) communication, and 3) information/education.

We all would agree with these concepts as being important, but I would like to highlight some simple tactics that (in my humble opinion) can help with all of these.

Think Out Loud

  • Just like in grade school, you won’t get credit for your work unless you showed it.  Your thought process is just as important (if not more) to the parents as is the final answer… particularly when the final answer is “It’s Just a Virus.”
  • Your “medical decision making” is not only important to document, it is also important to tell the families.
    • For example: A child with 4 days of diarrhea presents to you. Entering the room you find the child doing backflips and eating potato chips and you, rightly, have a strong sense that the child is doing well and likely has a viral illness.
    • You smartly document a thoughtful consideration of hemolytic uremic syndrome, necrotizing enterocolitis, and dehydration.
    • You discuss oral rehydration therapy and prepare to discharge them.
    • Yet, the patient’s family will not give you full credit for all of the mental work you did if they merely hear you announce that the patient “just has a virus.”
    • Furthermore, if that child goes on to later be diagnosed with inflammatory bowel disease, the perception that you jumped to a incorrect conclusion may loom large in the parents’ minds.
    • Announcing your DDx and Thinking Out Loud shows you are, in fact, considering many problems and are not being dismissive.
  • You can Think Out Loud while you examine the child.
    • “Oh look… here is appendix is and it is not tender… great!  Oh, here is where his gallbladder resides… it isn’t tender either. Excellent!”
    • This saves time and also reinforces how thorough your examination is — Bonus Points!
  • This also helps you with medical students / interns!
    • It reinforces good communication with patients and parents.
    • It also points out the specific things that need to be considered for that case.
    • It also reinforces to the family that you are all on the same page!
  • This helps with team work also!
    • By thinking out loud, your entire team or nurses and techs get to hear what you are considering and what you think needs to be done.
    • Then everyone is on the same page.
    • Occasionally, you have to think a little LOUDER, so that everyone can hear you (naturally, with patient privacy in mind). 🙂
  • This also can save your rear end!
    • It is more than just a Public Relations ploy.
    • Thinking Out Loud can remind you of something that you almost forgot!
    • It reinforces your own differential diagnosis.

Don’t Say “It’s Just a Virus.”

  • Yes, we care for a lot of viral illness in the Peds ED.
  • Don’t ever forget that viruses can be quite deadly… and the word “just” before them seems to minimize their impact and the parental concern.
  • If the answer is that it is a virus… consider first announcing with all of the terrible things that you Do Not think it is, rather than simply saying “it’s a virus.”
  • After the family hears that you have considered appendicitis, hepatitis, cholangitis, necrotizing pancreatitis, and small bowel obstruction they are more receptive to your words about how “fortunately, you believe this to be due to a viral infection.”
  • “It’s just a virus” is like a slap in the face to parents.  Try to avoid saying it.  Particularly since viruses can be deadly.

Satisfy the Needs

  • Every patient encounter is pivoting on a particular need. Satisfying that need will often lead to the greatest parental satisfaction.
  • Often that need is evident:
    • “You need to have your bone put back in place.”
    • “You need bronchodilators and close attention.”
    • “You need antipsychotic medications.”
  • Occasionally, that need can be cryptic.  When it is obscure, it is ok to ask what the perceived need is.
  • Do NOT Assume you know what the family believes the need to be.
    • If you assume what the need is, you may be incorrect and nothing will serves as a faster way to lead to dissatisfaction than being seen as a doctor who “doesn’t listen.”
    • Often, once made evident, the need is easy to satisfy… sometimes, like in the case of antibiotic requests, the need is satisfied by education.

     

So, while my personal goal is not to score highly on parental satisfaction surveys, I do think that the techniques above can lead to both quality care and parental satisfaction… again… in my humble opinion.  I welcome yours.

 

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

6 Responses

  1. Jonathan says:

    Documenting one’s thoughtful consideration of necrotising enterocolitis in a child eating chips and doing backflips could be considered … interesting. I mean, have we really ruled out Ebola?

    • Sean Fox says:

      No, certainly the patient “could still have Ebola.” In fact, telling that family that “it’s just a virus,” would be correct. The main point, however, is not to “rule-everything-out,” but rather to be sensitive to the family’s concerns. Often, by merely addressing the concern for appendicitis, we are able to alleviate their concerns and avoid a huge, unenlightening work-up.
      Thank you,
      Sean

      • Jonathan says:

        I totally agree with the sentiment of the article, but was going off on a tangent — I don’t really think we want to encourage people to document their careful consideration of completely impossible diagnoses. Verbalising that it’s not scary-disease-that-parents-are-worried-about is essential, but I imagine we’d all agree that any list of differential diagnoses made in the records should have some degree of likelihood.

        • Sean Fox says:

          Sir, we are in the same page. Yet, we should all still remain vigilant for those conditions, like NEC, that can present in subtle fashions and be easily overlooked in the correct clinical setting. Yes, the kid who is eating potato chips doesn’t make me think of NEC, but the neonate who is “just vomiting” does. In the end, it is a challenging job that we have and we need to remain humble, unless we would like to be humbled.
          Thank you,
          Sean

  1. September 18, 2015

    […] and Cat Scratch Disease). Additionally, we are aware of how important it is to avoid the “It’s Just a Virus” statement. On occasion though, the cause of the fever will not be clear, but the prolonged […]

  2. January 22, 2016

    […] the Ped EM Morsels have requested that we remove the phrase “it’s just a virus” from our lexicons. One simple reason is that viruses can lead to significant illness also […]

Leave a Reply