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As one who works in hospitals’ Emergency Departments, I can attest to the incredible care hospital staff members try to provide. In the Emergency Department, for example, long hours, rude patients, high stress and unknown diagnoses are regular aspects of the job, yet somehow doctors, nurses and techs manage to take care of it all. It is a team effort. It is not easy. It is not perfect. But we do our very best.

That being said, a hospital can be a scary place for patients. I was reminded of this recently when I spent the day at the bedside of a friend who was admitted to the hospital. It was an interesting experience. Instead of being the doctor in charge of patients in the Emergency Department who had symptoms from yet-to-be-diagnosed problems, I got to observe healthcare from the viewpoint of a friend of a patient who had already been worked up in the Emergency Department, had a known diagnosis, was neatly packaged and labeled, and admitted for further care.

I watched a nurse try to give my friend a medication although there were clear vital sign indications not to. I had to say something so the nurse wouldn’t wrongly medicate my friend. It was clear that she had not even bothered to check the vital signs. Because there was an order to push medicine, she was going to push medicine – even if it was wrong to do so.

I watched as my friend – an intelligent and inquisitive person – simply ask the nurse later what a different medication did and what it was even for. She didn’t know. She self-consciously slipped out to research it on the internet. She was going to push a medication that she knew nothing about.

I saw how inpatient floors come to a near-halt on weekends. Skeleton staffing, techs not available to perform routine studies, nurses working on floors they’re not familiar with . . . a lot of meaningless downtime resulting in patient’s racking up huge inpatient bills for an extra day or two simply because they have to wait through the weekend until things get back up to speed on Mondays.

I witnessed that fine line patients are forced to walk to keep insurance companies happy. For instance, there are medications and procedures that are “protocol” for all inpatients - which are simply a way for hospitals to cover their own backsides. A good example is that almost all inpatients are supposed to be injected with blood thinners daily. This makes sense for patients who are suddenly bed-bound for days and days – they are at risk for developing clots, and so the blood thinner is given to prevent this. But my friend had been in the hospital for all of 8 hours. My friend was up and regularly walking the halls. I am certain people have been home sick and lounging on the couch for longer than my friend was. Yet the doctor wanted to push blood thinners anyway. Because it is standard of care to do so. Because it is protocol. Because it is on the checklist. Another medication. Another poison with the potential for side effects. I wanted my friend to decline as it clearly was not needed. But the question came up: what happens when patients refuse things in their inpatient stay? Do they run the risk of the insurance company refusing to pay for an “uncooperative patient’s” hospitalization? The answer is yes. Insurance companies look for any way not to foot the bill. And so inpatients become trapped. They can either accept meds and treatments that are not necessarily needed, or they can run the risk of being slapped with a $50,000 inpatient bill.

I saw the shock and almost annoyance when the patient actually asked questions about the care being provided.

I got to see how a busy, overworked inpatient doctor may check in on the patient for 10 minutes early in the morning, and not see that patient again for 24 hours. I spend more time at the bedside of paitents with splinters.

It was a learning experience for me. Fortunately, my friend was fine. But hospitals are scary places.

I go to work every day to help others. And while I sincerely hope that patients are satisfied with the care they receive, making patients happy is not my focus. That isn’t my job. Saving life and limb is what I am in the Emergency Department to do.

Yet social, economic and cultural changes are finding their way into Emergency Departments and forcing the focus to change. Patient satisfaction is being tracked almost obsessively more and more.

Patients are asked to fill out surveys about their Emergency Department “experience.” They are called in follow up to see if they enjoyed their time at the hospital. Banquets and national award ceremonies are held to honor the Emergency Departments that had the happiest patients.

In the written and telephone surveys, patients are asked questions such as: Were you happy? Did you like the care you received? Did you feel that the doctor was sympathetic? Did the doctor take time with you? Was the staff polite to you? Did you get the care you wanted? The results of these surveys are then evaluated – and whatever the patient states happened, happened. End of story.

Never mind the fact that refusing narcotics to a drug addict is the right thing to do – that person left the Emergency Department extremely unhappy and so it is deemed that he received bad care.

The woman  is upset about her Emergency Department bill when she “only” came for evaluation a sore throat - even though she was the one who chose to use an Emergency Department for her non-emergency.

Forget that the man who wrote a complaint letter sexually harassed several female staff members while he was in the Department – he felt that the doctor was not sympathetic toward him and so he clearly did not get good care.

Even though the guy did not come to the Emergency Department until his days-old wound was markedly infected, he was upset with the doctor about how widespread his infection was - somehow making it the doctor’s fault or problem.

Ignore the fact that the woman who claims the doctor was not listening was also in the midst of a profound psychiatric episode and had no idea what was going on – she states the doctor did not listen, and so the doctor must not have listened.

It doesn’t matter that the person came to the Emergency Department for a splinter removal that took all of five minutes to accomplish – she is dissatisfied that the doctor did not spend enough time with her, and so shame on that doctor.

Don’t pay attention to the part where the patient screamed and swore at the doctor about her anger regarding the limited television programming that was available in her private room. She said that she did not enjoy her stay in the Department, and so this complaint must be followed up on.

The message being sent is that patients should view an Emergency Department like a customer service business. We are training the public to think that an Emergency Department should be keeping them happy and catering to their wants, not saving lives. We are encouraging them to expect an Emergency Department to be a place where they can get whatever they want – rather than receive what they need. The new mentality is that staff shouldn’t be respected – they should be despised. I see it every day, including in the patients who come stomping out of their rooms and demand that the doctors to bring them hot coffee . . . blind to the fact that the doctors are a tad busy taking care of those who are actually sick.

But an Emergency Department is obviously not a customer service business. It can never be. It is not a restaurant. It is not a hair salon. It’s not a clothing store. It is a place where staff must prioritize the sick and where saving lives is the goal. Keeping people happy while they wait in their private rooms and watch reality shows on flat screen televisions is not. In an Emergency Department, the customer is not always right.

To borrow a line from someone who said it far more eloquently than I: “We are here to save your backside, not kiss it.”

But unfortunately, this very distinct line between customer service businesses and emergency medical care is getting erased. Why?

The ridiculously high cost of providing and receiving health care.

Medicaid typically pays only a low percentage, if any, of someone’s medical costs. Meanwhile, more and more people are uninsured and relying on Medicaid to cover their medical bills. Throw on top of that the fact that people are flocking to Emergency Departments in higher numbers than ever. The end result is that, despite the astronomical number of patients that most Emergency Departments are treating – being stretched well beyond the patient capacity they were designed for, Emergency Departments are getting only a tiny amount of compensation for all of the care they provide. Revenue is plummeting.

The only way to make up the difference? Raise the cost of medical care. Bring in as much revenue as possible from those few paying/insured patients, since it’s the only money some Emergency Departments see. Emergency Department bills are high because the Department is trying to break even so it can stay open and continue giving care to that community. Trust me, the doctors don’t see that money.

Insurance companies’ response to the increasing health care costs they’re asked to cover? Raise the cost of health insurance premiums.

(And then malpractice costs skyrocket with it – which obviously means more and more doctors go out of business, fewer primary care doctors are in the community, and even more people then use the Emergency Department for their non-emergencies. Another layer to the mess.)

This increased cost of health insurance, of course, only means that even fewer people are able to afford it. Which means more people applying for Medicaid. Which means even fewer paying patients. Which means even higher health care costs. And so the vicious cycle continues and the pool of paying patients (“customers”) shrinks more.

For example, where I work, only 10-15% of patients have insurance; the hospital eats the cost for the other 85%.

So this has made the rare insured patients an extremely hot commodity. Emergency Departments need them financially, and so we must cater to them. We have to keep them happy. Private rooms, bigger rooms, better meals, nicer televisions, fresh coffee, room service, solicited feedback, apology letters . . . the Emergency Departments that can still afford to do so are scrambling to please the patients so they will come back again.

And now those paying patients are wanted even if they come for non-emergencies. Forget public health and teaching patients about appropriate uses of Emergency Departments – the message has been turned on its head. We want people to come for their non-emergencies! We want you to use Emergency Department resources for your runny nose! We want you to take our time even though it should be devoted to the truly sick. We need your money!

And this is why doctors are hounded to keep those paying patients happy. We are provided with paycheck bonuses if our patient satisfaction scores are high. But the conflicts of interest inherent in this mentality are boding badly for how policies may continue to evolve in the future.

I chose Emergency Medicine for a reason. But changes are in the air. Only time will tell how things will play out.