You know them, you’ve received some, and so have your colleagues: those zinger questions—the tough questions your patients ask that momentarily throw you for a loop. Sometimes they’re simple, other times complex, and their psychological origin can be multifaceted. In any case, responding to zingers requires calm, diplomacy, and tact.
“How you respond to the inevitable zingers depends in large part upon your preparation,” writes Laura Sachs Hills in her Nov/Dec 2005 article in the Journal of Practice Management.1 That preparation, she suggests, is best established using staff training, group work, brainstorming, and role-play scenarios.
Both hospitalists and primary care physicians, writes Bernard Lo, MD, must be prepared for patients to ask difficult questions or make unsettling comments, even about the hospitalist system itself.2 Anticipating the nature of those comments or questions is likely to help the hospitalist respond in the moment.
“I don’t see these so much as zingers as challenging or uncomfortable questions or attempts by patients to assert some control,” says Steven Pantilat, MD, FACP, associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco, and past president of SHM.
Dr. Pantilat believes that the term “zinger” can imply they are used with malicious intent, yet, he comments, “I’m not sure they are, even if they are an attempt to exert control or challenge the physician. I suspect they arise from fear or other responses.” Below, some of the zingers Dr. Pantilat has dealt with.
How long have you been a doctor? “I’ve now been one long enough not to be flustered by this question, but many hospitalists are young and may be taken aback,” says Dr. Pantilat. “It’s a challenge to the doctor’s authority and expertise.”
Doc, you look so young is a related comment, believes Dr. Pantilat—one that can be interpreted as a compliment or a zinger. “My standard response is always, ‘I’m old enough to take that as a compliment,’ ” he says. “These days I really mean it.”
Vineet Aurora, MD, hospitalist at the University of Chicago Medical Center, says she is sometimes asked, “How old are you?”
“I think it happens to a lot of women who are or look young,” she says. “I usually just state my age, [which is] 32. Often they will say, ‘Oh you look much younger,’ and I take that as a compliment and laugh it off. I think most of the time our patients are just curious. It may also be related to height, and several of us speculate that shorter women may experience this more.”
Ian Jenkins, MD, a hospitalist at the University of California, San Diego, and an associate professor of clinical medicine, shares this zinger: You don't want to order this MRI for my back pain because it’s expensive, so why don’t you just admit it?
His response: “That’s right. We have a certain amount of money to take care of you and the rest of our patients and to do the best job possible. We can’t waste any of it on unnecessary tests or therapies, so you’ve gotten exactly what I would want if I had your back pain—a thorough history and physical exam.”
Here are some zingers from Vijay Rajput, MD, senior hospitalist at Cooper University Hospital, Camden, N.J., associate professor of medicine and program director, Internal Medicine Residency Program, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Piscataway, N.J.º
What’s going on [with my condition]? “Sometimes when I say, ‘I don’t know,’ the patient comes back with, ‘How come you don’t know?’ I usually say, ‘Do you think that we need to know everything in medicine?’ ” says Dr. Rajput. “They usually say, ‘No, not necessarily, but I thought for my condition you might know.’ ”
Dr. Rajput continues, “Sometimes I tell them, ‘Medicine has advanced too fast … many times we [need] more updated knowledge, and sometimes we are not updated … . I would rather update the knowledge and do the right thing for you … than provide you with care with a half-knowledge.’ Most of the people will like and understand that answer.”
Dr. Rajput tells another anecdote: “One time I was rounding with the team on the floor and we all—students, residents, a pharmacy student, and myself—were Asian, [with] three of [us] … born here in the U.S. The patient asked, ‘How come there are too many foreign doctors in this country?’
“That was a zinger,” recalls Dr. Rajput, “and my team thought I [would] pass [on it], but I didn’t. I gave the patient a straight answer with a true explanation. It took a few minutes to explain it in detail.
“I asked him, ‘What is [your] perception?’ He did not have an answer. I explained to him that 25% of [the] doctors [in the U.S.] are not born in this country, and we have a constant need for more doctors. We have proper mechanisms [in place] so that these doctors are trained as well as in American schools and residencies before they start their practice. I also explained the relationships with Educational Commission for Foreign Medical Graduates (ECFMG), National Board of Medical Examiners (NBME), and Council for Graduate Medical Education (ACGME) and said that three out of four of us are U.S.-born and not ‘foreign’ doctors.”
David M. Grace, MD, of The Schumacher Group is a hospitalist practice director in Lafayette, La.; he remembers this zinger: If it’s OK with you, I’d like to stay today and go home tomorrow.
“At least once a week, I have a patient who just doesn’t feel up to going home at the appropriate time of discharge. My response always starts with ‘Why?’ All patients have the right to a safe and stable discharge from the hospital, and it’s important to ensure that no pertinent issues have been overlooked. Is their home support system not ready yet? Is payday tomorrow, and they can’t afford their medicines today? Are they just scared?
“Once I’m satisfied that no occult dangers exist, I sit and discuss the situation with the patient. I first remind them of our discussion … at admission; it’s the same discussion I have with every patient,” says Dr. Grace. “During the admission process, I outline what objectives need to be reached prior to discharge. I emphasize that the role of hospitalization is not to cure the patient but to ‘rectify the problems that require inpatient care’ and allow the convalescence to take place at home.
“Occasionally I have patients [with whom] my first-line strategy doesn’t work, and I move on to plan B. Plan B is where I quote statistics such as, ‘100,000 patients per year die in hospitals due to errors, and on average, each inpatient will have one medication error per day.’ Continuing to stay in the hospital beyond today will shift the risk/benefit ratio to a position where the patient would have additional risk but no additional medical benefit.
“Plan C is rarely used, but it’s in my arsenal,” he says. “I remind the patient that I’m responsible for doing what is medically appropriate, and I reiterate that I understand their concerns, but I cannot commit healthcare fraud by documenting that the patient is not stable for discharge when they are stable. I then shift the decision back to the patient by closing with, ‘We don’t force patients to leave or drag them out of the hospital; however, you need to check with your insurance carrier about whether they will cover the cost of a non-necessary additional hospital day.’ I inform them that the hospital will likely charge the additional day to the patient, and I don’t want to see them get an unexpected bill.”
Another of the zingers Dr. Grace has dealt with: I’m supposed to have test X done as an outpatient, but now that I’m here in the hospital, can we just do it now?
“On days where Lady Luck is shining on me, it’s a test we need to do as part of [the patient’s] acute work-up, and everything works out well. More often than not, it’s a test or procedure unrelated to the admitting diagnoses and one [that] is far more expensive to do as an inpatient, compared with an outpatient study.
“When possible, I’ll explain to the patient that the test they want may not be accurate in the setting of an acute illness, such as the test for lipid levels,” he says. “If the test doesn’t fit into that category, I’ll explain—depending on the request, such as one for an MRI or CT—that they may make it halfway through the test, and the test will need to be aborted because of an acutely sick patient who requires immediate intervention using that piece of equipment, which for the patient would mean that they may need to go through the procedure a second time, or possibly even a third.
“Failing that approach,” he continues, “I often make the insurance company the ‘bad one’ and inform them that their carrier may not pay for the test as an inpatient as it’s not related to their medical illness, and they should check to ensure that the bill won’t be passed on to them. Often the patient, who knows how much of a headache it can be to deal with their insurance company, will drop the request.” TH
Andrea Sattinger writes frequently for The Hospitalist.
- Hills LS. How to answer the most common zinger questions. J Med Pract Manage. 2005 Nov-Dec;21(3):153-155.
- Lo B. Ethical and policy implications of hospitalist systems. Am J Med. 2001;111:48-52.