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After the Match

After the Match: The Most Important Formula in Medicine

Cook, Thomas MD

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doi: 10.1097/01.EEM.0000434477.04030.16

    Act 1: It's Friday afternoon on a holiday weekend. You notice everyone heading home early on your way in for the evening shift.

    You notice a crowd of folks in the small corner room of the ED despite the two-family-members-per-patient rule. The patient is a sickly, elderly man with a plastic bag filled with an array of medicines. You scan the EMR and see he has pan-organ failure, and the first thing the family says after you introduce yourself is, “We cannot take care of grandpa anymore. Why can't anyone fix him?”

    Ugh. How can I fix the “unfixable” on a Friday before a three-day weekend when no one wants to work? This sucks.

    Act 2: You round on a 50-something woman in the chest pain unit. She was admitted the day before when she experienced chest pain and shortness of breath. Her initial ED workup was negative, and she was admitted for observation. She hasn't worked since the Reagan administration, but she was not happy to stay because she had “so much to do.” Cardiology saw her briefly that morning and sent her for a stress test. The result is negative, and you were told to discharge her.

    You tell her that her tests are all normal, and she can go home. She blows up and chews you a new one. “I want to know what is causing this pain. I have been lying here all day, and no one has told me what is going on!” This sucks, too.

    These scenes are repeated every hour of every day in every ED. It's the same story in the end. The patients are angry because they want something they think you have and are unwilling to give them. You hate it. The nurses hate it. The patient hates you. You feel the weight of this stuff pressing down on you like a STEMI.

    Act 3: We learn a lot of math before residency training. It's crammed into our heads starting in grade school. We even take calculus in college because it is imperative to our ability to function as doctors. (Of course, I am thankful for this because I use calculus all the time in my practice.)

    Then we learn about all sorts of formulas in medical school and residency that will help us heal the sick. Anion gap, ejection fraction, A-a gradient, cardiac index, creatinine clearance, peak expiratory flow rate, bladder residual, osmolar gap, and the fractional excretion of sodium are some of the favorites. All of these attempt to take the vast subjectivity of medicine and wrap it into objective formulas.

    I am always amazed, however, that the most important formula is rarely taught. I never heard it once during medical school or residency, and residents haven't a clue what it means. It is one of the most important principles for all service industries, and yet most folks in medicine haven't a clue it exists.

    S = P/E

    Next chance you get, try Googling this phrase: “Satisfaction equals performance divided by expectation.” It will turn up an endless stream of business theories on how to make customers happy, and it is the very foundation of how to satisfy patients based on what you can actually do.

    But there is a catch. Businesses try to improve “performance” to increase “satisfaction.” But patients haven't a clue about what we can and cannot do to satisfy them. (“Cure pancreatic cancer? They can do that now; I read it on the web.”) Their expectations of what we can do are huge regardless of how many health problems they have accumulated over a lifetime of good times. You, therefore, will have to perform at a level just short of God for them to be satisfied with your work.

    The key for many doctor-patient interactions is not how to improve “performance” to increase “satisfaction.” Rather, you need to recognize quickly when you have an “expectation” problem. You need to address their expectations up front. If you do not, you will not only be unable to increase “satisfaction,” but the patient will think you are holding out on him. He will think you have the solution in your back pocket, but you are just not willing to give it to him. He is looking for a solution that you not only do not have but that does not exist.

    The key to the first case is to begin a dialogue, explaining that the patient is at the end of his life and the solutions the family seeks are not available here or anywhere else. This isn't easy. It requires years of practice, and family members may not be ready to accept your answer. There are ways to ease the patient's suffering and support the family through this difficult time. The answer is not miracle treatments but nursing support and a realistic discussion of end-of-life issues.

    In the second case, you're already screwed. The physician who saw the patient before you needed to adjust “expectation.” The patient needed to hear that observation is boring, that not much will happen, and that she will not see a physician for hours. (That is why it is called “observation.”)

    She needs to hear that we only test for “bad things,” and what she wants to hear from the doctor the next day is that we don't know what is causing her pain. She needs to understand that it is bad if a physician walks into her room the next day and says, “We know what it is.” Tell her she does NOT want to hear that. What she wants to hear the doctor say is, “Beats me. I haven't a clue, but it's not going to kill you. You get to go home.”

    Many times the art of medicine is not pretending to be able to do something you cannot do but adjusting the patient's expectations to be in line with what you actually can.

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