ER Goddess: Stop Letting the Kids Run the School : Emergency Medicine News

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ER Goddess

ER Goddess

Stop Letting the Kids Run the School

Simons, Sandra Scott MD

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Emergency Medicine News 39(1):p 9, January 2017. | DOI: 10.1097/01.EEM.0000511944.50897.99

    Basing medical care on patient satisfaction is as smart as basing elementary education on child satisfaction. The patient who wants a cheeseburger while going to the OR shouldn't influence hospital reimbursement any more than the child who wants recess all day should influence school reimbursement. By tying health care funds to the opinions of patients, we are letting the kids run the school.

    Doctor-patient relationships are based on the trust that we'll use our expertise to better those we serve. We spend nearly a decade training with the altruistic aim of helping the sick, not with the profit-minded scheme of selling to customers. “The customer is always right” was one of my dad's mantras in his sales career. He probably never imagined that patients, who didn't go through medical school and residency, would become customers.

    “They're not customers. They're patients. Customers pay,” quipped one of my colleagues to an administrator. He was right. Many of the sick we see can provide no payment in return, but we treat them anyway because we took a Hippocratic Oath to uphold ethical standards and care for those in need. That is not a customer service model.

    A patient care model, unlike a customer service model, requires tough love. We should never be rude, but we must be effective guardians of health. We need to be able to tell people what they don't want to hear without sugarcoating it. That's what I did when I tried to safeguard the health of an opioid addict by having an intervention-style discourse in front of her mom. I got a patient complaint for my sincere effort to help. She was dead from an overdose within a year. Maybe if we weren't so afraid of getting in trouble, we could speak the truth not only to patients like her but also to loved ones who might help them. Instead, we shy away from difficult conversations that might prevent a death because patient satisfaction trumps saving lives.

    What's wrong with medicine these days is what's wrong with America. Personality and “customer service” are valued more than competency, honesty, and outcome. Gone are the days when we could take advantage of a teachable moment and tell patients what they need to hear. Now we are coached to say, “Thanks for coming to the ED.” I'm a doctor, not a saleswoman. Unfortunately, with Press Ganey hanging over our heads, we're too eager to please everyone and too afraid of offending anyone.

    Are They Real?

    More than ever, physicians have to worry about the image conveyed to patients. Many female physicians are turning to hair buns and fake glasses to sell themselves to their patients in the name of higher patient satisfaction scores.

    We'll soon have to wonder whether glasses in the ER are real as doctors succumb to the cultural demand to change their appearance to meet others' ideals instead of worrying about what really matters. It may influence your impression of me, but you are not getting better care if I wear glasses, so why are we tying reimbursement to patient perception? Our priorities are wrong.

    And why are we tying reimbursement to speed? The Centers for Medicare & Medicaid Services emphasize ED throughput metrics as if faster medicine and better medicine are synonymous. Again, our priorities are wrong. They might even be unsafe. I have to explain myself when my average wait time goes beyond 10 minutes. It should go without saying that your issue might not be emergent if wait time affects whether you come to the ED, yet wait times are posted on billboards for all to see.

    It's gotten so ridiculous that a patient who had a full abdominal pain workup, including labs, urine, and a CT, came to my desk, and griped, “Can I have my papers yet? I've been here one and a half hours. This is the worst service ever.” We've created a culture of petulant consumerism in which doctors are customers' servants rather than healers.

    Under-promise, Over-deliver

    We should be managing patient expectations. I can serve the best hamburger, but you are going to be disappointed no matter how well I do my job if you came to McDonald's expecting a steak. “Do what you say you're going to do” was another one of my dad's mantras. I won't promise you a 30-minute stay, but I will promise you the best medical care I can give. That does not mean an MRI for chronic back pain or a dermatology consult for a rash of six months. These unrealistic expectations set us up for patent satisfaction failure. It's better to under-promise and over-deliver instead of making promises that we can't keep.

    Even if we do our best, people are people. Someone will always be unhappy about trivialities we cannot predict. I've been fussed at for getting into a room too quickly and too slowly, talking too quietly and too loudly, wanting to admit a patient to the hospital and to send one home. It's impossible to please everyone, so why are we chasing patient satisfaction and accepting the impractical, if not impossible, “anything to keep them happy” approach? We should prioritize what doctors' main focus has been all along — doing what's medically indicated.

    It's no surprise that studies are bringing to light that patient satisfaction does not equal better medicine. Surveys quantifying how satisfied patients are after an ED visit do not correlate with appropriateness of care any more than surveys quantifying how happy students are reflect how much they've learned. Disempowering doctors and forcing them to cater to the whims of patients has contributed to overprescribing narcotics and overutilizing lab and radiology tests. Let's untie hospital payments from patient satisfaction and return our focus to healing patients rather than pleasing them.

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