Many years ago I was with a friend sitting in Taco Bell. We were talking about things we normally talked about at the time, video games, why girls didn’t like us, video games, roleplaying games, plans for taking over the world, etc. As we started to leave, we noticed a stop sign on the door. Underneath the word “Stop” is said “are you leaving fully satisfied, let us know, we are listening.” My mind being what it is thought this could be a really great thing to put on my bedroom door. (Not that there was ever anyone in my bedroom at the time who would offer a comment on it) But the marketing and public relations people over at Taco Bell seemed to think that actually asking people if they were happy and why or why not could improve their business. You see, knowledge is power. You can try to guess your customers, patients, John’s, punters, (whatever you want to call them) are happy or not and the reasons why. But seeing things from your own point of view will likely lead you to believe nothing is wrong or erroneously conclude what is wrong.
When I teach, at the end of every class, there is a survey. There are the obligatory bubbles to fill in of “fully satisfied” to “very unsatisfied” on the 1-5 scale. But more important I think are comments. I encourage people to comment. I am told soliciting comments weakens the value of the survey, but knowing you did something that made people very satisfied or very unsatisfied doesn’t actually clue you in on what you did well and should keep doing, or what you really don’t do well and should stop or improve.
Recently there is a lot of talk on customer satisfaction surveys in medicine. In every discussion is the obligatory mention that happy patients have worse outcomes according to some study or another. It basically uses the scientific method to create a study and enforce our point of view that we are right and therefore patients must be wrong. Unless of course they give good reviews, then we can just chalk that up as they “get it.”
Now in some countries, these surveys are mandatory. In some they are an optional effort to improve. But they usually have a bunch of questions that don’t really address patient concerns.
Because of my experience with this from teaching, I just outright solicit feedback. What did you like? What didn’t you like? What would you like to see changed? When I or my family go to the doctor (that’s right, I don’t take care of everything myself. That is like a lawyer representing himself with facts he believes are true and doesn’t actually know. Plus I don’t have all the equipment needed to take care of people properly at home.) I am sure to tell them what I liked and didn’t like. They don’t always appreciate it I am sure.
I have said it many times. I will say it again. Modern medical systems do not work for patients. Not because they wanted antibiotics and didn’t get them. Not because they had a treatment plan they found on WebMD and the doctor didn’t verify that they in fact have the most rare cancer known to man and are going to die in hours.
But here are a couple of observations of mine on what is not working for patients.
The medical system does not respect the patients’ time. It is a primary care provider who is constantly late, the surgeon who “get’s around” to talking to the family post operation, the call center that tells patients they can get an appointment for their UTI sometime next year, or that most services only operate on bankers’ hours when people who need care actually have to go to work or school.
As providers, we have all kinds of excuses. The paperwork needed done, there were “complications”, X amount of patients needed to be seen, etc. The fact is there are not enough doctors. The system needs to increase the amount of them. In fact, I know of absolutely no medical system in the entire world that has enough doctors, much less, too many. Bottom line, it doesn’t work for the patients.
Providers do not take the time to explain things. You see, we work in the system. For me it is like a second home. I know how long everything takes to do; I know who is on what list. I know the pathophysiology of diseases inside out. If I don’t know, I look it up, and then for at least a few days, I know. I know the guidelines. I know what diagnostic tests hurt and which ones don’t. I know why we are doing them and what I want to see or not see to help me make a decision on something. Patients don’t know any of that. They are lucky if they called the correct number to go to the correct provider. Even before we can “explain things” in their language, we need to tell them what to expect. Simple things like: “you are not about to die and the blood test results will take between 45 minutes and 2 hours, for reasons beyond our control.” “You will get an x-ray today, I do not know when. It could be in minutes or hours.” “I will tell you what I find out or know as soon as I find out.” “You are going to have to come back.” “This is not going to be better by tomorrow morning and you will miss work.” All of that information is needed or desired by patients before you start “speaking their language” when talking about their illness and treatment options.
I draw on my teaching experience when talking to patients. I know a major part of my job is teaching them. Have you ever been in a class where the teacher explains something for hours and despite everyone looking at each other with utter confusion, the teacher then asks “does everyone understand?” (Everyone nods yes) “Does anyone have any questions?” (Nobody has questions) Because nobody wants to look dumb? Because their brains are basically toast because it was too much info in too short of time? Because you are such a dull speaker nobody wants to listen to you another minute? For any number of reasons not mentioned here? So class breaks up and everyone leaves. The exact same thing applies to patients!
This was really driven home with me when I was working in an ED. A 13 year old boy had fractured his femur riding an ATV. He was lucky that was all, those things are death traps. He was being supervised by his grandfather and as the official supervising parent with the inability to contact other parents; an orthopedic surgeon offered him 3 treatment options. Said grandfather did not understand exactly what those options meant. So he asked. Our orthopod went on to describe plates held together by screws, pins inserted lengthwise through the bone, and listening to it being told in “common language” I laughed about how if we were outside the hospital, we would probably be tried for crimes against humanity for planning such things. In the end, grandpa was doing his best not to faint or vomit, he meekly managed “whatever you think is best doc.” This man did not understand the procedures. He had to be taught exactly what they were. He was totally lost on “growth plates” and “medullary canals” but when broken down into “we are going to screw a plate to his leg.” He understood perhaps more than he wanted. The orthopod was not “explaining” the procedure or treatment, he was teaching him what it was! Teaching and explaining are not the same thing.
I might be wrong! I tell that to every patient. I am giving you my very best opinion. Based on what I think. I tell them why I think so. I show them my evidence to support it. I explain what could be beyond my ability to predict or correlate. I tell them why I don’t do certain things. I make sure to remind them I cannot promise any outcome, but I will give them my very best effort. I tell them this because while every healthcare provider in the world may know these things, patients do not. They need to be taught how medicine works. What its limits are. That it is not McDonalds where you order off the menu and get exactly what you ask for.
It does take a few moments to do this, but I find that not only does it make the patient more at ease; it builds their confidence in me. It also reminds us both I am not all powerful and all knowing. We laughed when Donald Rumsfeld said it in a press conference, but there are known knowns (things we know we know), there are known unknowns (things we know we don’t know), and there are unknown unknowns (things we do not know we do not know).
Finally, I like to ask whether the patient understands, regardless of if they say “yes” or “no” I summarize it anyway, just like I do when I teach students. Then I ask what they liked, what they didn’t, what they would like to see different. I acknowledge their gripes, even if I have to admit to them there is nothing I can do to change it. I do what I can to adopt what they suggest will help; not only for them but for other patients.
Satisfaction surveys do not change how I practice. Issues are addressed with patients most of the time before they wind up on a survey. I also get a lot more and nicer compliments than many of my peers. Not because I am any more deserving of them, but because I use patient feedback to work for me. I understand that patient “needs” usually have nothing to do with medicine. Certainly they have illnesses, and those illnesses need treatment. But illness does not affect patients. What affects them are the consequences of the illness. How does the illness change their life, not just what symptoms does it cause.
Some will chalk this up as “good customer service” but I think it is actually more than that. I think it actually understanding what the patient is trying to say or ask. Giving the patient what they expect will never satisfy them. Their demands are unrealistic. We must teach them what to expect, making every effort to under-promise and over-deliver. Not only does that take the fear out of the satisfaction survey and make it something to look forward to. It provides more effective medical care.
No doctor should be focused on what they are not going to do or give to patients. They should be focused on what they are going to do or give them.
One more thing…Most patients really hate paternalism. Treating patients like that should be for an exceptional few, not as a rule for all.