Customer Satisfaction

I think this is one of the most interesting aspects of the current healthcare debate - is healthcare a "good", in the economic sense?  Does it work the same way?  Is consumer behavior even remotely similar regarding the use of medical care as it is regarding other consumables?   Now, I am no expert in economics, nor am I an expert in medicine or healthcare finances... but I do know a little about these things, and I would argue confidently that it is not.  This is just a small, small sliver of one concept in the overarching  debate about how we ought to think about healthcare and what we ought to do about it in this country, but the following article about idea of "customer satisfaction" in medicine helps to illustrate just how abundantly complicated this issue is.

Hospitals Aren’t Hotels

By Theresa Brown

March 14, 2012 

"You should never do this procedure without pain medicine,” the senior surgeon told a resident. “This is one of the most painful things we do.”

She wasn’t scolding, just firm, and she was telling the truth. The patient needed pleurodesis, a treatment that involves abrading the lining of the lungs in an attempt to stop fluid from collecting there. A tube inserted between the two layers of protective lung tissue drains the liquid, and then an irritant is slowly injected back into the tube. The tissue becomes inflamed and sticks together, the idea being that fluid cannot accumulate where there’s no space.

I have watched patients go through pleurodesis, and even with pain medication, they suffer. We injure them in this controlled, short-term way to prevent long-term recurrence of a much more serious problem: fluid around the lungs makes it very hard to breathe. 

A lot of what we do in medicine, and especially in modern hospital care, adheres to this same formulation. We hurt people because it’s the only way we know to make them better. This is the nature of our work, which is why the growing focus on measuring “patient satisfaction” as a way to judge the quality of a hospital’s care is worrisomely off the mark. 

For several years now, hospitals around the country have been independently collecting data in different categories of patient satisfaction. More recently, the Centers for Medicare and Medicaid Services developed the Hospital Consumer Assessment of Healthcare Providers and Systems survey and announced that by October 2012, Medicare reimbursements and bonuses were going to be linked in part to scores on the survey. 

The survey evaluates behaviors that are integral to quality care: How good was the communication in the hospital? Were patients educated about all new medications? On discharge, were the instructions the patient received clear? 

These are important questions. But implied in the proposal is a troubling misapprehension of how unpleasant a lot of actual health care is. The survey measures the “patient experience of care” to generate information important to “consumers.” Put colloquially, it evaluates hospital patients’ level of satisfaction. 

The problem with this metric is that a lot of hospital care is, like pleurodesis, invasive, painful and even dehumanizing. Surgery leaves incisional pain as well as internal hurts from the removal of a gallbladder or tumor, or the repair of a broken bone. Chemotherapy weakens the immune system. We might like to say it shouldn’t be, but physical pain, and its concomitant emotional suffering, tend to be inseparable from standard care. 

What’s more, recent research suggests that judging care in terms of desirable customer experiences could be expensive and may even be dangerous. A new paper by Joshua Fenton, an assistant professor at the University of California, Davis, and colleagues found that higher satisfaction scores correlated with greater use of hospital services (driving up costs), but also with increased mortality. 

The paper examined patient satisfaction only with physicians, rather than hospitals, and the link between satisfaction and death is obviously uncertain. Still, the results suggest that focusing on what patients want — a certain test, a specific drug — may mean they get less of what they actually need. 

In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should. 

To evaluate the patient experience in a way that can be meaningfully translated to the public, we need to ask deeper questions, about whether our procedures accomplished what they were supposed to and whether patients did get better despite the suffering imposed by our care. 

We also need to honestly assess our treatment of patients for whom curative care is no longer an option. 

I had such a patient. He was an octogenarian, but spry, and he looked astoundingly healthy. He’d been sent to us with a newly diagnosed blood cancer, along with a promise from the referring hospital that we could make him well. 

But we couldn’t. He was too old to tolerate the standard chemotherapy, the medical fellow on duty told him. When I came into his room a little later he said to me, with a stunned and yearning look, “Well, he made it sound like I don’t have a lot of options.” The depth of alienation, hopelessness and terror that he was feeling must have been unbearable. 

The final questions on the survey ask patients to rate the hospital on a scale from worst to best, and whether they would recommend the hospital to family and friends. How would my octogenarian patient have answered? A physician in our hospital had just told him that he would die sooner than expected. Did that make us the best hospital he’d ever been in, or the worst? 

Hospitals are not hotels, and although hospital patients may in some ways be informed consumers, they’re predominantly sick, needy people, depending on us, the nurses and doctors, to get them through a very tough physical time. They do not come to us for vacation, but because they need the specialized, often painful help that only we can provide. Sadly, sometimes we cannot give them the kind of help they need. 

If the Centers for Medicare and Medicaid is to evaluate the patient experience and link the results to reimbursement, it needs to incorporate questions that address the complete and expected hospital experience. It’s fair and even valuable to compare hospitals on the basis of how well they maintain standards of patient engagement. But a survey focused on “satisfaction” elides the true nature of the work that hospitals do. In order to heal, we must first hurt. 

Theresa Brown, an oncology nurse, is a contributor to The New York Times’s Well blog and the author of “Critical Care: A New Nurse Faces Death, Life and Everything in Between.” 

Thursday Top Ten

1. My mason jar habit is getting out of control.  I can't really explain why, but I just love them.

(1a.) Now that the weather is warm enough for iced coffee, here is the best and easiest way to make it (and the reason I purchased even more mason jars recently): take your quart-sized mason jar. Add 5-6 T coffee grounds. Add water. Shake. Refrigerate overnight. Give the jar another little shake, and strain using a french press, or--the no-clean-up way--pour out through a coffee filter and toss the grounds. Voilà!

2. My favorite little study buddy.

3. There is a new tv show with AMANDA PEET in it??!?  I LOVE her!!!  And it's good!!  (But don't watch it if you are just going to judge my taste in television when you don't agree.)

4. My sister-in-law's sister-in-law has a blog... and she just had TWINS.  AND she is an actual photographer, so head over there if you want many more and much better pictures of something much cuter and more exciting than anything happening in my life these days.

5. Leftover chicken curry.

6. New soft happy-yellow purse from Target.

7. Izzy and her squeaky hippo.

8. The Wii I impulsively bought from Craigslist and Just Dance 3.  Jake set it up for me while I was out at boot camp tonight, and when I got home, I begged him to do "just one song" with me... after the first song, he challenged me to best out of three.  I now feel like this:

9. I now have to go whip up a Powerpoint presentation on insomnia for our didactics session tomorrow... it might will be a late night (How's that for irony? Actually, it might be a very effective teaching tool - I can demonstrate in real time the personal and professional consequences of not sleeping enough.)

10. This song. 

Happy Thursday, everyone!

Palliative Care

Last week my subspecialty rotation was palliative care.

And I almost lost it.  About 57 times.

There was lots going on... I have been sick, I was PMS-ing, I am apartment hunting and very behind in my studying and feeling very overwhelmed about both of those things and about life in general... anyway, like I said, just lots going on.  Lots of reasons for my feeling extra emotional.

But then I got to palliative care, and first of all, all the doctors and NPs on the service are awesome.  Like, really awesome and amazing people.  And the work that they do is just incredible... they give the kind of care that I think about 90% of people who want to be doctors think they want to give (until they get to medical school, and then internship, and then residency, and then fellowship, and then by the time they are finally practicing on their own and earning more than a public school teacher's salary, all of those ideals are long since gone and they have become bitter people with inflated senses of self-importance and discussions about "best patient care" have become relics of a distant past... I digress.)  

Then I got to palliative care, and it was all I could do to not have to run sprinting from every patient encounter, bawling.

Palliative care docs really take care of people.  And not just patients--they take care of their patients and they take care of their patients' families and friends.  They support the support system.  "Palliative care" means best supportive care; contrary to common belief, it encompasses hospice care but it is not the same as hospice.  It is not just end-of-life care--there is a lot more to it than that.  Yes, it often comes into the picture near the end of a patient's life, but it is not limited to it.

Palliative care providers focus on caring for the whole patient, including their medical, physical, emotional, and spiritual needs.  Palliative care teams frequently help with pain management; what is unique about their approach, though, is their implicit recognition that pain does not exist solely on the physical level.  Palliative care will help to manage pain from all its myriad sources, whether from metastatic cancer or from broken relationships.  Quite often, this involves simply listening.  Just sitting with a patient, or the patient's daughter, or the patient's brother, or the patient's entire extended family.  And really listening.  And it is truly powerful, what that one act can accomplish.  It can be a healing act.

There is an art to this act, and it is one that the providers I worked with last week had down beautifully.  I sat with them as they broke bad news to patients and their families, reviewed pain medication regimens, gently emphasized that it was now time to start planning for a move to hospice, tactfully facilitated meetings about living wills and code status and DNR orders, compassionately counseled struggling children of critically ill ICU patients.  

And I could not help it--during those meetings, I would start to think, what if this were my mother on this ventilator?  What if this were me and my siblings, discussing my father's care?  What if it were me having to make these decisions? 

I repeatedly had to do the thing where you suddenly focus very intensely on something on the floor and you force yourself to think about how your shoes are pinching your toes, or baseball, or the parking ticket you just got, or the laundry that you need to do when you get home, and you blink furiously to keep the stinging in your eyes from leaking all the way out.  It took every ounce of concentration I had not to burst into tears multiple times.

I found myself at home at the end of those days, really needing to de-brief with my friends and my classmates.  I couldn't even tell some of the stories from the week without breaking down.  Even now, as I type this, I can feel the knot rising in my throat.  It was a powerful and touching week... and even though I absolutely loved the experience, I am not sure that I have it in me to do that kind of work day in and day out.  I am not sure that I know how to tread the line well enough between being destroyed by the everyday tragedies that surround you in that setting and just becoming hard and unfeeling, shutting it all out.

I recently read about a program designed to do just that--to help physicians navigate that emotional in-between.  I think the idea sounds amazing, and I am even more excited because Emory happens to be one of the institutions joining up to implement it this year.  

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Sharing the Stresses of Being a Doctor

By Pauline W. Chen, M.D.

September 15, 2011

One afternoon, a doctor friend whose clinical skills and bedside manner I’ve long admired called wanting desperately to talk about her day. Exasperated, and feeling as if she had no one to turn to at work, she reached out to me, her friend.

Earlier that day, a transplant patient had threatened to stop taking one of his medications. Proud of his looks, he had become despondent when the drug made his gums swell. “He thought he looked like a freak,” my friend said.

But he needed the drug to keep his body from rejecting the transplanted organ, so my friend tried to reason with him. When that didn’t work, she began bargaining, then pleading and cajoling. The more he refused, the more frustrated she got. To her, swollen gums seemed like a small price to pay for a lifesaving transplant, and she found herself growing increasingly angry with the patient.

“All those ideals about empathizing with patients and respecting their choices went flying right out the window,” she said. She had thought about asking a colleague at work for advice but feared she would be judged, even blamed. “Everyone is ready to tell us to be caring and compassionate, but it’s really hard sometimes, trying to do to the right thing all alone.”

Studies have shown that health care that respects patient values and preferences influences how well patients do. Statistics show that such compassionate care can improve control of diabetes, increase patient adherence to treatment recommendations, decrease the use of costly diagnostic testing and lower hospitalization readmission rates for ailments like heart attacks and pneumonia.

But the mounting evidence has also led to a flood of new mandates, how-to tips, scorecards and reimbursement policies linked to the new standards. And there is no shortage of experts eager to explain it all and to remind clinicians to, well, be compassionate.

The enthusiasm reflects excellent intentions, of course. The problem is that when faced with a complicated case that falls outside of the relatively simplistic boundaries of the irreproachable truisms, caregivers are almost always on their own. That professional isolation — and the moral distress that goes with it — has contributed to alarming levels of professional burnout.

But one organization has been working to change that by quietly focusing where others have not: on supporting caregivers in their everyday clinical work.

Inspired by the experiences of Kenneth B. Schwartz, a Boston health care lawyer who died of cancer in 1995 at the age of 40, the Schwartz Center for Compassionate Healthcare has for the last 15 years run a program known simply as Schwartz Rounds. Held on a monthly or bimonthly basis in hospitals, nursing homes, community health centers and academic medical centers across the country, these rounds, or meetings, are an opportunity for clinicians to discuss emotionally challenging cases or issues in their work.

Led by a trained facilitator, the rounds attract up to 200 doctors, nurses, social workers and other caregivers and employees. There is a strict code of confidentiality. Typical topics include cases in which a clinician and patient can no longer communicate effectively because of differing religious views, instances in which a caregiver makes mistakes and situations in which patients or their family members become violent with caregivers.

The discussions that ensue are often emotional. But instead of focusing on blame, discussion leaders work to transform these stressful moments into an opportunity for clinicians from all disciplines to encourage and support one another. “With problems like these, people usually just end up pointing fingers,” said Dr. Stephen Nalbach, a resident in neurosurgery at Brigham and Women’s Hospital in Boston. “Schwartz Rounds is like a conversation where we get to debrief and learn from others and try to do better, instead of just moving on and forgetting.”

While early critics might have been skeptical about the effect of these meetings, a recent study in the journal Academic Medicine has shown that clinicians who attend Schwartz Rounds feel significantly less stress and are better able to cope with the demands of their work. The more frequently they attend rounds, the more easily they discuss sensitive issues with their patients.

What’s more, they feel energized about their work and better equipped to come up with new strategies for handling difficult patient situations. Institutional culture has been shown to improve as well, with about half of all participants citing a greater focus on patient-centered and team-based care at hospitals that hold Schwartz Rounds.

The change even trickles down to the language of the workplace. “At some centers, ‘Schwartz’ has become a verb,” said Julie Rosen, executive director of the Schwartz Center. “To ‘de-Schwartz’ means to lose one’s compassion, and to ‘Schwartz it’ means to add conviction and compassion to a job.”

Offering these rounds requires a significant commitment from both the center and the more than 200 hospitals that currently hold the rounds. The cost for the first year, not including the time and effort of on-site clinicians who must step away from their work to attend or those involved in the planning of each meeting, is approximately $15,000 per institution. The Schwartz Center, which relies primarily on philanthropic sources for its own operations, generally pays a large part of these initial costs, but thereafter each site shoulders most of its own expenses while the center provides ongoing support in the form of evaluations, regular visits and handouts and other materials.

Despite these expenses, the center is continuing to expand the program. An additional 31 hospitals, including Emory University Hospital, Geisinger Medical Center and Stanford University Hospital, have joined the program this year. The center has also begun working with hospitals in Britain, where six centers now hold Schwartz Rounds.

In an essay he published shortly before he died, Mr. Schwartz described the relationships he had with several of his caregivers during his final months of life. Struggling to come to terms with leaving behind a wife and 3-year-old son, he wrote that the “acts of kindness — the simple touch from my caregivers — have made the unbearable bearable.”

“If I have learned anything,” he continued, “it is that we never know when, how or whom a serious illness will strike. If and when it does, each one of us wants not simply the best possible care for our body but for our whole being.”

His legacy has made that possible for all of us, patients and caregivers.

You Can't Handle the Truth?

Writing for the Well Blog on the New York Times, Dr. Pauline Chen has produced numerous essays that I always find very interesting and oddly well-timed. 

This particular subject has come up recently in conversations with friends: when doctors are less than totally forthcoming with their patients.  We would know - we are the medical students who silently observe behavior on both sides of the patient's door.  It doesn't escape us when the doctor, by way of explaining a little about the patient's history and current problem, tells us that their tumor is inoperable, and then steps confidently into the examination room that holds the waiting patient, and tells them that "there might be something we can do."  And then, after exiting the room and shutting the door, shakes his head and says to us, "No.  There's no way he is going to make it."

I am not exaggerating at all about that story.  I was the medical student.  My peers and I all have multiple versions of our own, variations on the theme.

Not every doctor does this.  I have observed physicians who truthfully and tactfully lay out everything they know for their patients and allow them to make truly informed decisions.  But plenty of them fudge or obscure the truth.  Maybe some of the difficulty lies in what the "truth" is in medicine... doctors certainly do not know everything, nor can they predict every outcome.  Getting a second opinion is not necessarily  mistrustful or naive.  Then, too, there are surely patients who do not want to hear that their options have run out, just as there are patients who definitely do want to know, for whom a brutally honest prognosis will help them to prepare emotionally, spiritually and otherwise for what lies ahead.

If your doctor really believed there was nothing more he could do for you, would you want to know?

When Doctors Don’t Tell the Truth

By Pauline Chen, M.D.

March 1, 2012
New York Times

Every spring, a former patient and his elderly parents would drive two hours to the hospital carrying chocolates for the staff — an epicurean celebration of the man’s successful liver transplant a few years earlier. The patient, tall, in his 30s and with sandy-brown hair, handed out the boxes, and his parents, their parched-earth faces beaming with joy, shook everyone’s hands.

But each time the parents came over to me, there seemed to be a moment of hesitation.

On the night of their son’s transplant, I was the doctor who relayed the grim details of their son’s state. As he lay in the intensive care unit waiting for the organ, I described to them his deep coma, his complete dependence on a breathing machine, his blood, which had become as thin as water, and his need for such high doses of an intravenous infusion to support his blood pressure that if we couldn’t do the operation soon, it would be impossible to move him even the few hundred feet to the operating room for a lifesaving transplant.

Because I believed that it was my duty as their son’s doctor to be truthful, I told them that their only child might die.

Fortunately, my dire prediction proved incorrect. And while I never questioned the importance of a doctor’s honesty, every year that couple and their son returned, I wondered again if my devotion to this professional ideal had come at a significant cost: their hope.

According to a study published last month in the journal Health Affairs, I am not the only doctor to have struggled with transparency and honesty.

Researchers from the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston created a survey based on the Charter on Medical Professionalism, a widely accepted code of professional behavior that upholds patient autonomy and the crucial role of physician honesty and transparency. Doctors who took the survey received $20 and were asked about their attitudes and their behaviors in the past year.

While a majority of the nearly 2,000 doctors polled believed that physicians should never lie to patients or fail to inform them of the risks and benefits of a procedure or treatment, a large number also revealed that they had not been completely honest or transparent over the past year. More than half had described a patient’s prognosis more optimistically than warranted. More than 10 percent had said something untrue. And even though almost all the doctors said that they believed confidential health information should be disclosed only with authorization, more than two-thirds had revealed private health information to others without the patient’s explicit permission.

“These results reveal a breakdown in communication that makes patient-centered care much more difficult,” said Eric G. Campbell, senior author of the study and an associate professor of medicine at Harvard Medical School, who directs research at the Mongan Institute.

The researchers were not able to assess why some doctors might have been compelled to veil or avoid the truth, but “I don’t believe doctors set out to be dishonest or have some kind of malicious or nefarious intent,” said Dr. Lisa I. Iezzoni, the study’s lead author and a professor of medicine at Harvard Medical School, who is director of the Mongan Institute. Dr. Iezzoni noted that some doctors might have worried that talking about a topic like weight loss could offend an overweight patient and even backfire. She added that others might have glossed over a terminal diagnosis, fearing that the patient and family members would never recover from a frank discussion of such devastating news.

But however well-intentioned these assumptions about how patients will react are, they are also often incorrect. Studies have shown that even in the gravest of circumstances, patients prefer accurate and honest information. Patients with a terminal diagnosis, for example, may be grateful to have the chance to put their personal affairs in order before it’s too late. “Patients need the truth so they can best make decisions for themselves,” Dr. Iezzoni noted.

The best approach, for both doctors and patients, may be to discuss preferences about communicating before difficult medical issues arise. “Patients need to sit back and think about how they’d like to learn about something related to their health,” Dr. Iezzoni said. These preliminary discussions are especially important for patients who may not want or be able to tolerate full disclosure, as in the case of children who are ill, individuals with progressive conditions like Alzheimer’s or Lou Gehrig’s disease, or those who come from cultures in which it may be acceptable to disclose a terminal or difficult diagnosis to the family but not to the patient.

Despite what some might consider dispiriting findings, the researchers remain optimistic about ways to improve communication and the future of the patient-doctor relationship. “I see patient-centered care as a work in progress,” Dr. Iezzoni said. That work includes teaching young doctors better communication skills, establishing reimbursement systems that allow time for conversations and recognizing just how challenging honesty and transparency can sometimes be.

The last time I saw the parents of my former patient, I finally summoned up the courage to revisit our conversation on the night of his transplant. I apologized for having been perhaps too honest.

As I spoke, I saw the parents’ smiles disappear, and once again I sensed that painful moment of hesitation.

Then the patient’s mother stepped forward and clasped my right hand. “That was a terrible time,” she said. “But,” she added, looking at her son, “what if things had turned out differently and we hadn’t even known?”

Git 'er Done

Happy St. Patty's Day!!

★ I am in serious Getting Shit Done mode, and I like it.

Work out: check.
Cook a week's worth of dinners: check.
Clean out closet: check.
Get GA driver's license: check.
Register car: check.
Take car in for maintenance: check (and ouch).
Order books: check.
Answer email: check.
Give the dog a bath: check.
Basic Life Support certification: check.
Do taxes: check.
Wash white coat: check.

★ Also, there is this:

My Colorado plates... on my dining room table.

Brand spankin' new GEORGIA plates... ON MY CAR.

Yes, it has taken me this long to get new plates for my car. (Don't turn me in... I have actually also lived in Massachusetts and Virginia since buying my car six years ago, and didn't ever get plates in those states, either.) Part of it is that I hate taking care of stuff like "registration", and part of it is that I didn't want to take those green mountains off of my car. I feel like Colorado is a big part of my identity... it's kind of sad to have to give up this sign of my home state. Sort of silly, I know. 

Random Things

★ A couple of weeks ago I discovered the best-ever chili topping: goat cheese!! I had a bunch of friends over for dinner and I made so much chili that there was a ton left over, but no leftover sour cream. What's a girl to do? Well, when I have goat cheese in my fridge, the answer is usually "put it on top." Because the result is pretty much guaranteed to be delicious. (The same principle applies to cilantro, avocado, peanut butter and Nutella. Trust me.) 

★ New fuchsia lip gloss:

Three Weeks Into Clinical Rotations

... and I am the happiest I have been thus far in med school.

I am starting out on the Ambulatory Care block (referred to derisively by some as "shambulatory", but whatever). This just means out-patient care, and it has the reputation, deservedly, of being one of our easiest rotations, mostly because the hours are regular, we have weekends off and there is no call. 

The first six weeks consist of mornings in pediatric primary care and afternoons in subspecialty outpatient clinics, a week each in six different subspecialties: ENT, ophthalmology, orthopedics, palliative care, dermatology and urology. Everything so far has been very interesting, although it is obvious that there is no way I can go into ophthalmology, because I can never spell it correctly. The second six weeks will be all adult primary care. 

My pediatric clinic is actually the same one I went to every other week for OPEX during first/second year (I am with a different attending this time around).  It is 95% Spanish-speaking, and I love the crap out of it.  So many adorable, fat, beautiful Latin American babies everywhere... I want to take them all home all the time.  The Spanish part is my biggest challenge so far; I am sure that I would have no idea what was going on medically, either, even if I could understand everything that was being said, but mostly I feel like an idiot every minute I'm there, just trying to communicate on an embarrassingly basic level.  I am slowly, slowly getting a little more comfortable, though, and am so glad I am doing it. 

So many stories already, but they will have to come later... Martin just got here for some Atl fun!  :)

While Mom is at Work

Izzy has a dog-walker that takes very good care of her during the middle of the day when I can't make it home.  Feeling grateful for my pup and the people who help me keep her healthy and happy.

Gratuitous Doggie Cuteness

Who could believe this is actually the face of a trouble-maker??  

Really, though, don't let those professional sad-puppy-eyes fool you...

If You Are Wondering What Med School Is Like...

Seriously.  This is absolutely dead-on.