“Mommy? If he loves her, why is he doing mean things to her?” My son asked.
I don’t even know exactly how or why but we were listening to The Phantom Of The Opera soundtrack in the car. They wanted me to explain the story line as they were listening.
The Phantom is angry because he loves Christine and wants her to be with him but she does not want to go. Yes, it is like he is stealing her, taking her to his lair, his home under the opera…
“Yeah, mommy. Why? Why is he mean to her? You don’t do that if you love somebody!” my daughter chimed in.
Good question, kids. Good question….
It is interesting how accustomed to things we become, how we just accept them without question. Like hurting someone we love. It just happens. Is there ever a reason? Love by its very nature is painful. It hurts.
How to explain that paradox to a preschooler?
“You love you each other don’t you?”
“Yes!” they said in unison. (It happened to be a good day. Generally the answer would be no.)
“But you hit each other and steal toys and say mean things to each other don’t you? Why do you do that?”
There you go.
“Doc, my knee still hurts!”
“Still?” Flipping through the chart. “Wait. We haven’t talked about this before.”
“I know.” She smiled sweetly and expectantly.
“Right. It never got better.”
“What have you been using for it to help?”
“Has it been swelling?”
“I don’t know.”
“Did it look swollen?”
“I wasn’t really paying attention. I just don’t want you to rule out the possibility that it might have been swollen at some point.”
“So it is not swollen now?”
She pulled up her pants leg and carefully examined the knee. Then she pulled up her other pants leg and carefully examined her other knee. “Well, I guess I don’t know. What do you think?”
“Uh. No. It does not look swollen right now.”
“Ok. How long has this been going on?”
“Oh, it’s been going on a little bit.”
“How long is that?”
“Well, a little while.” She seemed a bit frustrated over the restatement of the question.
“Really, you need to give me a time frame. A few days? A few weeks? A few months?”
“Well…..” Long pause as she thought back. “I don’t know exactly.”
“That’s OK. I don’t need an exactly. You can approximate it….”
Going with my mother to see the orthopedist. She does this to me on purpose, doesn’t she? Surely.
Here is a link to an article in the Atlantic, The Trouble With Satisfied Patients. The gist of the article is that often hospitals with the highest patient satisfaction demonstrated some of the worst patient outcomes.
I first discussed the patient satisfaction issue a few months back in a post entitled How Satisfied Are You? In it I had linked to another article in JAMA that pointed out that patients who are more satisfied with their care spend more money on that care and are more likely to die.
How can this be?
Is it possible that we are emphasizing the wrong things when we are talking about and measuring patient satisfaction?
Case in point: When my son was born I took him to the hospital to get his second newborn screen done, the one that checks for certain genetic and metabolic abnormalities and that is required by the state. I held him as the woman stuck his foot and squeezed it hard milking enough blood out of the wound to fill up the required bits of paper. He screamed bloody murder until he was hoarse and his face was beet red. It seemed to take an eternity, an eternity of having my own heart torn to shreds as I watched him suffer. I know how this works. I know it is necessary. Yet I experienced a very visceral hatred of that woman for hurting my baby, the depth of which shocked even me. Was she incompetent? No. But if you had sent me a survey to ask if I was satisfied with his care, I would have marked an unequivocal, very emphatic “NO” even though there was no way she could have done her job better.
Another example? I hear patients complain all of the time about not getting a response when they need assistance getting to the bathroom. One just a few days ago was telling me that he ended up soiling himself and the bed because after two whole hours no one responded to his pleas for help. This is from a hospital with an agressive PR campaign and a community perception of excellent care. If patients are happy with their care, they think they are getting better outcomes than they really are. Smoke and mirrors. This hospital has a cadre of employees that visit patients during their hospitalization in order to identify unsatisfied patients and give them coupons for discounts at the gift shop or cafeteria. Screw that, I say. Just help them to the dang bathroom for crying out loud! The hospital should not be intended as a resort. It is for healing and should in the process of that maintain dignity and humanity whenever possible.
When the push to start measuring patient satisfaction started a few years ago, I was totally behind it. I liked the shift from the perception that we were doing the patient a favor by deigning to see them to a more customer service oriented approach. At the time it seemed the focus was on providing quality care in a more humane way. I like that. I like that a lot. I am not afraid of being measured over it. But over the years the focus is slipping into something not quite so positive… I DO care when patient satisfaction is costing people their lives. So should you.
5% of my salary is tied to patient satisfaction. Right now in our organization there is an emphasis on patient wait times. Generally I run on time or pretty close, but there are days when I just cannot win no matter what I do. In fact, a couple of years ago the “random” survey was inexplicably sent out to a ton of patients who were seen the day after Christmas. We worked in a lot of people who needed to be seen that day and as a result we were running over an hour behind. The survey asked patients how long they had to wait, not whether or not they were happy about getting in to be seen. We took a huge hit on that time thing despite the fact that patients said they were overall very happy with their care. Should we have refused to see those patients in order to preserve our numbers? I have been told yes. I am certain that is not the right answer.
Have you received a survey in the mail about your visit to a physician or hospital before? There is a lot secrecy I think about how those things are scored. Did you know that for a score to count positively, you have to mark “exceeds expectations”? Anything less counts negatively. Even if you mark “good”. If you exceed expectation on everything isn’t that just average? Aren’t we setting ourselves up for failure? And in order to stave off that perceived failure is it possible that we are pouring resources into things that are not actually improving patient care?
Another consideration: Is it that patient satisfaction as it is currently measured is mutually exclusive of the most competent doctors? Can the two not mutually exist in the same person? Perhaps. Some of the most brilliant minds are just not capable of being hand holders or shoulder huggers. Do we want to exclude brilliant minds from practicing because of this? I am not sure that is in anyone’s best interest, either. I have seen and heard of more than one physician forced out of a hospital system because of low satisfaction scores. They were excellent physicians who had saved many lives. Will they be replaced by more personable doctors who are less competent? In some cases, yes.
So, what do patients want? What do they need? Do they want to be seen within fifteen minutes of their appointment time every time? Or do they want a physician who feels free to take their time, listening to complaints, coordinating care collaboratively? Do they want someone to help them get to the bathroom or just someone at checkout who says they hope you will fill out the survey saying that they have provided you with “excellent care” because using the same verbiage that is on the survey results in higher scores?
So do I care about patient satisfaction? Sure. But I am not going to be losing sleep over it. In the end I expect my patients to be treated as I would expect my own family to be treated. That does not mean handing them a cup of coffee at the door. That means making sure their referrals and procedures are scheduled in a timely fashion, that bloodwork and imaging results are communicated to the patient, that we minimize medication errors, and that we smile when we do all of this because it is a pleasure to serve our patients.
Since I can remember I lived in a vivid fantasy world where I was loved by a handsome, powerful, brilliant man who was tall and muscular and who had just the right amount of chest hair. In my fantasy he would make fulfilling, passionate love to me with the haunting swell of a cello and the flicker of candlelight playing in the background. I did not ever know this man, but I was certain he existed somewhere. I can still see every detail of him, except for his face, even now…
That is not how the story really goes, however.
I don’t remember getting married. At least I do not remember the details. There is a piece of paper with my signature on it but I do not remember how it got there.
I don’t remember where I got dressed before the ceremony. The dress was a pale yellow, though. I do know that because it still hangs in my closet. There is only one picture taken of that day that I am aware of, and it is blurry.
I don’t remember my vows. I do remember insisting that the phrase “obey” be cut from them a few days prior but I do not remember actually saying, “I do.”
I don’t remember my wedding night except that I was mortified that my parents and the rest of God’s creation knew what was going on in that hotel room that night.
No. I was not drunk.
To be honest I am not sure when I stopped remembering these details. I have not thought much about the event until last night. I was a bit shaken by how much I was missing…
It was not a happy time.
My parents had said that it did not matter who I was marrying, they would never pay for any amount of a wedding for me since I was going to medical school. Even after seven years of “dating” this man with their seal of approval, my disobedience to the divine order of things would not be sanctioned by them.
So we eloped.
We planned it in a week while I was going through medical school orientation.
My wedding dress was sewed by my almost mother-in-law from the pattern and fabric I had initially picked out for bridesmaids dresses. We were married under the giant tree on campus at sunset by a religious studies professor who happened to be an ordained minister.
I told my parents the day before. I did not allow them or anyone else to “give” me away.
The ceremony was on a Saturday.
On Monday, I started my first day of classes.
Then gross anatomy happened.
Family and friends whispered about it being a shotgun wedding and waited expectantly for the bulge to show. The bulge never materialized and the whispers eventually died down but not until after quite a bit of unkindness had taken place. They just did not understand and I did not know how to explain it to them.
I was afraid to do it alone.
To be continued…
“Doc, I can’t stand him. I don’t want to go back. Ever.” She sat with her arms crossed across her chest, scowling.
“Oh.” I felt awful. I work hard to refer to the best possible specialists. Did I miss the mark for her somehow? “Tell me why.”
“He told me that my dizziness was because of BPPV and that most doctors don’t even know what those letters mean.”
Most doctors meaning me?
“Benign paroxysmal positional vertigo?”
“Yes! THAT! You know what it is?” She sounded impressed.
“Uh. Yeah. I was not aware that most doctors don’t know what BPPV is…”
“Well, then he said sarcastically that he knew I would go home and read all about BPPV and then I would know more about it than any doctor… any doctor except for him, that is.”
Any doctor, including me? Why did I feel defensive, like he was pointing the stupid finger at me, too?
“He is one hell of a pompous ass. I know you like him and all but he just rubs me the wrong way.”
I sent this patient because she was convinced that she had had a stroke.
Sometimes I send patients to specialists because I really don’t know what is going on. I am not supposed to know every single detail about every single possible disease or symptom out there. There is an awful dang lot that can go wrong with the human body. It is my job to try to rule out the easy stuff and refer to a specialist when necessary.
Sometimes, though, I already know what is wrong. Like this time. Not that she remembered the conversation we had had about BPPV some weeks before. She was a super nice, very sweet, intelligent woman but patients are conditioned to regard primary care physicians with a certain amount of suspicion and some just won’t let go of the worst case scenario until they hear it from an “expert”.
This has become a pattern with him. I guess I will stop referring patients to him. For now. When they start forcing us to only refer to other physicians within the system, I won’t have a choice.
“Spell the word frog.”
“F-R-O-G.” He searched my eyes hopefully to see if he had gotten it right.
I nodded. He beamed, proudly.
“Good! Spell… Blog? Wait. Really? Blog is your spelling word?”
“YOU have a blog, mommy! How many followers do you have now?”
Oh. You know do about that, don’t you?
I made up a number. My actual number of followers vs the “real” number of active readers… vastly different, but that is not something you can explain to a five year old during spelling word practice.
“Wow!” He sounded impressed.
I may have exaggerated a wee bit.
“Ok, now spell the word. Blog.”
“Perfect!” I gave him a high five.
The things they teach kids in Pre-K nowadays… *shakes head in disbelief*
“Doc, I can look back on it now and see that the whole episode was such a blessing. I could not see or understand it at the time, no matter what you or anyone else said. I lost myself in it. But here on the other side I can look back on the person I was then and the person I am now and know it was for the best.”
I nodded, remembering my own eureka moments over the years. There was such joy when that realization finally hit. That was the point when you knew you were climbing out of the hole. I could see that joy on her own face.
“As women, we work so hard pouring ourselves into our careers, you make it your identity, and when something comes along that shakes that very foundation, you realize what is important. You have to or you won’t survive.
“At the end of the day, for me, it is my family that is the key to my happiness. My kid hugging my neck and saying he loved me? I realized that nothing would ever change that no matter whatever else was going on outside.”
I could remember those months of blackness as she tried to claw her way out.
“I was broken. Breaking isn’t all that bad, though. It broke open reserves of strength I didn’t know I had. On the other side I can look back and see this did not destroy me and know that I can survive it again if necessary.”
Exactly. And whenever I start to forget that, something always happens to bring me back… My own heart feels so raw, still.
She took a deep breath. “So, I said all of that to say that I think I am ready to get off of my medication.”
I gave her a big hug. “No doubt. Here is how you do it…”
“For what?” I was checking his preventive care screen, making sure I didn’t need to harass him about his colonoscopy.
“I’m getting married on Tuesday.”
I looked up at him and smiled. “That’s wonderful news!”
He had been terribly lonely since his wife had died suddenly a few years back, though he had sworn to me at the time that he would never marry again.
I clicked over to the social history screen so I could update his marital status.
“You know her,” he said.
“Oh, really? Who?”
He told me the name.
My blood ran cold.
I had treated her for a head cold a few weeks before. She had told me she was going on a honeymoon in a few weeks, flashing a giant diamond that sparkled almost as brightly as her smile.
“I am going to make a lot of money off of him…”
He was going to have his heart broken.
“Congratulations!” I said to them both.
Every single dang time I go to pull out my credit card to pay for something I have heart palpitations. Panic.
My card is missing! Oh, lord. No, wait. Here it is. Whew…
There is something inherently wrong within my being that always expects the worst, the proverbial anvil hanging over my head, ready to crush my skull and my spirit at any moment.
Sure wish I could fix that.