When does it become patient pandering? by Ruben J. Nazario, MD
Published in the March 2012 issue of Today's Hospitalist
I'VE BEEN SEEING A LOT WRITTEN RECENTLY about the "patient experience." A recent blog on one of my LinkedIn groups states that "medical practice is driven by the combination of patient experience and perception of services provided to them."
The Cleveland Clinic has gone so far as to appoint a chief experience officer to "ensure care that is consistently patient-centered by partnering with caregivers to exceed the expectations of patients and families." But what exactly is the "patient experience?" And has the pendulum swung too far, from patient centeredness to patient
Equating a visit to the emergency room to a visit to Disney World cheapens the efforts of providers who work long hours because they love to heal.
First, let's tackle the definition of "patient experience." Jennifer Robison of Gallup Management Journal describes it in terms of emotional engagement, as in "engaged patients are better for hospitals, and engaged hospitals are better for patients. Engaged patients have a better experience because it is psychologically and emotionally gratifying."
She equates the patient experience to the alliances we feel toward a brand, a restaurant or a sports team. She rightly argues that "spiffy lobbies and a full roster of classes," which are the tactics hospital executives usually reach for first to improve patient satisfaction surveys, are not the keys to providing a first-class patient experience.
Instead, Ms. Robison identifies four "psychological elements" that inform patients' hospital experience: confidence, integrity, pride and passion. She argues that a hospital that provides good hospital care and service, and does so with these four attributes, will score high on the patient experience meter.
Nobody argues that our health system must improve its relationship with our patients. For too long, physicians viewed themselves in a paternalistic role, one in which they possessed all the knowledge and patients were supposed to do what their doctors said, no questions asked. This behavior—coupled with the spread of malpractice lawsuits, medical scandals, egregious errors in medical practice, and the cozy relationship between physicians and pharmaceutical and medical device companies—eroded the public's confidence in physicians.
Then, the widespread availability of health information on the Internet broke physicians' monopoly on medical knowledge and allowed patients to come to the examining room already armed with questions, ready to challenge doctors on their choice of treatment and diagnosis. The pharmaceutical companies soon followed, filling the airways with direct-to-consumer advertising and telling patients to ask their physicians if name-that-brand medicine "is right for you."
Hospital administrators and the federal government noticed this resurgence in patient power, this Examining-Gown Spring, and decided that power now rested in the hands of the infirm, not in the hands of the healers. Patient-centered care gave way to the patient experience and patient satisfaction surveys. Patients became consumers—and thus the pendulum began swinging too far.
There is nothing wrong with informing patients about a hospital's quality or giving them adequate information about side effects or rates of surgical complications to allow for informed decision-making. But to encapsulate a patient's illness within a rubric so shallow as the "patient experience," as if a visit to the emergency room could be equated with a visit to Disney World, cheapens the efforts of health providers who work long hours in the face of shrinking reimbursements simply because they love to heal.
Patients aren't consumers
It also demeans patients by putting them in a category of consumers. Remember, patients are not consumers in the general sense of the word; they don't pay directly for health services.
And it is demeaning to call patients "consumers" because health care is not about what happens around the patient. It is not about palm trees, clean beaches or great ski slopes. Health care is what happens to the patient. And while consumers can buy things they want to happen to them, like a massage, most health care (except for preventive care measures and elective procedures) happens when we don't want it. We don't seek to be hospitalized, to have surgery or painful procedures done, unless we have to.
The "patient experience" as a commercial construct to garner and maintain patient loyalty is folly. Patients go to their nearest hospital because of distance or acuity, or because it is the only facility in a rural area or the inner city. Patients sometimes don't have a choice as to where to obtain health care, and they are not consumers looking for an experience. They are looking for answers, support, hope, expertise. A nice grand piano in the lobby does not provide that.
Partnership, not pampering
Instead of focusing on experience, let's focus on perspective. Patients need information and choice, but they need their health care providers to guide them along. Patients need clean rooms and healthy food, but not concierge service. They need the ability to compare health facilities and outcomes, but not the right to be so pampered that it obscures the real jobs of nurses, cafeteria workers or housekeeping staff. Patients are the center of care but as partners, not as dictators. And administrators should focus on true quality measures that determine the actual benefit of treatment plans and protocols, not the latest score on patient satisfaction surveys.
The French deconstructionist philosopher Jacques Derrida wrote that Western civilization has always thought in terms of binary opposites: good and evil, heaven and hell, and yes, patient and physician. He noted that these opposites are not equal but hierarchical, with one governing the other.
For years, physicians were superior in the patient-physician relationship. Now, it seems the patient is on top. Derrida writes that this reversal does not end the struggle of the binary relationship; on the contrary, it maintains the same tension. Eventually, this tension unravels—or deconstructs—the relationship. In deconstruction, a new framework can emerge.
Let's deconstruct the patient-physician relationship. Let's stop calling our patients "consumers." Let's create a true partnership between providers and patients, free of pandering and paternalism. That should be the true patient experience.
Ruben J. Nazario, MD, is a pediatric hospitalist at Inova Fairfax Hospital for Children in Falls Church, Va. Check out Dr. Nazario's blog and others on the Today's Hospitalist Web site at www.todayshospitalist.com.