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January 26, 2012

The "patient experience": Is it patient pandering?

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 Office 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 pandering?

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 first-class patient experience.

Instead, 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, and egregious errors in medical practice, and the cozy relationship between physicians and pharmaceutical and medical device companies—eroded the public’s confidence on 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 their 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 swung too far.

There is nothing wrong with informing patients about a hospital’s quality or providing them with 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.

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, warm beaches and 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 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.

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 the housekeeping staff. Patients are the center of care but as partners, not as dictators. And health 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.
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5 Comment(s)

Jeff Bennett wrote:
Another tour-de-force from Ruben! In the war of WOW! that hospitals seem to be engaged in, the disconnect between the fluff and the stuff is evident to many patients as well. In the end, value is based on the ability to deliver understanding, comfort and healing. Systems that truly get that have always stood out from the rest (even if they don't have spiffy lobbies).
Lexington, KY | Fri, Jan 27 2012 15:26 PM

Susan Spencer wrote:
I agree that it takes much more than a spiffy lobby and piano music in the background. However, the government has now taken notice of the patient perception of care received or "experienced." Yes, it has taken the government to finally say that the patient's perception of his or her care must improve beyond what our industry has provided in the past many years. I also believe that we can do a much better job in health care in providing a hospital stay that includes the best quality of care with a safe environment.

HCAHPS results are not a measure of patient satisfaction but more the patient perception of the QUALITY of care received while hospitalized. HCAHPS provide the basis for our reimbursement now (value based purchasing). Questions from HCAHPS include, "Did my physician listen, communicate the plan of care and explain things in a way that I can understand?" Other questions target information about medication communication, nurse communication, quiet and clean environment, discharge instructions and pain medication. Answers are based on consistency.

Shouldn't this really be considered the minimum standard for any patient? HCAHPS is not a patient satisfaction survey but rather how well the providers performed these things "always" within a quality, safe environment. What would you want if you or your loved one were the patient?
Canton, Ohio | Fri, Mar 2 2012 10:53 AM

Ruben Nazario wrote:
Jeff, thanks for your comments. Value is definitely linked to understanding our patients and helping them in the healing process.

Ms. Spencer, I don’t disagree that we need to provide the best quality of care available to our patients. My concern is how that quality is measured. In my first draft of this post, I actually was going to discuss HCAHPS, so I’m glad you’ve brought it up. Like you said, HCAHPS measures PERCEPTION of quality, so in that sense I find it a useless (and maybe even misleading) measure of true quality.

I agree that a physician who listens to his or her patients is better in terms of humaneness, but what does that have to do with that physician’s analytical or procedural skills? If I am nice to my patients but have the highest rate of central line infections in my hospital, how does that improve the patient’s experience? So, yes, listening to our patients, improving communication, explaining things to patients ARE at least the minimal aspects of the physician-patient relationship. (I would say they are the cornerstone.) But in my mind they are not true measures of health quality.
Falls Church, Va. | Fri, Mar 2 2012 12:47 PM

David Hayes wrote:
The recent article in Archives, "The Cost of Satisfaction, " perfectly points out the consequences alluded to by Ruben. What if your patient's only definition of satisfaction is overutilization of narcotics? Where in this "measurement" of patient satisfaction is the control for inappropriate or dangerous expectations?

Read the article. The most satisfied patients also were the most hospitalized, used the greatest amount of pharmaceuticals and medical services, and were at elevated risk of death! Pandering to patient perceptions has serious consequences; more "joy rides" and "pleasure units" in the medical arena have exactly the opposite consequences as the government intends. Certainly, the paternalist model of medicine is long dead, but the current patient satisfaction frenzy essentially nullifies professional judgment, thus satisfying Murphy's Law of unintended consequences.
Scottsdale, AZ | Tue, Mar 13 2012 05:56 AM

Frisco Morse wrote:
I could not agree more. It seems like the foucus is on factors that don't make for better care. Our patients are often times more concerned about eating a meal than what I have to say about their condition.
Lawrence, Kansas | Wed, Jun 13 2012 09:27 AM


About Ruben J. Nazario, MD
Ruben J. Nazario, MD, is now medical director at Inovalon, a health care data analytics company, and is medical editor for Elsevier's First Consult. A pediatric hospitalist, Dr. Nazario is a veteran of both community and academic pediatric hospitalist programs. All material represents his own views and does not reflect the views of his employer.
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