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“Always”

Patient experience beyond top-box scores

October 2017
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Published in the October 2017 issue of Today’s Hospitalist

I KNEW THINGS would be challenging the moment I stepped into the room. Mr. R. had the look and manner of the patient I dread: The Very Unhappy Patient. Mr. R., now on his twelfth day in the hospital, did NOT want to go to another skilled nursing facility after hospital discharge—which he informed me of by interrupting me in midsentence as I introduced myself.

I sat down.

As I listened to the litany of Mr. R’s complaints and observed his closed body language and flat affect, I was struck by how profoundly depressed he was. Often patients accumulate letters, flowers, cards and crossword puzzles as hospital days pass. The room was bare.

Mr. R. had reason to be unhappy. He was 57 years old, lived alone with no family support, and couldn’t work due to chronic pain and disability caused by diabetic neuropathy and lower extremity vascular disease. And he had osteomyelitis—again.

He wanted to go only to his home. It didn’t matter that he could barely walk on his one weight-bearing limb and that travel to his hyperbaric wound treatments would be challenging. It didn’t matter that the wound and vascular surgeons recommended skilled nursing facility care for several weeks. As he also informed me even before I had asked, he did not want any more Percocet or opiate pain medication.

In spite of myself, as he talked, I had an unwelcome and intrusive thought: “There go my HCAHPS scores … ” It didn’t matter to Mr. R. that I was doing everything our hospital’s patient experience administrator would want me do to make a positive impression: know the details of his medical history and hospital stay, smile, make eye contact, sit down, give my shiny photo-adorned individual business card, answer all of his questions, empathize—and care.

A list of complaints
After all, through years of training and literally thousands of patient interactions that had nothing to do with HCAHPS surveys, I already knew and practiced what our patient experience folks tell us. I’m far from perfect, but I take pride in patient communication because I know it works.

I also know what many of my colleagues know: a hospital is a complex, challenging environment. Hospitalists often deal with dysfunctional communication from consultants or colleagues, patients become upset that their primary doctor never visits, support staff or nurses confuse patients by making offhand comments about medical care, and there can be extreme practice and communication variability.

Which leads me back to the intrusive thought I had about the HCAHPS. In a few weeks Mr. R. might hobble to his mailbox and open an HCAHPS survey. In spite of many days in the hospital and the many providers who cared for him, the summary opinion of all of those physician interactions would be attributed to me because my name is on the survey as the attending of record on the day of discharge.

Mr. R., for example, said he did not want to be a complainer. But he did want to rail against what he described as the horrible bedside manner of one of the surgeons. He wanted to vent about one of the wound consultant physicians who first visited him in the company of a nurse. “The doctor pretended he was nice,” but when the same consultant visited alone to re-examine Mr. R. another day, the doctor was callous and “didn’t give me the time of day.”

He complained that he met one hospitalist for one day only “and then he was gone!” He wanted his door kept shut and it often wasn’t. He complained in detail about shortcomings in technique and dexterity in the care of his leg wounds. And he was sick of hospital food.

Legitimate concerns
As I listened to his wide-ranging gripes, I had another intrusive thought: “He’s right.” I have observed the practice of the wound consultant in question and share a similar opinion about his communication style, although I am confident in his clinical skills. I know that aides do not always close doors. I know that our wound nurse can be overwhelmed by her caseload and that on weekends wound care suffers. I eat the same food in the cafeteria and do not look forward to the “pizza soup” that will be in rotation the next day downstairs.

I pushed away my self-serving lament about HCAHPS surveys and worked to address Mr. R’s concerns. I tried to relate his “difficult” behavior to what it was—an attempt by a depressed, isolated, observant patient to maintain control in a hospital environment where patients lose all independence. I acknowledged that he didn’t want more Percocet but tried to treat his pain adequately. Although I did talk with him about treating his depression, I didn’t start an antidepressant because of concerns about SSRI interaction with his antibiotics—and because he wasn’t interested in exploring other treatment options in the hospital. I collaborated with nursing to make sure we were communicating consistent messages to him.

Maybe I helped make him reconsider, or perhaps the words of our team of nurses, case managers and social workers influenced him, but Mr. R. ended up changing his mind and decided to continue his osteomyelitis care in a skilled nursing facility. Ironically, patients who are discharged to skilled nursing facilities do not receive HCAHPS surveys. So Mr. R wouldn’t have a chance to rate me, to answer “always” or otherwise. And that is fine by me.

O'doyleThomas J. Doyle, MD, 
is an internist who practices hospital medicine in Massachusetts.
 Send him an e-mail at tjdoyle7@gmail.com.