I want to write about how to use patient comments effectively, but before I do, I think it is important to explore the value of patient comments and how they can be misused or misunderstood. People think that, unlike numbers, which need a narrative to be understood, verbatim comments (the free text of what a person said), or even summarized comments (comments bucketed by some natural language processor) provide a more open-ended easily accessible understanding what patients care about enough to talk about. But if face-to-face conversation can lead to misunderstanding, the transcript of someone’s words with no intonation, or ability to ask follow-up questions is even worse. One might think that you don’t need context or narrative with these written words, but in reality you need more. Without it, those comments will be misunderstood and misused.
A million years ago, I taught political science. Two-thirds of my course load was teaching introductory classes.1 One theme that would run through my American Politics class was the importance of the “American Myths.” Myths are ways to explain natural things and human behaviors using language which is not, perhaps, literally true, but illustrates a deeper common connection or aspiration. It isn’t about lying, but about using stories to express complex concepts and talk about who we are, or, perhaps more accurately, who we wanted to be. For those who are not tracking me, here are two examples.
- “George Washington chopped down a cherry tree and then said, ‘I cannot tell a lie.’” The fact is that there is no evidence that this ever happened. It first appeared in the 5th edition of a biography written in 1806, seven years after his death. It was embraced as a useful myth to portray our founding fathers as virtuous and honest, implying that the work they did to found the government was ‘for the people’ and not self-centered.
- “Anyone can grow up to be president.” While factually true providing that the person meets the criteria laid out in the Constitution, I am not sure if anyone really believes this. But it speaks to an aspirational sense of American politics, that there is no divine right or genetic lineage that assures or denies your ability to rule. Your active participation can change things for the better.
For me, the question is not about whether these, and countless others, are true, but what they tell us about what is important or praiseworthy about who we are. In short, the stories we tell reveal a lot about who we are, either individually, or as a society. You may want to put values on these, as ‘useful’ or ‘harmful’ myths, but I would caution you on this. They are simply stories we tell ourselves. If they are used to deceive or injure, it is because of the teller and the elements they highlight, rather than the myth itself.
For those who are starting to wonder where I am going with this, I also think the myths we tell around a hospital also say a lot about who we are and what we think is important. Likewise, the way we highlight or dismiss patient comments and feedback speaks to what we think is important. You might think, NO, Joe, they speak to what the patients think is important. But I would disagree. Unless you read and share every comment (which I do not recommend2) or feed them into an AI device to summarize them (which probably violates your own hospital’s IT policy about PHI as well as the new 1557 rules), you are cherry-picking the comments that reinforce your preconceived understanding and dismissing comments that seem irrelevant to you and the story you are creating. In other words, you are picking the ones that speak to your myth even if you may not even be cognizant of it. And if you are not aware that you are doing this, you are probably not aware of the myths that you are creating, or worse, letting your audience create their own myths.
I will discuss a few of these myths staff pull out of patient comments, but as I write, I hope you will start identifying others in your organization. 3 Remember that they are less about what is ‘true’ and more about what the teller thinks is important. The other thing to remember is that, just like the essay on attention, if you are not crafting a mythology to contextualize a story, people will create their own and it probably won’t be helpful. In the next essay, I will talk about how to view patient comments and put them in a useful context. Here, though, we will wallow in the mud of how people will learn the wrong lessons from patient comments.
The biggest myth in a hospital is that success and failure are always on a razor’s edge.
You hear this on the clinical side4 to be sure, but it also exists on the service side as well, where a patient’s experience can plummet on one small thing done by one person. There is this perception that in order to succeed with patient experience the service must be perfect and there can be no dissonant notes. Just one food-service person having a rough day and not smiling can turn a 9 into an 8.
The reality is, though, that an overall score is not dependent upon any one encounter. Even if they, in the comments, call out a rude doctor, nurse, transport person, or other patient, that alone is not likely to impact their scores. How do I know? Because when I worked for a research company, we added a question to the survey that asked a patient who gave a second-box answer (an ‘8’ or a ‘very good’) why they didn’t give a top-box response and, far and away, the top three answers were: I Don’t Know, Nothing, and It Could Have Been Better. Now, if the patient gave an even lower score, they may have come up with more “Staff was Rude,” but for those folks, who were one step away, there was no smoking gun. If it really was one frowning face, the patient would have said, “STEVE! It was Steve who screwed everything up!” and that never appeared in the comments.
This myth that we are on the razor’s edge between success and failure feeds into the corollary myth that every vote counts (sorry I reverted to may American politics myths again), that every person matters. While I discussed this in a previous essay, I think it is worth calling out that this is the perfect example of a healthcare myth, as it has aspirational value, but it is not really true. It is hard to imagine that a surly janitor would be more detrimental to an overall score than a fantastic care team is beneficial to an overall score.
Another corollary myth is that scores are driven by staff likeability and it is all about personality. If a staff member is introverted or has resting bitch face, there is nothing that can really turn that perception. In the last essay, I stated that for feedback to have resonance, it needed to applicability; it must have an aspirational direction. Without this takeaway, people will often discount patient comment feedback as ‘be nicer’ or ‘be more like Daisy.’ Daisy is a wonderful nurse. She is thoughtful, understanding, she listens and answers questions as if she has all the time in the world. As a result, she gets a lot of comments in the survey results about how awesome she is. But, instead of realizing that Daisy exhibits behaviors that are positive to patients, staff will often discount those comments by saying that “this is just the way she is” or “that’s just not who I am.”
Some comments will degrade Daisy or what she does (“you are asking us all to be Daisy-Robots?”) but even the positive staff comments will simply say that while she is great, there is nothing to be learned from her.5 It all came down to ‘personality’ and either you get along with people or you don’t. But this is also a myth. While it is true that some people are more outgoing, quicker with a joke, more personable, this does not mean that introspective, thoughtful people cannot also get good scores. People who are authentic, the best version of themselves, get good scores. People who pretend to be something that they are not don’t get good scores. Everyone knows a friend, coworker, teacher, boss who cannot tell a joke to save their lives and yet they continue to try. Others, who are more casual or friendly, will try to put on an act of what they think “professional” looks like. I am not sure which of these people are more uncomfortable to watch. Patients see phony just as you do.
It is true that some of those who embrace the personality excuse are those who wear their toxic personality on their sleeves. They will either defend their behavior with some version of “I don’t have to be liked; I am in charge” mantra. Or they will maintain that they are liked by some, though they can never provide receipts for that. While I will tell audiences that you only need to be the best version of who you are, these folks need a completely different approach.
The overriding myth to these provided is that THIS ISN’T OUR FAULT! The problem is with scheduling or the emergency room nurses or the hospitalists or the staffing ratio or the patients themselves. Like so many other myths on this page, it can have some broad truth in understanding patient feelings. After all, not everyone at a hospital is having their best day. There are bottlenecks and frustrations. Things almost never go as smoothly as you want them to. The implication in this myth, though, is that the staff is powerless to do anything about it. In a vast majority of the cases, though, the negative event is not the score-killer. It is how people respond to that negative event. The dagger is not the patient comment about something negative happening, but the fact that the patient follows it with, “…and no one cared…” Patients know shit happens, but won’t tolerate staff pushing away that problem with a ‘that’s how things work around here,’ ‘that’s not my department,’ or ‘they are always like that.’
Most of these failures to properly internalize the lessons, though, have more to do with leaders’ failures to properly put them in a useful context. I have said in the past that if you don’t actively set patient expectations, don’t be surprised when they set them for themselves. Likewise, if you don’t explain what lesson is to be learned from this experience, don’t be surprised if people learn the wrong one. From here, if you don’t address or correct this wrong lesson, it will develop a life of its own. It will get propagated and even morph into a more complex set of misunderstandings. It will get other myths attached to it. Note that the myths mentioned above actually feed upon each other and support each other. Once you accept the first one, you are more likely to accept the second, third and so on. Even if you kill off the original idea, that hydra now has multiple heads.
1I got great student evaluations, so I often joked that, as the introductory class guy, I was the department’s carnival barker, convincing impressionable freshmen that political science was the major for them. Some of you may find this a weird flex, which it is, but I am devoid of normal flexes, so I gotta take what I can get.
2If you have read all your comments, you know that a large percentage of them are useless “Nothing” or “I don’t know” comments, or otherwise useless because they are broad platitudes or complaints. You will quickly skim for substantive ones and the ones that resonate will be the ones that align with your own expectations. If you give them to staff in a big unorganized pile, I can assure you that they are not reading all of them. They will see the first dozen “It was great!” feel good about themselves and stop reading.
3I have said before that I have heard ‘facts’ in hospitals like “complex surgeries are the patients who have stays longer than expectation” or “our problem with sepsis is that other hospitals transfer us their super sick patients so they die on our watch”, and every time I explore these myths, I find that while they feel true to the speaker, it is not actually based on any fact. These sorts of myths require their own essay.
4Now before you get wound up and say, “But healthcare IS life-or-death,” I will say, yes, SOMETIMES it is. But for every cutting-edge surgery with a high margin for error that can only be performed by a small select group of doctors, there are thousands of knee replacements, normal pregnancies, broken bones, and appendix operations. And, while, yes, these can also go sideways, and there are medical errors and hospital-acquired infections, please do not try to convince me that a vast majority of hospital patients—even the terminal ones—are one small slip-up or lapse in attention from catastrophe. Hospitals can be dangerous places, but, while the chance of suffering a catastrophic outcome is not 0%, it is also not 100%.
5When I left teaching, the department average of professor scores dropped precipitously, both because I was liked by my students and because, in teaching introductory classes, I generally had the largest classes with the most student responses. Instead of considering what they could do to bring the sizzle to their teaching, the department created a factor to adjust the data for a more apples-to-apples comparison of the pre-Joe, Joe, and post-Joe epochs. Yeah, I know that this is another flex, though perhaps a bit less odd.
PX Matters with Joseph Snipp 
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