When I speak to audiences about processes and strategies for improving the patient experience, I stress that before we can talk about ways to improve the patient’s perception of care, we need to stop doing things that needlessly antagonize our patients. We need to stop punching patients in the face. My desire in saying this is to focus on behaviors that often have been engrained into our process and reframe them through the eyes of our patients. Things that we do that seem normal to us, but things that our patients can find aggressive or even insulting.
We all agree on some universal or abstract truths, like the best way to achieve weight loss is through proper diet and exercise.1 It is in the operationalization of these abstract truths, though, where we argue and fall short of success. We agree in the abstract that we should not punch patients in the face, but then we do something that essentially does that very thing. For example, I hurt my knee over a month ago. After observing RICE2 for a couple weeks with no significant improvement, I decided to book an appointment with my primary care doctor. Making an appointment is ‘easy’ says the patient portal and then it sends me through a complex decision tree full of jargon and duplicative choices. (For example, it asked which of my established doctors I wanted an appointment with, then it asked me which clinic I wanted to go to, while including a list of clinics my PCP doesn’t practice at, then when I selected my clinic, it asked me which doctor I wanted to see. Um, the same one that I picked at the beginning?) So, before you tell me that you don’t punch patients in the face, consider how often you do things to make your life easier rather than making your patients’ lives easier. Then consider how many of those things are really necessary and how many of those things are done simply because they are just the way we have always done things.
One note before I begin. Why do I use such violent imagery? It is meant as an exaggeration designed to snap people out of the vacant mindset where they do what they do because it is always what they have done. I could say, “first things first, we need to be nicer” and everyone would agree that we certainly do need to be nicer. But this just feeds into a positive self-image, whether that positive self-image is warranted or not. Some of the most cantankerous people I know will profess to being nice. They are the ones in the back of the room that are nodding vigorously to your request, saying, “Yes, YOU ALL need to be nicer!”
So, instead of stressing augmentation of a positive behavior, where everyone can pat themselves on the back, I am asking an audience to stop destructive behaviors. They may start by being defensive and sputtering a “but, but, but I don’t punch patients!” but when we move to the discussion of concrete behaviors, they are forced to acknowledge that maybe they do punch patients more frequently than they thought.
Like so many of my essays, this one started as one essay and then ballooned into two parts. Both focus on clinician behaviors and how patients perceive these behaviors. I could probably write another bunch of essays about other things, like phone trees, patient portals, or other user interfaces that are confusing and frustrating. But for now, I will focus on things that are more immediately under the control of frontline folks. In this part, I will discuss clinician behaviors that are, at least in part, are the product of how we service patients generally. As always, this is not meant to excuse the behaviors but simply explain the behaviors relative to how we structure workflow. I will focus on two sentiments I have heard people say, explaining why they do what they do.
These patients are exhausting and I am tired
This is, frankly, the excuse I am most sympathetic with because some of this exhaustion is out of their control. For example, many organizations will focus on the losses and not the wins. They will obsess on how we failed some patients and ignore how we succeeded with others.3 Organizations fail to realize what this focus does to staff. Organizations that focus only on PX failures—that obsess with the negative comments and the patients who give low scores—leave staff feeling like failures, especially if the organization does not also celebrate wins. Staff are left to feel like they are the problem. They are the impediment. I often joke that no one has ever leapt out of bed, rubbed the sleep out of their eyes and said, “I cannot wait to get to work and learn how I disappointed my organization! I can never get enough of being told that I screwed stuff up!” The average hospital, depending on the care space, has 75%, 80%, even 90% of their patients loving the care they got, so if the organization exclusively focuses on the 10%-25% of those left behind, they are effectively telling their staff that they are the problem.
But staff will do this to themselves. When I hear clinicians claim that all their patients are idiots, or drug seekers, or combative, I know that they have allowed a vocal minority to color their perception of “all patients.” Most patients are NOT drug seekers. Most patients are NOT combative. Idiocy is more of a judgment call, but most patients don’t know as much about medicine as a clinician does, so they may appear idiotic by comparison.4 The reality is that most patients respect the knowledge base and opinion of their physician and care team; they want to do the best-practice behaviors to get them healthier.
Yes, explaining the same thing a thousand times to a thousand patients can be exhausting. It is also exhausting when you are explaining it a thousand times to a single patient. These interactions, especially when combined with arguing with Dr. Google, can throw your appointment schedule and your sanity into a woodchipper. But as I have mentioned before, the biggest challenge is not to let one single patient interaction color the rest of your encounters during the day. We all need to compartmentalize frustrating interactions with patients, customers, or coworkers, so they don’t bleed into other interactions with different patients, customers, or coworkers. Sometimes this includes taking a minute to decompress before engaging with the next patient, customer or coworker. I cannot expect you to deliver best-practice PX with everyone, if you don’t have an off-stage area where you can occasionally blow off some steam.
Remember, you being tired or frustrated is not your patient’s fault. When I was traveling around the country, catching red-eye flights, working 11- or 12-hour days at hospitals, all while trying to keep up on my email and other client requests, I would joke with audiences about how I was just going to sit back, click through the slides, and phone-in a low-energy presentation, because I was tired. I would point out that there were people in the room who felt that this would be disrespectful of them and a waste of their time. After all, they are more tired, stressed, and busy than I was. I would agree and then say, “And your patients would say the same thing about you.” They are anxious about a chronic condition. They are worried about family history. They are stressed about how they can fold this clinic appointment into their busy day. They are concerned about how this illness or condition will affect how they can care for everyone in their lives that relies on them. So, you having lingering frustration about a patient from four hours ago, is disrespectful of them and their time. Yes, you are stressed and stretched. Sometimes this can bleed into your relationships with patients, coworkers, and even family. But while this may explain it, it doesn’t excuse it. Being tired is not an excuse for punching a patient in the face.
I am busy so I don’t have time
One of the ways we can punch patients in the face is by not engaging in a conversation. Making declarative statements about a patient’s pain and the plan-of-care without engaging with a patient is often explained away by saying that there isn’t time for these conversations. Sometimes the entire concept of patient-centered care is questioned when clinicians will complain that healthcare is not a democracy. This drives me crazy for two reasons.
First, it assumes that all situations fit neatly into one ICD-11 diagnosis5 which in turn calls for one and only one best-practice solution. In reality, many conditions are less black-and-white and require a nuance, or even a difference of opinion. This is why the phrase “get a second opinion” has meaning. For example, I have shared in the past that I have intermittent AFib. Seems straightforward, except that my primary care doctor and my cardiologist don’t always agree on how “intermittent” it is and this bleeds into whether I should take certain medications prophylactically or not. So, while not a democracy, it does raise the question on whether I should get a say in whether I want to accept the minimal side effects in taking a drug that might not really benefit me day-to-day. Even when the diagnosis is clear, there is always a debate on what the response should be.
Second, it assumes that everyone has the same goal in mind. Many trees have been felled in the service of books exploring the tension between quantity-of-life and quality-of-life, so I will assume my audience is aware that sometimes people are less interested in fighting for every last breath than simply enjoying moments with family and friends as they enter the two-minute-warning of life. Meanwhile, clinicians have a reputation for never giving up the fight. I am reminded of a joke:
Why do they nail coffins closed?
To prevent the oncologist from trying ‘just one more treatment.’
This joke is funny because it reflects clinician behavior. I believe I told the story about my almost 100-year-old grandmother with dementia who fell and broke her hip. The orthopedic surgeon immediately booked a surgery bay for the following week. We declined the offer and she ended up dying three days before the scheduled surgery time.
When clinicians say that they don’t have time, or that this is not a democracy, they are defining the medical problem simply as a puzzle to solve or a problem to fix. They are not considering the full picture.6 By not including discussion generally, they actually make it more difficult to generate collaboration when critical decisions need to be made. I have an in-law who has been battling cancer for five years. I have spoken of elements of her care before, and I could probably write a case-study on her patient experience some other time. But recently, during a meeting with the physician assistant, my in-law mentioned that she detected another two lumps and wondered if the current chemotherapy was working or if we should try a different one. The PA looked her and said, (and I quote), “Well, we are running out of options.” While she may have simply meant that we should not change horses mid-treatment, this phrase was a punch to the face.
Since the beginning, she had not been included in a broad game plan. Instead of laying out the process and discussing the eventual possibility of palliative care and hospice, she was simply given a series of drug cocktails with no discussion of diminishing returns or that there was not an infinite number of these to try. Instead, her oncologist was being more cheerful than the prognosis warranted. Make no mistake, I appreciate his effort at keeping her spirit buoyed as individual treatments became incrementally less effective. But encouraging her with “there always another cocktail to try” optimism was great until it ran into the wall. Having a conversation now about end-of-life issues feels more urgent and depressing than if the table had been set three years ago. I know that this is easier said than done. This is a complex and emotionally-charged conversation. It must involve the patient, an advocate, family members, etc. But it still starts with the physician.
I am keenly aware that these behaviors are locked into broader issues of error-correction or a clinical mindset that sees every problem as solvable. That is why I classify these as more process-oriented. Many health issues have obvious solutions, and many patients are happy to relinquish decision-making control to follow the course of care that will most easily fix the issue. But even in these situations, treating a patient like a human can help them be a fully-participating member of the care team and not an obstacle to the healing process.
1OK, in the real world there is probably nothing that has universal agreement. My social media is filled with various folks wanting to share with me the “one hack to reduce belly fat that big pharma doesn’t want you to know…”
2Rest, Ice, Compression, Elevation. The last three were easier to master, but my neurodivergence and my two 90-pound dogs make “rest” a challenge.
3I sincerely believe this is because medicine is focused on fixing problems and eliminating errors. Failures in care—adverse drug events, surgical site infections, slips and falls, unexpected mortality—address the core competency of a hospital. So, it is vital to dissect failure. Successes are expected and are therefore not examined. Even organizations that celebrate “good catches” (where someone caught an error before it reached the patient), most are more focused on the error itself rather than the person who saved the day.
4When I am feeling especially onery, I have accused doctors of being idiots when it comes to statistics or even patient experience, just to show them how it feels to be judged as inferior. I once called a Chief Medical Officer a “sucker” and a “sap” when it came to surveys, but that is a story for another time. I do not recommend this approach to others, unless you feel you DO know more than them on these topics, or at least can fake it effectively.
5This stands for International Classification of Diseases, 11th Edition, which is a disturbingly detailed list of all potential health problems and their classification number.
6Yes, I know that I am painting with a broad brush in primary colors. My experience is that in the past thirty years, many end-of-life conversations have become far more nuanced. It is less clear if in less dramatic situations this has become more collaborative. To keep with my football analogy, doctors may be more attuned to patient interests at the ‘two-minute-warning’, but they may not be as engaging for input during ‘halftime adjustments.’ There may be a twelfth chemo chemical available, but perhaps a patient would prefer palliative care.
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