Most patient experience is simply realizing that there is a human being attached to the broken leg you are fixing.1 I know that this is simplistic and obvious, even as I have written over 200,000 words on the topic over the past year or so. But while this seems so trite as to elicit eye-rolls, I am surprised how rarely that folks consider the impact on patients when they do NOT concern themselves with patient-centered care. When one defines PX as mints on pillows, forgetting the mint seems a trifle. But when you realize that PX is essentially recognizing the humanity of others, failing to honor that is nothing short of disrespecting another human being. If you do it accidentally because of distraction or workload, that is one thing. That was the subject of the last essay. If you do it cavalierly or even purposely, that is more problematic, as it speaks to who you are, or, at the very least, who you show to other people. That is the subject of this essay.
In the last essay, I gave healthcare workers an escape hatch. I gave them the benefit of the doubt that their approach to patients was predicated upon workload or their commitment to best-practice care. In this essay, though, I will focus on two reasons that we punch patients in the face that will require a look in the mirror. Some may push-back on this, saying that I don’t know what being a trained clinician is like: the stresses, the frustrations, the paperwork, etc. A careful reading of this essay, though, will show that while I may reference healthcare examples, the behaviors I discuss are not unique to healthcare and calling them out does not require an advanced medical degree. Anyone who has worked with, worked for, lived with, or interacted with other humans has seen these behaviors at play. The most self-aware of the readers may actually even see themselves in these behaviors sometimes. So, while this essay wears a lab coat, it may be the most broadly relatable essay I have written.2
Before continuing, this essay, like so many others, can be viewed as less “black and white” and more a matter of shades of grey. I have had clinicians proudly proclaim that their efforts to punch patients in the face are intentional, designed to be the nudge needed to force patients to confront their own bad decision-making. Some will even discount patient survey results because they are doing what needs to be done and those chasing 9s and 10s are the ones who are doing the real disservice to patients. Are there times when clinicians need to speak in simple declarative ways to make a point? Absolutely. In fact, I would argue that clinicians should always speak in simple declarative ways. My request of you, the reader, is to determine if these are straightforward moments of communication or if something else is at work here.
Hey, the truth hurts sometimes
Sometimes we punch patients in the face on purpose. Clinicians will maintain that sometimes you gotta be blunt. I have previously mentioned the emergency department doctor that scratching out the pre-printed discharge instructions for a patient and wrote in large, bold writing, “STOP USING HEROIN!” I would include it in presentations and people would nod and even laugh. And, yes, we have all been to a point of exasperation with a patient, a coworker, or a family member, where it feels like the only answer is to verbally punch them in the face.
But then, I ask, “when you explode in this way, was this really for them, or was it for you?” If you asked that ED doctor why they wrote that on the after-visit summary, they would probably admit that it was more out of their own frustration than it was an effort to break through to the patient. We have all been frustrated with someone to the point where we say some version of “BECAUSE I SAID SO!” or “PULL YOUR HEAD OUT OF YOUR ASS!” When I have resorted to one of these lines, it was less about any effort to communicate and more about my own frustration at my failure to communicate. It was specifically designed to end a conversation and not as an effort to start a conversation. Writing “STOP USING HEROIN!” on an AVS may be cathartic, but that cannot be confused with any real effort to communicate.
Now some of you may be thinking, “But Joe, didn’t you just write about the fact that we need to be clear and honest with our patients?” Yes, I did. But this is not being clear and honest. This is about shutting down conversation. These moments carry an implied “OR ELSE!” Heck, when dealing with your children or coworkers, these messages will carry that explicitly. In healthcare, this approach is generally attached to a patient who is noncompliant and has been noncompliant for an extended period of time. It also defines this noncompliance as an active choice to be noncompliant.
Now, there is no shortage of books on understanding free will through the eyes of hyper-rationalism or codependence and I have no interest in wading into that debate. I think, though, that we can agree that somewhere in the middle of this conversation is the realization that all of us are confronted with obstacles and that sometimes those obstacles waylay us, if not completely defeat us.
More importantly, we tend to minimize others’ obstacles as we compare them to our own obstacles. Consider, for example, Americans who are chronically underweight. When about 75% of Americans are overweight, being fat carries a lot of empathy. We all have that obstacle, so we can all be empathetic to the challenge. We don’t provide that same level of empathy to those underweight. When they confess their struggle to put on healthy weight, instead of empathy, the number one response they are confronted with is, “I WISH I had your problem.”
This allows us to gate-keep what are legitimate obstacles and what are sometimes called “first-world problems.”3 This allows us the ability to both dismiss problems as imaginary as well as defining noncompliance as simply being weak-willed. Everyone reading this knows that being obese or using heroin is a bad idea with long-term negative consequences. Even those who are currently fat or using heroin know this. So, using this sort of “I call it like I see it” approach to healthcare is not really being helpful. It is punching a patient in the face about something that, in all likelihood, they are already punching themselves in the face about.
It’s not my job to care about your feelings
I was in Kankakee, Illinois once talking to a room of doctors about the patient experience. An oncologist interrupted me and said, “I tell people they have cancer all day long; they aren’t going to give me an ‘Excellent’ on a survey.” I responded, “Well, if you tell them like that, I am not surprised.” He later confessed that, since he was working on his three-year retirement plan, if any patient came in with a complicated case, he would refer them to a sister hospital an hour north in Chicago. So, not only was he punching them in the face, but he was also kicking them out the door. In Kankakee, there are two hospitals and they are literally across the street from each other. So, when I relayed this story to the vice president of the physician’s group, she feared patients might cross the street to the competitor. I commented that those would be the lucky ones. The ones who could not leave because of insurance were the ones really made to suffer.
I am not interested in trying to encourage that oncologist (or anyone else) to care more about patients for the sake of survey results or corporate branding. Someone with a goal of making their own lives easier or with one foot out the door is not interested in PX scores or market share. I am only interested in asking them about how his patients respond to his abrupt language; asking him to think about what his behavior was saying about himself. Do you think patients are entitled to compassion? Does this language demonstrates compassion? If you feel uncomfortable these emotions, do you advocate for other resources, like care navigators, to provide the compassion the patients need? Heck, do you have a box of tissues in your office when you deliver your declarative pronouncements? I am certainly sympathetic (and have written essays on it) that clinicians cannot be emotionally tied to every patient. That will burn people out fast. But we can often discard simple human understanding as we protect ourselves from the tidal wave of empathetic emotions.
I remember having a conversation with a physician’s group in Wisconsin as well as their senior leadership. I had a doctor directly ask me why he should care why he was perceived by his patients. I said something to the effect of:
I know what they [motioning to the administrative leadership] want me to say. They want me to talk about keepage and leakage and market share. But I know that you don’t care about that. Your schedules and your panels are already full. You couldn’t handle more patients if you got them. You also feel like you don’t get the credit that you deserve for bringing millions of dollars back to the hospital as it is. I will tell you a secret. I don’t care about market-share either, at least not as a primary goal. I care about the patient experience. You should as well, not because of any of that other stuff, but because patients who think their doctor is compassionate and is really listening to them are far more likely to do what they ask of them. They will be more likely to ask for help with challenges and obstacles they face, if they think you care. If they think you are awesome, they are less likely to fight with you over process. All of this means that ‘winning’ at patient experience means getting them to better manage their own condition when they are out of your line-of-sight and that reduces some stress on your tight schedule.
Here is an example from my life. About fifteen years ago, my doctor said that my cholesterol was a bit high and that I had two choices. I could focus on an improved diet and exercise to drop my number, or he could put me on a statin. I was already trying to exercise and eat a healthy diet, so I opted for doubling-down on that. He nodded and said that we could meet up again in six months to discuss how that was going. Six months later, my number was basically where it was before. So, he said that I could really focus on diet and exercise, or he could prescribe a statin. I realized that I my efforts weren’t working so I said that I was ready for that statin. Notice that he did say I was a failure or say “I told you so.” He didn’t say that I wasn’t really trying hard enough. He didn’t say, “we tried it your way, now we will try it my way.” He knew that, whether I was trying hard or hardly trying, the results were the results. He knew that those six months were a small price to pay for me to be compliant for the rest of my life.
He knew that being right was less important than being understanding. He knew me well enough to know that I wanted to feel in control and him questioning my willpower was not going to get me to give in to his solution. He knew he was right, but that he could not force the issue. Being right was not the issue. Getting me to be compliant with my own health was the issue.
In healthcare, there is an expectation that clinicians need to be right. They cannot make mistakes. This essay is not about that. It is about the fact that many feel the need to be right at the top-of-their-lungs. People all around you (maybe even you) think that being right requires no explanation or justification. They think being right is a “get out of jail free” card, a protection against being rude. Being defiantly right does not make you an expert or an Alpha. It isn’t an excuse to punch people in the face. It just makes you an asshole.
1Whenever I have been asked what I do for a living, on an airplane or at a cocktail party, I often define my work as teaching doctors that there is a human being attached to the appendix they are removing.
2Or not. Just because it is my intention does not mean I will succeed.
3For those not familiar with this term, it is reserved for complaints or problems that are especially minor or trivial. If your only complaint about your day is that the barista misspelled your name on your latte, then you have a first-world problem.
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