I have written before about one of the key challenges with patient experience work is that it does not as easily conform to traditional accounting principles. This is certainly problematic when PX professionals are called to provide return-on-investment (ROI) calculations for their work or when belt-tightening is needed to address budgets shortfalls. All areas in business are not locked into linear relationships where X effort will consistently yield Y results. No matter how much money Marketing spends, you will never have 100% of the market share. No matter how much money Human Resources spends, you will never have 0% undesired turnover. But even within this fuzziness, PX can struggle because even a positive experience doesn’t necessarily lead to an immediate tangible fiscal value. The concern in this essay, then, is not about ROI, but about what misunderstandings emerge about patient experience when that traditional accounting gap exists.
Briefly, this accounting gap exists because healthcare does not respond to positive service scores the way other industries do. I just saw my primary care doctor a couple of weeks ago and I took the post-visit survey. I gave him all top-box responses because I think he is an excellent provider. But that admiration doesn’t mean that I am going to see him again anytime soon. That is not how healthcare works. So, Dr. Smith’s value to me or the organization cannot really be measured in repeat visits. He is not a sandwich shop or a coffee house that might benefit from my increased usage based upon good experiences.
Because we cannot easily1 provide concrete cost/benefit calculations this leads to a more insidious problem. There are those in healthcare who discount patient experience and its data collection as simply a “popularity contest.” This notion is problematic precisely because while it is often subtly referenced, it is rarely called out and addressed. It therefore exists in something that I have previously called “the healthcare mythology.” I use the word “mythology” purposely because healthcare (just like everything else) has stories that illustrate things simply with the aura of accuracy that are not true. We accept them as truth, even without proof.
I had an entire section when I taught in college about the myths of American Politics. Stories like “George Washington chopped down a cherry tree” or “anyone can grow up to be president” are repeated not because anyone really believes them, but because they speak to broader social aspirations, like “our statemen are honest” and “we live in an egalitarian country.” To be clear, myths are not by definition bad or damaging; they are just a shorthand way of talking. They just shouldn’t be mistaken for facts.
In patient experience, one damaging myth is that the data just reflects a popularity contest. Why do I call it a myth? It is simple and has the aura of truth. The logic is:
- Patients who like their doctors are going to give them high scores
- Doctors who get high scores from their patients are, by definition, popular
- Therefore the measure is simply a measure of popularity.
So, the claim has the patina of truthiness.2 But there are some underlying elements of this claim that frustrate me because it leads conversations in suboptimal directions.
Problem with Popularity
As we will see in some elements discussed below, there is this broad prejudice against popularity. It seems that for some, there is a zero-sum game where pursuit of popularity comes at the cost of some other metric. When I taught, I got very high ratings in student evaluations. My scores were routinely the highest in the department. Some, especially those in other social science departments, might have grumbled about the fact I had full classes because I was popular, implying that I was prioritizing showmanship over academic rigor or handing out A’s like they were Halloween candy. But my grades were submitted like everyone else’s and if my distribution of grades deviated from the norm, it would have been noticed and discussed. I taught mostly introductory classes, targeted at Freshmen and Sophomores. My desire was to inspire an interest in political science. I defined myself as the carnival barker for the department and while I was there, political science became the third-largest major. Being popular does not mean being lenient or sacrificing a thoughtful treatment of the material. It means connecting with your audience in a meaningful way that inspires different life choices.
Ego Protection
To be honest, it is mostly doctors who make the claim that PX is all about popularity. I have never heard a nurse, phlebotomist, or imaging technician make this claim and certainly have never heard a non-clinician make this claim. Please, if you are a nurse, or have heard a nurse or other clinician make this argument, call me out in the comments. Further, this is never something someone says who is in the top 10% of the comparative database. I have only heard this from doctors who are not performing well in the comparison, using it as an excuse for their scores. I discussed this in the last essay, when I talked about doctors who take pride in being assholes in telling it like it is.
This is, frankly, a larger trend in humanity, where we seek to protect our own ego or self-image by denigrating clubs that we cannot get into. When I was in a punk band in high school, we were not popular because we were not any good. But we said that we were too edgy to be appreciated by a mainstream audience. That the crowd just didn’t understand our artistry. That not liking us said more about you than it did about us. We could fit in, but we chose not to. And we might have actually believed this. Anyone reading this might say, “Denial isn’t just a river in Egypt” and you would be right. What does it say about doctors who complain that they are just misunderstood or underappreciated and imagine that they could get good scores, but they don’t want to?
Calling it a Contest
Part of the problem is that by using the word “contest,” it minimizes the importance of the work. Yes, organizations may celebrate high-scoring and that implies winners and winners implies losers. So, assuming we don’t distribute participation ribbons, it is a contest of sorts. Heck, many organizations I have worked with also put some cash on the line as well.2 Once we put money in the mix, it becomes easy to lose the plot of the work. The money and the victory become a goal in-self, instead of it being simply a measure of how well we are at connecting with patients.
Part of the reason why this is so damaging is because it encourages behaviors that are not aligned with the overall goal. Some are darker, which we will get to in a minute. But many behaviors are simply silly, and their silliness encourages people to doubt the overall value of the scores. I have cautioned doctors to NOT fall into the car dealership trap. We have all likely had interactions with aggressive vendors, who will deliver service and then will end the conversation with something like, “You will get a survey and if there is any reason why you cannot give me a 10, tell me know, so I can address it, because if you don’t give me a 10, I will be fired and my children will be left to beg on the streets for food…” My apologies to those who work in car dealerships, but you must know by now that you have this reputation. I don’t blame you. I blame your boss.
This begging for scores seems especially problematic in healthcare, since healthcare comes with a reputation of getting proper care by people who are more concerned about that than some survey scores. While I could write another essay on why I hate this approach, I will leave it with a simple statement. It doesn’t work. I usually will ask a crowd, “Would you give someone a 10, even though they gave you only average service, just because they asked for it? Then why would you expect your patients to do that?”
Bad Care
We now get to the thing that most troubles me about calling PX a popularity contest. The deep concern is not that people think that those with high scores are simply better at playing the game because they can smile, tell a joke, and beg for 10s. The darker concern is that physicians are delivering care based upon the desire to get a good score. This belief
is predicated upon one core belief about patient satisfaction: that physicians, in trying to gain positive scores, will give patients whatever they want.
If pressed, no one will accuse their fellow doctors of delivering non-best-practice care. Because they know that, on balance, that there are a bunch of guardrails that prevent craziness. Are there doctors that will prescribe antibiotics to children who won’t benefit from them simply because their parents complain loudly? Are there doctors who will run excessive tests because a patient threatens legal action? Are there doctors who will send patients out for needless tests because they can get a kickback from the independent lab or imaging office? Are there doctors who hand out opioids for every claim of pain? Doctors that make these insinuations also know that there are rules and regulations enforced by their employer, the medical board, and both state and federal agencies to prevent this. Not to mention the fact that every insurance company has teams of people to challenge bills based upon medical necessities. I won’t say it NEVER happens, but I will say that there are plenty of eyes reviewing decisions that doctors make. It is amusing that the same doctors that complain about having big brother looking over their shoulder at every moment of the day, still imagine that the doctors who win at PX are doing so because they are handing out blank prescriptions and worthless procedures with no oversight.
The problem with these unspoken beliefs is that it cheapens the work that many clinicians do to provide patients with thoughtful, patient-centered, best-practice care. When people challenge these metrics as “for show” or “based upon popularity” they not only justify their own disinterest in working on them, but they also suck the oxygen out of the room do discuss these issues thoughtfully. It is amazing how just one vocal doctor (or nurse) can derail any conversation about patient experience. I have countless stories where one crabby apple gave the average performers an excuse to hate the high-performers rather than learn how to be one of them.
1I say “easily” because with a big enough dataset containing all sorts of variables, we could build a model for PX and profit. Or at least I could. To paraphrase Archimedes, give me a large enough database and a computer to run it on and I could move the healthcare world.
2I am fascinated that a word that Steven Colbert made up to describe things that seem true but are not true is now happily accepted by my Microsoft Word spellchecker.
3There is yet another conversation for another time. Putting money on the line has upsides and downsides.
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