Friday, April 4, 2014

Doctors should be more like…



A while ago, Atul Gawande, the noted surgeon-author, wrote a long piece in the New Yorker on why healthcare should look to a restaurant called the Cheesecake Factory for some guidance on how to standardize things.

This was met with some derision by a number of physicians who pointed out, among other things, that the food at the Cheesecake Factory is not great and is loaded with calories. But I guess it's at least it’s "standardized" mediocre and unhealthy food.

Then a doctor named Peter Ubel wrote in Forbes magazine that doctors should take a cue from Starbucks about how to deal with people. He went so far as to say that baristas have more emotional intelligence than physicians.

He says the Starbucks staff are trained to placate angry customers using the mnemonic “LATTE,” which stands for “Listen to the customer, Acknowledge their complaint, Take action by solving the problem, Thank them, and then Explain why the problem occurred.”

I have never worked at Starbucks, but when I was a surgical chairman, I unknowingly used most of their principles in dealing with patient complaints about my attending and resident staffs. I could add another. I used to ask the dissatisfied patients and families "What can I do to make you happy?"

I was surprised that in many cases, the complainants could not think of a single thing that would make them happy. The question often completely diffused the confrontational nature of the encounter. You might want to try it sometime.

Another way of looking at this issue was suggested by a Twitter colleague, Dr. Edward J. Schloss, who tweeted that we work for the government, and we should be compared to the Bureau of Motor Vehicles or the post office, not Starbucks.

Since doctors are already notorious for making people wait, comparisons to the BMV would seem appropriate. And some docs also take forever to return phone calls, similar to the post office's habit of delaying the mail.

Surely physicians look better when compared to another government agency, the Internal Revenue Service, especially now that the IRS has been accused of selectively harassing certain political groups and spend lavish amounts of money on conferences.

At least no one has suggested comparing us to pilots lately. I have dealt with that analogy decisively in the past here.

Why should practicing medicine be compared to any other occupation?

Doctors are unique. None of us is perfect, but despite the occasional bad apple, most of us are doing the best we can for our patients under difficult circumstances.

26 comments:

Ryan Gray, MD said...

"Doctors are unique."

You had me until this last paragraph. It is this thinking that has such a stronghold on physicians that makes change, or even the mention of change a difficult proposition.

If someone dares to mention aviation and how we've reduced errors there, the physician screams "I'm a doctor, not a pilot - I'm UNIQUE."

I'm sure if we look at every job in this country, people working in that career think they are unique, and for the most part, YES, they are, and so are we as physicians.

But that doesn't mean we can't learn from each other, no matter what field the knowledge is coming from.

Anonymous said...

Given Atul Gawande's manipulation of data in the Darthmouth study to support cutting hospital funding (claiming that there would be no impact on health care), I would ignore everything he says. Just a shill for insurance companies and the govt (is there a difference these days?)

I think the medical profession will only be able to progress in a logical and rational manner when its practitioners alongside patients/communities are able to make decisions without the constant hindrance of politicians and health insurance CEOs.

Anonymous said...

I think Gawande's artcles have all been intelligent, measured attempts to address problems in the provision of medical services.

Politicians and insurance CEO's will always be involved because they are paying the practitioners and hospitals. The old screed that we doctors are unique and must only deal with patients is nonsensical on the face of it. Do you not get paid by Medicare, MediCaid, and private insurance?

Unless you are a cosmetics only physician (and I would consider the "physician" term lightly), then you have to answer to your contractors.

Or you can follow your self-professed principles and refuse all public and private insurance. You will prob. starve, but at least then you can practice medicine as you feel fit.

Anonymous said...

The trouble with claiming uniqueness is that of course every job is unique. It doesn't mean that we lord it over everyone and say we have nothing to learn from other areas.

What if your lab tech says that his job is unique (which it is) and you have no say on how he does his job. You would prob. get him fired. Similarly, a physician is hired by the government or insurance company to do a job. Why shouldn't they dictate certain (very loose) parameters and guidelines?

We already have multiple examples of cardiologists collecting millions for unneccesary procedures, and expensive nonsense like spine surgery for chronic pain . I would say medicine needs more oversight, not less.

Skeptical Scalpel said...

I thought this post was pretty straightforward, but it appears that it wasn't. Where do I say that we have nothing to learn from other professions, or we don't need guidelines?

Pilots basically all do the same thing and use a machine called an airplane. There are numerous different types of doctors who take care of patients, who unlike machines are also unique.

There already are many doctors who no longer take insurance. It's called concierge medicine. Trust me, they aren't starving.

It is ludicrous to compare a restaurant to a hospital or a barista to a doctor.

Anonymous said...

Concierge practices (all are primary care docs AFAIK) spend a lot of time dealing with insurance entities because the vast majority of their clients' expenses will still be paid by insurers.

A doctor can't just go and do something because he wants to and convinces the (usually medically naive) patient. Surely the payer has something to say about it?

Even now, the insurer usually pays even in the absence of of any evidence of utility. Physicians are given vast latitude.

Taken to the extreme, some physicians want all encounters and interventions to be purely between them and their patients, but paid by a 3rd party no questions asked. All financial considerations aside, do we seriously want a single physician to practice with no oversight?

Yes we are all unique, and every patient is unique. So is every pilot, and policeman, and every passenger and criminal. Every teacher is unique; every student even more some.

How is doing an elective lap chole more unique than a pilot landing in differing wind conditions?

I am a doctor myself, but I find some of our self-importance to be unwarranted.



William Reichert said...

I would not use Starbucks as a model for interacting with the customer. I was there yesterday, There was no soap in the bathroom.
I spoke to a barista who acknowledged my concern and the
did nothing to correct the deficiency and certainly did to thank me for
my concern. Nor did I see a check list for her to refer to when this issue presented itself.
Medicine is undergoing a transformation from a private enterprise to a public enterprise. Think of the difference between so called "public" health and "private" health. The faith now devoted to the uncritical worship of the evidence in "evidence based medicine"( treating groups instead of individuals ) ignores the recognition of the
fact that what is unique about medicine is not the physician but the patient.And the relationship between the two. The airline pilot flies one plane and the passengers are cargo.

Skeptical Scalpel said...

William, thanks for commenting. In fairness, one anecdote does not mean Starbucks has poor service any more than one bad experience with a doctor means that all doctors give poor service.

Your point about patients vs. airline passengers is a good one. I have expressed similar thoughts in a post from 3 years ago. http://skepticalscalpel.blogspot.com/2011/01/patients-are-not-airplanes.html

Anonymous said...

Doctors should be more like Doctors.

I remember a time when a Doctor was a health expert; they understood the body - including mind & soul and was able to reassure the patient, even if things weren't going well.
"I'm sorry, but we have to amputate your foot."
"Thank you Doctor."

Now it seems like Dr. So-and-So is the pinnacle expert and the collection of organs that appear are mental puzzles to be played with. They've lost the connection with the person.

"Due to the rapidly progressing infection with necrosis of the subcutaneous tissue and encroachment on the talus I could try a removal of the calcaneous only but the risk of relapse is too great so I will be performing a BTK amputation."
"WTF did you say?"
"I'm cutting off your leg."

Also note the difference between the traditional "we" and "I." Add in the wall of specialization that prevents a physician from taking responsibility and the patient often feels alone. Who can they turn to if not to the Doctor?

Medicine is compared to other industries because its recent progression has been in a direction that leaves patients knowing it could be better - and Doctors used to be the best.

Skeptical Scalpel said...

Anon, I guess doctors could be more like . . . doctors. Things seem to have evolved in a perverse way.

William Reichert said...

Skeptical:
You are right. However, Mr Ubel was quoted as saying that" doctors should take a cue from Starbucks on how to deal with people" since
"baristas have more emotional intelligence than physicians."
He did not say "some" but implied "all".
IN my experience ( 45 years) most of the time when patients
and or family get angry it is not about something that can be
remedied by providing them with a free Latte or with( by what has been recently suggested by "evidence") an apology. Sometimes
we can address their concerns and improve the situation. More of often, however, the reality of illness is not so simple.
Suggesting that all our "customers" can leave our offices on a happy caffeine high like Starbucks is insulting to the world physicians
live in. I recently had to tell a patient that he had both AIDS and TB.
He was NOT happy. I was not happy. I cannot make him instantly happy. . I can offer to be there and treat him. I am amused when critics compare the situational challenges of what physicians experience to that of someone who serves you a cup of coffee.
I do not think this makes doctors more "self-important" than
any one else. But it does make our patients concerns more important than someone who was served a bad cup of coffee.

Skeptical Scalpel said...

William, I agree that unhappy patients and families are a lot different than people who have a problem with their coffee order. It's much harder for doctors and hospitals to do "service recovery." Your story about the patient with AIDS and TB is right on point. the nature of our business is that all patients eventually die.

DD said...

Making patients happy vs. satisfying the immediate needs of the coffee or lunch seeking crowd requires us to remember one thing --not only all patients eventually die, all PEOPLE eventually die. In addition to remembering that fact, we should interact with patients applying this question: '"how would I want my care to be delivered?" answer it for yourself, and then act accordingly. DD

William Reichert said...

DD,
I could not disagree more with the idea that we should treat our patients as we would wish ourselves treated. Patients are profoundly different one from another. Some welcome humor, some do not. Some long for the "straight truth", some prefer a less direct more nuanced discussion.Some welcome scientific facts, some are repelled by this approach.Some wish God be included in the treatment plan.Other not. Some want a single physician to assume the complete management of a problem. Others embrace multiple specialists offering their differing points of view based on their unique training and experience.
Treating patients as we would wish ourselves to be treated can turn out to be a disaster. Even baristas know this:
"Want room for cream with that grande,sir? or not"?

Anonymous said...

Humans will always have medical problems. Most doctors try to fix chronic problems that can not be fixed easily. Patients expectations are very high from the doctor. When patients research the problem they understand the problem and have realistic expectations and can help the doctor help him. No need for a free Latte.

Anonymous said...

Let me address a few comments here:
1) I could easily tell you what would rectify the situations in problem doctors I've had in the past. Not listening to patients, not reassessing their "treatment plans" when they weren't working, a poor attitude if everything wasn't perfect & blaming the patient for the outcome when a number of times it was not the patients' fault, lack of education, too much workload and not able to delegate. For starters.
2) Doctors are not unique in that they perform a service. I've seen how some perform a service and it needs to be better. I've seen some who do a good job and others who just pay lip service to anything that isn't a cough, cold or flu that can be treated easily. See #1. Fix the problems in #1. That includes learning from patients who are credible and simply educate those who aren't.
3) A restaurant and doctor are going to get a reputation when they're crappy. It is up to the medical profession to fix it. When you don't, that's why you see the legal remedies, the hatred and mistrust of doctors as a whole, when we know you stick up for each other and not us. If you are first, why should we be expected to trust you that you are looking out for our health?
4) As for the barista, that's how I see a lot of medicine react. That's why doctors are getting blamed for bad reps, allowing those who shouldn't be doctors to keep on working in patient care, missed and delayed diagnoses, etc. Respect and trust are earned, not bestowed.
5) I've seen evidence based medicine work for a lot of instances that doctors can't figure out. Had they reviewed the research, they would have found their answers. This means they're not educating themselves or taking the time to keep up with advances. Why trust someone like that? If we can do it, and then give you evidence, and you still don't treat us, or you can't give us a medically based answer, why should you be trusted?

Why does the medical profession demand double or triple blind placebo studies, but it is ok if base everything on their experience or what they were taught in medical school, and demand "woo" come up with double blind placebo tests when they will blatantly ignore their own research for an answer?

DD said...

Mr Reichert: Following the basic tenet of "do unto others" does not preclude personalization. We all want to be treated with respect and we all want optimal care. That was my point.

William Reichert said...

All,

I have seen a recurrent theme in these posts suggesting
a profound faith in "evidence -based medicine". While the basic idea of evidence based medicine cannot be disputed ,this is a little like saying that the idea of "truth" cannot be disputed. There are many
things about evidence based medicine that are troubling including the significance of the "evidence".

But beyond that there is another very disturbing situation:
www.medpagetoday.com/PublicHealthPolicy/ClinicalTrials/37506

Anonymous said...

What is the alternative to evidence?

20 years ago, as a resident, I did something and the patient survived! Therefore I will do it from now on.

It is really curious that doctors, with supposedly scientific backgrounds, are claiming that because every patient is different (duh) they must ignore evidence.



Skeptical Scalpel said...

DD, thanks for clarifying.

William and Anon, in addition to William's link, here's another discussion of what can happen with slavish adherence to evidence-based medicine http://buff.ly/MJPESy.

Also, guidelines are simply that--guidelines. They may not apply to all patients.

Jay said...

Missed this until now. Thanks for including me in your thoughtful post. My comment about doctors being compared to the BMV was said with tongue firmly in cheek. That said, like all jokes, there is an element of truth here as well.

Edward J. Schloss MD
@EJSMD

Skeptical Scalpel said...

Jay, I thought your tweet about the BMV was spot on and very funny. It actually was the inspiration for this post. Thanks.

Hope said...

Interesting post. I was a waitress on-and-off for nearly a decade before I transitioned into residency. During college and graduate school I clocked hours and hours at everything from local creperies to major corporate outlets (similar to Cheesecake). I understand in a way what Gawande is saying -- but it applies more to the logistics of residency than the profession of doctoring. As a medical student on rotations and even now during surgical residency, I feel like being a waitress was probably one of the most valuable experiences I had to prepare me for this job. Astounding, right? Dealing with people, biting my tongue, trying to make others happy, learning to be as efficient as possible (when your tip is on the line, you somehow find the energy to power through exhaustion!), working as a team, prioritizing and multi-tasking. I learned all these things in a fast-paced corporate restaurant environment. Strict rules, stupid policies, lots of red tape. It's pretty much a blueprint of residency except, of course, that sick patients are inherently more important than fussy customers, and there is less room for errors. Despite this fundamental difference, something I lament about to my husband all the time, is that I felt like my co-workers at corporate restaurants were more willing to help out, lend a hand, be team players and go for the long haul than most of my co-residents! At the restaurant, if you took the last of the salad or cheese in the kitchen, you just automatically went to the back cooler to get a whole other stash - you'd never leave an empty container for the next person to deal with. In the hospital, I can't tell you how many times I've been dumped with unfinished discharge summaries, crappy signouts, holes in prescriptions and other annoyances that do add up, all because someone wanted to take a short cut. I've also found that many residents have problems multi-tasking and prioritizing throughout the day...checklists looks like war zones and yet not much has been completed. While I know that the professions of food service and health care are fundamentally different, in an era of ACOs and HCAHPS, it's frightening how SIMILAR the roles of customers and patients have become. As a waitress, I had little power and my job was to serve. Somehow, doctors are moving from respected individuals with valid opinions to vehicles of servitude. That's another point entirely. But I think Gawande has some valid points with which I agree myself, purely from my own experiences.

Skeptical Scalpel said...

Hope, thank you for the very thoughtful and pertinent comments. I agree with you about teamwork. The shift mentality makes it so easy to dump work on the incoming shift.

Medicine is definitely a service business and patient satisfaction is important. Maybe all med students should work as wait staff for a summer at their local Cheesecake Factory.

Anonymous said...

@hope. Loved your post.

I do wonder how premed work experiences color a physician's work habits.

I only did some math tutoring and manning the student center kiosk in college. A fellow resident did pay his way thru college as a male stripper. Another guy invented and marketed a pet perfume (prob. common now but it was big deal back in the day).

As far as I know, we are all just boring everyday docs these days.



Skeptical Scalpel said...

Thanks for commenting.

I can see how working in an information booth and tutoring might help one achieve a better bedside manner. Male stripping? Not so much.

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