Mailbag – Dr. Sally Field edition

Operative and Myrmidon Wrangler DT (not to be confused with Operative R2DT) writes in:

Oh Noble Hoopy Frood Dr. J, 

As you are no doubt aware, Medicare is starting to use the results of patient surveys in calculating reimbursement for hospitals. So if the doc is a jerk, or a nurse doesn’t fluff the pillow enough, the hospital loses money. Obviously, hospitals are putting even more of a focus on getting good satisfaction scores – what was once a marketing issue now hits the bottom line directly. 

That’s why I was intrigued when I read this article at In it Dr. Pho* points out that aiming for patient satisfaction isn’t necessarily in the patient’s best interest , as giving people what they want doesn’t work all that well if, say, they want oxycontin for a hangnail or antibiotics for a cold. 

It gets worse, though. A study he quotes suggests that the more satisfied with their healthcare, they more likely that they had more drugs, more expensive doctor visits and tests, and no better care. And what’s worse, the highly satisfied were more likely to die than the less pleased. 

So why the heck is Obamacaid pushing for high satisfaction scores? Do they think that the decreased compensation will offset the more expensive care? Or is this yet another unexpected consequence from our amateur-in-chief? 

Here’s hoping that your Valentine’s Day didn’t start with V.D. 



* The name of my favorite soup restaurant

XOXO back atcha, in a completely straight, Matt Damon/Ben Affleck sort of way, DT.

Keep them Myrmidons myrmidoning, rather than other Greek activities…

So, for our readers, Dr. Pho was opining on the notion that Medicare is beginning to reimburse hospitals, in part, for good patient satisfaction scores. The issues that he raises are, indeed legitimate. Patient satisfaction can result in greater health care spending via more tests and treatments. Furthermore, said treatments can lead to complications, including death. Indeed, when Dr. J. consents patients for invasive procedures, he always ends with, “…and any time you come near a doctor or hospital, there is a small chance of death.

Dr. J. would like to add that patient satisfaction is also a critical component of healthcare because on the flipside, unsolicited patient complaints are a powerful predictor of lawsuits. Patient satisfaction both brings return customers to a healthcare system, but it probably decreases the likelihood of law suits.

Furthermore, he thinks that CMS (Medicare) is looking for ways, other than fee-for-service to reward doctors and hospitals for ‘good behavior.’ So, the combination of productivity, being likable and not screwing up (nosocomial infections, complications, etc…) in aggregate should decrease costs in aggregate.

Now while Dr. J. believes the best solution are market based solutions which balance quantity, quality and likeability nicely, we haven’t taken healthcare back to the individual, yet, and insurance companies and the government are writing the checks on our behalf, so sadly, patients and doctors are their bitches to some degree.

Like all things that look good on paper, these types of payments may not work out very well in practice.

There in lies the problem.

Rather than spell it out, let Dr. J. tell you a parable about Three Little Doctors (twhom he trained with):

First is Dr. Rarity:

Dr. Rarity was the captain of the cheerleading squad in high school, and always, more than anything wants to be liked. She works very hard, albeit in first gear, she writes the longest and most exhaustive patient notes, and she speaks a mile a minute to convey ALL of the information to you in the shortest amount of time. During her training, she made a couple of mistakes that lead to a couple of patient’s demises, but she felt horrible about it, and her attendings fell on their swords for her. She is really sweet and polite, except when she asks you a question, then she insists on talking over you while you try to answer the question. Annoyingly, she spent a year at Beth Israel Deaconess in Boston when her stallion was training up there, so even though it is Harvard’s C-list hospital, she will brag about being ‘Harvard-trained.’

Her patients love her because, as Dr. J. has said,  she is real sweet and kinda cute when she has her face on, and for whatever complaint a patient has, she orders a test or ten to get to the bottom of it. When she discusses the case with the consultant, she sells it like there’s no tomorrow so the consultant. Consultants like her because she keeps them busy. Her patients love her for it because they feel she is doing something.

She is the sort doctor that you and Dr. Pho bring up because she is very skilled in being liked, and to be fair she is a decent doctor (not the best, mind you, but good enough). She over tests, and potentally there are economic and patient risk downsides. Since neither they, nor we are on the hook for it, nobody cares, yet. The doctors that she refers to, however, are teh awsum, and thus the complication rates are neither on her, and are less likely to happen due to their skill.

So, what she loses in individual productivity, she makes up by taking time with her patients and ordering tests for them, making them happy. Her documentation is spectacular, so she can bill the max for any patient encounter. Further she doesn’t get dinged for complications, as she doesn’t do anything that directly puts her patients in harms way, she farms that out to her friends.

As a parenthetical, Dr. J. has never recommended her to a friend or family member. Not because there is anything wrong with her, but simply that there are always better choices.

Second is Dr. Rainbow Dash:

Dr. Dash was educated and trained alongside as Dr. Rarity. Despite this, she is very different than Dr. Rarity. While she is also, pleasant and polite, she believes in doing right by the patient in all matters. She is patient, a very good listener and very caring and compassionate. She knows the medical literature and is very evidence-based in her practiced. This, however, has gotten her into trouble.

She has had a few ‘VIP’s’ referred to her her clinic. One such VIP was expecting an ‘annual’ stress test. Now given the patient was both clinically asymptomatic and not an airline pilot or bus driver, there was no reason to do an ‘annual’ stress test. That is so Clinton era. Dr. Dash took her time to explain why this test was unnecessary and that the false positive rate was sufficient that it might result in a heart catheterization. Despite the fact that she does some of her own procedures and reads imaging studies, she does not over-utilize tests. After talking in circles with the patient, she ultimately ended the discussion, as she had other patients to see, rather than backing up her clinic even longer for this VIP. There were subsequent back and forth phone calls with the patient’s wife, the clinic medical director, and the patient’s primary care provider. There was a second VIP patient who made similar demands on her, and if Dr. J. recalls correctly, some of them involved either pain meds or meds outside her typical practice jurisdiction. Ultimately she chose to fire the patients and no longer accepts ‘VIP’s.’ if they are the type to want to drive their own care sans their own medical degree.

So, Dr. Dash’s bottom line is buoyed up by productivity, and quality. Her patient satisfaction markers are fine overall, but she tends to miss the high mark for a bonus. The reason for this, of course, you site. A rotten apple of a patient won’t be magically transformed into a ripe one by her charm, or by way of abuse of the system.

The third Little Doctor is none other than Darth Ponicus, both a Sith Lord and a physician (any resemblances to avatars living or deceased is purely coincidental).

This brings us to Dr. Darth Ponicus. Darth Ponicus trained a couple of years ahead of the other ponies.

During his training, he carefully watched and observed his mentors. He observed what worked and more importantly, what didn’t work.

The first observation that he made is that it is absolutely critical that you know your stuff. Understanding medicine is the absolute keystone of the practice of medicine, because if you don’t understand it, you can’t apply it.

Second, you need to listen to and know your patients well. You are providing (an important) service to them, therefore, it must be delivered in a manner in line with their worldview. Your patients want to like you, so it is should be relatively easy to bring them around to their point of view.

Third, be honest and forthright, and try to anticipate and discuss problems before they happen. Dr. J. has talked about this before. When a patient develops CHF, or a cancer, for example, begin to talk about the fact that it is a progressive chronic illness that you will manage with them until it becomes unmanageable, and then you will work with them to keep them comfortable, and that you will revisit this conversation when the end is near, hopefully a long time from now…a patient that knows they have a chronic disease that will ultimately take their life is a better ally in the management of that disease than one who is blinded when they are endstage because you were afraid to discuss it with them early, and often.

Fourth, Darth Ponicus learned the power of myth from his oldest and wisest mentor. This is important because sometimes patients come expecting a specific treatment or therapy, and it may not be the right one. The classic example of this is the mom who brings her wee tot in expecting antibiotics for a cold.

Darth Ponicus spent time in Ole’ Doc Baker’s pediatric office during his medical school training. Ole’ Doc Baker taught Darth Ponicus that a patient will come in clutching a diagnosis or therapy as a talisman of hope, tightly in their hand (metaphorically speaking), and that you will be able to do the right thing so long as you can replace that talisman with another. So, when mom came in wanting antibiotics for her precious snowflake’s cold, he would name the illness a cold or a virus. The naming of a thing is a powerful thing. He would explain the side effects of antibiotics (diarrhea, yeast infections), and that they do not treat viruses. But more importantly, Ole’ Doc Baker would give her free samples Tylenol, Motrin, and cold remedies that will make her precious snowflake feel better with a request for her to please bring her child back in two days if they are not better.

Also, Darth Ponicus was taught that if you can’t replace the talisman now, it can be replaced later. In other words, Ole’ Doc Baker would say to the patient, “Before, we do test x, we need to do test y. This is the safest way to proceed as test y will answer a question I need to know before doing test x.” Then when test y gives us the diagnosis, it, along with the diagnosis can replace the talisman of hope that was test x.

As a consequence, Darth Ponicus is the triple threat. He is productive, provides quality care, and has very high satisfaction ratings. So, while it is hard, it is possible to balance these apparently conflicting benchmarks, but it is only done well by the rare physician.

Like Darth Ponicus, Dr. J. has embraced and used this technique to assure the patient that what you want is also what they really want. They can leave happy, and without driving unnecessary, and potentially hazardous care. It just takes an understanding of patient psychology and the role of a physician as not only a caregiver, but also as shaman or medicine man.

About Dr. J.

Dr. J. was born the son of a New Atlantean sharecropper who cornered the market on notoriously delicious seaweed Himanthalia elongata (popularly known as Thongweed). With his newly minted seaweed fortune, Mr. J. the Elder sent his son to attend the Academy of Sorcery, Alchemy and Surgery where the good doctor apprenticed with the finest sorcerer surgeons in New Atlantis. Dr. J.'s areas of expertise grew to include bleeding, cutting for stone, trephination, medical divination with outstanding spatial and temporal resolution, cybernetic sorcery and medicinal alchemy. When King Orin of Atlantis fell ill with the Ick, Dr. J. stepped in with an elixir he devised from a combination of minerals, herbs and saps. Curing the king, Dr. J. gained significant notoriety which afforded him the luxury of time to devote himself to his side hobbies which include porpoise racing, the study of supply-side economics, cooking and raising his lovely merchildren alongside his lovely bride the archconservative Mrs. Dr. J.