Recently, I had occasion to refer a non-urgent patient through the chairman of a prominent medical school department and, frankly, didn't expect much. They tend to be remote and frosty, even to colleagues. Busy and all that, they say. So I was shocked to get an immediate and warm response. He and his assistant could not have been more helpful or courteous and it got me reflecting upon the state of service in American medicine as separate from "quality" — whatever that ends up being (see past columns for that headache).
For much of the last 50 years, good service from physicians was too often honored only in the breach. The average patient's convenience ("that's why they call them patients") was always second to the physician's prerogatives, and the implied disrespect was too often mirrored by the "protective" office staff. However, there is a rising sense that consumer-oriented service, rather than physician-oriented service, is not only important for the success of a doctor's business, but also for the effectiveness of his or her health care. (Editor’s note: See Shirley Mueller’s newest blog relating bad experiences at doctors’ offices.)
It's easy to see how this state of affairs developed. First of all, there has always been a shortage of physicians — by total number, by specialty and by distribution. So all concerned accepted a triage mode of rationing precious access out of necessity. There was a skew to the privilege point of view. And access has never been a formal, standard or rational process.
Physicians were, until relative recently, independent, isolated and, unfortunately still, untrained to a best practice’s ideal of service. And one largely unaddressed, unspoken part of medical training is the passed down sense of arrogance and entitlement that too many doctors unconsciously — or sometimes consciously — acquire.
Then we mixed in the rapid technicalization — to coin a word — of medicine which increased the cost and restricted access even further. The rise of insurance coverage somewhat ameliorated the problem of increasingly expensive access, but became a fiasco in the Age of Managed Care. This period was specifically focused upon restricted access and added yet another disincentive for improved physician-to-patient service.
Going hand in hand with managed care contracts is the paperwork monster. This problem dwarfs all prior experience and thereby greatly and adversely affects the potential for physicians to spend time with their patients, which is a hallmark for good service and good medicine. And don't get me started on HIPAA.
What's more, technology and the insurance industry have combined inadvertently to boost physicians' incomes to the top of the middle class and, for those in certain procedure-oriented areas, to real wealth. Financial success, sustained over time, can add another layer to the sense of physician entitlement mentioned earlier. And physician entitlement, among other negative aspects of our current "system," is certainly a service orientation killer.
To offset some of these trends came evidence-based medicine and the consumer movement. The consumer movement's effect is obvious; it has made us more aware and more likely to say “I do not want to be treated disrespectfully and my time is also valuable. And I want to know more about my medical condition and I am asking more informed questions. And I want a cogent, easily understood explanation, thank you very much. Doctor, you are not here anymore to tell me what to do, you are now here to explain my choices so that I may decide for my own life and body.”
And all of this is certainly overdue.
And the internet, with sites such as Yelp, has made communicating peoples' experiences easier and thus has empowered patients further to speak up, positively or, too often, negatively. What was the plaintive cry in the movie Network?
"Damn it, I'm fed up and I am not going to take it anymore!"
For the evidence-based piece, increasing attention has been paid to the study of service, attitudes and effectiveness. The results clearly trend toward better service allowing people to be less anxious, more pleased and therefore more receptive to medical recommendations. Being less anxious and more receptive gets right to the major problem of non-compliance, or as I wryly tell some patients "nine times out of 10, if you don't fill the prescription, take the medication, do the therapy etc, it won't help you."
If you are quickly greeted on the phone by a well-trained and pleasant human — instead of a mechanical algorithm — to answer a question or to make an appointment, you open the door to a positive experience. Or if the doctor has a well-designed and user-friendly website, you start off with a receptive attitude, inclined to enhance your experience. If you then find a clean, attractive waiting room, with fresh magazines, which you do not have the excess time to actually get into, and again, a pleasant, well-trained assistant who gets you set up comfortably and quickly for a short wait, your willingness to understand and get involved goes up. And how would it be if the doctor actually walked into the waiting room to welcome you before turning you over to his or her assistant? That would be a "wow."
Medicare recently cancelled a proposed "secret shopper" program, but it can be a useful tool for the doctor who wants to improve service. Years ago I gave a talk to a group of doctors with that very recommendation, and I recall attention to improving physician service was not warmly received at that time. Thankfully, the times they are a-changin'.
You could hire a consultant to do this, but I recommended that you buddy up with a colleague at another office. It costs nothing, takes little time and can be a real eye opener. Each doctor anonymously calls the other office, makes an appointment, shows up on time and goes through the process, taking notes as he or she goes. When you compare notes later, you will be impressed with both the obvious deficiencies revealed as well as the occasional new idea that you can adapt.
Having been through the process, when you make the changes, you will get nothing but positive feedback from your patients and your staff. And you will function more effectively as a physician as you perceive (or even measure!) the improvement in your personal outcomes and office morale with the new, more service-oriented practice.
The effect on your bottom line will bring a smile as well. It’s a win-win, as the business types like to say.
Jeff Brown, MD, is a Board Certified Family Practitioner, currently doing geriatrics as a Medical Director, and is also a consultant for the California Medical Board. Dr. Brown can be reached at email@example.com.
Jeff Brown, MD, is a Board Certified Family Practitioner, currently specializing in geriatrics as a Medical Director, and is also a consultant for the California Medical Board .