What Do You Care What Other People Think? is the title of Richard Feynman’s semi-autobiographical set of memoirs. It includes an account his work uncovering the cause of the 1986 explosion that destroyed the Challenger Space Shuttle. The title comes most directly as quoted from some key interactions with his first wife, Arlene, who died in 1945 from tuberculosis, but is used more broadly to convey one of the central ideas of the book, which is namely that Feynman was much more dedicated to the search for truth than in making others approve of him, and is something of an encouragement to the reader to do the same. Indeed, worry about what other people think of you, is a considerable source of stress and unhappiness. However, in the practice of medicine, we are both implicitly and explicitly encouraged to put a lot of effort into caring what other people think of us, perhaps to the detriment of everyone.
In second two years of medical school, most students are in “clerkships”, which basically means doing short rotations in different clinical specialties, being apprenticed under the interns and residents, for example spending one month in general surgery, three weeks in gynecology, three weeks in obstetrics helping with labor and delivery, etc. A big part of a student’s grades come from the evaluations, so what the residents think of the student is very important. It’s a bit like a probationary period of a new job or the stress of trying to make a good impression a first date, but it last for two years. You might imagine that trying to do a good job taking care of patients for the first time is very stressful, or that trying to assimilate all that medical knowledge is stressful, but time and again the most stressful part seems to be trying please everyone, particularly your supervising physicians. Presumably the thought is that this stress of trying to please everyone is a good forcing function to encourage the student to be a good doctor, namely by being the kind of apprentice-doctor that resident wants. The system has been largely successful, and it has been used to train doctors for many years. At our medical school, patient evaluations also go into the mix of what gets graded. That seems like a good thing, namely patients should be able to give some feedback and evaluation about their care. It’s also an important taste of future practice, where physicians are increasingly evaluated by their patients in a variety of also increasingly public venues.
From specialized sites like HealthGrades.com and RateMDs.com to general customer satisfaction sites like Yelp.com, physicians can be publicly evaluated and rated. This can be somewhat controversial, not just for physicians, but for businesses in general. An evaluation does not mean that the rater even went to see the physician, for example, the rating might come from something else. Those providing ratings might be biased, maybe a small handful who had bad experiences might be the only ones motivated to comment, or perhaps the doctor gets “ringers” to provide good evaluations. However, those public ratings are here to stay, and are likely to become an increasingly important mechanism in consumer choice for physician, in much the way that Yelp has become a very important part of how people make restaurant decisions.
Medical institutions themselves are a little more careful in methodology, but they are wholeheartedly embracing customer satisfaction metrics. They don’t just collect information about physician interactions, but on hospital food quality, parking access, and anything that is part of the patient experience. Before I was ever in medical school, I read about the rise of patient surveys, and I thought it was a tremendously good idea. Healthcare providers need to know how their patients are doing, and things which previously went unnoticed as problems, such as poor dental/oral care within the hospital, are highlighted. Things can only improve with feedback. As someone who does data mining, I know that the more information we have, the more we can learn.
The use of patient satisfaction surveys gave rise to economic opportunities as well. Hospitals now use companies like Press-Ganey and Gallup to do customer satisfaction surveys. The incentives for healthcare providing institutions like hospitals is huge, the companies that sell survey tools say that the implementation of customer feedback can increase revenues by 5% a year. Happy patients are happy customers. If you are selling a product, including healthcare, caring what your customers think about you seems very much in your self-interest.
Patient satisfaction surveys have certainly worked in the sense of reshaping care. There is a much greater focus on customer satisfaction, and healthcare providers are made well aware of their ratings. They are thus encouraged to do things to make their patients happy. This is clearly a good thing, right? The point of medicine is to help patients recover to lead happy, healthy lives and/or give them care and comfort in a time of illness. Patient satisfaction should be a pre-eminent goal.
However, the dark side to this customer driven approach is that it encourages physicians to over-treat. Whether it is through giving more dangerous pain medications, giving antibiotics unnecessarily, or ordering too many tests and procedures to demonstrate active care. Recent studies seem to suggest that all this focus on patient satisfaction has actually been leading to increased patient death. An example is a big study from UC Davis in the Archives of Internal Medicine. The short summary of the results is that higher satisfaction was later associated with greater use of medical resources but also higher mortality. The article was summarized and commented on in the same journal issue, and you can find numerous discussions of this phenomenon online. Over-aggressive treatment to make patients happy is sometimes killing them.
The most extreme example might be Stephen Schneider of the Schneider Medical Clinic in rural Kansas, which had a large number of poor patients which chronic pain conditions who were being treated over-aggressively with powerful opioids, contributing to the deaths of several patients. Schneider and his nurse wife were convicted of serious charges and are currently incarcerated. He over-prescribed, and if we take the charitable view, it was to alleviate the pain and suffering of his patients. The less charitable view is that he did it to make lots of money through his fees. Satisfied patients in pain kept coming back for prescriptions and he could charge them. However, that leads to an obvious question of where the line is drawn. As medicine is increasingly focused on patient satisfaction, not only to improve care, but to make happy customers who return to that provider, when is a provider being a good healthcare giver making patients happier and when does a provider become a criminal, exploiting patients and putting them at risk? Rachel Aviv wrote a very nice piece in the New Yorker on the Schneiders. If you don’t have a subscription, you can read a commentary on the article here.
What are the ethics of this over-aggressive pain treatment? It might be worth mentioning that we are taught in medical school that it can actually be ethical to prescribe powerful pain medication to alleviate pain, even if it has the side effect of hastening death. The rationale given is that it is like a risky medical procedure. It is ethical for a doctor to perform a risky medical procedure on a patient in an attempt to cure them, even if the likelihood of success is small and the risk of death high, as the patient can choose to take that gamble. Every surgical procedure involves some risk, so in some sense every medical procedure has a chance of hastening death. However, it is ethical to let a patient decide if they want to take that risk, on the chance that they will get an outcome they want, such as curing a disease.
However, that is obviously a bit at odds of the Hippocratic Oath, and “Do No Harm”.
Obviously there needs to be a balance. You should care what people think of you in that it gives you feedback on how to improve what you are doing, giving you an external view. It’s important with patients, as you need to understand their perspective, which is very different from yours. However, you shouldn’t let the opinions of others bring you down or lead you astray into doing the wrong thing. Sometimes, perhaps, you need to be a little bit of a Honey Badger.