Has Patient Satisfaction Gone Too Far? — The Case for Jerks in Healthcare

Among healthcare leaders, there has been a call to arms of sorts, which has swelled over the last five or so years, to rid medicine of, well, jerks.

The more technical term we've been using to describe this phenomenon of clinicians (mostly physicians) who are condescending, argumentative, aggressive and/or refuse to play well with others is "disruptive medicine."

In 2008, The Joint Commission created a new policy classifying disruptive behavior as a sentinel event, urging the organizations it accredits to take a zero-tolerance approach toward such situations.

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According to TJC, disruptive behaviors include "overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities."

Research has shown that both overt and passive behaviors are not rare (98 percent of healthcare workers reported observing such behavior, according to a study by the American College of Physician Executives) and can be detrimental to patient safety.

As a result, healthcare systems across the country have cracked down on disruptive behavior, choosing to cite physicians rather than looking the other way — the typical response by administrators for many years. In extreme cases, hospitals have dropped credentials or fired physicians for disruptive behavior.

At the same time, Medicare and commercial payers have begun to reward clinicians for strong patient satisfaction scores. Physician groups have also begun compensating clinicians based on their scores. In rare cases, clinicians with the lowest scores could be dropped from networks or fired.

Despite trends toward kinder, more empathetic, clinicians, Wen Shen, MD, an endocrine surgeon at the University of California-San Francisco, says the push for "a kinder, gentler surgeon" is misguided.

"My profession is filled with exceptional individuals who do amazing, lifesaving work. Many of us are jerks," Dr. Shen writes in an article for Pacific Standard, a publication put out by the Miller-McCune Center for Research, Media and Public Policy. "This is the trouble with surgeons. We are a sub-tribe of doctors who have long been celebrated for our abilities yet reviled for our personalities."

He continues:

"Within the past two decades, though, the surgical profession has attempted a wholesale revamping of its image and ideals. Compassion, communication, and collaboration are now strongly emphasized during training. It’s been a rapid and turbulent metamorphosis that has undoubtedly led to improvements for patients, hospital co-workers, and even surgeons themselves. Nonetheless, in the process, surgery may have created its own identity crisis. We want to believe we’re better off with nicer surgeons. But what do we lose?"

While Dr. Shen admits many of the effects have been positive — a 2011 survey that found patients who perceive higher levels of empathy in their surgeon have better outcomes — he worries our industry's push for more likeable surgeons may have unintended consequences.

Has our emphasis on patient satisfaction gone too far?

Perhaps, yes.

Consider the following example Dr. Shen shares with readers:

"In his 2012 book Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Johns Hopkins surgeon Marty Makary describes two very different attending surgeons whom he encountered during his residency. One was nicknamed 'Dr. Hodad' and was universally beloved by patients for his warm bedside manner. The 'Hodad' nickname bestowed upon him by the residents, however, stood for 'Hands of Death and Destruction,' because the man was a terrible technical surgeon with poor results. Another surgeon on the same faculty was nicknamed 'The Raptor' for his cold, abrasive personality. This surgical bird of prey frequently infuriated patients, staff, and co-workers, but, as Makary recounts, he had amazing technical abilities, and his patients did far better than those of the kindly Dr. Hodad. Unaccountable is largely about health care transparency and how better public reporting of outcomes will create an environment in which bad surgeons like Hodad can no longer thrive. However, when I look at the other half of Makary's duo, I suspect he's in trouble, too."

Which is the better surgeon?

If I had to pick a surgeon for myself, I'd want The Raptor, and I assume most of you would choose the same.

Yet, under current reimbursement models, Dr. Hodad would be rewarded and The Raptor could lose out on income.

Yes, our system has mechanisms to address surgeons with the poorest technical skills, but, technical skills are less easy to judge than bedside manner. So we assume that if we like the surgeon, he must be good, when in fact there is very little correlation between likability and technical skills.

Sure, for primary care providers, a strong physician-patient relationship is important for helping patients manage health and encouraging healthy behaviors. For surgery, that relationship doesn't really matter. It's great if it exists, but doesn't have to.

Are we punishing great surgeons (or stunting surgeons in training) just because they don't do well in teams?

Should we?

"According to a 2013 study in Annals of Surgery, directors of surgical fellowship programs nationwide are dissatisfied with the technical abilities of new residency graduates, estimating that fewer than half of them are able to perform even the most basic operations independently," writes Dr. Shen. [emphasis mine]

That's scary.

Are there enough surgeons with both the technical and emotional skills? Is there a middle ground?

Beware of the middle ground, argues, Dr. Shen, and I can't disagree.

"We want it all: brilliant technical surgeons with outstanding interpersonal skills. In trying to shape our trainees to be all things to everyone, however, we run the risk of creating a workforce caught somewhere in the middle, not doing anything well. Residents already face increasingly stringent limitations on work hours and therefore have fewer opportunities to hone their operative skills. We worsen the problem by piling on multiple competing priorities and then getting upset when residents don't meet our expectations...It's a delicate balance, and we know we can do better. But any surgeon will tell you that the scalpel doesn't cut as well when it loses its edge."

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