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Hospitals Aren’t Hotels
by Theresa Brown, The New York
Times
March 14, 2012
“YOU should never do this
procedure without pain medicine,” the senior surgeon
told a resident. “This is one of the most painful
things we do.”
She wasn’t scolding, just firm, and she was telling
the truth. The patient needed pleurodesis, a treatment
that involves abrading the lining of the lungs in an
attempt to stop fluid from collecting there. A tube
inserted between the two layers of protective lung
tissue drains the liquid, and then an irritant is
slowly injected back into the tube. The tissue becomes
inflamed and sticks together, the idea being that
fluid cannot accumulate where there’s no space.
I have watched patients go through pleurodesis, and
even with pain medication, they suffer. We injure them
in this controlled, short-term way to prevent
long-term recurrence of a much more serious problem:
fluid around the lungs makes it very hard to breathe.
A lot of what we do in medicine, and especially in
modern hospital care, adheres to this same
formulation. We hurt people because it’s the only way
we know to make them better. This is the nature of our
work, which is why the growing focus on measuring
“patient satisfaction” as a way to judge the quality
of a hospital’s care is worrisomely off the mark.
For several years now, hospitals around the country
have been independently collecting data in different
categories of patient satisfaction. More recently, the
Centers for Medicare and Medicaid Services developed
the Hospital Consumer Assessment of Healthcare
Providers and Systems survey and announced that by
October 2012, Medicare reimbursements and bonuses were
going to be linked in part to scores on the survey.
The survey evaluates behaviors that are integral to
high-quality care: How good was the communication in
the hospital? Were patients educated about all new
medications? On discharge, were the instructions the
patient received clear?
These are important questions. But implied in the
proposal is a troubling misapprehension of how
unpleasant a lot of actual health care is. The survey
measures the “patient experience of care” to generate
information important to “consumers.” Put
colloquially, it evaluates hospital patients’ level of
satisfaction.
The problem with this metric is that a lot of hospital
care is, like pleurodesis, invasive, painful and even
dehumanizing. Surgery leaves incisional pain as well
as internal hurts from the removal of a gallbladder or
tumor, or the repair of a broken bone. Chemotherapy
weakens the immune system. We might like to say it
shouldn’t be, but physical pain, and its concomitant
emotional suffering, tend to be inseparable from
standard care.
What’s more, recent research suggests that judging
care in terms of desirable customer experiences could
be expensive and may even be dangerous. A new paper by
Joshua Fenton, an assistant professor at the
University of California, Davis, and colleagues found
that higher satisfaction scores correlated with
greater use of hospital services (driving up costs),
but also with increased mortality.
The paper examined patient satisfaction only with
physicians, rather than hospitals, and the link
between satisfaction and death is obviously uncertain.
Still, the results suggest that focusing on what
patients want — a certain test, a specific drug — may
mean they get less of what they actually need.
In other words, evaluating hospital care in terms of
its ability to offer positive experiences could easily
put pressure on the system to do things it can’t, at
the expense of what it should.
To evaluate the patient experience in a way that can
be meaningfully translated to the public, we need to
ask deeper questions, about whether our procedures
accomplished what they were supposed to and whether
patients did get better despite the suffering imposed
by our care.
We also need to honestly assess our treatment of
patients for whom curative care is no longer an
option.
I had such a patient. He was an octogenarian, but
spry, and he looked astoundingly healthy. He’d been
sent to us with a newly diagnosed blood cancer, along
with a promise from the referring hospital that we
could make him well.
But we couldn’t. He was too old to tolerate the
standard chemotherapy, the medical fellow on duty told
him. When I came into his room a little later he said
to me, with a stunned and yearning look, “Well, he
made it sound like I don’t have a lot of options.” The
depth of alienation, hopelessness and terror that he
was feeling must have been unbearable.
The final questions on the survey ask patients to rate
the hospital on a scale from worst to best, and
whether they would recommend the hospital to family
and friends. How would my octogenarian patient have
answered? A physician in our hospital had just told
him that he would die sooner than expected. Did that
make us the best hospital he’d ever been in, or the
worst?
Hospitals are not hotels, and although hospital
patients may in some ways be informed consumers,
they’re predominantly sick, needy people, depending on
us, the nurses and doctors, to get them through a very
tough physical time. They do not come to us for
vacation, but because they need the specialized, often
painful help that only we can provide. Sadly,
sometimes we cannot give them the kind of help they
need.
If the Centers for Medicare and Medicaid Services is
to evaluate the patient experience and link the
results to reimbursement, it needs to incorporate
questions that address the complete and expected
hospital experience. It’s fair and even valuable to
compare hospitals on the basis of how well they
maintain standards of patient engagement. But a survey
focused on “satisfaction” elides the true nature of
the work that hospitals do. In order to heal, we must
first hurt.
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