Is the patient always right?

Patient satisfaction has become a prominent goal in health care. Is this a good thing?

At first blush, it seems right enough.  In patient-centric medicine, decisions are no longer based on the whims or habits of the physician, but on a combination of the best evidence and the patient’s values and preferences. Instead of the old paternalistic approach where the good (passive) patient obediently follows doctors’ orders, patient satisfaction aims to place the patient at the center of care. From this perspective, the business adage that the customer is always right seems applicable to health care.  

I’m not so sure.

A few weeks ago I participated in a group of clinicians being coached on how to keep patients happy. The goal was to improve ‘patient satisfaction scores’ on randomly distributed NRCPicker surveys.   (In most institutions, passing - and thereby avoiding a cut in pay - requires being in the top 25th percentile. This guarantees that only 1 in 4 clinicians can pass, regardless of how good they are or how hard they try. That insanity is for another day’s discussion. We will also skip, for today, the data that shows that patient satisfaction scores are higher in patients who get more care, not better care, and that recent studies have shown that outcomes and satisfaction are inversely correlated.)

We saw a series of short videos and a collection of handouts, replete with cute mnemonics like AIDET, BATHE,  HEART, ISBAR, NURSE, IPASS the BATON, DIVERSE,and SIMPLE. These (and others) are aimed at teaching clinicians techniques for making patients feel good, and were valid conceptual frameworks for improved communication. Somehow, it felt wrong. I kept imagining we were all waiters and waitresses being taught how to butter up restaurant patrons to improve our tips. It took a while for me to realize what bothered me so much about this: actual good care - like good food - was assumed but not addressed.

Some in the group were vocally unhappy about the emphasis on making patients happy. Patients are not always right, they argued. What if they want things that are useless, inappropriate or dangerous? Should I give them antibiotics for their viral illness? Should I make sure they have as much pain medication as they want? Should I order the MRI or CT or PET scan for a minor and self-limited complaint? If I don’t, they’ll be unhappy and grade me poorly. Why did I bother with years of training if I am simply a complicated carbon-based vending machine, dispensing whatever patients request?

The answer from the moderator boiled down to three statements: 

• We wouldn’t dream of infringing on your professional judgement. 
• Don’t do anything you think is not the best possible care. 
• Simply do the right (medical) thing, but do it in a way that always makes them happy.  

In short: Give them what they need but convince them it is what they want. They don’t have to be right, they just have to feel right. 

My first reaction was: that’s easy for you to say, never having actually taken care of patients.  How does that work for you at home? Are you always able to simultaneously keep your 17 year old  child or your spouse or parent happy while doing what you knew to be the right thing?  (I didn’t think so.)

On further reflection, I arrived at a very different perspective.  (Hiking in the White Mountains of New Hampshire is a wonderful cognitive resource.) The answer to ‘is the patient always right?’ is so hard because it is the wrong question. It reminds me of the old joke: “When did you stop beating your wife?” A question framed as right and wrong guarantees a loser: if you win, you lose, but if you lose, you also lose. In a truly collaborative relationship, it isn’t about winning versus losing.

Health care is not a contest of wills or a battle of agendas and goals. It is not about clinicians making sure that patients are on the ‘right’ path or do the ‘right’ thing. It is (or it is supposed to be) a collaboration aimed at shared goals. It must be based on trust, listening, and shared knowledge. As soon as a clinician thinks in terms of right/wrong, the process is in trouble. If a clinician argues, cajoles, tries to prove a point, tries to sell the ‘correct’ decision, or tries to manipulate or negotiate toward their ‘position’ it is a sure sign that the relationship is in trouble. 

As individual autonomous agents, patients have the right of choice. Both the patient and clinician bring information, values, skills and experience to the interaction, and neither is obligated to do what the other thinks is right or best. There is no ‘right’ answer which the clinician reveals to the patient. There is no ‘right’ choice which the clinician sells the patient. The clinician does not ‘win’ by getting the patient to do something any more than the patient ‘wins’ by getting the clinician to do something - because winning and losing are not part of collaboration.

Where does that leave us?

The goal is not to give the patient whatever he wants to keep him happy, or to give him what we (experienced clinicians) think he needs, carefully doing it in a way that keeps him happy. The goal is to work with the patient, listening to and understanding his concerns and helping him understand ours, and then working with him to help him make a decision. He is not obligated to follow our advice, and we are not obligated to accede to his requests, but we both must be ‘satisfied’ that we are working together on shared goals. If not, we should part company. 

Perhaps talking about a couple of the allegedly contentious examples that came up in our session can clarify how this works in the real world. It is a mistake (and lazy) to frame these as whether or not the patient is right, or is entitled to what he wants.

• The patient with self-limited muscular low back strain requesting an MRI.  Asking about why he wants the MRI, what he is worried about, and how he thinks the MRI will benefit him allows the clinician to address what the patient actually wants: to know what is going on with his back, what the best treatment is, and what is likely to happen.
• The patient with three days of viral upper respiratory symptoms requesting antibiotics. Some conversation will likely show that the patient doesn’t want the antibiotics (which cost money and cause diarrhea and indigestion and are a nuisance to take) but wants relief from facial pressure, or assurance that they won’t miss work with a sinus infection, or to feel better before they leave for vacation next week. Knowing what the patient wants will better allow the clinician to treat the real issue.
• The patient with an exacerbation of a chronic pain syndrome after raking leaves requesting an increase in his opioid.  He surely doesn’t want to be constipated or addicted or impaired while driving or working.  He might want to be able to sleep despite the pain, or be able to play catch with his grandson after school, or be comfortable enough to help his wife with the shopping. 

In order to pick the best tool, the clinician and patient have to fully understand the job from both the clinician’s perspective and the patient’s perspective. We clinicians don’t get to define the job only from our perspective. 

Of course, there will be times that a patient is not satisfied with what a clinician offers or how he/she offers it. If the patient and the clinician cannot agree on the job, on the parameters of a solution, or on the definition of success, they cannot collaborate. That presents a new dilemma: what to do when collaboration is not possible? That will be a topic for a later discussion.