Wednesday, September 26, 2007

The Roar on the Other Side of Silence

The September 27th issue of the New England Journal of Medicine features a short article by Dr. Katherine Treadway that lucidly describes the way medical students and residents learn to detach themselves from the human meaning of the life and death events they are involved with in becoming physicians. Treadway explains in a compassionate manner that if students did not distance themselves from the dead person (“cadaver”) they dissect in anatomy class they might faint rather than learn. Likewise with surgery and the effort to resuscitate people who have experienced cardiac arrest.

The novelist George Eliot described this phenomenon in an unforgettable manner: "If we had a keen vision of all that is ordinary in human life, it would be like hearing the grass grow or the squirrel's heart beat, and we should die of that roar which is the other side of silence. "

The same dynamic applies to health organizations. Insurance companies talk about “covered lives.” Policy analysts discuss “consumers” (i.e. – patients) and “providers” (i.e. – caretakers). These terms serve an important purpose -- they capture a component of reality that might be overlooked or underemphasized. But the detachment that allows efficient functioning can deprive those in organizations of a textured appreciation of what their work, whether in medical records, a billing office, building services or the executive suite, means to real living people. With too little detachment we are overcome by the roar on the other side of silence. But with too much detachment health work becomes sterile, and those we serve know our hearts are not in what we do.

A key function of organizational ethics is to help organizations get the balance right – not too little detachment but not too much. Organizations that aspire to excellence must risk listening to the dangerous roar.


Anonymous said...

Press-Ganey scores appear to be the way that hospitals are trying to demonstrate their level of customer satisfaction, which perhaps is a proxy measure for the organizational "listening to the roar on the other side of silence." Hospital administrators and physicians report that portions of their salaries are held at risk depending on these scores. Holding portions of salary at risk is believed to serve as a stimulus to improve these scores. Published comparisons of hospital scores are assumed to help patients choose a hospital.
What is the validity of Press-Ganey scores; how is the data gathered and processed; what is the correlation of patient satisfaction and good medical care; what are the moral dilemmas involved in tying salary to such measures; what are the moral dilemmas in presenting such data to the public?

Jim Sabin said...

Hello Eric:

Your thoughtful comments raise a host of important questions. I will do some research about the validity of Press-Ganey scores and their correlation with other measures of quality. Some years ago I received satisfaction scores for my outpatient psychiatry practice along with the range of scores in my group and nationally. These were VERY meaningful to me --not because salary was tied to the measures - it wasn't - but because of personal ideals.

Re moral dilemmas -- validity is the key factor. IF Price-Ganey scores truly correlate with central objectives "pay for performance" (P4P) can in principle support ethical aims, but that hypothesis itself requires testing. Likewise with making the data public.

I will write at more length about this in coming weeks.

Thank you!

Anonymous said...

Office-based practice lends itself to scoring individual doctors' performance. Whereas current hospital practice provides a panoply of care-givers. It is often hard for patients to know who is a doctor, who is their primary doctor and who is the specialist. In a typical 3.5 day stay, a patient may be initially evaluated by an emergency department physician, admitted by a hospitalist, cared for by a second hospitalist during the day and by other hospitalists at night. In addition, specialists, PAs, students, therapists, case managers, etc. work with the patient. Most patients can at best give a global assessment, though certain care-givers may stand out as particularly good or particularly bad.

Jim Sabin said...

Hi Eric --

Thanks for this further helpful comment.

I agree that a patient's global impression does not give focused guidance about what went right or wrong in their hospital experience. There is, however, an important upside for global scores. It encourages all of us to take more responsibility for what our colleagues are doing. I practice in a group setting, and when my patients report an unhappy experience elsewhere in the practice I always apologize that "we have disappointed you," and at least sometimes find I can do something about the problem.

I haven't yet done the research I promised on Press-Ganey scores, but I still plan to do it!