Songs that cure dry socket?

Disability Law

I find the last paragraph of the excerpts from the AP article (below) to be a great example of doublespeak.
For more in depth information on the bill referenced below and the issues surrounding it, go here.

McCain vows to back changes to disabilities law
By Jacques Billeaud, Associated Press Writer
Jul 26, 2008

COTTONWOOD, Ariz. - Republican presidential candidate John McCain is pledging support for a proposal to expand protections for disabled people under an 18-year-old landmark civil rights law.

Speaking from Arizona by satellite to a disabilities forum in Columbus, Ohio, McCain said Saturday that revisions to the Americans With Disabilities Act must leave no doubt that it was intended to protect from any discrimination that's based on physical or mental disabilities.

The Supreme Court generally has exempted from the law's protection people with partial physical disabilities, as well as people with physical impairments that can be treated with medication or devices such as hearing aids.

"We must clarify the definition of a disability to assure full protection for those the law is intended to serve," said McCain, who was spending the weekend at his nearby northern Arizona getaway.
...
McCain said blame for the narrowed scope of the law shouldn't be placed on the Supreme Court, but rather on Congress. "In all due respect, I would put the blame right back on us for not writing legislation that is strong enough and specific enough so that the Supreme Court wouldn't even have to consider these cases," McCain said.

consent

The capacity in which I deal with consent processes is quite different from the issue at hand in the story below. The people I am obtaining consent from are in a research setting, not a treatment setting. Thus, in the contexts I am most familiar with, the issue of withdrawal or refusal on the part of the patient/participant is to be assumed a basic right. As a researcher, I am very careful to not only explain this but to make the environment felicitous to such a choice on the part of the people who reply to recruitment for our studies. As a teacher, I give my students examples of behavior which would constitute a "cost" for withdrawal, such as adopting even a negative tone of voice or posture with a potential or actual participant.

My point is, I am biased. I realize that this withdrawal/refusal bias is not quite appropriate when it comes to medical treatment as opposed to behavioral (or medical) research. So I try to keep that in mind as I turn over the story below about a mother who refused two (related) types of Lupus treatment for her minor daughter. Still, I can't help feeling that the choice to bring neglect charges here was a poor one. How much information was she given? And most importantly, were the medical providers aware of and sensitive to the reality of this woman's distrust which was fueled by - if not entirely based on - the suffering her daughter was experiencing?

It's not the best written story. As with any media account, there is trimming and fluffing. I've taken out what seems to be fluff but I can't make up for the lack of information. Still, it's the only story on this case out there at the moment. It's a tragic situation, one I can't help relating to somewhat since I also have trust issues with medical providers which have lead to some very and I'd say inappropriately contentious encounters. I can only imagine I'd be the same way if I had a kid who was sick.

I present the information in the article as food for thought. The issue being not whether the mother's judgment was correct or incorrect but whether the issue of patient or patient advocate/guardian trust could be better recognized and better addressed in such situations.

Excerpted from the Hartford Courant
Girl In Medical Dispute Dies
By Hilary Waldman and Colin Poitras, Courant Staff Writers
March 12, 2008
Chelsey Cruz, a 15-year-old who ended up at the center of a custody battle between her mother and the state that left each side accusing the other of harming her, died suddenly Tuesday.

The state Department of Children and Families last August filed charges of medical neglect against the girl's mother, Kimberly Castro, and took custody of the East Hartford teenager.

Castro had disagreed with three teams of doctors who treated Chelsey for lupus.

DCF stepped in following a complaint by child welfare authorities in Massachusetts. Chelsey at the time was being treated at Children's Hospital Boston.

Doctors from Connecticut Children's Medical Center in Hartford and Yale- New Haven Children's Hospital had filed complaints with Connecticut authorities, contending that Kimberly Castro was hurting her daughter by objecting to the treatment they recommended. Those charges did not stick.

After the Boston complaint, however, DCF placed Chelsey in the custody of her grandfather, who agreed to follow the doctor's orders. Both sides were awaiting a final ruling in the case when Chelsey died.

In an interview last autumn, Chelsey, an honors student, said she felt her mother was acting in her best interest. She said her biggest wish was to go home and be healthy.

"I feel kind of angry that I'm not able to be with my mom right now," Chelsey said in October.

Michael Perez, Castro's court-appointed lawyer, said Chelsey was taken to Connecticut Children's Medical Center Tuesday morning and probably died of cardiac arrest caused by sepsis, an overwhelming infection that can shut down the body's organ systems very rapidly. Perez said an autopsy is planned to determine the exact cause of death.
...
The dispute over Chelsey's care began almost six years ago, when doctors at Connecticut Children's Medical Center diagnosed the girl with lupus, a disease in which the immune system mistakenly attacks the body's healthy tissue.
...
Chelsey, her doctors said, had a serious complication called lupus nephritis, which can cause devastating kidney damage. They prescribed steroids and an immediate intravenous infusion of Cytoxan, a drug approved for cancer treatment that has shown promise in stopping or slowing immune system attacks in lupus patients.

When Chelsey continued to be wracked by complications, including abdominal pain and diarrhea, her mother lost faith in the doctors at Connecticut Children's Medical Center. Castro transferred Chelsey to Yale-New Haven Children's Hospital. There, the doctors found that Chelsey's kidneys had failed.

They blamed the lupus, but Kimberly Castro blamed the medication.

At Castro's request, the Yale doctors switched Chelsey to a newer form of treatment. But that, too, caused serious side effects and Castro objected to that, too. That's when Yale called DCF, accusing the mother of medical neglect.

After an investigation, DCF determined that Castro simply no longer trusted the doctors. As a compromise, DCF and Castro agreed that Chelsey's care be transferred to Children's Hospital Boston.

But it wasn't long before the same fight Castro had at Connecticut Children's and Yale broke out in Boston. Castro did not want any more Cytoxan or the alternative drug, Cellcept. The drugs, she said, were killing her daughter.

After a lot of angry back-and-forth, an order of protection was signed in Massachusetts in late August. Until Chelsey was returned to her grandfather's home in East Hartford, a uniformed guard was posted outside her room in Boston to prevent Castro from taking her daughter out of the hospital.
...
Perez said a Superior Court trial on the medical neglect charges had just concluded in February and that Castro was awaiting a ruling. And he said, she remains convinced that the strong medications were too much for her daughter.

"Ms. Castro strongly believes there is a connection between the drugs that were being used and the results today," Perez said.
....

the WTF files

From a local paper this week:
School administrators locked down two schools Thursday afternoon as five middle school students were rushed to hospitals after swallowing various pills. A sixth student didn't require hospitalization.

The students showed up in the nurse's office after lunch complaining of feeling sick after they took over-the-counter and prescription medication, Police Chief Mark Palmer said.
...
Officials say the pills likely came from students' homes, and six students took about six pills. None lost consciousness, police said.

The pills were aspirin; Naproxin [sic], an anti-inflammatory; Xenical, a diet pill; and tetracycline, an antibiotic.

Aside from seeing the obvious reminder for parents to keep their pills out of reach of children (and that may mean locking the pills up), and feeling a bit of relief that the kids didn't get into something like dad's valium or mom's zoloft, this story leaves me wondering....
What on earth were the little tykes hoping to accomplish with this particular cocktail? Were they looking for that elusive but excellent tetracycline high?

fuel for the fire

Another Lyme headline. The part that spooks me is the third paragraph.

(excerpted from the Stamford Advocate)
Medical board approves probation, fine for controversial doctor
Associated Press
December 18 2007
HARTFORD, Conn. -- A New Haven pediatrician who has been praised by patients but criticized by the medical establishment for the way he treats Lyme disease was reprimanded, fined $10,000 and placed on two years probation by state regulators Tuesday.

The Connecticut Medical Examining Board voted unanimously to impose the sanctions after concluding that Dr. Charles Ray Jones violated care standards by diagnosing Lyme disease in a boy and his sister and prescribing antibiotics based on a phone conversation with their mother, months before he examined them in May 2004.

The board also found that Jones broke standards by failing to reconsider his diagnoses of the children after lab tests came up negative for the tick-borne disease, which can cause painful arthritis, meningitis and other serious illnesses if not treated promptly.

Board members further concluded that Jones was wrong to prescribe antibiotics for nearly a year without repeat exams and without any arrangement with another doctor, because the children lived in Nevada, to monitor for any side effects of long-term antibiotic therapy.

Hartford lawyer Elliott Pollack, who is representing the 77-year-old Jones, said he will appeal the board's decision.
...

Other things aside for a moment, I know it's hard but try, consider that part of the board's ruling was based on the finding that Dr. Jones "broke standards by failing to reconsider his diagnoses of the children after lab tests came up negative for the tick-borne disease". I thought that a Lyme diagnosis was supposed to be more based on clinical presentation than lab values. What crazy Lyme-loving website did I get that from? The CDC, among others.

Lyme disease is diagnosed based on symptoms, objective physical findings (such as erythema migrans, facial palsy, or arthritis), and a history of possible exposure to infected ticks. Validated laboratory tests can be very helpful but are not generally recommended when a patient has erythema migrans.

On the CDC Lyme website, this passage continues with a helpful link to the current, detailed recommendations on serological testing for Lyme. If you do click there, what you get is a report called "Recommendations for Test Performance and Interpretation from the Second National Conference on Serologic Diagnosis of Lyme Disease".

The Second National Conference on Serological Diagnosis of Lyme Disease was in October of 1994.

I'm going to let you all do the math. You'll do it faster than me. I nearly had to count it out on my fingers...good thing it wasn't much older or I'd have run out of fingers!

My point. There are two, or one somewhat bifurcated one depending on how you look at it. My point is that the CT board's finding engenders and perpetuates too high a level of confidence in serological testing for the clinician dealing with the realities of Lyme presentation. The board's level of confidence would be well founded if the testing had improved much in the over 13 years since the "current" test performance and interpretation recommendations were made. It has not. I wonder now as I so often do when I read the latest Lyme fueled controversy story (or maybe more appropriately, the latest controversy fueled Lyme story) - Can't we do better than this?

under pressure

Stressed? You will be next Monday!
PRNewswire, via Scientific Blogging
LONDON, December 6
According to the results of a recent survey, if the festive pressures haven't got to you already, they will do next Monday - it's officially the most stressful day of the year.

An independent survey, commissioned by healthcare provider, HealthSure, has revealed that the British public will be at its most stressed on Monday 10 December between the hours of 8am and 10am.

You can read the whole article at the link through the title above. I wonder if anyone's done similar research for the U.S.

bye bye candy man?

Excerpted from today's Hartford Courant:
UConn Prescription: No Freebies
Doctors, Medical Students Urge Committee To Ban Gifts From Drug Companies
By William Hathaway
Courant Staff Writer

The University of Connecticut Health Center is debating whether to become a no-pizza zone for pharmaceutical sales reps.

Spurred by a national student-led campaign to ban drug company freebies, Health Center officials Wednesday updated doctors and medical students on a committee's work to create uniform policies on accepting gifts, fees and educational reimbursement from drug company marketers.

Students and some doctors who crammed into a small meeting room at the Farmington campus, in turn, urged officials to completely ban such gifts.
...
Medical schools such as Stanford, Yale, University of California-Davis, and Michigan have already adopted such bans, Fleg said.

Where's my lollipop?

Or, "A long ranty rant about medical insincerity by someone who is likely a bit dopamine depleted"

I've been thinking about some of my least favorite contradictions in medicine and health perspectives. I suppose these could be called hypocrisies, but I feel this term implies belief which I am very reluctant to attribute. Contradiction, I think, as a word is more neutral on the existence and legitimacy of beliefs underlying the observables I am reacting to.

A recent round of Lyme related news items in the mainstream press as well as my own attempt not to smoke this week (been 7 days without) have brought these contradictions to light.

Let's take the smoking first since it's a shorter rant, er, argument.

I pay taxes on my cigarettes which are meant to discourage my smoking (supposedly). I'm not allowed to smoke in most places, or sometimes even near places. Again, that is meant to discourage my unhealthy habit. There are companies which are charging smokers extra fees on top of the employees' contributions to cover their premiums, the reasoning being something like this: In the case of smokers, companies and their advocates say it's a matter of promoting health and of fairness, given that smokers, as a group, generate higher costs for employers through direct health care expenses and lost productivity. 'It's an equity argument,' said Helen Darling, president of the National Business Group on Health. 'Part of my costs going up is because of the behavior of other people.'" (Spouses, Smokers Earning Penalties - Hartford Courant, 10/14/07)

I accept the reasoning behind these rationales. I don't know that I believe they are what is truly the driving force for some policies and behaviors, but I at least accept the stated reasoning as sound. What I wonder though is where's my state subsidized lollipops? Where's my insurance coverage for smoking cessation therapy, devices, assistance? The funding could come out of the massive sin taxes I've paid for the last 10+ years I've been a smoker. So the government, my employer, and my insurance companies want to encourage me to quit smoking so much so that they will charge me extra for continuing to smoke. But they are unwilling to put anything INTO helping me stop smoking. I kinda think if someone wants to regulate what legal, addictive substances people do and where and how they do them, those someones had better be willing to pony up when the miserable addicts try to comply.

And then there's Lyme. This one can be summed up as the logical proposition - It's not Lyme or you're crazy. This is the diagnostic choice you will face if you have Lyme Disease and you do not feel well after 3 weeks of oral antibiotics. The contradiction lies in the statements of compassionate skepticism espoused by various champions of this proposition.

Over at the Hartford Courant, my local but not very good news paper, some fellow has written these four articles in the last 2 weeks.
Debate Deepens Over Lyme Treatment
Study Casts Doubt on Lyme Disease Treatment
Lyme Disease Diagnosis Challenged
No Basis for Chronic Lyme Disease

Reading them, I find myself wondering if the writer was spawned in a lab by a mad scientist who had obtained genetic material from both Jerry Springer and Geraldo Rivera. This would explain so very many things, not the least of which is the author's apparent grudge against science and even a sheen of objectivity.

While I'd like to think the reporter is guilty not just of perpetuating but also of fabricating the disparity between the "sides" of the controversy, I know he is not. The phenomenon at the heart of the controversy comes down to a poorly defined yet nonetheless associated set of people (or as they are less humanly called, "presentations" or "cases").

- Some people diagnosed with Lyme Disease do not get better after the accepted, recommended minimal treatment, a 3 week course of oral doxycycline.
- Some of these people's diagnoses were based on symptoms, signs, and labwork which meet even the rigid surveillance criteria (as well as the less rigid clinical/diagnostic criteria).
- Some of these people's diagnoses were based on signs, symptoms, and labwork which meet clinical criteria accepted by most main stream doctors and medical providers.
- Some of these people's diagnoses were based on signs, symptoms, and labwork which meet the clinical criteria accepted by only some doctors (often called "LLMDs" but that category is another catch all).
- Some of these people were diagnosed and treated soon after the probable time of infection.
- Some waited years be diagnosed and treated.
- The types of symptoms all of these people continue to experience post treatment fall into roughly three categories (skeletomuscular, neuro/cognitive, constitutional).
- Some people report overlapping classes of continuing symptoms post treatment.
- Some people report only one type of these continuing symptoms post treatment.
- All of these people are grouped as a single population when placed in the context of the highly divisive and divided Lyme Controversy.
- By the Chronic Lyme people thinking, all of these people are actively infected with the bacteria which causes Lyme disease and will get better with more or the right antibiotics.
- By the anti-Chronic Lyme people thinking, all of these people do not have Lyme Disease. Further, some (perhaps many) never had it.

It doesn't take a genius to know considering only the parameters of this population that the set of (dubious) chronic Lyme patients is hardly a homogeneous group. Then one must consider the heterogeneity of treatment among any super or subset of that population (i.e., Who got IV antibiotics for 21 days? 28 days? Which antibiotics? Who got more than one course? Who got 2 months of oral antibiotics? 3? 4? Do I hear 5?) .

Clearly there is an impossibly confounded bundle of factors in treating this group and their complaints as any thing like an even functionally defined set. Moreover, you'd think it would be equally obvious that any conclusions made based on some just can't be legitimately extended to all. And yet they are. That's part one of the contradiction in the Lyme Controversy.

Part two is what happens when anyone who falls into that poorly defined group seeks medical attention for what ails them. The mainstream reasoning is that these people do not have Lyme, BUT, goes the mainstream reasoning, we are not dismissing their symptoms. We are just saying it's not an active chronic Lyme infection causing the symptoms. BUT we won't develop or advocate research protocols and plans to see what IS causing the symptoms. And many of us will toss you out on your ass if you have the temerity to continue to come into our offices complaining of feeling "tired all the time" or "achy all over" or "foggy" after we have issued our "it's not Lyme" proclamation.

I'll buy the argument of "it's not an active infection" for me and people who have very similar histories to my own. I will buy it for the sake of argument and, for myself given my family history of autoimmune disease, I'll buy it even for the sake of medical practice.

What I don't buy is that the mainstream, anti-chronic Lyme people actually believe that the set of people we are calling here the (dubious) chronic Lyme patients have anything physically wrong with them. If that were a sincere and genuine belief on the part of the practitioner, these patients wouldn't be turning to any number of alternative or non-mainstream and sometimes quite dangerous treatments. They'd be taken care of by their own mainstream medical providers. If it were a sincere and genuine belief on the pat of the researcher, I'd be seeing calls for research participants for autoimmune studies on people with a documentable history of past acute Lyme infections. I look. Believe me. I don't see those studies.

In short, if the "there is no such thing as chronic Lyme" declaration wasn't equivalent with "and you sick people aren't really sick", we'd see at least some research on what is causing some of these people to get sick and others of these people to stay sick.

Hey, if you see that, you let me know. Also, send lollipops.

creepy cat

(Sunday, July 29: Updated with NEJM link)

This was just too odd to pass up. My father raised my siblings and me with what's best described as an unhealthy sense of skepticism. Such unwillingness to ever suspend disbelief might make for being a good scientist but I've seen that over application can result in a somewhat annoying human. I often find I want to believe...but I'm always held back by skepticism, usually right from the outset. So on reading this story (excerpted below), my tendency is toward the assumption of a non-causal or at least not directly causal relationship between death and the cat.

I think that the article does a reasonably good job of keeping the report on the up and up though. Most likely because the doctors referenced in the article do.

When death comes calling, so does Oscar the cat

PROVIDENCE, Rhode Island (AP) -- Oscar the cat seems to have an uncanny knack for predicting when nursing home patients are going to die, by curling up next to them during their final hours.

His accuracy, observed in 25 cases, has led the staff to call family members once he has chosen someone. It usually means the patient has less than four hours to live.

"He doesn't make too many mistakes. He seems to understand when patients are about to die," Dr. David Dosa said in an interview. He describes the phenomenon in a poignant essay in Thursday's issue of the New England Journal of Medicine.

very private medicine

(excerpted from The Boston Globe)
MDs offer new services, for $3,600 yearly fee
By Liz Kowalczyk, Globe Staff
June 30, 2007

Two popular Boston internists are closing their busy practices, leaving most of their 7,500 patients to find new doctors, as the physicians open a small concierge practice that will charge individuals a $3,600 yearly fee to join.

Dr. Jeffrey Bass, 50, of Brigham and Women's Hospital, and Dr. Ronald Katz, 51, of Beth Israel Deaconess Medical Center, are the latest physicians to give up large traditional medical practices, in which doctors see a patient every 15 to 30 minutes, in favor of a slower pace and potentially higher income.
....
Concierge medical practices, despite criticism that they shut out all but the well-off, continue to attract doctors and many patients who say the practices let physicians provide more personal care in an unhurried atmosphere.

Some of the extras Bass and Katz are promising were once considered standard parts of a doctor's portfolio, but now, most primary care doctors say they are too busy to provide them. Most notably: visiting patients in the hospital, same-day appointments, and nearly around-the-clock access to their doctor.

"I understand why the doctors are doing it," said Dr. Richard Parker, medical director of the Beth Israel Deaconess physician organization. "They want more time with patients, fewer hassles, to get paid better. But it's a symptom of the poor state of affairs in primary care; many doctors are looking for the exit."
...
Bass and Katz, who plan to open their new practice in September, mailed letters to their patients and created a website explaining the change earlier this month. Katz said his new practice, to be called PersonalMDs, will allow him "to practice a bit of old-fashioned medicine" at a "less intense and frenetic pace." He works about 55 hours a week now, he said, and sees 25 patients a day. He expects to work a similar number of hours, but see far fewer patients daily, and the practice will accept only 800. Among the services Katz and Bass will offer are long visits, "24/7 availability," a waiting room with Internet access, a yearly consultation with a nutritionist, and home visits.

Bass said he expects to have 400 patients signed up by next week, "which shows me there's a need and want." A number of his patients are doctors, he said, which "validates the model."

Penny wise...

...pound foolish. It's not just insurance companies who follow this model. In some defense - some small wee bit of defense - of such policies, the financial wisdom of preventative care and education is not easy to see. Possibly for some, it feels like speculation, like placing a bet. Good odds or not, they are too queasy with the idea of spending some money now to save a whole lot of money later.

From The Boston Globe
Health support for poor to take hit
'08 budget cuts care of chronic ills
By Alice Dembner, Globe Staff
June 19, 2007

HOLYOKE -- A program that has improved the health of low-income patients with chronic illnesses faces deep funding cuts in the pending state budget, even though top state officials touted similar disease management strategies just a month ago as a crucial way to improve healthcare quality and cut costs.

The 2008 budget, now being hammered out in a legislative conference committee, is likely to contain less than one-third of the $2.6 million that the statewide CenterCare program received this year to pay for a broad range of health education and support services at community health centers.

In Holyoke, where diabetes strikes hard and often, the program has helped hundreds of patients at a community health center adopt healthier lifestyles and reduce their blood sugar levels, an improvement that could eventually cut their risk of serious complications nearly in half. Diabetics are offered exercise classes, instruction about the disease, home visits by community health workers, one-on-one sessions with a nutritionist, and drop-in sessions that teach healthy eating.

"I lost 63 pounds and I'm controlling my sugar," said Iris M. Santiago, a patient in Holyoke. "They've helped a lot of people's lives."

The proposed funding cuts threaten the Holyoke program, which has been recognized as a national model, as well as similar efforts at 29 other community health centers statewide. CenterCare this year paid for disease management services for only half the low-income patients eligible across the state -- about 5,000 -- according to the Massachusetts League of Community Health Centers. The program helps patients with asthma, cancer, heart disease, and depression, in addition to diabetes.
...
State Senator Steven C. Panagiotakos , chairman of the Ways and Means Committee, said the Senate reduced funding for CenterCare because "we are able to address many of the preventative care and disease management needs" through the state's health insurance initiative because many of the program's uninsured clients will get coverage.

But community health center officials say their efforts go far beyond that funded by most insurers, because their patients need more support to overcome the additional barriers to good health presented by poverty and low literacy.

CenterCare was established in 1988 as a managed care insurance program for low-income patients but never got off the ground. It then funded care for the uninsured at community health centers, and most recently has been paying for disease management, according to the community health centers league.
...
Since the program started at the health center in 2003 the average blood sugar levels of diabetic patients -- called hemoglobin A1c -- have dropped from 8.4 to 7.5, according to Dawn Heffernan, who manages Holyoke's program.
(presumably this last bit refers to patients in the program or some subset of them who consented to sharing lab values)

Mystery Patient

On sly, workers rate hospital service
By Liz Kowalczyk, Globe Staff
June 13, 2007

The young woman slipped into a busy primary care waiting room at Beth Israel Deaconess Medical Center, took a chair in the back row, and pretended to read Shape magazine. As patients streamed in, standing in line to speak to a receptionist, she began taking notes on a form concealed in her magazine.

"She was engaged in a very long personal conversation," the woman wrote about one of the receptionists, who was talking to another employee. "At one point the line was several deep, but the person . . . was not helping to check people in."

The note-taker is a mystery shopper, one of a new breed of hospital employees in Boston and nationwide who secretly watch fellow workers to see whether patients are treated courteously and helpfully.

Beth Israel Deaconess began a mystery shopper program two years ago to monitor telephone operators who schedule appointments for patients and later expanded the program to outpatient waiting rooms in November.

Executives credit the shoppers with bringing about vast improvements, especially in telephone etiquette, with instances of poor service becoming far less frequent. Since staff began posing as patients calling to make appointments, the average customer service rating the callers gave telephone appointment specialists, on a 1-to-5 scale, jumped from 2.6 (fair) to 4.8 (excellent).

Read the full story at The Boston Globe

Critique of medical mystery shopping, article and concept:

It is possible that the program BI/Deaconess has put into place has had the effect of improving medical service, which it seems should be the goal of any improvement in patient/provider relations and should be properly measured in terms of patient outcome as well as by patient satisfaction/service ratings. But from this article, there is no way of knowing that. In the Globe story, the medical center's goals for improvement are stated in terms of patient loyalty and competition with other high quality area hospitals (for patients, presumably privately insured patients). The measurements which are meant to bear on these goals are given in terms of customer service ratings (the 5 point scale).

The big threat poor service presents is not simply a reduction in patient satisfaction (i.e., happiness with the courteousy of the receptionist, satisfaction with the speed with which the phone was answered) which may result in patients lost to a better, or at least more pleasant, medical group. The big threat discourteous "front end" medical encounters have is that they can create unnecessary impediments to communication and therefore threaten satisfactory medical outcomes.

A patient who feels he has been subjected to rude or overly distant treatment before ever setting foot in the exam room is primed to interpret later, crucial interactions with the medical practitioner negatively. Such negative priming is a set up for communication failure. Even if this failures occur only on small, local scales in the discourse, those little failures can add up to trigger distrust behaviors in the patient, e.g., witholding information or offering over-explanations of trivial details. They can also cause the provider to feel the patient is being unnecessarily offensive and can make the provider start acting defensive.

Feedback happens, and then you're in a loop. I've seen this as both a patient and a witness to provider/patient interactions. It can get ugly. It can be subtle. But it's always bad. Even in a non-worst case scenario, a patient who has been negatively primed may be unwilling or unable to make the necessary basic connection which facilitates any communicative exchange let alone ones where the purposes are multilayered and complex, like collecting a full and relevant a history as possible or educating a patient on sucessful home care for a newly diagnosed condition. The success of such discourse goals relies on at least a minimal degree of communicative openness of the patient. If your patient shuts off before you start talking, you're going to see that patient again - oh yes. Your diabetic patient is going to show back up with a foot ulcer because while he understood every single word which came out of your mouth about his condition, something was blocking those oh so important supralinguistic cues which would have communicated the gravity and absolute necessity of practices like daily foot exams and proper preventative care of his feet - like not wearing shoes which pinch or otherwise do not fit well.

Now that is a bad outcome.

Asking someone explicitly "how happy were you with the service?" is certainly one way to measure the affect with which that person entered the exam room, but implicit measures like outcome, understanding instructions, perception of physician's openness, are important too. Data from those implicit measures linked with improved "customer service" and higher "customer satisfaction" like scores is what medical providers need to see if they are to be sold on the idea that attending to customer service is anything other than needless, wasteful, and insulting pandering to corporate culture.

I worked in hospitals during the late 80s - mid 90s. I think I was there for what was the beginning of a serious push to consumerize medicine. Such promotions were not received well by the staff at either hospital I worked at. I remember at the first hospital we had "Total Quality" something-or-another workshop sessions with outside patient relations specialists. Except they weren't patient relations specialists or patient relation workshops, they were customer service specialists giving us a customer service workshop. The vocabulary was straight out of a department store employee training program (which was not lost on the medical staff). Many members of the non-clerical nursing staff felt seriously cranky at being told to adopt a "customer is always right" mentality with a patient population. Some of them were outright hostile. "If the patient were always right, we wouldn't need hospitals. They could just diagnose themselves!" one nurse argued to the receptive audience sitting at the smokers' picnic table during a break from the training workshop. Her sentiment was echoed in the workshops as well. We had a week of this training and I recall one day where only half the staff returned after the break.

Although there were some beneficial elements to what we were being sold back then, the "customer service" approach failed to gain a foothold in the hearts and minds of the staff. There was a clear disconnect between what the service specialists running the training knew about patients, health care work and medical culture and the realities of patients, health care work, and medical culture. But there was also the sense that medicine was special, that health care was immune, something separate from mundane concerns like putting your best face on for a patient (essentially all we were being asked to do). What was misssed and what I came to understand as I matured in my job was that patients are like the very worst customers ever. They are having THE WORST DAY, each of them. They've been robbed of some self determination, each of them. Even if it's just to have had their day hijacked by a miserable headcold turning into something bacterial, or to have had their summer vacation plans wrecked by hearing they need to have surgery and they can now chose betwen taking time off to relax or taking time off to be cut into...because the job does not allow time off for both.

Being told I should treat these people like they were the most special person ever, well, in that context it makes sense. I wasn't always great at it, but I thought about how much it sucked to go to sleep at night in a hospital and that usually set me right. But I didn't do it because I felt it was a good idea from a profit optimization perspective (which essentially is what underlies goals like "increased patient loyalty"). I did it because it was the right thing to do from a humanist perspective and because it was the right thing to do if I wanted to do my job right.

Here's how it worked.

Getting into an argument with an argumentative patient is not going to help ANYONE, in fact it's going to slow me down. I will spend time on that and I won't get these orders entered. The patient who was just admitted will not have his blood drawn on the very next phlebotomy round (in 20 minutes) and will have to wait at least another two hours, unless the doctor wants to make it a stat draw. The doctor wants, no NEEDS, some of this bloodwork now. So she writes it for a stat draw. I page phlebotomy, they come and poke him, but meanwhile there are three other labs which had been written and transcribed for a routine draw and which the doctor forgot to add onto the stat draw. Now the patient is going to feel like a pincushion. And probably come out and tell me so. Moreover, the dinner tray will be delayed for this other guy until I am done with the argumentative patient. It will come up very late, he will eat it very late and he will vomit later, and the house officer will be paged because the patient is vomiting...very very late. The patient I let bait me into an argument will have called family from his room and they will have called the desk - not necessarily to complain about the "rude clerk" but to ask if their father "really is going to be discharged tomorrow and if so, when? I need to know when. I can't just wait around again..." The family will be irritable and will irritate the nurse I have to page to speak to them (some of them btw, the other two were in earlier tonight and the nurse already told those two all of this already). Or maybe she is very sweet and nice and isn't irritable but is now running behind. She will subsequently forget to let me know when she hung the antibiotic and I will not be able to time the peak draw after. The secretary whose shift is after mine will have to deal with an angry resident who is looking for that peak level. After being yelled at for the earlier shift's mistake, the secretary will call radiology to schedule a portable X-ray and when she is told it will take several hours, she will get cranky with X-ray.

...And it will just keep on spreading...

And I could have stopped it or at least not participated in it by being more tolerant with this patient who is being inappropriate if you hold people having that bad a day to the same standard of "appropriate" as you do people who aren't.

The general messages and principles of customer service are in fact the ones I found myself employing in good patient interactions - or in setting to right bad patient interactions. Those are things I think of in terms like "I don't have the right to get in the last word" and "It doesn't matter who started it". I learned these things but not from the quality/customer service training, although these messages were right there in the quality/customer service training. Why wasn't I able to pick the message up from the training? Packaging - the total quality training person did not know enough about medical culture to know what language to put it in. And also that I had been indoctrinated into the health care culture as staff. Mom had been a nurse forever. My aunt was a nurse. My boyfriend, fiance, and then husband was a doctor. As someone who had been raised on the medical culture, the idea of applying customer service models to medicine raised my hackles, just on principle. It took me many years and some time as a patient to really fully understand the obstacles a poor attitude can have on patient relations, and the very negative effects poor patient relations can have on people's spirits, and the connections between that and medical outcome.

If obstacles to clear communication can be prevented or reduced, then a drive to improve "customer service" in the medical setting clearly has genuine positive value. But until that value is shown, it will be hard to convince the medical community of the worth of such indirect measures as the third person evaluation of the "front end" service. The medical community has as an easy critique in the fact that the worth of such measures relies on unstated assumptions about what elements of medical interactions are important to the patient/care giver relationship and what are not. I.e., someone eating a donut at a desk (one of the instances of "bad service") is not something which will predispose me to a negative experience or sense of being on the receiving end of a callous medical staff, at least the donut alone certainly won't.

So then what are the right things to measure? Trust, understanding, and outcome would be good places to start. There is overlap in "customer service" and "patient relations", but it is certainly not a full overlap. To perhaps overextend the retail metaphor, there needs to be a good product as well as a smiling clerk who sells it to you. Without attention to the quality of the product, conceding to the push to smile, nod, and wave feels like selling the patient short and selling yourself out.