I was surprised when I began receiving gift cards to a national chain of coffee shops in recognition of positive patient satisfaction comments from my emergency department patients.
Reviewing them in my provider report card genuinely felt good, especially when someone remembered my name in a follow-up phone call while saying something positive. Still, the token incentive met with disapproval for several reasons.
In particular, the most meaningful comments expressed gratitude for an experience consistent across an entire spectrum of interactions with multiple people, many of whom were not named and were going unrecognized.
Rather than outline the shortcomings of contingent rewards or list better ways to support the intrinsic values of a profession characterized by high levels of autonomous motivation, I prefer to make my experience relatable by parodying an iconic scene from the movie Batman: The Dark Knight. While there is no villain “who wants to watch the world burn,” here, Alfred’s sage advice — we lose something in the assumption that we understand another’s motivations without orienting ourselves to their point of view — still applies.
INT. LOCATION #1- THE BAT CAVE
Bruce Wayne, dressed in business casual attire and somewhat distracted by data streaming across multiple computer screens, politely converse over breakfast with his butler, Alfred. Mr. Wayne is upset about declining patient experience scores for Gotham General Hospital’s Emergency Department. Bruce Wayne’s frustration is evident — an attempt to improve the scores by incentivizing physician behavior using gift cards to Gotham City Coffee has not been successful. Steadfast and diplomatic, Alfred provides counsel to his employer.
BRUCE WAYNE: The board of directors knew the patient experience scores would take a hit during COVID, Alfred. But this is different; the most recent patient comments about the emergency department at Gotham General Hospital crossed a line.
ALFRED: I beg your pardon; I believe we crossed the line first, sir. The health care system has squeezed citizens to the point of exasperation and given the patients no other recourse. And in their desperation over the declining scores, the board of directors turned to a rewards system they don’t appear to understand.
BRUCE WAYNE: What do you mean?
ALFRED: Well, sir. Say I ring my doctor in the morning with a simple question. If the problem is even remotely acute, a medical assistant refers me to the walk-in clinic. Once I arrive, the greeter tells me they can only book so many appointments per day, and the schedule is often already full.
BRUCE WAYNE: But that’s ridiculous—- the sign says “walk-in” — who approved that idea?
ALFRED: I’d rather not say, sir, but they cited preventing burnout. At that point, sir, the patient decides the only reasonable solution is to go home and wait. Before they depart, they are reminded to proceed to the emergency department or call 9-1-1 should they feel worse.
BRUCE WAYNE: What do they do?
ALFRED: Not wanting to trouble anyone with what they know is a minor concern, most opt to wait at home.
BRUCE WAYNE: Is that seriously how it works? Is there more?
ALFRED: I am sorry to say there is. Before primary care offices close for the day, doctors start making callbacks and reviewing abnormal laboratory and radiology results. Those patients, many of whom have been waiting all day for instructions, are referred to the emergency department for anything remotely resembling an acute problem. By that point, the schedule at the walk-in clinic schedule is quite full.
BRUCE WAYNE: You … cannot … be … serious.
ALFRED: I am afraid so. The situation in Gotham is quite desperate. To improve the patient experience scores, anyone receiving positive written comments in a patient experience survey is given a gift card to Best Gotham Coffee.
Sir, the strategy isn’t working.
BRUCE WAYNE: Well, no kidding. What about that tall, goofy-looking ED doc, Marc…, Matt — something. Didn’t I send him four cards last month? You remember him — the super-polite guy who said he would work all night for an endless supply of coffee and peanut M&M’s?
ALFRED: Master Wayne, I believe he was making a point about the difference between compensation and incentives at your expense.
BRUCE WAYNE: Are you sure?
ALFRED: Quite positive.
BRUCE WAYNE: Wait a minute — what are we doing about providers who receive negative comments?
ALFRED: Master Wayne, you’ve been advised to refer to those “as opportunities for transformational intervention.” Would you like more time to review the after-action items from the quarterly report?
BRUCE WAYNE: Stop it, Alfred. You know what I mean.
ALFRED: The hope is that underperforming doctors will see their colleagues drinking free coffee and then be motivated to improve their patient experience results.
BRUCE WAYNE: That’s depraved. Who came up with that? The Joker?
ALFRED: Doubtful— you locked him up last month.
BRUCE WAYNE: Doctors aren’t complicated, Alfred. We only need to figure out what they are after.
ALFRED: With respect, sir, perhaps you are dealing with a group of people you don’t fully understand. A long time ago, I was working as a consultant for a hospital in Burbank, and the local administrators tried improving patient experience scores by rewarding physicians with gift cards for designer coffee when they received great comments. But the patient scores never went up and the cards, once distributed, were nowhere to be found. So my friends and I went looking for the cards. But after six months, we never observed the doctors drinking fancy coffee.
And then, one day, I was leaving for the evening via the Emergency Department lobby when I noticed a small child playing with a stack of emerald-colored gift cards as thick as my thumb — the doctors had been giving the cards away.
BRUCE WAYNE: So, why accept them in the first place, Alfred?
ALFRED: Well, maybe they thought they were being polite, or they wanted to be good sports. Or, perhaps, they weren’t given a choice. What we observed, Mr. Wayne, was that their behavior wasn’t motivated by the allure of free coffee.
(picks up the breakfast tray, turns, and starts walking away)
We concluded that the doctors considered the positive comments their reward, as hard as that might be for you to believe. Frankly, I hope my physician isn’t seeking praise for providing exemplary service with an incentive of free coffee.
(over his shoulder, and louder, while exiting left)
I suggest, Master Wayne, that the next time you want to understand why a seemingly well-adjusted adult would put on an uncomfortable outfit and hide their face behind a mask to stay up all night helping other people, you should ask one. You may realize that you’re not the only one who believes Gotham is worth saving.
BRUCE WAYNE: (Stands alone, center stage, stunned silence)
While I love coffee and peanut M&Ms, being given a gift card as a reward for positive patient feedback only provides physical evidence of an imperfect understanding of the doctor-patient relationship. According to my value system, earning a few kind words from a grateful patient or family is already enough. The familiarity of my experience and reaction among colleagues suggests a much larger problem arising from the business side of the house of medicine — an epidemic failure to understand what is actually happening at the bedside, which is causing leaders to misjudge how to motivate providers to make a positive impact on patient experience.
Performance metrics such as patients per hour, door-to-provider time, and diagnosis-specific quality measures are valuable in helping to objectively measure an individual’s performance. From the point of view of patient experience, they don’t connect to the big picture because, in most systems, these end-points aren’t correlated with the number of times the provider helps the team “win.”
By a win, I don’t mean a shorter LOS or generating more RVUs per hour than the next person — I’m talking about a win from the patient’s point of view, specifically a positive comment about their experience. Instead, most providers operate in a system where the penalties (a return visit with an admission and patient complaints) are tabulated and tracked over time, while the number of times an individual’s actions helped the team “win” are not.
Creating wins is difficult because the interactions are complex, and an individual’s experience relies on multiple variables, including the provider’s ability to connect and demonstrate an understanding of the patient’s needs.
Accounting for the characteristics of professions composed of individuals with high degrees of autonomous motivation leads me to propose a different systemic intervention. What if inspirational motivation and idealized influence were combined to attune the system’s design and operation with the values and ideas of those who consistently create positive impacts on patient experience? With this in mind, a more effective intervention would involve making time to converse over coffee and collaborating on how to improve things for the patients. I think the time spent listening to and supporting this endeavor would be worth more to these individuals than being given a free cup of coffee.
The author is an anonymous physician.