The difference between care and service is significant

My father, recently retired, spent over 40 years in private practice. After dinner, he would sift through piles of paper charts and call patients with their lab results. As a grade schooler, what impressed me the most was that he knew many of his patient’s phone numbers by heart. Of course, this was in the days before HIPAA and caller ID, so scattered charts on the dining table and calling patients from the home phone was just the way he did business.

The point of this story is not to bemoan the current state of medicine, where it feels like doctors spend 75 percent of their time battling with the electronic medical record, 15 percent of their time battling with insurance companies for authorizations, 10 percent of their time apologizing to patients for running late, 10 percent documenting patient-care hours and another 10 percent of their time actually providing the kind of care they went to medical school to provide. (Wait, does that add up to more than 100 percent? You get my drift.)

No, the point is to figure out how to provide the kind of care old-school doctors could provide in the current environment. When my father was starting out in practice in the mid-1970s, his mentor advised him that patients want three things: availability, affability, and ability (in that order). Even then, the tension of service (availability and affability) over care (ability) existed. But what happens when availability and affability trump ability? Where I was a cardiology fellow in the early 2000s, there was a floor of the hospital reserved for important people with shiny wood laminate floors and afternoon tea.

But when a patient went into cardiac arrest, the bag-valve-mask was hidden behind fancy wood paneling, and no one could find it for a few precious minutes. I’m sure the patient satisfaction scores on that unit were very high, but one could argue that the most important question on such a survey should be, “Did you live, or did you die?”

So I wish that the medical-industrial complex comprised of patients, insurance companies, and administrators would allow physicians to prioritize care over service. I have no solution to the rising tide of acronyms designed to complicate our professional lives, but I wish we could convince patients that outstanding care is essential and good service is not.

One lesson I learned as a patient: it’s OK to wait your turn. I’ve called the pediatrician’s answering service late at night about a fevering toddler. I’ve felt the irrational parental fear, the frustration with the endless automated phone tree and interminable wait for the pediatrician to call back. But just because I want to call the physician’s cell phone and get an immediate response, doesn’t mean that, medically, I need that immediate response. My first wish: that patients understood that it’s OK to wait your turn. Doctors don’t keep patients waiting because they’re arranging tee times or martini lunches. How do I try to make this wish come true? When I keep a patient waiting, I apologize but also let them know that the delay wasn’t because I was drinking coffee or watching television, but providing care.

Another lesson I learned as a patient: It is important to trust the experts. I chose my obstetrician because he was experienced. When I was admitted to the hospital in labor and asked about my birth plan, I said, “My birth plan is Dr. B.” (And an epidural, let’s be honest.)

Because the music and the lights and the decision to ingest the placenta were window dressing; all I needed was a healthy baby, and Dr. B was my best shot to make that happen. I wish patients knew that Dr. Google is not a substitute for years of training and practice. Just because you can read medical facts doesn’t mean you understand the context and judgment and experience cannot be distilled into a website. How do I try to make this wish come true?

When a patient asks for antibiotics for a viral upper respiratory infection or a stress test to evaluate noncardiac chest pain, I believe it is acceptable to say that you know more than they do and explain the flaws in their medical reasoning.

Of course, wishing that patients would wait their turn and accept that the doctor is the expert does start with patient trusting that their physician’s sole motivation is optimizing health and well-being. The best way to share this: tell and show. Tell by explicitly stating this obvious fact to patients and show by recognizing that there are instances where better service does mean better care. A heart transplant patient saw me for a routine follow-up visit. He had a lung nodule incidentally noted on chest X-ray and was scheduled to see a pulmonologist two weeks later. His anxiety was palpable: was it cancer, infection or just an incidentaloma? Waiting two weeks would be torture, so I asked the pulmonologist for a favor: The patient lived two hours away, could he or his partners add him on for a same-day consultation? There are some patients who would demand service, and there are others who medically deserve it. Knowing the difference and acting upon it makes for outstanding care.

Care is the effort we expend to optimize our patients’ health and well-being. Service is the details that lead to burnout. I wish patients knew that when the service appears suboptimal with long wait times or doctors not ordering the tests they believe they deserve, the real question is whether their care was compromised. As physicians, we cannot easily stem the outside pressures on the system, but we can try to strengthen the patient-doctor relationship, one encounter at a time.

Michelle M. Kittleson is a cardiologist.

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