Patient satisfaction through a hospitalist lens [PODCAST]

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“In addition to leaking private information to an unauthorized individual who just happened to ask for Ms. Mann by name, Larry commanded Nigel to worsen this HIPAA violation. Given the tone of his command, Larry must have felt right proud of his informing an aggressive, unconfirmed querent. If so, perhaps he should have paged Nigel prior to blindly succumbing to clamorous callers.

During all of his back-patting, did Larry consider that maybe the unauthorized querent was unauthorized for a reason; that maybe the querent’s aggressive nature may overwhelm even Ms. Mann who may have hoped not naming that person would prompt staff to shield her from the unwelcomed? With that in mind, can Larry be certain he expertly met Ms. Mann’s needs? By jeopardizing Ms. Mann’s privacy (or safety), did Larry meet patient satisfaction goals?”

Adedotun Adewusi is a hospitalist and co-author of Under the Collar: Frank Conversations about Healing that Harms: Simply Speaking.

She shares her story and discusses her KevinMD article, “By jeopardizing privacy, did this physician meet patient satisfaction goals?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Dotun Adewusi. She is a hospitalist, and she’s the co-author of the book Under the Collar: Frank Conversations about Healing that Harms: Simply Speaking. And she contributed an article from that book titled “By jeopardizing privacy, did this physician meet patient satisfaction goals?” Dotun, welcome to the show.

Adedotun Adewusi: Thank you for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Adedotun Adewusi: Well, I started off from more of a science, engineering background. I went to the University of Texas at Austin and did chemical engineering with the intention of going into medical school, because at the time I felt that I was probably going to seek more of a biomedical engineering angle with impacting the world. I ended up actually liking internal medicine and pediatrics, so I sought a med-peds residency in Grand Rapids, Michigan, after medical school in San Antonio, Texas. And since then, I actually found my niche in hospital medicine. I’ve worked as a hospitalist in Michigan, New York, Pennsylvania, and now California.

Kevin Pho: What are the challenges that you face currently as a hospitalist today?

Adedotun Adewusi: I think one of the main challenges is balancing the health care of medicine that I’m trying to give to my patients with expectations that are being defined or dictated by non-medical personnel, and not wanting to sell my patients short, giving them the best care I can, but still somehow finding a way to finesse or meet certain so-called guidelines that may not traditionally fit what I had expected medicine to be.

Kevin Pho: Now, in general, what are some of those guidelines that hospitalists are expected to meet?

Adedotun Adewusi: Well, the first that come to mind from a hospitalist perspective are core measures. When we talk about core measures, length of stay, right? The shorter the length of stay, the more benefit for the hospital or the facility, the cost-versus-benefit ratio, so to speak. And you’re trying to balance that with making sure that you’re serving the patient with what the patient needs. Some patients, depending on their background, need more education, and some need more access, whether it’s because of socioeconomic limitations. And if we try to fit every single patient into just a minimal length of stay, we might sell somebody short. So that’s one thing that comes to mind.

And then in terms of documentation, you have to be sure to word your records a certain way to establish that the care that you’re providing matches the severity of the patient’s condition, for instance. And what I find is I spend a lot of time in documentation, and I want to remember that my documentation is not the reason that I’m practicing medicine. It’s the patient, right? So you could spend five minutes with patients and 15 minutes documenting. That’s a problem for me. So those are two of the struggles that I work with on a day-to-day basis.

Kevin Pho: Now, in general, do a lot of hospitalists feel pressured by the administration to really shorten length of stay? And what happens if those hospitalists don’t meet that standard?

Adedotun Adewusi: Well, there’s not a punitive repercussion, so to speak, like an immediate one, for instance. But the emphasis that the administration can put on the hospital takes away maybe the praise or the recognition that should be applied to the fact that somebody that had a very severe condition and had multiple readmissions to the hospital, or initially a very dire prognosis, now actually has a better chance of survival, right? So you’re thinking, “Gosh, I was able to impact this patient’s life positively,” but the patient probably stayed twice as long as the administration would have expected for that condition. Yet rather than the recognition for the fact that now this patient might not be coming back to the hospital as frequently, you’re being asked in more detail to elaborate on why your length of stay was double the expected time. So there’s not an actual punishment. It’s not like you’re not allowed to work or you don’t get compensated, but maybe some of those extra recognitions for what else you’re doing don’t get brought forth because of the focus being somewhere else.

Kevin Pho: All right, so let’s talk about the story that you shared on KevinMD, and it’s titled “By jeopardizing privacy, did this physician meet patient satisfaction goals?” Now, for those who didn’t get a chance to read that story, can you just summarize it for my audience and share the story of why you decided to write it?

Adedotun Adewusi: Well, I’ll start off with why this was written. It’s actually an excerpt. It’s a chapter from a book that I co-authored with my best friend. We both attended an internal medicine residency together, and she practiced briefly and has since retired from medicine. But we still share similar experiences, and I still vent and use her as a pressure valve, so to speak, when I share my own personal experiences. And so venting sessions turned into debates about just our behavior as professionals and medical practitioners in general. What drives these behaviors? Is it stress? Is it administration? Is it something completely unrelated to our work? Is it apathy? Is it fatigue, depression? What is it, and what can we do about it? And how is it directly impacting our patients when we’re not even really thinking about it? And so this turned into an idea for a book about how we could detail these conversations and just allow them to be a reflection of what we’re doing to each other while we’re trying to take care of our patients.

And so how we did it was each chapter just discusses an interaction. And being a hospitalist, I’m speaking from a hospitalist perspective, and hospitalist interactions with patients, with nurses, with other hospitalists, subspecialists, and administration. So this particular chapter is addressing, when we talk about some of the other pressures from administration, patient satisfaction, right? And so you want to satisfy the patient’s experience in the hospital while still meeting those core measures, length of stay, that the administration is requiring of you. And some of the patient satisfaction has to do with improving the experience of those outside of the patient, like the family members.

And sometimes, where a provider might think it’s a heroic effort to make sure that everybody involved in that patient’s admission is satisfied with the experience, including family members that are just concerned about their loved ones, is that provider actually now overstepping their boundaries? Because by reaching out to everyone that’s not necessarily the patient, or that has been identified by the patient as a permissible family member, for instance, did you actually satisfy that patient’s experience in the hospital, or did you just violate that patient’s privacy? So that’s where this chapter stemmed from. And then within the chapter, it’s actually discussing how one hospitalist that’s cross-covering for another hospitalist overstepped those boundaries and therefore affected how the initial hospitalist’s future interactions with the patient would go.

Kevin Pho: Now, in a primary care setting, of course, I’m very familiar with patient satisfaction, and more and more compensation models are affected by a physician’s patient satisfaction score. Now, do hospitalists also face those same compensatory consequences of patient satisfaction?

Adedotun Adewusi: Yes, yes. At least within some of the practice models I’m familiar with, there is a pocket of your compensation that is related to different values that are determined to be important, whether the value is access, the clinician’s participation in kind of a greater quality improvement for the institution, and then a fraction of that is also patient satisfaction. So in this particular setting, patients after their hospitalization are approached to give feedback. They use the common forum, which is the HCAHPS score, to determine the height or the impact that patients experience. And the patient now ranks his or her experience in the hospital based on feeling like he or she might have gotten good updates from the nurses, the doctors, they understood what was going on, they felt valued, and they felt that their voice was being heard. And sometimes providers can feel like there are some external factors that keep this patient from understanding the intentions of those that are trying to care for them in the hospital setting. But yes, similar compensation models exist even in the inpatient setting.

Kevin Pho: So in the outpatient setting, sometimes the most satisfied patients don’t necessarily receive the best care. And I know that there are some studies that show that people who are the most satisfied actually receive worse care. And sometimes if a patient just asks for medications, a physician can’t just give it to them and hope for high satisfaction scores. Now, in the inpatient setting, have you come across that tension between good patient care and patient satisfaction? And if so, how do you reconcile that tension?

Adedotun Adewusi: That’s a wonderful question. And it is ironic that sometimes people with the best care are not necessarily feeling the most satisfied by their experience, and the other way around. I have come across that, and it often does fall behind what is my intention for the patient, what is my goal to improve that patient’s health, and what is the patient’s experience. If a patient comes in with one presentation and you uncover that, “Oh, gosh, you’re just worried about this particular symptom, but my test and evaluation has revealed that you actually have a lot of underlying symptoms or underlying conditions that are affecting and causing this symptom,” if somehow I can’t communicate that to you as a patient, and I just go down this rabbit hole of all these other things, you’re going to feel like I never addressed that one symptom that you came through with.

So what I recognize is that communication is key, right? So the way I can match my intentions with the patient’s expectations is just to continuously communicate. Let the patient understand why I may not be addressing an issue the way he or she would have expected, why he might not be receiving a particular medication that he expected to take, whether it’s something for a chronic condition or an acute condition. That’s really key. And compassion, of course, because you have to understand that, for me, I see a certain condition frequently, and so for me, it’s a very commonplace condition. But for that one patient, they’re the one person that has that in the world, as far as they’re concerned. And I need to let them understand that I recognize their priority over mine.

Kevin Pho: We’re talking to Dotun Adewusi. She is a hospitalist, and she wrote the KevinMD article “By jeopardizing privacy, did this physician meet patient satisfaction goals?” Now, with more and more people becoming hospitalists, and hospitalists, of course, are a hugely growing profession, I think that sometimes care can be perceived as being more siloed. And I think one of the biggest issues sometimes is, when patients are discharged from the hospital, do they get appropriate follow-up with their primary care? And you have that transitional care that sometimes gets lost. So I was wondering if you could comment on that. What are some ways that you feel can improve that transitional care between the inpatient and the outpatient side?

Adedotun Adewusi: Communication, and I guess transparency in what we’re doing and revealing that to the patient, helps. Patients often don’t know the intricacies of what providers are doing behind the scenes, so to speak. They might see your face, and you give them a several-minute update about your recommendations and their condition, but they may not recognize that that five-minute or 10-minute conversation was preceded by an hour-long discussion among several providers, subspecialists. And so, trying to be more transparent so they understand the intricacies of what we’re doing. It doesn’t take too long. It’s just rewording our communication differently.

Also, making a more concerted effort to reach out to providers, because in this world of hospital medicine, the person that’s taking care of the patient in the inpatient setting is often no longer the same doctor that’s most familiar with them, that they see more regularly in the outpatient setting. So reaching out to that provider more readily. And I do think that hospitals, if they create some sort of more consistent system where even after the patient leaves, perhaps making systems that can reach out to those patients at least briefly in the immediate post-hospitalization period, so the patient doesn’t feel like they were just lost to the world, thrown out to the wolves, and forgotten and never approached again.

In the times when I’ve reached out to patients post-hospitalization, things that I thought that they understood very clearly while they were under my care in the hospital, I recognized that somehow, after they left, the world started all over for them again, and those things fell to the back burner. So it allowed me an opportunity to kind of re-emphasize the importance. So reaching out immediately post-hospitalization, communicating with their providers, and being more transparent in what we’re doing besides just that conversation that we’re having with our patients.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Adedotun Adewusi: My take-home message is that when we’re training as future physicians, it’s harped on us, the science, the medicine. But what we didn’t emphasize, or what we haven’t emphasized, is the non-medical and non-scientific factors that come into play on a day-to-day basis and in turn impact our health care delivery, whether it’s our own interactions with our patients or our interactions with each other. More importantly, our interactions with each other are not really spoken about, because we’re not thinking that our mutual discussions would actually affect somebody completely outside of us, right, because they’re not the professionals. But that is a key factor that I think we should all start thinking about, outside of the medicine and science that we’re so good at already.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Adedotun Adewusi: Thank you for the opportunity.

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