Sunday, July 28, 2013

I felt like I had to defend why I was there

Patients from around the world write to tell me of their hospital experiences.  It seems that each one offers a series of lessons.  The most interesting stories are not those associated with reportable adverse events.  They are the ones that demonstrate inefficient work processes and insensitivity to patients' needs.  My hope in posting them here is to prompt administrators and clinicians to think about doing better. It doesn't matter if the particular event occurred in your hospital.  Chances are that something like it has.  We need to stay focused on continuous improvement based on call-outs from the front line staff and on reports we receive from patients.

Today's story involved a woman in the mid-thirties.  Three years ago, her primary care doctor noticed a lump in her breast and sent her in for imaging studies.  While the doctor did not think the lump was cancerous, she ordered studies just to be sure.  The result was satisfactory.

The woman returned for another periodic physical exam a few weeks ago, and her doctor again noticed the lump in the same place.  While reasonably confident it was not problematic, she again ordered a mammogram and ultrasound out of an abundance of caution.

The patient arrived at the hospital's breast imaging center at 1:50pm for a 2:00 appointment, did the paperwork, and was directed to back room holding area to await the mammogram.  At 2:30, the tech showed up and spent less than 10 minutes taking the picture.  Then it was back to the waiting room until 3:20, when the ultrasound tech came in and spent less than ten minutes doing her job.  The radiologist arrived and spent five to ten minutes reporting on the results, which again confirmed that there was no problem.  Elapsed time, almost two hours for at most 30 minutes of useful time spent.

So, conclusion number one.  Here is a center that needs a lesson in Lean.  The number and duration of wasteful steps is obvious. Compare this to other clinics that have applied the Lean philosophy and techniques to improve customer (and staff) experience.

But we have to return to the doctor to reflect a different sort of problem.  As the radiologist was reporting the current test results to the patient, she noted that the 2009 studies had shown no problem and asked the patient who had noticed the lump, implying in the ears of the patient that she (the doctor) was wondering why the test was being repeated. 

The patient reported to me that, while the radiologist had not been dismissive, she did make the patient feel "like I had to defend why I was there."  The patient was therefore left to wonder whether the radiologist's reading of the current images was likely to have been less than thorough.  Had the doctor been diagnostically anchored by reviewing the 2009 test results, or was she able to put those results aside and view the new images without prejudice? Our patient now feels that she has to request a second reading by another doctor.

I'm sure that the doctor did not mean to raise these doubts by her comments, but we need to understand that when a woman is asked to have breast imagery done, she is likely to be quite sensitive to the choice of words used by the clinical staff.  Here, instead of offering reassurance in the face of negative images, the doctor's remarks managed to cause the patient unnecessary concern.


Barry Carol said...

I wonder about the role defensive medicine played in ordering both the first test and the second test. I had a primary care doctor say to me recently: “I spend my day covering my ass.” Perhaps safe harbor protection from lawsuits if evidence based guidelines and protocols are followed would change this attitude. It would probably have to happen at the state level though because federal action is unlikely anytime soon.

I also think the lengthy elapsed time to complete the test and receive the results is an all too common example of how little respect too many doctors and hospitals have for a patient’s time. While emergencies come up and can cause understandable delays, lots of providers deliberately overbook both to maximize their income and to ensure that they don’t have to waste any time waiting for the next patient to arrive. A patient’s time is worth zero in their mind.

Anonymous said...

Everyone will become a patient sooner or later, and that includes healthcare professionals. I've come across disgruntled professionals (who also were pts) wondering whether to bill where-ever they had their appt for their time.

Neil Bonginkosi Lawrence Taverner said...

From Facebook:

The patient may have been too sensitive. I routinely ask every single one of my breast lump patients who noticed the lump as it has clinical significance . also, a good radiologist would be required to not dismiss the previous results but to actively compare the new results with the old ones. this is correct practise. I understand that a patient is going to be sensitive in a situation of cancer screening, but, other than the time issue, I do not think there was a mistake made clinically.

This is just to add another perspective to the same scenario.

Paul Levy said...

That absolutely could be true, but do you blame her for being so? This is about the MD's communication skills in this kind of environment.

Thomas Connors said...

From Facebook:

Myself and some relatives just spent 7 hours in the ER at Boston Children's tonight. As you said, it is poor customer service to have such a long duration compared to the actual useful service time. Operations management is sorely lacking in the health care system...

Paul Levy said...

Yes, but EDs have different issues, in that triaging of more acute cases can often push other patients down the queue and cause appropriate delays.

Linda Galindo said...

This was so "spot on" I had to re-post it. Thank you!

Paul Levy said...


This was not that kind of case or doctor at all. There were other bases for the test that I have not disclosed at the request of the patient.

Thomas Connors said...

From Facebook:

Toyota manufacturing, lean, process improvement, time and motion studies- many ways to fix inefficient systems and provide lower cost and better outcomes