Random Thoughts from a Restless Mind

Ever listen to how people address folks on the providing side of the customer service continuum? Do you ever stop to listen to yourself, or think about how you will sound before you speak? Fascinating. In North America we are moving ever more swiftly to an economy that is majority a service economy; we don’t really make stuff so much anymore, we help people use stuff someone else made, or provide assistance based on a knowledge base or skill set. Listening to people on the receive side of the equation is fascinating.

We have been forced to change our EMR at SkyVision. Our office is running behind schedule because of this. My ears are on high alert for how our patients are reacting. I’m prompted to this line of thought by three interactions in the office that happened while I was loitering at the reception desk. Three individuals not so much requesting a service but demanding it, doing so with a tone that implies not only a deep sense of entitlement but also a deeper lack of regard for the individual who will provide that service. Both in tone and content the to-be-served make it clear to the service provider that he or she is there to serve only them. In fact, the servers only reason to exist is to serve, as if the to-be-served were some kind of different, superior version of the species. It’s loathsome, actually.

I spend every waking moment of each working day on the “serve” side of the equation, whether I am a SkyVision plying my profession or CFB coaching. Having achieved some measure of expertise in both it’s very rare that I am on the receiving end of this type of behavior, but it does happen. More often is the case that it is someone lower on the org chart who gets this. The receptionist, phone operator, or check-out person who gets this “lower life-form” treatment, not the doctor or business owner.

Life can be hard for these front line people in a service business. There’s not only a “customer is always right” mentality on the other side of the interaction but also a sense that being a customer who will get what they want is as much as human right as Life or Liberty. That’s what it sounds like, anyway, if you are off to the side listening. No matter how frustrated one might become from a service situation gone wrong it’s important to remember that there is no continuum in the relationship when it comes to the inalienable rights, nor is there any evolutionary hierarchy across that desk or over that phone line.

Danny Meyer, the great NYC restauranteur, is probably closest to correct when he says “the customer is not right all of the time, but mostly right most of the time. A customer [only] has the right to be heard.” How you express yourself when you are on the “receive” side of the customer service experience is not only an important measurement of how you value the person across from you providing the service, but frankly is probably also a predictor for how likely you are to be successful in being heard. It’s instructive that none of the three SkyVision clients who made difficult (bordering on unreasonable) requests in an unpleasant manner were accommodated because doing so would have required an extraordinary effort which may not have been successful in any event.

Sorry, no pithy statement to wrap it up this week. In the end we all want what we want, and we all need to be heard. It helps to look at the person on the other end of the service divide as if you were looking in a mirror. Would you say that, like that, to the person in the reflection?

“I’m sorry, Doctor, but we can’t have you give that talk; you have a conflict of interest since you’ve been paid to do research on that medicine.”

“Well, Senator, it’s a conflict of interest for a doctor to sell those crutches in his office.”

“It is the opinion of this newspaper that physicians should declare to each patient any ownership interest they might have in a surgery center so that the patient is aware of any conflict of interest.”

And on and on the drums beat, droning incessantly and insistently about the dreaded “conflict of interest”.

In a world now run by the terminally attention deficited, with multi-tasking and synergy-seeking all the rage, we apparently have one domain in which nothing but the purest, most antiseptic, monastic and single-minded devotion to a single task and goal is acceptable: the provision of health care in America. Think about it…the simple existence of OTHER interests is de facto evidence of some nefarious CONFLICT of interest. The underlying assumption appears to be that it is impossible to have any additional interest–ownership of a business, a consulting agreement, stock or stock options–without the ability to devote your primary attention to the best interests of your patient. Any other interest is automatically bad, and every physician is guilty and can’t be proven innocent. How did we come to this?

There are issues and examples both substantial and trivial, and yet each of them is addressed as if they are one and the same. I bought pens last month for the first time in my professional career (I graduated from med school in 1986). It was weird. Who knew that there was a place called Office Max and that this huge store had not one but TWO aisles of pens to peruse?! I think it was Bics in a KMart the last time I bought a pen. Somehow this fact means that I have been making decisions for my patients based on all those pens I DIDN’T buy all these years. There’s only one problem with that: I don’t remember a single thing about even one of those pens.

And yet somehow accepting those pens is a “conflict of interest”. Seriously.

Why is it that if I somehow get something from someone, big or small, even if I perform some service or even buy something from them, that it’s a “conflict of interest” if some company or other might make money from what I do for my patient? Why is every peripheral interest that exists around the little silo in which I practice medicine–a space occupied by me, my staff, and my patient–why is that automatically a “conflict of interest” with some sort of negative connotation? That I must be doing something bad? Why not just “another interest”? Why can’t these things be a “convergence of interests” between what is best for my patient and any of the other stuff that might be going on around us?

Listen, I get it. There have been instances where docs have pushed inferior products on their patients because they had a significant financial incentive to do so. I’m reviewing a med-mal case right now where the plaintiff had an eye problem which resulted in cataract surgery. The cataract surgeons are not being sued, but I looked over the surgical record and saw that they put an inferior POS lens implant in this guy’s eye, and I KNOW they did that because they own the surgery center and that lens is dirt cheap. THAT’S a conflict of interest. But for every surgery center owner like this putz I know 50 who put in state-of-the-art implants because that’s what’s best for their patients. Those docs still make a profit, but it’s smaller because they are putting the patient first. Why is THAT a conflict of interest?

It’s not.

Three different companies make 3 versions of the same kind of medicine, all of which have identical efficacy and safety, and all of which sell within pennies of each other. How does one choose among them if one needs to be prescribed? Is it such a heinous insult to humanity to choose to prescribe the product from the company that pays the doc to consult on some other project? Or the company that brought in lunch? Or (GASP!) the one that left a couple pen lights in the office? Tell me, how and why is this a “conflict of interest”?

This trivialization of the concept of “conflict of interest” is actually weakening the protections that we should have against REAL conflicts that cause real harm. Pushing unproven technology (artificial spinal discs, anyone?) on unsuspecting patients prior to definitive proof in return for obscene “consulting” agreements, for example. Applying the same degree of moral outrage to a ham sandwich as we do to conflicts which truly pit the best interests of our patients against some profound interest on the part of the physician that prevents him/her from centralizing the patient is farcical moral equivalence. I think it is actually harming our patients.

Our most renowned medical editors, innovators, inventors, and teachers are withdrawing from public positions that require a monk-like aversion to these “conflicts of interest”. Who will replace them? Will the ascete cocooned in the conflict-free zone and unaware of what developments are on the way contribute? How about the teachers? Will we be taught by “specialists” who put together the purest power-points from the latest scrubbed articles, priests who are not stained by the sins of the those who are touched by the commerce of medicine by actually touching, you know, patients?

Here’s my bid: a true “conflict of interest” is one in which there is an essential tension between what is best for a patient, and some other ancillary benefit that might accrue to the physician. Something that makes the doc think about that other benefit first, before the patient. Everything else is an “additional” benefit. We should stop this silliness; stop trivializing the concept of “conflict of interest” through the dumping together of all other interests in the same gutter. We should all be allowed to ignore all but the truest of conflicts as we continue to put our patients’ interests first.

We should be allowed to seek a “convergence of interests.”

It’s become quite fashionable to call oneself “patient-centered”. It’s rather trendy, in fact. Large, quite famous medical institutions now trumpet their new “patient-centered” care initiatives. The hiring of a “patient experience officer” is front page news in Cleveland. The airwaves are choked with advertisements from doctors and hospitals alike, beaming with pride and anxious for you to know that now it’s “all about you, the patient.”

What it really turns out to be is LIPSTICK ON A PIG.

It’s the same hospital with the same staff and the same processes. The same doctors are in the same offices and get paid the same way. A new paint job and new curtains cannot hide the fact that you wait just as long sitting in the same, old chairs in the same old waiting room. No amount of  advertising or re-branding is going to magically change a 1990 Mercury Sable into a brand-new Mercedes 500SL, and if you close your eyes  you still know which one is taking you for a ride.

Since when is “it’s all about the patient” news? Isn’t that the way it’s supposed to be? Do the doctor and the nurse have a job because a patient needs their care, or is the patient there so that the doctor and the nurse can have jobs? How many times have you wondered if that big, beautiful new $100 Million hospital wing is being built to handle all of the patients who must be turned away, or if the hospital will now embark on a campaign to find patients to fill that new, superfluous edifice? Or worse yet, if the $100 Million addition is simply a way to launder all of the “revenue in excess of expenses” generated by the “non-profit” hospital?

Medicine is the ultimate consumer service business. Even more so than any other service business because the people who bring you medical care have been entrusted by a patient to do some version of the next right thing for that patient; they have been trusted to put the care of the patient before their own care and feeding. We do a wonderful job of curing disease in the United States, but we don’t do such a great job of caring for patients, lost as we are in our zeal to care for diseases. Patient-Centered Medicine means looking at the curing of diseases from the patient’s viewpoint rather than the doctors’ or the nurses’ or the hospitals’.

Patient-Centered Medicine is all about the patient’s EXPERIENCE.

Enter Skyvision Centers, a unique take on eyecare built from scratch centered around the patient experience from the ground up. Two eye doctors, an ophthalmologist and an optometrist, left a very successful practice (where very high quality eye disease care is still being offered) to start something new. Something radical. Something truly focused on the patient experience from the very beginning. We had nothing but our names and our reputations. No patient lists. No accounts receivable. Heck, in the beginning we didn’t even have an address! All we had was a blank piece of paper with “Skyvision Centers” written on it, and a picture of a patient in the middle. We built our business around that patient and her experience.

Benchmarks? Sure! We went out and benchmarked Nordstrom’s and the Canyon Ranch Spa and the Ritz Carlton to learn about the best practices in customer service. We studied the mechanics of the Toyota manufacturing methods to learn about flow processes, accuracy, and safety. We built an office that allowed us to maximize our efficiency in a setting that looks and feels more like a boutique hotel or retail setting, with lobbies rather than waiting rooms.

Every staff member went on a customer service “field trip” where we ate lunch at a Holiday Inn and dinner at a Ritz Carlton. We witnessed three of our staff members experience a makeover at the Almay counter at Dillards, and then watched three other staff members ENJOY a makeover at the Bobbi Brown boutique at Nordstrom’s. We checked into a room at the Holiday Inn to have a standard hotel experience, and then checked in and spent a night at the Ritz Carlton. All of us. The non-doctor staff and their spouses stayed on the concierge floor, the docs in regular rooms.

And then we brought it all together and made it Skyvision! Our goal is for each patient who comes through the door to have an experience that is more like the Ritz Carlton than the Holiday Inn. More like Nordstrom’s than Dillard’s. We measure every step of the patient experience and constantly evaluate our customer service just like we evaluate and measure our medical outcomes. We agonize over each sub-par visit or less than stellar service evaluation.

Why? Well, why NOT? Where does it say that providing the best possible medical care with the best possible outcomes has to be coupled with less than the best possible experience? That the most important person in the process is anyone other than the patient? We’ve all seen the check-in process at a Holiday Inn and at a Ritz Carlton. They both work, but they sure feel different, don’t they? Why is it that the majority of check-in processes at medical offices and institutions feels more like a busy airline ticket counter during a storm than the front desk at Canyon Ranch? If the cosmetics cost the same at Dillard’s and Nordstrom’s (you know, like your co-pay for a visit), why is it that you feel so much better after shopping at Nordstrom’s?

We all took a financial bath in the first four years of Skyvision Centers. Hey, starting from scratch is hard! In the end, though, we created what is one of those very rare creatures, a true Patient-Centered Medical practice. It should make you wonder how much better your experience would be if all of those busy practices and all of those hospitals building their new wings took some of the money they are spending telling people that they are “patient-centered” and actually tried to put YOU in the center. We’re pretty much an open book. We’re happy to be the benchmark. Heck, we’ll even go along on their “customer service field trips”! This Patient-Centered Medicine is more fun to provide, too.

But until they do, until all of those folks advertising their all-new, all-you, “Patient-Centered Medicine” spend some time looking at the experience of receiving medical care from the viewpoint of the patient, all of us who are those patients had better pucker up.

The pig just got her make-over.