What If What Patients Want Is Not What Patients Need?

What If What Patients WantThis may come as a surprise given how much I advocate for letting patients take the lead in setting their own health goals, but I believe that it’s a mistake to let patients completely lead their own care.

That’s because many of the things people value in daily life aren’t compatible with treatment for illness and injury. Medications may have irritating side effects. Surgeries and physical therapy cause pain (that we hope eventually fades as the body heals). Now that patient satisfaction is part of the recipe used to reimburse hospitals for care, there have been some unintended consequences where trying to make patients happy may disrupt the process of making patients well.

To take one example, consider the perspective of Amy Bozeman, a nurse:

Comfort is not always the same thing as healthcare. As Bozeman suggested, when representatives give warm blankets to feverish patients or complimentary milkshakes to patients who are not supposed to eat, and nurses take them away, patients are not going to give high marks to the nurses.

Another specific example comes from measuring patient satisfaction around pain management. As I noted in a post about the law of unintended consequences, this may have led to physicians prescribing more pain medication than they might otherwise in order to boost their satisfaction scores. Medically speaking, it can be risky to take too much pain medication under some circumstances, but patients, focusing more on their immediate experience and less on the academic risks and benefits of medication, would opt for relief over caution.

How can we reconcile patient wants with medical success? I think there are two key avenues to take:

Treat patients respectfully and as individuals.

Treating patients with respect may help providers to deliver unhappy truths (“this will be painful,” “you’re going to need to give up drinking,” etc.). I see this as a corollary of self-determination theory, specifically relatedness; acknowledging people as individuals whose wishes are meaningful is part of engaging them in behavior change dialogue.

Having an engaged and motivated provider workforce helps with this. One study found that when nurses in a hospital had a better work environment (adequate staffing and empowered employees), patients had better outcomes. Treating other people well, especially if being nice requires emotional labor,  can be hard work. Providers who are supported by their own work environment have a deeper well to draw from for resilience and strength, which permits them to give better and more individualized care to patients.

Recognize where you make the goals, and where the patients do.

Some health care activities happen within the hospital or doctor’s office; others happen in the patient’s day-to-day life. In general, the closer a behavior is to the four walls of the clinic, the more likely the provider should be the one setting those goals. I think of it in terms of “Whose job is this activity?”

The surgeon performs the surgery, and therefore can and should set the conditions under which that surgery can be safely performed. Even though the surgery might ultimately be more successful on a patient who then makes major dietary and activity changes upon discharge from the hospital, it is not the surgeon’s job to make those changes. It is the patient’s, and accordingly it is the patient’s right not to make those changes (or to make them partially, or gradually, or intermittently).

In many ways this comes back to learning how to speak the patient’s language and find a common goal. Most health care professionals seek to achieve the best possible health outcome for patients and feel that they’ve been successful when that occurs. Patients may or may not share that view, but likely have some other goal motivating health-related behaviors. Having the conversation about what matters to the patient is a way to treat the patient respectfully and as an individual, and it also may help patients to decide that they want to pursue healthy behaviors outside of the clinical setting.

If you’re a provider, doing your job well may sometimes feel at odds with making patients happy. And if you’re a patient, feeling satisfied with your care may not fully align with receiving medically optimal care. In both cases, it’s important to remember that both patients and providers want what’s best, so a search for common ground might serve fruitful.