Greetings gentle reader. It is time once again for your favorite scrivener, keyboard in hand, to journey forth and regale you with his tales of death, decay and diagnostic derring-do. Although Dr. Cranky would like to say that his recent absence has been the result of arduous travel to far corners of the Earth in search of spiritual enlightenment from parts unknown, the reality is far less exciting. In fact, the simple truth is that Dr. Cranky has only now managed to overcome the restraints which bind him in his padded cell so he might compose yet another missive to exorcise the demons which poke and prod at his deranged mind. Today we have an especially onerous succubus to confront. Your faithful servant intends to talk about that modern medical horror which dare not speak its name. It is an unholy terror which strikes fear and loathing in the hearts of physicians throughout every nook, cranny and broom-closet of the great house of Medicine. This very day Dr. Cranky intends to discuss, for your intellectual consideration, that abomination known as Press Ganey!
“My goodness Dr. Cranky,” you might say, “you never cease to amaze us with your strange terminology. Please inform us. What is this “Press Ganey” of which you speak?” Quite simply, Press Ganey is the name of a business organization which surveys patients to determine how satisfied they were with their hospital visit. And, just like the brand names “Q-tip” and “Xerox” have come to represent all manner of cotton swabs and photocopying processes, so too has Press Ganey achieved its status as the archetypical example of a patient satisfaction survey. You would not think any rational human being would be terrified of such a thing, much less a group of highly educated and venerable doctors. And yet, Dr. Cranky has sat in meetings and witnessed discussions filled with such intense passion that he thought the Almighty Himself would open up the sky and rain lightning bolts down upon “those monitoring b*stards” with righteous indignation. Oh, the weeping and gnashing of teeth he has seen! And, after much consideration, Dr. Cranky would like to say the following to any medical professional who might feel this way: grow up and get over yourself!
To hear physicians tell it, Press Ganey is nothing less than a product developed by the most depraved and psychopathic minds our twisted society has yet to offer. The horrors of Auschwitz, Andersonville and the Soviet Gulag combined are nothing when compared to this bestial concoction of pure evil! As Mr. Kurtz’s final words summarized toward the end of Joseph Conrad’s Heart of Darkness, “The horror! The horror!” But what are the components of this hideous monstrosity which appears to have been conceived by no one less than Satan himself? What is it that is so abhorrent? Let us look a little closer at just what we’re talking about, shall we?
From the Emergency Department standpoint, a Press Ganey survey looks at all aspects of a patient’s visit. There are sections which include the arrival process, nurse behavior, physician behavior, the testing process (including evaluations of laboratory and x-ray technicians who perform the services), how family and friends were treated, and so on. All responses are graded on a 5-point Likert scale with the evaluation categories ranging from “very poor” (which is associated with a score of 1), to “very good” (which yields a score of 5). What follows next is a copy of the entire doctor’s section as taken from one of Dr. Cranky’s actual returned surveys:
The scene of the crime
And that, my dear reader, is it. What you see above is the sum total of how emergency department physicians are graded using the Press Ganey methodology. Note that this is not one of those “your doctor, was he an enemy or just a foe?” type of surveys you tend to see in popular magazines. The choices don’t range from a score of 1 being described as “Adolf Hitler and the Terrible, Horrible No-Good Very Bad Day” to 5 being “Pol Pot and the Giant Killing Field.” Rather, it asks four simple questions:
1. Did your doctor treat you with respect?
2. Did your doctor listen to you?
3. Did your doctor tell you what he was going to do and what your evaluation showed?
4. Did your doctor do what he could to make you reasonably comfortable?
Forgive Dr. Cranky, but he doesn’t understand where the controversy lies. Maybe he is just a doddering old dinosaur who has yet to fall in the nearest tar pit. Perhaps he didn’t get the memo. Is it unreasonable for a doctor to treat his patients with respect? How can someone diagnose disease if he is unwilling to listen to those under his care? What’s so inappropriate about telling someone the results of their laboratory and x-ray studies? Is it not our job to treat pain, alleviate suffering and offer emotional support? It seems to your earnest host that this great evil, this putrescent stain, this bane of modern medical practice is nothing more than a reasonable attempt to measure and quantify how well physicians treat their patients as fellow human beings.
This, of course, begs the question: why are America’s doctors getting their knickers in such a twist? What is it that is so repulsive to those educated men and women Dr. Cranky regards as his compatriots? Off the top of his head, your host would like to offer a few basic thoughts.
First of all, young doctors are molded to be arrogant a**holes long before they pick up their first stethoscope. This occurs through two separate mechanisms: the process students must go through in order to get into (and through) medical school as well as the educational system once they get to their internship and residency training. Let us start at the medical school pre-admissions stage. In order to have a reasonable chance at admission, an undergraduate must excel at courses whose difficulty inspires nightmares which would put Freddy Krueger to shame. For example, the minimum requirements of Dr. Cranky’s medical college thirty years ago included of a year each of biology, physics, general chemistry, organic chemistry, biostatistics and calculus. This did not include your host’s elective course work in biochemistry, embryology, physiology, mammalian anatomy, vertebrate morphogenesis and research so he might be more competitive. And mind you, all of this was before he was even allowed to set foot near his future alma mater’s front door.
Once admitted, if a medical student wishes to get into a competitive residency training program such as Emergency Medicine, he must continue to excel. There are additional courses in anatomy, physiology, histology, pathology, neuroanatomy, pharmacology and therapeutics to name but a few. And don’t forget the two years of clinical rotations, either. The amount of reading and study required is Herculean at its easiest. It is said that if medical students were to have two a*ses they would work them both off in the course of their studies. It is not unusual for prospective doctors at this stage to see many of their classmates quit and fall by the wayside. “Obviously, they didn’t have the right stuff,” those who persist say to each other. If one survives to the end he is keenly aware that he has overcome great difficulties which would make ordinary men and women weep copious, bitter tears of exhaustion. “We who have made it through are different! We are special!! We are part of an elite few!!! And now our patients, those mere mortals we left behind so many years ago, actually expect to be satisfied with their care? Don’t they know what we’ve been through? How dare they!! What insolence!!!!”
At least that’s the ego-trap many young doctors fall into. In reality, all they do is come to believe their own hype – just like any other group of individuals who manage to overcome a period of tribulation together. You can see it in many disparate groups from military recruits once they have finished basic training to college professors after they have been granted tenure. The more arduous the training, the greater there will be a feeling of privilege. Yes, medical school is difficult but it’s not impossible. After all, your earnest host made it through, didn’t he? And this is from a man who sometimes can’t even remember what he ate for breakfast this morning.
More culpable, however, is the clinical training process which follows such initial indoctrination. Consider the following example. Dr. Cranky did his internship at a well-regarded educational institution whose basketball team, in the words of the prevalent internet meme, perpetually “sucks.” It was at this medical center where your faithful scribe had the unfortunate experience of receiving tutelage from the notorious Dr. G. The psychological scars inflicted upon Dr. Cranky’s personality by this malicious martinet can still be seen to this day. Dr. G was a man born of the strictest Prussian military tradition. He especially liked to play a sick and twisted game with those under his supervision. Medical students everywhere fear it. There are many names it goes by, but Dr. Cranky and his intimates would often refer to it as “quizmaster.” In this game Dr. G would ask one of his young charges a question. If the intern answered correctly he was rewarded with yet another interrogative. This would continue until he inevitably answered incorrectly at which time the poor wretch was publicly derided as being the most unworthy piece of subhuman slime the medical education establishment had yet been forced to endure. Didn’t you know that when Dr. G. was an intern he ALREADY knew the intricacies of renal failure?
Curiously enough, despite all the heat that was generated by such exercises it was never followed by any light. Dr. G. loved to castigate us but would never actually teach anything. Instead, he would admonish us for hours about how we needed to read more. It was as if he couldn’t be bothered to mingle too long and share his omniscient brain with us unwashed riff-raff. Although he desperately wanted to, the young Dr. Cranky could never summon up the courage to point out to Dr. G that if he would just spend a fraction his time actually instructing us then perhaps we would know such facts, too. If all of this seems like some form of institutionalized child abuse, let your host confirm for you that it is. And, just as the cycle of abuse is commonly transferred from parents to their children so too is it transferred from young doctors to their patients.
Dr. Cranky understands why hospital administrators feel an obligation to use devices like the Press Ganey survey. Quite simply, they need to measure patient satisfaction because the existing medical establishment is not concerned enough to do it for themselves. America’s doctors like to deal in cold, hard, scientific facts. It’s only natural, given that we’ve spent the majority of our lives living and breathing such things. We’re not very good at this feel-good warm-and-fuzzy squishy stuff. At yet, such human decency is exactly what is called for. We’re so busy concentrating on the science that we completely ignore the need to practice the art of medicine. And why is this? Perhaps it’s because many of us are left with a feeling of privilege because we overcame the odds and managed to survive the selection and training process. Then again, it might be that more than a few of us have had the humanity burned out of our very souls from abuse and are just hollow shells of the men and women we used to be.
But there is good news – it does not have to be this way. To be honest, when Dr. Cranky first discovered that the hospitals he works at were going to engage Press Ganey to survey his patients he was mortified. After all, it is normal to fear that which you do not understand. He had heard unfounded horror stories from some of his friends in the Emergency Medicine community and didn’t like the idea one bit. But then he looked carefully at exactly what standard he was being held to and it all made perfect sense. Yes, we doctors are not good at the squishy stuff but we can learn to be. It’s really not all that difficult. And as a bonus, your humble chronicler has found that with such effort comes a new-found satisfaction with caring for others.
Dr. Cranky remembers a distinction the Big C used to make about the difference between doctors and physicians. “A doctor,” he once said, “is nothing more than a technician – someone who uses a set of cold, unfeeling tools to fix a machine. A physician, on the other hand, is a healer. He understands that he has been given the unique privilege of helping a fellow human being in ways unimaginable to others. People entrust us with their wives and husbands, daughters and sons, mothers and fathers. Oftentimes they place their very lives in our hands with the belief we will do what is right. Never forget that this is something sacred. We are all so much more than just the sum of our physical parts. A doctor may fix the body, but only a physician can heal the man!”
Dr. Cranky’s most beloved mentor then spoke the following words. Those who are familiar with Rudyard Kipling’s epic poem If will recognize it as the Big C’s version of the last stanza:
“If you can talk with drug seekers and keep your virtue,
Or walk with CEO’s- but not lose the common touch;
If neither drunks nor abusive types can hurt you;
If all people can count upon you, and never have it be too much;
If you can fill the unforgiving minute
With your knowledge and save a life, what then;
Yours is the Earth and everything that’s in it,
And you will be an emergency physician – a true healer of men!”