Seeing Stars | Iris Wertheim, MD

Iris Wertheim, MD

As is my regular practice, I called her the night before her surgery to let her know I was thinking about her and would be ready for her in the morning. We chatted about the plans for her daughter’s senior prom, and she was reassured and calmer by the end of the call. Now, today, on the morning after her surgery, I explained that the mass in her pelvis was ovarian cancer and had spread to other parts of her abdomen. Maybe she already knows, as so many of my patients intuitively do, but she hasn’t yet heard it from me. Rounds on the first day after cancer surgery are where I have had some of the most intimate and difficult conversations with patients. Today, I sit down and am fully present. I have spoken these words too many times to recall. Delivering bad news never gets easier, but sadly, I have gotten used to it.

When I say “cancer,” she appears startled, though we had spoken openly about my suspicions beforehand. “Did you get it all?” I emphasize the positives knowing that despite my protective instincts, I will not be able to completely shield her from unpleasantness. We briefly discuss chemotherapy and that outcomes are uncertain. What is certain is that her life and the lives of those who love her will never really look the same as before. Her identity will morph in ways yet to be realized and now forced to make room for: “cancer patient.” Another certainty, as she navigates new terrain, I will be there for her. We have known each other only a few short weeks, but it already feels like a lifetime of deep connection.

Today, we focus on how best to get her back on her feet as she recovers from yesterday’s surgery. “Doc, one more thing,” she asks. “Will I lose my hair? What about my daughter’s prom?” I sit back down as I know the importance of answering all the “one more things.” There will be many more to come and once I’ve answered all her questions for this morning, I say goodbye and tell the nurses the orders for the day including an extra-large dose of TLC. I am saddened to leave her alone.

I rush across the street and summon the wherewithal for a full day of patients in the office. I need to review a CAT scan before meeting with the first patient of the day. The poltergeist in the computer is slow to rouse. I wonder if the radiologist has emailed me the findings but no message yet. However, there at the top of my inbox- WHAM! “Dr. W., Your patient satisfaction star card is ready for review.” This month it reads 4.79 out of 5 stars, down from 4.89. Though 4.79 sounds quite good, I am disappointed. This metric has uncertain significance at best. It will not affect my practice, behavior, or most importantly, the precious relationships that I have with my patients. The change of one tenth of a point belies a special absurdity. Despite exacting discipline in so much of my life, I cannot resist reading my “star cards.” Like so many of my colleagues, I strive for perfection. I try to be a “5”.  Annoyed and feeling vaguely harassed, I notice the next email subject line: “Your Monthly Medicare Relative Value Units,” a poor surrogate measurement of productivity and efficiency. That email can wait until later.  Earlier today in the hospital room, I was a human being privileged to counsel and comfort a patient, yet now I am reminded that we are providers and consumers subject to ratings on a scale like those by which restaurants are judged.

In a 2011 New York Times article, Paul Krugman questions the framing of medical care as a commercial transaction: “How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers?” The relationship between patient and doctor used to be considered something special, almost sacred.”¹ A decade later, star rating systems have only served to cast us further afield from that sacred space between doctor and patient.

Since health care star ratings were introduced in the 1980s there has been an explosion in the number of private companies providing survey services.² Designed to capture patients’ experiences effectively to enhance “customer” satisfaction and improve quality of care, the star card composite score is derived from a survey asking a patient to rate an encounter with a physician on a scale of one to five.  Did your provider explain things clearly? Listen carefully?  Give easy to understand instructions? Know your medical history?  Show respect?  Spend enough time? Patient feedback is critically important, and physicians should be held accountable for their behavior. Of course, we should listen carefully, explain clearly, be respectful and spend enough time, at the very least. But the answers to the potentially ambiguous star card questions and the number that gets churned out is not likely to be a true reflection of what occurs between a doctor and her patient.

Multiple studies have cast doubt not only on the correlation between patient surveys and surgical outcomes^3,4 but also on the ability for widely used physician-rating websites to help patients navigate to the “best” care. ⁵^,⁶

The complex and multifaceted relationship between a patient and her doctor cannot be reduced to five stars. Fewer survey responses make for less mathematical sense, diluting the result to no better than a “like” on a social media platform. The star card report contributes to the devaluation of healing and this barrage of metrics, aptly coined “measure madness,”⁵ erodes personal and professional dignity. High rates of physician burnout⁷, suicide, and divorce are driven in part by the scorched earth of financial pressures, efficiency-driven over-scheduling and, most recently, the pandemic. Beyond burnout, we should be fearful of compassion fatigue: the physical, emotional, and spiritual exhaustion resulting from the demands of being a physician.⁸ As the bioethicist, physician and friar, Dr. Daniel Sulmasy profoundly stated: “Compassion is the stuff of healing.”⁹ Who are we without compassion, and how can we allow the frivolity of star ratings to risk our capacity for it?

Every August, white coat ceremonies are conducted across the country for new students fidgeting with stethoscopes and starchy white coats. Excited by the prospect of one day vowing an oath to the medical profession, they are not told they will be called providers nor warned about the stars. Perhaps coming of age in a ratings culture will inure them. It is only later they will learn to compartmentalize the business of medicine while remaining loyal to their oath to care for patients. The roadmap to the way forward has yet to be drawn though there is already at least one movement afoot to reclaim our role as healers.¹º Five-star ratings should be exposed for their potential harm. Our focus should be on what matters most: meaningful relationships with and providing excellent care to our patients. Distractions by trivial metrics, like star cards, should be minimized.

One week after that post-surgical hospital visit, we met again in my office, and I was equipped with a pathology report. She had more clarity as we discussed possible treatment options. She was most worried about her children and husband. She decided to wait to start chemotherapy until after her daughter’s prom. I sat with her longer than the schedule allowed while I admired pictures of her daughter’s beautiful dress and we compared notes about teenagers. Three years later after arduous treatments and a ride on the rollercoaster of hope and despair, she died peacefully. That night as I learned of her death, I wept. There is no star card that could measure the connection between us.

Iris Wertheim, MD, is a Gynecologic Oncologist & Clinical Ethicist at Northern Westchester Hospital, Northwell Health in Mount Kisco, NY.

References

1. Krugman P. Opinion: Patients Are Not Consumers. New York Times. April 2011:23-23. nytimes.com/2011/04022/opinion/22krugman.html
2. Siegrist RB. Patient Satisfaction: history, myths, and misperceptions. Siegrist Jr., R.B. (2013) patient satisfaction history, myths, and misperceptions. AMA Journal of Ethics, 15, 982-987. https://www.scirp.org/(S(351jmbntvnsjt1aadkposzje))/reference/referencespapers.aspx?referenceid=2920114.
3. Tevis SE, Kennedy GD, Kent KC. Is there a relationship between patient satisfaction and favorable surgical outcomes? Advances in Surgery. 2015;49(1):221-233. doi: 10.1016/j.yasu.2015.03.006
4. Kohring JM, Pelt CE, Anderson MB, Peters CL, Gililland JM. Press Ganey outpatient medical practice survey scores do not correlate with patient-reported outcomes after primary joint arthroplasty. The Journal of Arthroplasty. 2018;33(8):2417-2422. doi: 10.1016/j.arth.2018.03.044
5. Report on report cards. HANYS. https://www.hanys.org/communications/publications/report_cards
6. Lagu T, Metayer K, Moran M, et al. Website characteristics and physician reviews on commercial physician-rating websites. JAMA. 2017;317(7):766. doi:10.1001/jama.2016.18553
7. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: Contributors, consequences and solutions. Journal of Internal Medicine. 2018;283(6):516-529. doi:10.1111/joim.12752
8. Jablow MM. Compassion fatigue: The toll of being a care provider. AAMC. https://www.aamc.org/news-insights/compassion-fatigue-toll-being-care-provider. Published July 11, 2017. Accessed November 15, 2021.
9. Sulmasy DP. The Dialectic of Healing. In: The Rebirth of the Clinic: an Introduction to Spirituality in Health Care. Washington, D.C.: Georgetown University Press; 2006:65-65.
10. Curlin FA, Tollefsen C. The Way of Medicine: Ethics and the Healing Profession. University of Notre Dame Press; 2021.