One Event, Two Stories

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I recently had a patient of mine undergo surgery to remove his gallbladder due to acute cholecystitis. He’d been out to dinner with some friends and had started to feel nauseated, then developed some right upper quadrant abdominal pain that necessitated ending the evening early. After a sleepless night, a morning episode of vomiting, and developing a fever, he came in to see me. I made the diagnosis, called a surgical colleague, and his gallbladder was taken out later that afternoon.

Afterwards, I talked with the surgeon, who reported the operation had gone well, with almost no blood loss. The gallbladder had looked “as if it was about to burst,” suggesting they’d gone in just in time, he said. It had been filled with pus and the surgeon considered the whole sequence of events “a real save.”

When I went to visit my patient in his hospital room, however, he painted a much different picture. He was extraordinarily grateful to be alive and to all of us who’d worked in concert to bring that result about, but what he was mostly focused on was how awful his minute-by-minute experience had been.

He’d been in terrible pain, he said, while in the ER waiting for the surgical team to come down and evaluate him. The ER doctors had given him pain medication that had dulled the gallbladder pain to tolerable levels, but the ER gurney, he said, had been incredibly uncomfortable. He’d had to wait in recovery for an hour before they’d gotten his post-operative pain under control (after asking a nurse several times to dial up his morphine, as the doctor had written she could do). He’d also had a terrible itch between his shoulder blades he was unable to reach himself and couldn’t get anyone else to scratch until he’d gotten his nurse’s attention for the pain issue.

When he’d finally been cleared to leave the recovery room, he’d been all but forgotten about for another hour until his hospital room was ready. He’d wanted to know the room number so he could text his wife, who’d had to leave the hospital to pick up their two children and take them from school to their grandparents’ house, but no one seemed to be around who knew.

Finally, when he’d arrived to his room, he learned he couldn’t eat anything (nor even drink water) until he started passing gas (a sign that the bowels had awakened sufficiently from surgery for him to tolerate food). Though he understood the reason for it, he hadn’t been warned about it and had been anticipating having a full meal once he felt hungry.

As I listened to his litany of complaints (all offered hesitantly: he wanted to make clear he realized these were small things given how close he’d come to death), I realized what a gulf existed between his caregivers’ goals for his hospitalization and his. Certainly, everyone involved had the same big-picture goals: for him to emerge alive and well. But not having been through the experience with him, his providers didn’t—and perhaps couldn’t—appreciate how much the little things he complained about affected his experience. He himself said he was willing to tolerate those inconveniences for the good outcome he got. But, of course, he didn’t get the outcome because he paid the price of those small inconveniences; they came because health care professionals who cared for him didn’t know exactly what the subjective experience of the illnesses they treated was like. If they had, those inconveniences would have become far more important for them to prevent.

Certainly, health care providers are incredibly busy practicing medicine and worrying about their patients’ health. And increasingly, I’m pleased to report, they’re worrying about patient experiences in the health care system as well. But good outcomes often come on the heels of horrible experiences—or just suboptimal experiences—that if health care providers were only more concerned about, could be significantly improved. Hospitalized patients really care that they have to wait thirty minutes before getting some water, or an IV changed, or a question answered. There are clear reasons for why the customer service patients often get is suboptimal, and it’s rarely a lack of caring on the part of caregivers. Providers are, in general, horribly overworked, and overworked people typically prioritize—which means, by definition, less important issues get pushed to the bottom of the list. And when the more important issues are matters of life and death, aiming to provide good customer service often finds itself playing second fiddle.

But more and more we’re recognizing that dissatisfying minute-by-minute experiences not only have as much, if not more, influence on how patients rate their overall experience than the health outcome itself, but also influence the recovery itself. Which is how a surgical team could consider a hospitalization entirely successful in every way, focusing as they do almost exclusively on the medical outcome, while the patient, though grateful for such a positive outcome, could decide never to visit the hospital again and complain bitterly about their experience for years (even while acknowledging the outcome was good).

My patient didn’t go that far, but he and I did converse about the details of his hospitalization for a good forty-five minutes and in that time didn’t touch on a single issue related to his medical care. We talked about empathy, kindness, and a willingness to make others feel comfortable in small ways. And what I realized afterwards was that small things often add up to produce a far greater impact than any of us realize.

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