Будянский - главная ›› Чужие посты ›› Туда же , хорошее эссе

Туда же , хорошее эссе






Well-Served as Patients, Dissatisfied as Customers

By RICHARD A. FRIEDMAN, M.D.

Posted on the walls of the hospital where I work are banners and billboards that invite patients to fill out satisfaction surveys. "Tell us what we‘re doing right and what we‘re doing wrong," they say.

Health care, if you haven‘t noticed, has become a highly competitive business. And, like all businesses, we aim to keep our customers happy. We‘ve even adopted business lingo: patients are now routinely referred to as customers or consumers.

No one would argue that hospitals and doctors should not be responsive to patients‘ concerns. But a business model that says the consumer is always right can clash with what is best for a patient, especially in the area of mental health.

Not too long ago, I received a call from a patient care representative at the hospital. A young woman who was in psychotherapy with one of my residents had called to complain about her treatment and demand a new therapist.

She was unhappy, she said, with what she felt was her psychiatrist‘s challenging manner, and she complained that he was occasionally late for appointments.

When I spoke to the resident, he confirmed that his patient was angry with him, but he was surprised at the intensity of her reaction to his comments and at her request for a new doctor.

Sure, he said, on occasion he had run over with another patient and had kept her waiting a few minutes, but he felt they had a good relationship. Then I met his patient.

She was a woman in her early 30‘s who was articulate and intelligent and angry. I asked her why she was so angry. Well, she said, her therapist was unprofessional for being late, but what really bothered her was his response to her anger.

Apparently, he had suggested that her rage over his tardiness was pretty much like her problem in all relationships: other people were perfect until they did the slightest thing to disappoint or frustrate her, then her adoration morphed instantly into rage.

His apology for being late had little effect on her reaction.

Like others who have what psychiatrists call borderline personality disorder, this young woman had a very fragile sense of self and drastic shifts in her mood in response to even the mildest interpersonal friction.

"Can‘t you just assign her to work with a different therapist?" the patient care representative asked me.

She understandably wanted to please this patient and was clearly worried that if she didn‘t, the patient might take her complaint to a higher level, like the Department of Health. It wouldn‘t be the first time.

I could have reassigned the patient, but it would not have been in her best interest. Her frustration and anger, I explained to the representative, were an essential part of the problem for which the patient was being treated in the first place.

And, her emotions were actually a sign that the treatment was doing what it was supposed to.

The representative insisted that the patient was going to make trouble and asked if we could find some way to "accommodate" her.

Considering that the patient had already fired two therapists in the previous year for nearly identical reasons, I said that switching doctors again would not only fail to solve the problem, it would be anti-therapeutic.

According to the business model that now permeates hospitals, all complaints must be taken at face value and assuaged, with little regard to the clinical context or to the effect on the patient.

But in good psychotherapy, it is not possible, let alone desirable, to keep patients happy and satisfied all the time. Frustration, anxiety and discomfort are unavoidable in life, and in therapy - particularly for patients with certain personality disorders.

This isn‘t to say that doctors and hospitals shouldn‘t submit to intense scrutiny of how they do things. But they can‘t be blind to the fact that good treatment doesn‘t always feel good. Conversely, sometimes patients feel good about years of bad psychotherapy that is doing little to help them.

For medical consumers, there is a message here: good medicine sometimes means that the customer - I mean patient - isn‘t always right.

Or even happy.