The satisfied patient is the one we’re killing

From a UC Davis study that analyzed a >50,000 person national Medical Expenditure Panel Survey:

The study found that patients who were most satisfied had greater chances of being admitted to the hospital and had about 9 percent higher total health-care costs as well as 9 percent higher prescription drug expenditures. Most strikingly, death rates also were higher: For every 100 people who died over an average period of nearly four years in the least satisfied group, about 126 people died in the most satisfied group.

Interestingly, more satisfied patients had better average physical and mental health status at baseline than less satisfied patients. The association between high patient satisfaction and an increased risk of dying was also stronger among healthier patients.

Despite the proliferation of Press Ganey, I don’t think anyone who has worked in healthcare would find these results surprising. Healthcare may be a business, but there’s still trouble in treating patients like regular customers.

Meet Patrick


The future of prostate exam training is here, and his name is “Patrick.” Half sensor-embued tush-model and half computer-simulated cartoon-man, Patrick promises to grade medical students on their technique while also “present[ing] a realistic patient encounter” including “software that enables him to interact emotionally with the student.” (Before the exam begins, he tells you how scared he is.) [via Medical Daily]


Atul Gawande1writing about useless medical care for the New Yorker:

One major problem is what economists call information asymmetry. In 1963, Kenneth Arrow, who went on to win the Nobel Prize in Economics, demonstrated the severe disadvantages that buyers have when they know less about a good than the seller does. His prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.

Interesting, in an otherwise thoughtful and well-written essay (as always), Gawande never once mentions fear of medical malpractice as a component that is driving useless healthcare utilization. His best anecdotal examples come from surgeons and proceduralists, who in private practice have an incentive to operate. The family doc, on the opposite end of the spectrum, doesn’t have a direct monetary incentive to order non-indicated radiological exams.

He also never mentions the “patient as consumer” either. Keeping private paying patients happy is the only real monetary incentive most providers have. The argument he references above is that doctors have the power and are (inherently?) inclined to over-test and over-treat. But anyone who has tried to not give antibiotics to someone with a viral URI knows that patients often go to the doctor to get what they want, not to find out what they need.

How I read NBME/USMLE questions

From a reader:

What’s your step by step process when answering questions on the NBME shelf exams? I have been reading the question first while highlighting the key words and then reading the answer choices (often glancing back at the words I highlighted to confirm that the answer choice I chose is correct.) With this method, I am sometimes pressed with time and tend to rush towards the end. Could you talk a little about your approach to questions on the shelf?

In the past, I’ve written about some of the ways I break down NBME and USMLE questions, but I haven’t actually written about how I really read one. That may be because the answer is relatively anticlimactic, but here I’ll talk a little bit about my focus on flexibility and speed over rigidity when it comes to approaching Step questions (with a few examples from the 2014 official sample questions). As always, this isn’t necessarily what you should do; it’s just my take. When I used to teach Kaplan MCAT, part of the “method” placed a lot of emphasis on using passage mapping as a consistent approach. If time management isn’t a problem for you, there’s no reason you can’t start/continue using these more involved strategies. But if you don’t have a big system and feel left out when you’re friends are fervently highlighting and using answer-choice first schemes etc, you’re not alone. Continue reading