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Saturday, December 1, 2012

How do patients view our care?

Back when I worked on a rural private ambulance, a pair of EMT-B coworkers tipped a stretcher over in the hospital parking lot - with the patient on it. The patient was not seriously harmed, fortunately, aside from a huge bruise on the side of her face. 

"Right here. Not here or here so much. Right here. .."
Now, the two EMTs were petrified about the near-certain complaint, firing, and lawsuit, but the patient just brushed it off - it turns out she had a real soft spot for those "ambulance girls."

On the other hand, I also have seen patients complain about some "trivial" matter, right after receiving high-level ALS care, true life-saving stuff. 

What happens after these complaints? The EMS crew becomes discouraged, the supervisor gets an earful, and the patient tells all their friends about their "terrible care." These sorts of complaints can be very frustrating, seemingly coming out of nowhere. 

Researchers in the UK decided to tackle this issue with a novel approach, aiming to explain the disconnect between the medics intentions and the patients perceptions.

                                                              *** Spoiler alert***
  Your patients may be judging the quality of their care based on non-technical aspects.

The study

In Patients' and ambulance service clinicians' experiences of prehospital care for acute myocardial infarction and stroke: a qualitative study, the authors carried out interviews with both patients and with "ambulance service staff." 

Researchers in this UK study chose to study patients who had been transported by the city EMS agency for a suspected MI or CVA. They also selected a groups of the "clinicians" (likely on the level of U.S. paramedics) who worked for the ambulance. In separate interviews, they asked these patients and providers various questions. (Unfortunately, they weren't able to link up the exact medic-patient pairs. That would have been difficult to arrange, I can imagine.)

So, after sifting through hours of recordings of interviews, the researchers found some interesting common ideas.

The patients placed a good deal of emphasis on how well (or badly) the medic was able to establish rapport, and explain their medical condition. The medics, for the most part, explained that they usually tried to provide reassurance and contact . Of course, a few medics explained that it wasn't their role to diagnose or explain the patient's condition to them, as "it’s up to doctors to make the ultimate diagnosis."

Pain management
This really was the only area in which the patients commented on the medical care itself. They may not know much about adenosine versus amiodarone, but they sure understand if their pain isn't acknowledged, much less treated! Of course, it proved to be a frustrating topic for the medics, as pain management often ends up near the bottom of the list of priorities during transport.

Again, patients may not know if the medic knows how to treat an MI, but they attach a good deal of importance to how quickly the ambulance arrives! Prehospital folks know this, and understand that a long response time "means that you are already on the back foot." More frustration - many patients viewed delays at ED triage as part of the EMS experience, if not precisely their fault.

Are these results expected? 
Yes & no. No one has done an academic study like this before, but that doesn't mean that people haven't been thinking about it. 

Allen Johnson, a paramedic-turned-hospital-CEO, wrote an article for JEMS back in 2010 about patient satisfaction in EMS. In The Customer's Always Right: Steps you can take to ensure customer satisfaction, he described most of the same issues that were raised in the new study. The article is not short, but I really like his summary:
Patients usually aren't qualified to evaluate the proficiency of our life-saving skills, but they are more than qualified to fully assess our interpersonal skills. And frankly, life-saving skills may be used on less than 1% of patients; our interpersonal skills are assessed 100% of the time.

A colleague once summarized the EMS patient's expectations to four simple points: 1) Get there quickly; 2) Be nice to me; 3) Tell me what you're doing, and 4) Take away my pain.
Leave it to a paramedic to boil down the research to this level!

So why do we care?
Because your bosses care. And their bosses. And regulatory agencies, Medicare, insurers,  the New York Times, as well as Yelp!

That is unlikely to be a surprise to anyone who has worked in healthcare for more than one day. In fact, large segments of the medical industry are devoted to measuring and reporting patient satisfaction, without any regard for the technical quality of the care. Everybody is being judged for patient satisfaction in medicine these day - including helicopter-EMS!

Critical (but also satisfied!) patients: Baptist LifeFlight
Money is also on the line now. Not only do emergency departments worry about patients choosing a different hospital, but they may also be payed less by Medicare if they have poor patient-satisfaction scores.

This attitude is now as dated as that nurse's cap.
Can EMS be far behind in this trend?

The bottom line
Be personable with your patient, communicate with them, and address their pain

Of course, you need to get that ECG, treat the hypoxia, and recheck the vitals signs. But those are, increasingly, not the only things that we are judged on these days!


  1. I have heard it said before that patients do not really understand the quality of care they are receiving, and that may be true in many instances. I am happy to see a study that shows that when it comes to pain management, they do understand! I hope pain management continues to gain traction as a priority for EMS and our patients.

    1. Yeah, it'll be interesting to see how this develops. I imagine the hospital-owned/ -operated EMS agencies will see some of this emphasis (especially with analgesia) at first, but that's a guess.

  2. One of my paramedic instructors stressed the importance of customer service by saying, "you can be the worst Paramedic in the world, but if you are polite, kind, and the patient believes you are empathetic, they will believe you've provided the best care in the world."

    1. And one of the founders of emergency medicine is fond of saying "Emergency medicine is show business for ugly people."