Do You Make These 5 Mistakes With Your Quality Improvement Program?


by:  David Kashmer (@DavidKashmer)


Here are 5 of the most common barriers I’ve seen to effective quality improvement in healthcare…


(1) Respond right away to the worst (or best) case

This one is a classic, especially in healthcare.  Some cases feel so bad (or so good) that we re-orient an entire system around that spectacular case.  The problem?  Responding to best or worst cases, without knowing how they fit into your overall system’s performance, actually tends to introduce more variation (and lower quality) into your system!  Before responding to a case that feels terrible (or great) make sure you know the distribution of data for your system, and where this case that felt so bad fits.  Remember:  failure to rigorously know how your system performs means that you run a high risk of creating worse outcomes when you make changes based on one case without fitting that case into the context of your system.


(2) Attribute the problem to the people involved (only)

Here’s another healthcare classic:  attributing some outcome to one person or personal failure.  In healthcare, we’re trained to very much focus on our personal performance, which is probably a good thing.  We’re tough on ourselves.  Often, in training young staff, we focus on an illusion where, by force of personal will, the doctor involved could’ve overcome all the friction in a system to achieve a great outcome.  (More on that here.)  We pretend it doesn’t matter that labs weren’t drawn, the equipment wasn’t there, or that the fact it was raining outside caused 200 patients to be present in the Emergency Department so that the system was over-run.  Failure to recognize the contribution of all six causes of special cause variation leads to an overly narrow focus on people to the exclusion of all else.


Guess what?  People are very important.  However, we’ve noticed that, when the system around the people is cleaned up and aligned with the desired outcomes, that the people suddenly look a whole lot better.  Often, I wonder whether the “people issues” like providers fighting in the Emergency Department, other friction between staff, and poor decision making are manifestations of a bad system.  After all, when the system is repaired, a lot less of what used to be called “people issues” come up.


(3) Fail to recognize the true message of your system

Interestingly, every system tells a story.  Data collection and visualization allow the central tendency of the situation to be appreciated.  Just as importantly, the variation seen in the system (which often relates to the risk that one patient will experience a bad outcome) can be readily appreciated by collecting data and visualizing it.


One fact that makes it tougher to recognize how your system performs is the focus on external benchmarks.  Whether it is the regulated nature of healthcare or not, focusing on benchmarks before you’ve improved your system may lead you to accept a worse performance than you could actually achieve.  Consider improving your system and eliminating defects first and then comparing your new achievement to external benchmarks.  No, you can’t stop measuring government and other accrediting body endpoints (nor should you) yet you can focus on minimizing your defects to the lowest possible number before you start to respond to external benchmarks.


Why is so important to get a clear, visual version of how your system performs?  It allows you to make interval improvement.  It allows the team to see how it performs as a whole.  It makes it obvious that, without improvement, the system performs at a certain level that will have some number of bad outcomes or defects.  It can make the team uncomfortable, yet the discomfort is the sign of impending growth.  Consider that, if you don’t have data, you just have an opinion based on the part of the system you see…as you see it.  More on that here.


In healthcare, once we see our true performance we are left with the decision to improve the situation or just to attempt to ignore it.  Casting the choice in this way can make us feel a little uncomfortable, and yet this discomfort often signals that we are about to break through to a new level of performance.


(4) Never figure out whether you’re doing better, worse, or there’s no change

There are some tough situations that exist out there in healthcare process improvement.  One of the most difficult is when the team feels it’s doing better but in fact there’s been no real improvement.  Just as tough is the feeling that there’s been no improvement, despite hard work, yet (in fact) things are improving overall.


These situations point to the importance of statistical process control, because one of the most useful elements of data driven quality improvement is that it has the power to disabuse us of confirmation bias (seeing what we want to see) and other pitfalls of process improvement.  Data driven quality projects allow us to see statistically significant, meaningful improvement or the lack thereof.  We may even see that, despite hard work, we have yet to see improvement.  In short, data driven quality improvement tells us about the performance of the system no matter what our gut may report.


(5) Failure to create a process that uses rigorous data and monitors your progress

In order to use data to decide what to do, we need to be careful to use meaningful data.  Setting up a process that collects meaningful data, supports the team’s needs, and keeps the team together in a non-pejorative manner is key.


Just as important as having useful data is to remember that your quality system needs to perform ongoing maintenance.  That is, once the team has improved some aspect of the program, the quality system needs to look in on that endpoint to make sure it’s still performing over time.  Failure to utilize ongoing surveillance of previous improvements just allows any gains to erode over time.


One nice way to express this sentiment is that quality improvement projects don’t end, they just enter a control phase.  No matter which technique you use, remember to look in on your previous work at certain intervals.  Be sure you check in on previous work so that you can “trim the weeds”.


Do you make any of these 5 classic mistakes with your quality improvement systems?  Don’t feel bad, most programs in healthcare commit at least one of these on a daily basis.  I hope that focusing on the root issues in your system with a rigorous, data-driven process will allow you to see that many quality issues aren’t as simple as a mistake or poor performance by one of your staff.  Meaning quality improvement that avoids these classic pitfalls can help your system progress to creating less defects and rework…then, suddenly, the people involved look a lot better!

Would You Know If You Were Incompetent?


By:  The Generation Y Surgeon (@GenYSurgeon)


There’s more to business than dollar signs and sales–a lot more.  Within the broad discipline of business, there is a focus on people: how they think, how they interact, why they do the things they do and how to get the most out of each and every member of the team.  Teamwork, interpersonal relations and communication can make or break even the strongest of businesses and as a result, our friends in business have invested a lot of time and energy into learning how and why individuals and teams fail or succeed.  

As providers we are required to function within teams. The environment is stressful, the stakes are high, the time crunch is unrelenting and our partners/coworkers can be challenging to work with.  There are tools available to help alleviate these problem interactions and inefficiencies yet very few of us use them.  Worse yet, we don’t even know where to look for help.

For my next few blog entries I would like to share some of the concepts and skills that I have found to be most useful in the hospital and clinic.  Thinking about our workplace in a different light, and learning just a few new tools to deal with people and stressful environments, can lead to positive changes…if you choose to experiment with some of these tools.  I challenge you to take these concepts and ideas into your own workplace and use them to create a happier and more efficient workplace for yourself and your healthcare team.


The Dunning-Kruger Effect


The Dunning-Kruger effect is one of my favorite proposals, especially when you think about what it means to providers, to medical education and to our own personal development.  If you’re not worried about your own personal performance after learning about this then, well, you have a problem.

The Dunning-Kruger effect is a cognitive bias whereby unskilled individuals suffer from illusory superiority, mistakenly rating their ability much higher than accurate.  (More about it here in that classic tome of knowledge, Wikipedia.)  Highly skilled people, however, tend to underestimate their competence and wrongly assume that tasks they find easy themselves are also found easy by others.  In other words, the unskilled don’t realize they are inept and the skilled undervalue their skill.  Again, this is a cognitive bias and it’s related to confirmation bias, meaning that people see what they want to see and ignore what they don’t want to see.  Most people believe that they couldn’t possibly be wrong or less intelligent than others so they develop an artificially inflated sense of self-esteem.  Unfortunately, this shields them from recognizing their own lack of skill, the extremity of their inadequacy, and the presence of genuine skill in others.  For these reasons, the incompetent tend to stay incompetent.

Think for a moment about what this means.  Try to remember the last time you felt truly competent and confident in your abilities…were you actually competent or blinded by your own ignorance?  Now think of the last time you felt inferior to your peers…was that your shining moment?  So…are you second-guessing yourself yet?  The good news is that you’re probably not as inept as you sometimes think you are…Yet, on the flip side, you may be lacking severely some skills without even knowing it!

Understanding the Dunning-Kruger Effect is the first step, now let’s apply it to a couple of scenarios:


-M&M conferences:  Providers know a lot and pay special attention to learn from mistakes.  According to Dunning and Kruger however, the inept are unable to recognize their own lack or skill, the extremity of their lack of skill and the presence of genuine skill in others…did you ever wonder why so many M&M’s repeat themselves?  It’s because some of the people in the audience are unable to see their ineptitudes and therefore fail to learn.  Wise physicians will tell you “know what you know, and more importantly, know what you don’t yet know.”  Incompetent physicians cannot fathom that there are things they do not yet know.

-Public opinions on vaccines and gluten-free diets:  As a provider you understand the science behind viral disease, vaccinations and how they impact the public’s health as a whole.  As a provider you’ve also seen the public refuse such vaccines.  Have you ever tried to explain the risk/benefits to someone who refuses vaccination?  Regardless of the data supporting influenza as a leading cause of death across all age groups, some people just cannot grasp the concept of vaccination.  We have been educated in virology, genetics, epidemiology and statistics and we’ve seen patients die from preventable causes.  Most patients have not.  This is why arguing with non-scientists about topics such as vaccination is so frustrating!  Because they have not been exposed to the skills/knowledge it requires to fully understand the topic they are unable to understand…and they don’t even realize how little they know!  They are so blinded by their lack of skill/knowledge in the topic that they cannot even see that they lack skill/knowledge.  (As an aside, I respect all educated decisions about vaccination…unfortunately most people who refuse vaccination are not equipped to do so.)

Now you know what the Dunning-Kruger Effect is and how it affects our daily lives.  You should find this concept unsettling because it uncouples perception and performance, leaving you wondering where you stand among your peers.  How can you correct your ineptitudes if you don’t even know you’re inept?!  Well the good news is that Dunning and Kruger also proposed that incompetent people will recognize and acknowledge their own previous lack or skill IF they are exposed to training for that skill.  So keep your eyes open and embrace those feelings of inadequacy…if you don’t feel incompetent sometimes you just might be, well, incompetent!

I hope you enjoyed this blog and learned a little something.  Take this new knowledge with you into the hospital or clinic and use it to better understand yourself and others.  And take it easy on yourself the next time you underestimate your own skill.

How To Run Thanksgiving As A Startup


By:  David Kashmer, MBA (@DavidKashmer)


Did you know that thinking about Thanksgiving as a startup just might help us focus on what’s really valuable about this great holiday?  Consider this as you take some time to think about how you’d startup Thanksgiving in your own unique way:


Step 1: What’s The Value Here Anyway?


Before you do ANYTHING, you need to decide what Thanksgiving means to you. What’s the value proposition? Is it the food, the time with family, the football game on TV? What is it exactly? It’s from that central decision that everything else flows…and I won’t answer it for you. Only you can decide, and decide you must, before moving on with your Startup Turkey Day.



Step 2: Build the Team


Ok ok…many of us who have started a business before think that you need at LEAST two things to make for a truly great business model: a great team AND a great idea. Which is more important? Well, I don’t think that question really matters! Because, experience teaches, if you don’t have the right team then there’s no idea that’s good enough to fly. If you don’t have at least a “good enough” idea then a great team can’t make it. However, I have seen a truly awesome team take the most marginal idea and make it gobble up the competition…


So, speaking of flight (and birds), what about Thanksgiving? (Ok the bad puns end here…) What kind of team will you need to execute the value proposition that is Thanksgiving?


Did you know, for example, that there’s evidence about startup team size and eventual success? Consider, for that reason, keeping the team size to 3 or 4. More on that here.


What about family? Should they be involved in your startup turkey day? Well, in general, I’d say DON’T start a business with your family(!) You can read more about it here. Yet, in this case, well…I mean it’s Thanksgiving! Probably not a good idea to keep the family out!


…and, hey, be sure to involve the family members who have complimentary skill sets! Maybe one person takes care of scheduling the when and where, another handles the setup of the actual event (tables and chairs), while yet another handles the food. Don’t forget that one family member who makes the stuffing you like so much.



Step 3: Use Some Tools


Ok, so now the three (or four) people of the team are all together. How will you all deliver the value that is Thanksgiving? Now it’s time to use a tool to make sure you are all on the same page as to what you’ll be doing, how it will deliver value, and how you’ll do all those things to make your Thanksgiving a success. For example, one tool that works great (WAY better than those old fashioned business plans that dissolve as soon as you make first contact with the market) is called the business model canvas. You can read more about the virtues of this great startup tool here.


As your team turns to the tool, think about what makes your startup unique and therefore somehow more valuable…take a moment to decide what your special sauce, exactly, will be…even if it is just cranberry.


Beneath, I’ve included an example of a partially completed business model canvas for a fictitious local startup, the Boxed Up Bird Association (BUBA pronounced “Bubba”).


Pretend your team of 4 decided that the central value proposition of thanksgiving was about sharing the feeling of thanksgiving with as many as possible, getting together families to share the holiday spirit, and uniting them over a tasty meal…Well, in that case, maybe your canvas would look like this:


A Sample Business Model Canvas for The Boxed Up Bird Association (BUBA, pronounced “Bubba”), a 501c3


BUBA seeks to bring Thanksgiving to multiple people by facilitating get-togethers, over food, for families that are separated somehow. Maybe BUBA, like in the canvas above, would help families share Thanksgiving when they are geographically separated…a military family could share thanksgiving via telepresence (eg gotomeeting or a similar platform) while BUBA sent them each a boxed version of a Thanksgiving meal to share. Maybe BUBA would do this by arranging all of the online get-together, the meal, and even the highlights of the football game. (Don’t forget to avoid spoilers across multiple time zones!)


While these families would get to enjoy Thanksgiving, so would yours. Seems like everyone would get what they need with the feelings of Thanksgiving…



Step 4: Like Your Idea?…Now Try And Kill It!


Just as many great, much-loved turkeys meet their ends around Thanksgiving, it’s time for you to try to end your idea now…while it’s on paper and before you’ve spent any resources on it!


Hey, we all fall in love with our own ideas. Now that you and the team have explored how you will deliver your Thanksgiving value proposition, it’s a good idea to try and figure out all the ways it won’t ever work. I tend to start with the Costs and Revenue section at the bottom of the business model canvas.  Maybe you’ll start with what it will take to get “customers” to participate in your greatest-Turkey-Day-ever experience.  Do customers even exist for this sort of thing?  And how could you know or find out?


For costs, I use worst-case scenario costs. Seriously, we’re dealing with a brand new, never-been-tried scenario here. It may even be an industry you haven’t been in before. You lack info. There’s uncertainty. Plan for the worst as you figure out what costs it will take to make BUBA (or your personal Turkey Day Plan) go!


I recommend completing the canvas with the costs you will have each month and the one time startup costs you will have. It will help you figure out how much funding you will need for the startup, and figure out cash flow issues in the future. (More on that later in the entry.)


Under revenue part of the canvas…same deal. How will you collect revenue? How will you avoid cash flow problems? What margin (after tax) will you need to make it worth your time? Can you justify the price you’d have to charge to get that margin? Are you ready to work this hard? Do you recognize the seasonal component of BUBA (or your startup) in your business canvas and cost structure? Tough questions! Again, plan for the worst so you don’t come up short. Figure out how much of your service / product / awesome Turkey Day Experience you will have to sell in order to at least cover your monthly costs (rough break even calculation). And, again, remember that Turkey Day is a seasonal experience…


The idea behind all this is the recognition that your startup is an experiment. You have unknowns that you should try to quantify as you constantly (and quickly!) learn. However, despite trying to minimize the unknown, you never really know how things will play until you run the test and loose your Turkey day startup on the real world. So, plan accordingly!


(Maybe, if you’re lucky, you’ll stumble on something that takes the Turkey Day experience and extends it throughout the rest of the year so that you can have income then too…like “Holiday In A Box” or something.  Who knows.)


If your idea survives this ruthless barrage of cost-loading and planning for worst-case-revenue, then move on to the next step. If it doesn’t, or it looks bad now (a wounded turkey but one that’s not dead yet in the best Monty Python sense), re-think what you’re doing! It’s much easier to pivot / adapt your business on paper before you’ve spent any money.


Step 5: Align The Team


Guess what, if BUBA (or your personal Turkey Day startup) takes off it is going to be TOUGH to keep all the players on the team aligned. From experience, let me say that now is the time to make sure you and all the teammates will be rowing the same direction at each stage of the company’s growth. When Aunt Maud’s awesome Thanksgiving whipped potatoes are a huge success 5 years in the future, that is NOT the time to sort out which team member contributed to the Turkey Day’s startup success. Do it now!


How do you keep everyone aligned? There are some really great tools for that such as dynamic ownership equity. Check them out and use them now! Look here. After all, one of the most common reason startups fail is mis-alignment of team members. Use the tools and avoid this terrible issue that seems to magnify as the startup goes on.


Step 6: Funding Turkey Day


Wow…all this because you decided to think about what Thanksgiving meant to you, and then you realized that the feeling of family and togetherness should be shared with everyone. You really signed yourself (and your team) up for something here, didn’t you?


Well, now, if you’ve made it this far it’s time to find funding for your startup Turkey day. How much funding do you need? Of course, it depends on the idea and your business canvas…


A classic (and very functional) recommendation is that you should fund your new business with 4-5 month’s worth of “runway”. That means, pretend your business won’t have ANY revenue for 4-5 months and yet will incur all of its costs. After 4-5 months, if your fledgling startup (sorry about another bird reference—promise about no puns violated) isn’t at least breaking even then re-evaluate the startup. Is time to pivot / adapt the business, or is it time to call this experiment unsuccessful and to move on?


Only you can decide.


Conclusion: However You Do It—Happy Thanksgiving!


If nothing else, putting this much thought into Thanksgiving allows for deep learning about what you really value in the day. Is it time with family? Is it giving thanks for what we have and sharing that feeling with others? Maybe it’s the food and football! Whatever it is for you and yours, have a Happy Thanksgiving from me and your friends at the fictitious Thanksgiving startup non-profit…The Boxed Up Bird Association (“Bubba”)!






4 Things Doctors Should Report When There’s An Equipment Problem

By:  Jaime Ennis (visit Jaime on LinkedIn here.)


For all you physicians, surgeons, and healthcare providers out there:  I’m the guy who works to make sure your equipment does all it’s supposed to for the care you give to patients.  Stapler misfire?  Broken laparoscope with lines on the screen?  I’m the guy for that stuff.  Let’s talk about how equipment problems are reported so that we can work together to make sure that we don’t have equipment issues that hinder your ability to do the best you can for us–the patients!


The Quality of Medical Device Reporting

Data is everything to a Quality Engineer, and when a Medical Device Report (MDR) is received we must follow a strict procedural approach to reveal the root cause. Often the information received is ambiguous and actually hinders a proper investigation! The Failure Modes Effects Analysis (FMEA) are updated,  Statistical Process Control (SPC) is analyzed, and Control Plans are reviewed…but the true value of the report is diminished when a reactive approach is taken and the preventative opportunity lost.  Let’s talk about some of the ideas that may diminish the best reporting possible.

Medical device manufacturers are doing it for the money!

True, but remember at the same time device engineers strive to deliver perfect products that meet the customer’s requirements and provide a positive, memorable experience. It’s for the docs, the manufacturers, and the patients. (Don’t worry, I know there’s a patient at the end of the stapler!) In manufacturing medical devices we choose to follow a difficult and costly path riddled with risk. We imagine being the patient who requires perfect quality the first time, every time, but our best efforts are only as good as the data collected from the field. I often wonder what percentage of mandatory reporting is misrepresented or the adverse event occurred during misuse and ultimately a misunderstanding of the devices design capabilities. Please help us understand the problem and we will fix it at any cost!

One MDR can take a year to resolve and is worth every second!

Without being specific, I have worked an entire year to improve a product without a single change to the design. The cost has yet to be realized, but $1,000,000 is a conservative estimate and will absolutely be captured in our cost of quality metric. In this example, different tissue thicknesses were evaluated and countless tests were completed to improve the device’s performance envelope. To validate the smallest process change, several thousand devices were assembled and tested in the predefined manner outlined with the devices approval. Imperceptible to the user, this device will now function in applications never imagined or planned for. This duration could have been reduced, but one MDR with very little information is all it takes to spend a year putting the pieces together. The next time a surgeon reaches for this device the last thing I want is the distraction of failure in their mind. 

Surgeons, help us help you!

Here are some simple rules to follow when faced with an MDR:

  1. Capture every detail: There is no technical detail we can’t unravel, and we will consult your peers to understand any situation. The more relevant detail the better we will serve you and this information may be passed down several times before it reaches the appropriate subject matter experts. Don’t be afraid to use that extra page provided to describe what happened.
  2. Include technique: When we set out to recreate the failure, your experience must be clear. We want to test devices in an accurate manner and this information is paramount. If a surgeon describes their experience firsthand, we won’t assume anything.
  3. Query your peers: Before committing to the content, consider every perspective of your surgical team. Perhaps they will add value and reveal something unperceived.
  4. Pictures speak a thousand MORE words: The most successful investigations I have participated in included reports that were accompanied by pictures. You may be contacted by the device manufacturer and pictures will always be valuable.

So, to all you healthcare providers, I want to say hello and let you know about what we do to make sure all those devices out there do the right thing for the first time they’re used and every time they’re used.

Thoughts, questions, or comments?  Let me know beneath!

You’re A Programmed Coincidence Machine, And You Can Do Better

By:  DM Kashmer MD MBA FACS (@DavidKashmer)


A Few What If Scenarios

Take a minute to answer these questions.  I’m really interested in what you think.  Nothing tricky here, just some interrogatives about what we commonly experience.  Picture each situation in your mind and see where they go…


(1) Lightning strikes a dried out log during a storm, what happens next?


(2) It rains for a half an hour and the ground is soaked.  Fortunately, the sun came out while it was raining and stayed out when the rain stopped.  You look up at the sky on this sunny day just after the rain, and you expect to see what?


Ok, so what about that first situation?  A flash of lightning violently strikes a log and you watch expecting to see what?  A fire?  How about the rain storm on a fairly sunny day?  You look up at the sky and expect to see what?  A rainbow?


Guess what…usually when lightning strikes a log there’s no fire.  And in most situations where it rains, yet it’s fairly sunny, there’s no rainbow.  Why do you intuit things that aren’t really going to happen?  (I do it too.) Why is our mental simulator WAY off?


The Mental Simulator We Have Is Way Off

Here’s why:  we’ve evolved as a programmed coincidence machine.  Look here.  Or here.  (Please note:  I did NOT offer Dawkins’ argument to agree with his conclusions about the Divine…I just offer some of that work to highlight how the idea that we seek order in randomness is very common.) Oh I didn’t make up that catchphrase “programmed coincidence machine”, yet it nicely captures the idea.  It is evolutionarily adaptive, so the line of reasoning goes, to notice “Hey that makes a fire!” or “Wow look at that unusual thing…”.  Noticing special cases is programmed into us.


Well, guess what…that leads us to lousy decisions about everything from investing to what makes us happy.  (Check out how our mental simulator fools us with respect to happiness here.) Strange, huh?  And counter-intuitive.  I file findings like this away with truisms like the Dunning-Kruger effect.


We Don’t Notice The True Message of the System

The bottom line is we don’t notice the full robustness of the situation, with all of its variation, central tendency, and beauty in the system.  We are easily distracted by special cases which don’t embody the full message of the system.  You see this all the time!


For example, what happens in the field of Surgery when a case goes wrong?  Well, it garners attention.  Sometimes we even react to the spectacular cases where the spotlight has shined and we miss the message and robustness of the system.  We overcorrect or, worse yet, under-recognize.  Often, in classic Process Improvement systems in Healthcare, we don’t know if this latest attention-grabbing headline / case is a issue, outlier, or exactly where it falls.  So we react (because we care) and disrupt a system with inappropriate corrections that actually induce MORE variation in outcomes.


Advanced Quality Tools Offer Some Protection

That’s why I work with these tools, and why I like to describe them.  Understanding Type 1 and Type 2 errors, working with data to represent the complete picture of a system’s variation, and knowing rigorously whether we are improving, worsening, or staying the same with respect to our performance are key to understanding whether and how to make course corrections.


I recommend using some rigorous tools to understand your team’s true performance, or else you may fall victim to the spectacular…yet distracting.


Disagree?  Have a story about being lead astray by intuition?  Let me know beneath.


Would You Like Fries With Your Healthcare?

By:  The Musing Medic (@TheMusingMedic)


One Night, While Working Triage…

Most of my professional time is spent in the emergency department, specifically floating on the floor or manning the triage office. Of those two places, my favorite is easily triage. There are a fair number of my colleagues that don’t care for triage for a few reasons. The most commonly cited reasons I have heard are too many patients and fear of missing something. While I can respect and understand both those reasons, I think triage houses prime examples of the patient vs customer debate.


I was covering triage for an entire shift the other day and was seeing patients at a high rate, hovering around eight patients per hour on average. Like most days, the majority of these patients were “fast-track worthy” and didn’t constitute a true medical emergency. In other words, they have an inconvenience-type problem rather than an emergency.


A Dental Pain Patient Complains We’re Not As Fast As Fast Food

So I am triaging one patient after another with a majority going from the triage office to the waiting room. The entire department was full that day and the non-urgent cases were forced to bide their time patiently. At one point, a patient who had presented with the complaint of dental pain became somewhat displeased with the length of time they had been waiting, which by my calculation was just less than an hour. This person started out relatively understanding and pleasant but then progressed to downright rude. But that isn’t unusual. We see this all the time. What really stuck with me was when they compared us to a popular fast food restaurant. They mentioned how they never had to wait as long for their dinner as they did to get a medical examination. How do you respond to this?


There is part of me that wishes I could have seen my facial expressions in response to this ridiculous comment. I think any health care worker would have the same response. My handing of the response was as good as could be expected. I conveyed my understanding but kindly refuted the notion that an ED is similar to a fast-food enterprise.


More importantly, this illustrates what John Q. Public thinks the ED does on a daily basis. We are not open 24/7 for every trivial complaint. (Some dental pain patients are very legitimate, yet this one was well known to use a dental pain complaint to attempt to obtain unnecessary narcotics.) We exist to treat diseases and injuries that are either acute or exacerbations of chronic conditions that could result in loss of life or limb.


The ED Isn’t A Fast Food Restaurant

The ED isn’t a fast food restaurant.  Do you know how I know?  Most fast restaurants aren’t open 24 hours and serving a burger is very different than working on someone who is near death.  I mean, come on.


When did patients think they became customers who are entitled to the same customer service that any fast-food restaurant or retailer extends to those who purchase their goods? Why has it gotten to this point? Who allowed it? And what do we do to curb this mindset? There is an issue of expectations that need adjusting.


Want the same level of speed and customer service you get with your burger at noon?  Vote for the government to reimburse us so that, at midnight, we have fresh staff who are just waiting to take your order.


Want outcomes that are perfect?  Require us to make only 7 meals instead of caring for hundreds of different conditions that vary by the patient’s age, sex, race, level of non-compliance, and a host of other factors.


…or with every dose of morphine we administer should we ask if they would like fries with that?