Letters to the Editor

Posted on June 21, 2010 –

April 7, 2010

I am writing in response to the magazine article “Peer Review: Beyond Clinical Compliance”, in Volume 13, issue 1, Winter 2010 of “CORRDOCS”

In this article Dr. John DesMarais, writes “….in general we accomplish this goal by assessing the number of written complaints from both peers and patients. That sentence should read “…….by assessing the quality of the written complaints from both peers and patients”. Does Dr. DesMarais contend that his providers were hired to “make the inmates happy.” If an inmate is being misdiagnosed, that is a valid complaint.

It is impossible, to practice quality medicine, and not receive grievances. Should the inmates direct their own care, or should the provider? Grievances are usually centered around the inmate’s misguided perceptions. Should all requests for increased narcotics, no work slips, and knee braces so that the inmate can play basketball be honored? Providers, who do not obtain grievances, and I have worked with many of them, are usually, in fact, lazy. They do not want to respond to grievances, or sit down with the inmate and explain their treatment plans. These are the providers who cause grievances. The inmates write “I do not want Dr. X as my provider, but Dr. Y. They forget to mention that Dr. Y will give them anything they want.

I would be interested in what your readers believe about this topic.

Sincerely yours,

Dr. Harry Mamis New York State Department of Corrections

Dr. DesMarais responds:

It is a common misconception among clinicians to misconstrue both the content and intent of service quality. The essence of a provider who is adept at patient satisfaction is comprised of 3 basic skills: 1) listening and reflecting, 2) expectation identification and adjustment, and 3) communication and education. It is not our desire that all of our clinicians just “be nice” and provide whatever the patient wants. On the contrary, Dr Mamis is quite correct in asserting that would be counterproductive. Our goal is to cultivate an environment which fosters positive personal and professional interaction.

Consistent with these goals we’ve established a list of “A” team behaviors which we try to build into our culture – namely confidence, competence, compassion, communication, teamwork, trust, teaching and laughter – which make these team members “fun to work with.” When people enjoy their jobs and are surrounded by positive team members, they simply act more pleasantly toward everyone and have the ability to be more tolerant.

It is quite true however, as my first partner in medical practice used to say, “not even Jesus could please everyone” and we know that with our population that is the case. Obviously, we just don’t count up the numbers of grievances without investigating for trends and validity; however, I stand by my assertion that service quality is important, since it involves physician behavior and sets the tone for the other team members. The heart of service quality for prisoners is the artful re-alignment of expectations; it’s learning the ability to say “no” without inciting anger and vengeance. These are teachable skills, accomplished, after some effort, by using tools like scripts, expectation setting, rounding and lines in the sand.

Dr Mamis is, of course, essentially correct. Patients do not know what “quality” medical care is. But they do know a quality physician when they meet one.

As physicians we consider quality care an accurate diagnosis, testing verification, and an excellent evidence based treatment plan implementation. As patients we’d be concerned with whether the physician was pleasant, listened and cared, and whether we had to wait too long.

As physicians we cannot afford to ignore service quality if we want to have our jobs in the future. Our turf has already been eroded by NPs, PAs and midwives who seem to understand these concepts much better than we do. I remember the first time I heard about these ideas as a medical director of an ED; my reply was classic to the CEO: “I’m not here to kiss their ###, I’m here to save it!” So was his response: “We live in a service based economy, get used to it.” April 12, 2010 I read the president’s message in the latest issue, about educating medical students about correctional medicine. One small aspect of this that I have done over the last few years is to get involved in the MECO program. MECO (Medical Education, Community Orientation) takes students in between the first and second years, the last time they have a summer break, and places them in communities to learn how doctors interact with the community. The hospital where I am on staff sponsors several students each summer. They generally spend a day with each of several doctors of different specialties. I have each of them shadow me for a day. They have generally found this to be an interesting experience. If you have a tie-in with a local hospital that sponsors a student, this can be a valuable exercise. W. Rankin, MD East Moline Correctional Center East Moline IL