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Patient "Styles" Need Different Care Strategies

We humans refuse to be standardized.

An unhappy patient at a doctor's office

A National Institutes of Health study reported that physicians whose patients rated them below the 65-th percentile on quality of care got sued for malpractice 26 percent more often than those ranking in the top third. Those ranked in the bottom third had more than twice the number of malpractice suits than those in the top third.

Do those results indicate incompetent doctors, cranky patients, or something else?

Doctors, nurses, and other healthcare workers love to share stories about the “patient from Hell” — the one who’s cranky, demanding, critical, eccentric, and seemingly never satisfied. Occasionally, they may talk fondly about the other ones — from Heaven — who are quiet, compliant, and don’t make things difficult. They usually don’t mention the other varieties, the “in-betweens.” Yet, these in-between patients may offer the greatest opportunity for personalizing and individualizing the patient experience. There, in that middle zone, lies the secret (I believe) to the integration of caring and curing.

Some years ago, while introducing the service management concept at Santa Monica Hospital, in West Los Angeles, my colleagues and I wanted to get a better understanding of patients as customers — a foreign concept at the time, and even a distasteful one for some medical practitioners.

We ran a series of focus groups with people who had been hospitalized, and also with people who had served as the primary caretakers for others in hospital. We wanted to know how they conceptualized their roles on the receiving end of medical care, particularly in a confidential setting with no healthcare workers present.

As the conversations unfolded, I began to notice several distinct patterns in the ways various members of the groups described their experiences.

The first and most obvious finding was that almost all of them declared a strong distrust of hospitals. It seemed that everyone had an uncle or a grandmother who had been done wrong by a mindless healthcare “system.” Horror stories were common, and freely shared. Several of those who had facilitated the hospital stay of a family member even referred to themselves as “guardians.” Clearly, many of them felt like victims, or potential victims.

But the second finding, which I found more intriguing, was that different people had distinctly different ways of coping with their anticipation of the experience, and different modes of behaving as they were living through it.

After viewing the videotapes of the focus groups a number of times, I began to see four distinctly different orientations — one might even think of them as “styles” — for coping with the patient experience. These psychosocial styles, or patterns of behaving, seemed to emerge from individual temperament, their ideology about the experience as a recipient of care, and their sense of their own entitlement, or lack of it.

I became aware of two distinctive psychological dimensions: an apparent desire for contact (or, simply, attention); and a desire for control. They seemed to be two relatively independent factors. Some people signaled a strong desire for a personal connection with their caregivers, and others much less so. Some people signaled a high need to feel “in charge” of their patient experience, while others presented as much more passive and compliant. Combined, they suggested four different coping patterns.

It appeared that each type of person sought a sense of safety and assurance in one of these four distinctive coping strategies.

And the third key finding — a general observation seldom contradicted by healthcare workers — was that they, the workers, tended to have one favorite type of patient: the amiable, compliant, undemanding, stoical one.

Because most in-patient facilities are necessarily very structured, procedure-based environments, somewhat reminiscent of a manufacturing operation, standardization has to be a top priority. Unfortunately, it becomes very tempting to try to standardize the patient as well as the procedure.

An in-patient stay is a distinctly anonymizing experience, and often an infantilizing one. From the ID wrist band, to the shapeless gown that exposes the derriere, to the unexplained procedures, to the total surrender of privacy, all the signals tend to confirm that the patient is some kind of raw material, moving through the system from intake through discharge. Just as a piece of sheet metal that’s destined to become a fender on a car is treated exactly like the ones that come before it and after it, so this “case” gets treated as one of a sequence. The patient who wants to deviate from the preferred pattern becomes a nuisance.

But the logistical convenience of the “one size fits all” approach to care delivery comes at a cost, and not just in malpractice settlements and premiums. In many cases, the decision to sue hinges on a sense of outrage or injustice about the way the patients feel they were treated. And angry people tend to bad-mouth service businesses far more often than the happy ones praise them.

According to the NIH study:

“Clearly, these studies underscore the well-known principle that good communication is the cornerstone of the physician-patient relationship. As the authors have often observed, and as is well documented in the literature, patients are not likely to sue physicians with whom they have developed a trusting and mutually respectful relationship. Simply put, patients do not sue doctors they like and trust. This observation tends to hold true even when patients have experienced considerable injury as a result of a 'medical mistake' or misjudgment."

Next, we wanted to see how healthcare workers might react to these findings, so we began showing the video footage of the focus groups to patient-contact workers in hospitals. We coached them to identify the four key coping patterns. Many of them had already been doing so, perhaps less consciously. Others apparently had been mostly oblivious to the differences and their implications.

We evolved a simple mnemonic device, in the form of a four-paned “window” diagram, to help them visualize the patterns and analyze the differences. The four “panes,” or quadrants, became “Q-1,” “Q-2,” “Q-3,” and “Q-4,” as shorthand signals for the individual temperaments. Care providers started saying, “She’s a Q-1,” or “He tends toward Q-2.”

By thinking carefully about each of the four key varieties of patients, the patient-contact workers could identify behavioral strategies for matching their preferences.

Q-1 patients, for example, present as polite, undemanding, "patient," stoical, and highly compliant. They score low on need for control - "Whatever you think is best, doctor" - and low on need for contact; they tend to suffer in silence. "I don't want to bother anybody - I'll be OK."

Q-2 patients, who are high on control orientation but low on contact preference, typically want more information — perhaps even technical details — and even like making some decisions about their care experience. “You don’t have to love me,” they’re saying, “but I want to know what’s going on.” They’re the ones who search the Internet and study up on their disorders. They watch the online videos of surgical procedures. They don’t want to be brushed off with simple, one-sentence answers.

Q-3s, by contrast — high on contact preference and low on control — usually seek reassurance. They’d rather not know about the scary details of the surgical procedure. They just want to know that everything’s going to be OK.

Q-4s — high on both dimensions — are often perceived as the proverbial “patients from Hell.” They signal their psychic needs with a whole variety of counter-dependent behaviors. But not all of them are obnoxious. Many are simply much more assertive than the norm, and they might be quite polite and articulate. And, of course, some are indeed inappropriately aggressive. They want to feel important.

As you read about these four patterns, I imagine that you’re visualizing yourself as leaning toward one of them as your psychological home base. What are your strategies for getting the care you need and deserve?

We can speculate: What would be the benefits if most of the millions of patient-contact events that occur each day (the “moments of truth”) were skillfully managed to account for the individual temperaments of the patients involved? Could it be done?

Maybe some day we’ll even have a better name for them than “patients.”

References:

“Communication Gaffes: a Root Cause of Malpractice Claims.” NIH Study, April 2003. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201002/

Service America! Doing Business in the New Economy. Albrecht, Karl and Ron Zemke. Chicago: Dow Jones Irwin, 1985. Re-released by the authors in 2008. https://www.createspace.com/1000238160

The Author:

Dr. Karl Albrecht is an executive management consultant, coach, futurist, lecturer, and author of more than 20 books on professional achievement, organizational performance, and business strategy. He is listed as one of the Top 100 Thought Leaders in business on the topic of leadership.

He is a recognized expert on cognitive styles and the development of advanced thinking skills. His books Social Intelligence: The New Science of Success, Practical Intelligence: The Art and Science of Common Sense, and his Mindex Thinking Style Profile are used in business and education.

The Mensa society presented him with its lifetime achievement award, for significant contributions by a member to the understanding of intelligence.

Originally a physicist, and having served as a military intelligence officer and business executive, he now consults, lectures, and writes about whatever he thinks would be fun.

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