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411 Brief communication IN PURSUIT OF PATIENT SATISFACTION To the editor: We were pleased to read of Parkland Hospital's PatientCentered Patient-Valued Care (PCPV) model, a program to orient hospitals and health services to the patient's needs and concerns as the patient defines them [Vol. 2, No. 3:338-46]. The need for such an effort is evident in virtually all contemporary health care institutions. Medical anthropologist Arthur Kleinman has described the physician/patient relationship as a cross-cultural experience.1 This dilemma also extends to others involved in the care of patients. We recently reported the results of a patient satisfaction study completed in 1989.2 Although the inpatient component of our study took place in a hospital with no formal PCPV program, we found some strong evidence that a PCPVlike environment resulted in striking differences in patient satisfaction scores. In the oncology unit, the patient satisfaction scores were significantly higher than those for other inpatient units. The oncology unit embodies the seven dimensions of patient-centered care (the foundation of PCPV care) to a much greater degree than do the other medical units. The entire unit is strongly patient- and family-centered, staff are specially selected and trained, social services are more focused, and even the food service is thoughtfully structured to meet the needs of oncology patients and their families. Despite being frustrated by the serious nature of the patients' illnesses, interns also reported benefiting from their rotation there. A serendipitous finding in our study was that it is difficult for patients to separate their perceptions of physician performance from the milieu in which the physician and patient interact. It may be unfair to judge the performance of physicians (in our case, medical interns) when they are asked to humanistically care for patients in very difficult environments. Teachers and evaluators of residents are deeply concerned about the effects of this environment. As painstakingly and painfully described by Terry Mizrahi, the socialization of internists which occurs during residency training in traditional models can be costly for physician and patient alike.3 We are pleased to see that the Parkland Hospital group was able to widen its project to include ambulatory care patients; the majority of medical care in the Journal of Health Care for the Poor and Underserved, Vol. 2, No. 4, Spring 1992 412__________________________________________________________ United States is now delivered in the outpatient setting. In our study, we found differences between inpatient and outpatient satisfaction scores which, when further analyzed, suggested distinct differences between the needs and concerns of the two groups. It is vital that health care professionals be aware of these differences. One wonders if it might be possible to incorporate "attention" into the Parkland PCPV model—attention to educating patients in how to be good patients. This follows from the model which views the physician/patient relationship as contractual. For example, the bane of house staff (and we suspect other caregivers as well) is the noncompliant, substance-abusing "problem" patient. Mizrahi's findings, mirrored by ours, are that the majority of inpatients seen by residents are not "ideal" patients which will fit without difficulty into the PCPV model. William James wrote in 1903 of what he called "tyrannical machines"— established practices which, although no longer productive, remain impossible to eliminate. Despite the enormity of the health care system in the United States and the economic realities of the 1990s, it is encouraging to see the development of the PCPV model. This endeavor is especially exciting in that all levels of health care delivery are involved. We do not believe that implementation of a PCPV system is inconsistent with providing what some health care professionals might consider more basic needs; hospitals can have both clean sheets4 and patient-oriented care. Susan C. Parker, M.P.H. Research Associate in General Medicine Frank J. Kroboth, M.D. Professor of Medicine University of Pittsburgh School of Medicine Room 166 Lothrop Hall 190 Lothrop Street Pittsburgh, PA 15261 REFERENCES 1. KkdnmanA,EisenbergL,GoodB. Culture,illnessandcare:Clinicallessonsfromarithropologic and cross-cultural research. Ann Int Med 1978 Feb;88(2):251-258. 2. Parker SC, Kroboth FJ, Hanusa BH. Do interns care for outpatients differently than inpatients? Clin Res 1990...


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