The Customer is NEVER Right - A Nurse Practitioner's Perspective
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"We've run ALL the test and it looks like you have disability!"

While driving two hours from the airport to a rural ED I was listening to NPR and a segment caught my attention. The segment was with Chana Joffe-Walt, a journalist, who was talking about work disability and how despite the advances in medicine and laws that ban workplace discrimination against the disabled, the number of people on disability in the United States of America has skyrocketed. Unfortunately, because of the rural location I was in it was difficult to follow the program as the transmission kept breaking up. So, I turned off the radio thinking I could find the podcast later online because whatever little I did hear interested me.
 
The next day I found the podcast and what had caught my attention, that back pain and mental health are the fastest growing causes of disability in our nation today. With back pain and other musculoskeletal problems accounting for 33.8% of the disabled in 2011 and mental health a distant second at 19.2%. Surprisingly, I also learned that today, when our workforce is the oldest, that only 10.6% of those disabled were because of heart disease and stroke. Although, in 1961, heart disease and stroke was the largest group accounting for 25.7% of the disabled and back pain and other musculoskeletal problems accounted for only 8.3% and mental health was slightly ahead at 9.6%.
 
Some may point to healthcare improvements in heart disease and stroke as being the reason for those numbers improving and I would agree. However, that does not discount that the oldest workforce ever is still the oldest workforce. On top of that, similar healthcare improvements have been made for back pain as well; in the book I cited that our nation spends some $85 billion annually in the treatment of back pain alone. Yet what has that money gotten us? And it is likely improvements have been made in mental health as well.
 
The NPR website graphics showed that between 1961 and 2011 conditions like neurological disorders, respiratory disease and others had all diminished and only cancers and diabetes had increased by 0.9% each and injuries had increased to 3.7% from 0.0%. The latter I found most ironic, as I thought that if for any reason to be disabled injuries would be a primary reason, but not the case, not even today when injuries only account for 3.7%. How did that happen? As others have all the other morbidities yet they go to work every day.
 
The NPR article also points out that, “Once people go onto disability, they almost never go back to work. Fewer than 1% of those who were on the federal program for disabled workers at the beginning of 2011 have returned to the workforce.” I bring that up because working locums, in Family Practice and Occupational Health, I recall at least three patients that asked for disability and they expressed disappointment when I told them I could not justify them being on disability. My reasoning, because others had the same morbidities, and some had more, yet they went to work every day. However, I am not aware if those patients complained or not.
 
So what does disability have to do with customer satisfaction, the theme of this blog? Absolutely nothing! However, if you have not already done so, read Chana Joffe-Walt’s article or listen to the podcast. The reason is because a few of her comments are really attention grabbers. As for critics, this is NPR and not Fox News. And like I mentioned in the book, no one is suggesting that patients not complain. Here, no one is suggesting those individual do not deserve disability. Instead, the conversation is that before given in to those individuals’ expectations that an honest discussion of the facts take place.
 
What was most notable about the segment, besides that back pain and mental health were the primary causes for disability today, was that an economist at the Federal Reserve Bank of San Francisco, Mary Daly, had co-authored a book in 2011 which hinted to the probability that welfare recipients would transition to the disability rolls, yet either no one read the book or cared as no one had noticed her pin-point accurate prediction. 
 
Now, why did I find that fact alarming? Well, because in The Customer is NEVER Right I cited a similar phenomenon with regard to the plethora of literature available that shows, (1) customer service has not moved the needle in customer satisfaction, or the customer experience as Lee, over at Disney, wants to call it now, (2) incentivizing and compensating healthcare workers for customer satisfaction scores did not result in better healthcare, if anything, it may be hazardous to patients, (3) healthcare directed violence had been studied to death, no pun intended, recommendations made and even feel good legislation passed, yet violence directed at healthcare workers, those helping others, has gotten more brazen, more frequent and more violent. Those but a few examples that customer service/satisfaction has done anything to change healthcare for the better. If anything, it may have made it worse with regard to medical care, cost, access and even violence directed at healthcare workers, to mention some of the collateral damage.
 
It is almost as if no one is paying attention to what subject matter experts are findings; be it in social safety net programs or healthcare. And if they have noticed, than maybe profits are clouding their decision-making.
 
From NPR’s article and podcast, one could get the feeling that lawyers are trying to make money on the backs of the disable and states of the union are punting to the federal government to save their states’ money by moving welfare recipients to federal disability programs. None of this is a conspiracy theory but simply my interpretation from what I read and heard on NPR, which by the way I thought was a great piece and more food for thought. I could absolutely be wrong and instead both the lawyers and states are simply being advocates for those persons. But, advocates without adversaries just does not make sense or seem transparent, however, I could be wrong.
 
Now, with all that said, I am concerned that The Customer is NEVER Right may just become another book on the shelf within the Barnes and Noble’s warehouse collecting dust and the cycle in healthcare continues. I say that because besides what I just mentioned about Daly’s book not being a megaphone for the discussed topic of disability, it seems my book has fallen into that same black hole. That said because I passed out some 50+ books, mostly to family, friends and colleagues, and in the four months since, I have gotten feedback from only three of them, two healthcare workers and one a childhood friend not in healthcare. So where are the others, collecting dust? Although, it is likely, those persons have more important, if not, better things to attend to first than to read the book I wrote.
 
Except, the sales at Amazon.com, Barnes & Nobles, Books-A-Million, iBookstore.com and the publisher have been less than 499, combined, something that tells me a lack of interest outside my circle too. Recently, I took out a one-page advertisement in the program book at an annual nursing conference with over 1,000 in attendance and although the ad may have generated the greatest sales at Amazon.com the traffic to the book’s website and Facebook page were but a bleb according to site activity reports.
 
I never thought The Customer is NEVER Right would be a best-seller, or even a good-seller for that matter, nor were my intents to find some other form of paying the mortgage, as being a nurse practitioner has not panned out. However, as I mentioned in the book, I began writing as a form of mental therapy, and at some point I thought there was a greater message in the book, not about me but for others in healthcare, as I know it is their story as well, and the book’s editor agreed.
 
With that said, I caught the tail end of a program on The History Channel where I learned that Albert Einstein’s Theory of Relativity almost went unnoticed as well. From what I recall, when Einstein needed to prove his Theory of Relativity he thought the best to do that were astrologist. However, initially, Einstein was not able to convince any of them to take up his proposal as the astrologist thought they had more important things to do. I am not sure if that is accurate or not, nor am I saying Daly and I are comparable to Einstein. What I am saying is that maybe that is the disregard for Daly and me, that others have other things to work on or worry about before they can entertain our findings. Another thought may be that no one wants to stir up a bee’s nest. Nonetheless, food for thought.
 
So, aside Daly and I pointing out some negative trends and our findings going unnoticed here is more food for thought as I compare the NPR segment to The Customer is NEVER Right. In 2011, the USA census was 311,591,917, so how ironic that 14,000,000 of us claimed disability that same year. Why? Because that comes out to 4.5% who are disabled, and that 4.5% got me to thinking, although critics will say it is a long reach and even apples and oranges. Nonetheless, “all fruit,” as I like to quote Alan Colmes and food for thought even. That “all fruit” (4.5%) is very close to 5%, a number consistent with a book cited reference, USA Today Snapshot, where 5% of customers said businesses “Don’t care about them.” Huh, 5%? Maybe and also mentioned in the book, 5% is simply a number that cannot be changed no matter what. Catering to that number is pointless because although that 5% may be appeased in the short run it is unlikely they will be won over. And bending over backwards for them will only condition them into behaving so that their exaggerated unrealistic emotional expectations are catered to. Yet others are willing to take the same product without bending over backwards and without complaint.
 
More numbers, I commonly see 25 patients in a shift, 14 shifts per month, 12 months in a year, which comes out to 4,200 patients a year. Of 4,200 patients seen yearly I would need 190 of them to complain, which according to some is possible although it has never happened, before I reached 4.5%. In no manner am I suggesting that complaining patients are all disable patients who likely will complain if they do not get it their way, instead what I am suggesting is that maybe, just maybe, in general, 5% of our nations citizens, disabled or not, give up, are not interested, think the world revolves around them or believe that others have it out for them.
 
Why do I say that? Because it seems that 5% is a consistent recurring negative percentage and while I know there is a polar positive 5%, that negative 5% makes me ponder. I realize some of the 14 million are disabled. However, how many of them are willing to go on disability not because of disability but just out of the desire knowing they will never have to work again; regardless the fact they will be poor the rest of their life.
 
So then, the same goes for complaining customers or patients, what keeps 4.5% of our nation’s citizens, 14 million, disabled or not, or 190 of the 4,200 patients I see yearly, from complaining when, for no reason other than their expectations are not met. Simply a thought. Maybe it is just that that number, be it 4.5% or 5%, is simply the empirical, bell-curve extreme number, positive or negative, regardless the topic.
 
Another comparison, in my book I mentioned that safety net programs stand in opposition to life betterment. However, Joffe-Walt made that point slightly clearer by stating, “The problem with using our disability programs as a sort of de facto welfare system is that [disability programs] are not designed to help people deal with their disability [like rehabilitative services], to get jobs, to make increasingly more money over a life time. They’re not there to catch you when you fall down and help you back on your feet.” As I said, slightly clearer, because where Joffe-Walt ties that definition to disability alone I would say it is not only the disservice of the disability system. Instead, I would say it is the disservice of all social safety net services, that testimonial coming from a childhood recipient of social safety net programs and growing up in that environment. Because, although many may make it out of welfare, some remain entangle in the safety net, rather seek trampolines that propel them up and out of the situation they find themselves in to seek better jobs where they “make increasingly more money over a life time.”
 
With that in mind, consider this mentioned by Joffe-Walt in the article, “Somewhere around 30 years ago, the economy started changing in some fundamental ways. There are now millions of Americans who do not have the skills or education to make it in this country.” By no means am I a subject matter expert with regard to our nation’s economy, in any aspect, but I would point to safety nets, that snare partakers, as the culprit for this misfortune in our great nation.
 
Another honorable mentioned for this blog’s title was “Do you like things to be stapled or paper-clipped?” A comment Joffe-Walt included to point out the extent disability advocates go of accommodating their client in order to pursuit their agenda, hidden or transparent. However, it was the comment that followed that got my attention and even caused me to bob and weave my head as Joffe-Walt threw, and almost landed, the following sucker punch, putting forward how successful the airline industry and healthcare insurance companies would be, and even would lead to a better world, if those industries too made similar accommodations.
 
“Customer service in its most aggressive form” is how Joffe-Walt described the work at Public Consultant Group (PCG), the leading disability advocacy consulting firm, which has a 70-75% success rate of moving persons off state welfare rolls and into the federally funded disability program. Huh!?! How convenient? But that is for another blog. For this blog the point is, PCG claims they are on the side of persons with disability, yet their agents get paid on commission and only when successful in moving one of those persons from welfare to disability. Sounds like healthcare worker incentive systems where bonuses are paid based on customer satisfaction scores instead of medical care.
 
Joffe-Walt commented that 70-75% success rate was “unheard of” but I would disagree as I see the 70-75% number, like the 4.5-5% number, both, more common than not. Like the normal distribution of a bell curve with 5% at each extreme and 75% inside the center dome. The USA Today Snapshot also held 70-75% as successful, however, Disney Lee is trying to sell the idea that healthcare can move the customer satisfaction needle pasted 75-80%, although it has not in decades of trying and why NOW Lee has a new bridge in NY he wants to sell you, called the customer experience.
 
Lastly, Joffe-Walt seemed to be startled when she heard that the government has “NOBODY” in their corner. “NOBODY!” Like, “NOBODY” to champion the government’s cause. And in that venue, the person presenting their case for disability, although more successful with an advocate whether a lawyer or one of PCG’s commissioned staff, for the most part is taken for their word as the government does not want to appeal confrontational. Where have I heard that before? Oh yea, from healthcare administrators who see conflicts between patients and healthcare workers as a risk to customer satisfaction, retention and ultimately the organization, regardless of good medical care and why patients are given the unchallenged verdict over extensively vetted healthcare workers. I thought advocacy is supposed to be because of adversary. Do I have it wrong?
 
Of course, I have it wrong. Because since the Greatest Generation, our culture has drifted more and more towards a nanny state where some suggest that services intended to help others should never be confrontational. Really? I guess then those who support that ideology must believe that likely the services would not be taken advantage of. If so, why not then just allow individuals to show up to some office and on their own take from the jar as they desired. If not practical, then why suggest to not being confrontational, the only manner to keep in check those wanting to beat the system and take more than what was theirs.

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