When this doctor gets a zero star rating

I can’t stop thinking about “customer satisfaction,” which is weird because I don’t actually have customers. I’m a primary care doctor for a group of patients in Martinsburg, WV, and have done so for almost twenty years. At its core, my job is the opposite of having it your way, like I’m told you can do at Burger King.

I don’t sell anything in my office except, perhaps, the benefits of good health. The medications I prescribe cannot be requested and are not for sale. I used to work in retail, so I know the dynamics of making customers happy and the practices of up-selling. I don’t offer fries or a large drink with that. I do, however, often pitch, “Would you like a flu shot while you’re here?” A statement that demonstrates my promotion of health and my lack of desire to please people.

In fact, I often tell patients which products they shouldn’t buy or use. I frequently deny requests for medication or tests, as they are often inappropriate, a waste of time and money, and some of them are risky. Patients tell me stories of their illness with the belief that certain treatments are needed to make them better. After listening and examining them, I often dash these desires. On my best days, I do this gently and with compassion. I present other options, or, more accurately, an actual plan, not a DIY internet recipe. With a wealth of experience, I have a lot to offer my patients, and it’s a joy to do so.

Giving patients good advice is my primary goal, which seems obvious, but, in an age of mistrust, we need to return to first principles. In order to help my patients I must ask probing questions and then perform, when needed, an invasive examination. Under ideal circumstances, I do this with sensitivity and tact. But, make no mistake, baring one’s self, figuratively and literally, the more you show and tell me, the more I can help. I genuinely try to respect the awkwardness and power imbalance inherent in this relationship.

This dynamics of me asking patients “nosey” questions and simultaneously not doing exactly what patients want is why I am ruminating over “customer satisfaction.” My patients—they will never be customers—receive an electronic survey after their office visit. You likely have taken one, and make no mistake, these “things” are now a permanent fixture in the American health care “system.” Their existence is simultaneously hilarious and galling to me, for reasons that increasingly sit in the forefront of my mind.

Not that long ago, a member of management, a “quality manager,” discussed with me how a group of my patients gave me low, and I mean low, ratings: zero stars. At the time, about 3 percent of respondents were truly upset about the health care I provided them. And, after a great deal of reflection, I want to explain why these particular zero-star reviews are a point of professional pride. Not shame. Not misunderstanding. Not an opportunity for improvement—pride.

How is that possible? A hallmark of primary care is that the next patient can bring me any kind of concern. And—boy oh, boy—they do just that. I care for sprained ankles, poison ivy, diabetes, asthma, obesity, high blood pressure, depression, prevention services, I could keep going. This diversity is why I love internal medicine. So many of these situations are straightforward, but underneath lurk darker things, like patients trying to file an illegitimate disability claim, obtaining narcotic pain medication, or stimulants. I am often begged for inappropriate accommodation in the workplace or school setting, so someone can personally benefit.

In a nutshell, I am often asked—begged, chided, cried to—to do medically wrong things. It’s a small percentage of patients, but it is consistent and real. It’s also why some people give me, deservedly, zero stars.

It’s a judgment call about where legitimate care ends and the bogus claims and fraud begin. But, after all of these years, I trust my gut when things smell fishy and patients’ stories don’t make sense. My guess is that one in every thirty patients, about three percent, are trying to get something from me. When confronted by this behavior, I have a couple of choices. I can accommodate these requests and turn myself into a medical equivalent of a candy store, where patients receive the treats they want. I’ve witnessed this behavior in my career, and it makes my blood boil.

The other choice is for me to be courageous, a good steward of public resources, medical funds, and use of limited tests. This requires me to say no and have firm boundaries, and it means that I must accept that there are zero stars. When patients do this, they indicate their dissatisfaction with their care—not a problem. Turns out, I feel the same way.

Ryan McCarthy is an internal medicine physician.

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