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Health Care: A Fertile Field for Service Research
The online version of this article can be found at: http://jsr.sagepub.com/cgi/content/abstract/10/2/111 can be found at:
Journal of Service Research
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Health Care
A Fertile Field for Service Research
Leonard L. Berry
Texas A&M University
Neeli Bendapudi
The Ohio State University
Health care is an enormously expensive, highly complex, patients’ ability to evaluate that quality (Adams and Biros universally used service that significantly affects 2002). Health care has a pervasive impact on economies economies and the quality of daily living. Service man- and the quality of daily life. America, for example, was agement, operations, and marketing scholars have much projected to spend more than $2 trillion (approximately to offer to a critically important, intellectually challeng- $7,000 per person) on health care in 2006 (Heffler et al.
ing, but deeply troubled health care service sector. In this 2005), and yet only 44% of a national sample of article, the authors use the opportunity they had to study Americans indicated satisfaction with the quality of U.S.
at one of the world’s most admired medical institutions— health care (ABC News/Kaiser Family Foundation/USA Mayo Clinic—as the basis for discussing the similarities Today 2006). Based on 2004 statistics, per capita health and dissimilarities between health care and other care spending in the United States ($6,102) is much higher services. The article takes the reader “inside” health than other countries such as Australia ($3,122), Canada care. The authors challenge service scholars to consider ($3,043), France ($3,566), Germany ($3,502), and the health care for their research activities and propose United Kingdom ($2,880) (Organization for Economic Cooperation and Development Health Division 2006).
The market mechanism that is taken for granted in Keywords:
health care service; professional services; other service sectors is broken in American health care.
service quality; service characteristics Unlike other services in which demand increases supply,in health care supply increases demand. More physiciansor hospital beds in a given region translate into more Health care is a rare service that people need but do not medical services rendered on a per capita basis with no necessarily want. It is arguably the most personal and improvement in the overall health status of that popula- important service that consumers buy, yet many studies tion group. In fact, medical outcomes and quality of care document wide variation in the quality of care delivered tend to be superior in regions with lower resource use and (McGlynn et al. 2003; Wennberg and Fisher 2006) and in care intensity (Wennberg and Fisher 2006).
The authors wish to thank Jeff Meyer, Mona Srivastava, three anonymous reviewers, and the editor for their excellent suggestions on an earlier version of this article.
Journal of Service Research, Volume 10, No. 2, November 2007 111-122DOI: 10.1177/1094670507306682 2007 Sage Publications JOURNAL OF SERVICE RESEARCH / November 2007 Consumers with health insurance do not pay the full academics to become more involved with health cost of the services they use once they meet their care. Such involvement could include covering deductible. In the United States, the “price” of a doctor’s health care service issues in courses, a focused visit is $20 (the co-pay), not the $90 the insurance pays.
research program, a sabbatical leave in the health This effect can be even greater in countries with national care sector, serving on a hospital board of directors,and many other activities.
health care systems. For example, in Germany, patientspay only a $10 co-pay for all doctors’ visits per quarter.
We begin by discussing the research we conducted Health care is the only service that consumers commonly that provides the foundation for our discussion of health purchase without knowing its actual cost. Nor is the infor- care. We then describe similarities between health care mation readily available to those who seek it. One execu- and other services. This material will be more familiar to tive tried to price a magnetic resonance imaging (MRI) service researchers, and we purposely are brief in this exam that he needed for a shoulder injury. With a high- section. Next, we discuss in greater detail dissimilarities deductible health plan, he would be paying the full cost, between health care and other services. Finally, we pro- and he wanted to compare prices among a dozen area hos- pose some promising research questions linked to these pitals. “Of all the places I called,” he wrote, “only two could or would tell me the cost. The response nearly acrossthe board was, ‘Well, you have insurance, don’t you? Whatdo you care about cost?’” (Cutler 2003, p. 22).
Health care benefit costs have become a major burden THE RESEARCH
for employers in the United States, threatening the globalcompetitiveness and even the survival of some compa- The basis for this article is a 6-month study of the nies. General Motors, subject to considerable speculation ideal service experience from the perspectives of that it is headed toward bankruptcy, estimates that its patients, clinicians (doctors and nurses), and nonclinical health care spending accounts for about $1,500 of the staff (allied health staff, administrative personnel). We cost of each vehicle it manufactures (Hawkins 2005).
conducted this study at Mayo Clinic, a highly regarded, Corporations contribute to inefficiency and waste in multispecialty health care institution that is more than health care. Companies that are rigorous and demanding 100 years old. We did the research at Mayo Clinic’s orig- purchasers of other goods and services are commonly inal campus in Rochester, Minnesota, and one of its timid and ill prepared when purchasing health care newer campuses in Scottsdale and Phoenix, Arizona.
services. In no other area of supply would businesses tol- We interviewed about 1,000 individuals in person or erate the cost increases and uneven quality that charac- on the telephone. One fourth of the respondents were terize health care (Berry, Mirabito, and Berwick 2004).
patients, including 192 we interviewed by telephone Service disciplines developed from the fundamental belief within 90 days of their most recent visit to Mayo Clinic.
that services are different from goods and require novel ideas, These interviews lasted between 20 and 50 minutes and approaches, tools, and strategies (Berry and Parasuraman focused on the patients’ best and worst service experi- 1993). Health care illustrates just how much services can dif- ences at Mayo Clinic. Respondents were encouraged to fer. Health care is a deeply troubled but critically important comment on any experience with Mayo Clinic and were service sector. It costs too much, wastes too much, errs too not restricted to their most recent visit. To strengthen much, discriminates too much. Health care needs more of the generalizability, we selected a random sample of patients brainpower of the people who read this journal.
from 14 medical areas: cardiology, cardiac surgery, der- matology, emergency medicine, endocrinology, execu-tive medicine, family medicine, gastroenterology, • The first is to present health care as a case study to medical and radiation oncology, neurology, orthopedic demonstrate how it differs from other services. In surgery, transplant surgery, thoracic surgery, and urology.
doing so, we hope to underscore the need to better The disciplines were selected to provide a broad repre- understand differences among services.
sentation of inpatient and outpatient services and various The second goal is to highlight specific service quality challenges that are salient and pervasive inhealth care but rarely discussed in the nonmedical In addition to the telephone interviews, we conducted service quality literature. We hope to interest a total of 10 focus group interviews with Mayo patients service quality researchers in health care as a set- and with clinical and nonclinical staff. Most of the remaining interviews were personal interviews with one • The third goal, building on the first two, is to stimu- or several Mayo clinical or nonclinical staff members.
late service operations, management, and marketing These interviews typically lasted 1 hour.
Berry, Bendapudi / SERVICE RESEARCH IN HEALTH CARE We also collected data as participant observers. We error because of the hospital doctors or medical staff observed numerous surgeries and more than 250 separate patient-physician encounters in examination rooms and Because health care services are provided for people, on hospital rounds. We took detailed notes during these rather than for people’s property, they typically are insep- observations; reviewed, supplemented, and edited the arable. Patients must be physically present where the notes while our memory was fresh; and had them typed.
service is rendered (such as a doctor’s office or hospital) Each week, we focused on one of the 14 medical spe- when the doctor or nurse is available to deliver the cialties listed above. We stayed in Mayo hospitals our- service. Inseparability can pose a hardship on patients selves as “mystery patients” and one of us (LB) spent a who are elderly, nonambulatory, or inconveniently day flying on the Mayo One emergency rescue helicopter located, and it often frustrates patients who may have to service. Mayo Clinic gave us complete access to study its wait for extended periods to receive service.
service culture and systems, and our study was approved Like most other services, health care is perishable.
by the Mayo Foundation Institutional Review Board.
Health care organizations create value through staff time Since completing our research at Mayo Clinic, we have and expertise, equipment, and physical space. When continued to study health care service and have visited a these resources are unused, the value that could have variety of other health care institutions in the United been created perishes. Medical administrators and physi- States. The analyses that follow are informed primarily by cians are well aware of the perishability of their service our research experience at Mayo Clinic but also are influ- and may overbook appointments or charge a no-show fee enced by what we have learned subsequently in other to compensate for missed appointments.
health care research and from the health care literature.
Similar to the use of other technical services, such as Although we have done our field research in the United repair or appraisal services, customers are at a consider- States, we believe our discussion of similarities and dis- able knowledge disadvantage when they use health care similarities between health care and other services will services. Health care is a credence service in that clinical generally apply to health care delivery in other countries.
quality often is difficult for the patient to judge even afterthe service is performed. Our patient interviews at MayoClinic underscore patients’ limitations in judging clinical SIMILARITIES BETWEEN HEALTH
quality. When we asked patients in the telephone inter- CARE AND OTHER SERVICES
views to describe their best and worst experiences withMayo Clinic doctors, virtually all responses concerned Health care services reflect several characteristics com- how the physician behaved (“the bedside manner”) rather monly associated with other services. They are, in essence, than the physician’s technical skills or expertise. This intangible in that the core benefits of medical diagnosis, finding suggests not only the importance of physicians’ treatment, and patient education derive primarily from per- interpersonal skills but also patients’ comparative ease in formances. Patients (and third-party payers) incur an evaluating them. Technical quality clearly is vital to expense rather than acquire tangible assets. Treatment patients but more difficult to evaluate. Our findings may itself frequently combines intangible services supported by also reflect patients’ inclination to assume a doctor is goods (e.g., surgery in a well-equipped operating room) clinically capable (Bendapudi et al. 2006).
and tangible goods supported by intangible services (e.g., Following one of our patient focus groups at Mayo pharmaceuticals and pharmacy services).
Clinic, a breast cancer patient who participated sent us a Health care services are both labor and skill intensive, handwritten note eloquently summarizing the complexity contributing to considerable variability in performance of health care services, the information and power advan- from one clinician to another. The variability is not just in tage of doctors, and patients’ need for doctors to be the service style and communication skills of clinicians behaviorally competent, not just technically competent but also in their technical skills. The latter is dramatically illustrated by a RAND Corporation study that found, onaverage, American patients receive appropriate medical We want doctors who can empathize and under-stand our needs as a whole person. We put doctors treatments only 55% of the time. The researchers ana- on a pedestal right next to God, yet we don’t want lyzed the medical records of 6,712 patients in 12 cities to them to act superior, belittle us, or intimidate us.
assess treatment of 30 medical conditions and compared We want to feel that our doctors have incredible the findings to accepted definitions of standard care for knowledge in their field. But every doctor needs to the conditions (McGlynn et al. 2003). In Europe, 47% of know how to apply their knowledge with wisdom and European Union citizens think it is fairly likely or very relate to us as plain folks who are capable of under- likely that a hospital patient would suffer a serious medical standing our disease and treatment. It’s probably JOURNAL OF SERVICE RESEARCH / November 2007 difficult for doctors after many years and thousands stressors include lack of contact with nature, lack of of patients to stay optimistic, be realistic, and physical and mental stimulation, and, in double-occu- encourage us. We would like to think that we’re not pancy patient rooms, lack of privacy. One of the most just a tumor, not just a breast, not just a victim.
egregious sources of stress in a hospital is noise. Noise Surely, if they knew us, they would love us.
sources are both numerous (alarms, hallway activity andconversations, roommates) and loud (use or movementof medical equipment, nursing shift changes) (Berry DISSIMILARITIES BETWEEN HEALTH
et al. 2004). One hospital study, for example, continu- CARE AND OTHER SERVICES
ously measured decibel levels during night shifts andfound that moving a portable x-ray machine in the hall- Health care clinicians may have to respond on demand way outside a patient room was as loud as if a motorcy- to medical issues ranging from the mundane (a common cold) to the critical (a heart attack). They must minister totheir patients’ physical and emotional needs in a humane Customers Are Reluctant
manner regardless of often less-than-ideal circumstances.
Even a “normal” day in a primary care medical practice The presence or possibility of illness thrusts people presents a potential rollercoaster of emotions and demands.
into the role of health care consumers. They often Although similar to other services in certain respects, approach a medical service such as an annual physical health care also has uncommon characteristics. The fol- exam, mammogram, or surgical procedure with reluc- lowing sections highlight dissimilarities that merit atten- tance, even dread. Much of the services literature natu- rally focuses on “want” services, such as recreation,entertainment, personal grooming, and communications Customers Are Sick
services; less attention is devoted to the study of servicescustomers need but may not want, such as health care and Health care customers are usually ill and under stress certain public services, for example, airport security and and (sometimes) live in the service “factory”—they are patients. Serving a customer who arrives with some com- Customer reluctance may affect service quality percep- bination of illness, pain, uncertainty, and fear presents a tions. Do customers evaluate desired and dreaded services unique challenge to health care service providers. The differently? It may also affect the degree to which cus- circumstances of medical customers can cause them to be tomers accept the “coproducer” role necessary for a favor- far more emotional, demanding, sensitive, and/or depen- able outcome (Bendapudi and Leone 2003). The dent than they would normally be as consumers. Emotions, successful delivery of health care service typically requires in turn, influence their ability to make choices. For a patient’s cooperation both during the encounter (e.g., example, increased levels of stress-induced anxiety have answering the clinician’s questions honestly) and after- been found to trigger preference for options that are safer wards (e.g., taking the prescribed medication).
(low risk, low reward) and provide a sense of control. On Service scholars rarely consider the issue of customer the other hand, when patients experience sadness, they unwillingness to perform the coproducer role. In health tend to prefer options that are more rewarding (high risk, care, customer wants and needs frequently conflict.
high reward) and comforting (Raghunathan, Pham, and Customer coproduction often involves directly con- Corfman 2006). Furthermore, patients are often likely to fronting fears (“Will the test reveal cancer?”), consider- experience mixed emotions, such as hope that a surgery able inconvenience and cost (“I can’t miss two weeks of will treat their illness, mixed with fear that something work to have the surgery”), and making lifestyle changes (“The doctor wants me to stop smoking, but I’ve never For inpatient health care services, the customer not been able to do it before”). A large part of the customers’ only visits the service facility but also lives in it. Few unwillingness may stem from their sense of loss of con- service industries have their customers sleep over; hos- trol over outcomes. When customers experience threat pitals do. Even when service quality is superb, the expe- emotions (e.g., anxiety) in face of low self-efficacy (i.e., rience of hospitalization is likely to compound the capability to affect change), Duhachek (2005) finds that inherent stress that accompanies illness. Hospitals are customers are more likely to engage in avoidant coping frightening places where patients undergo medical pro- strategies, which can lead to suboptimal decision making cedures and/or receive medical treatment. Patients are and behavior. For many medical services that patients not in control and cannot come and go at will. Patients need but do not want, avoidant coping strategies may do not enjoy themselves in hospitals. Hospital-related Berry, Bendapudi / SERVICE RESEARCH IN HEALTH CARE We observed the clash between patient wants and needs who asked the doctor how often she should take an AIDS at Mayo Clinic. One memorable service encounter test and if marijuana use could be causing her depression; involved a male patient during his first appointment with a a father who was concerned about the effect his son’s dis- family medicine physician. The patient’s wife made the ease was having on himself and on his relationships with appointment against her husband’s wishes. The patient other family members; an 87-year-old female patient was experiencing pain in his side. Suspecting early-stage with multiple medical problems who explained that she liver disease, the doctor questioned the patient about his could not afford her medications; a patient complaining alcohol consumption. He insisted he did not have a prob- of stomach problems who showed signs of clinical lem. The doctor was friendly but persistent. She told him, depression (“You are describing a woman in distress,” “Honestly, I’m worried about your liver. If the drinking is stated the doctor to this patient); a 97-year-old woman affecting your liver, it can kill you. You need your liver.” with heart disease who was under considerable stress The doctor wanted to admit the patient into the hospital for because her daughter had cancer; and multiple patients detoxification. He was adamant about not going to the hos- pital. The doctor then recommended other alternatives, During our time at Mayo Clinic, we continually were including one-on-one alcohol abuse counseling and struck by how little guidance our knowledge of service Alcoholics Anonymous. The patient was not interested.
quality offered for many kinds of service encounters we Pleasantly but firmly, the doctor told the patient that she observed. For example, one doctor kindly said to a wanted to help him and that she “could be a hard-ass.” She patient, “You wouldn’t feel that you had a full experience asked the patient to come again the next day with his wife if I didn’t remind you to stop smoking.” The doctor could when the results of laboratory tests would be available.
not have been nicer to this patient. But is this quality “Let’s approach this together,” the doctor concluded.
service? Would the doctor have delivered better quality From a service research perspective, this encounter is had he emphatically stated, “Your smoking may be fascinating. The physician delivered outstanding service slowly killing you. You must stop. Let me help you stop from a customer-need perspective. She was determined to help her patient. The patient did not at all seem toappreciate the service, however. Had the patient received Customers Need “Whole Person” Service
a satisfaction survey from Mayo Clinic following thevisit, the doctor probably would not have fared well.
The need to understand the individual customer holistically—and to customize the service accordingly— Customers Relinquish Privacy
is pronounced in health care. Health care services need tobe customized to fit not only a patient’s medical condition Health care services are inherently personal but not but also the patient’s age, mental condition, personal traits, private. Other services do not require customers to relin- preferences, family circumstances, and financial capacity.
quish so much of their privacy or to bare themselves Delivering quality service to all of the patients described in physically and emotionally as is required by medical the preceding section depends on a clinician’s ability and services. To receive the best possible care, patients may willingness to couple knowledge of medicine with knowl- not only have to disrobe, but also they may have to dis- edge of the individual patient. The requirement of whole cuss highly personal matters that they have revealed to person service characterizing all forms of health care few other people. Patients may have to undergo this expe- intensifies when patients become seriously ill. The diagno- rience with clinicians they are meeting for the first time.
sis of a serious disease turns a patient’s life upside down In observing doctor-patient interactions in examination and can greatly affect the patient’s family.
rooms and in the hospital, we were surprised by the fre- We selected excerpts from interviews with three Mayo quency and variety of patient psychosocial issues addressed Clinic clinicians to share in this section. They illustrate the by clinicians. Service providers outside of health care are emotional impact of a serious illness on a patient—cancer not required to tell their customers that they must lose in these examples—and the service quality opportunity weight, stop driving a car, or stop drinking alcohol. They embedded in truly understanding the patient and tailoring typically do not ask their customers to undress. In health the service accordingly. (The quotes also suggest the emo- care, clinician roles require all of this and much more.
tional impact on the clinician, a topic to be discussed).
In 1 week of observing doctor-patient interactions in Mayo’s Family Medicine practice, we observed the fol- A MEDICAL ONCOLOGIST
lowing: a young, overweight female patient who wascontinuing to use an over-the-counter weight-loss drug I want to know the person. What do they understand that the doctor had previously asked her not to use and about their situation and what do they want to know.
JOURNAL OF SERVICE RESEARCH / November 2007 I want to inform them, answer their questions, and Customers Are at Risk
resolve disparities. I want my patients to feel in con-trol. Patients often feel cancer has taken over their It is difficult to imagine a service where customers are life and I try to help them regain a sense of control more at risk than the health care service. A profession over their life. I like to give them something positive that is supposed to heal too often harms. Imagine an air- to think about and there almost always is something line pilot making the following welcome announcement positive I can relate. I want them to find reason to have hope. I do tell them this has to be a priority forthem, an investment in the future.
Ladies and gentlemen, welcome aboard flight 600 The first visit is a very delicate time. When bound for Dallas. This is your captain speaking.
patients come to see their oncologist they are Our flight time is three hours and 10 minutes and I incredibly vulnerable. I don’t want to brand some- am pleased to report that you have a 97% chance of reaching Dallas without being significantly injured One patient had recurrent breast cancer. The last or killed during your flight. Please enjoy the flight three visits it was worse news each time. I like to and be sure to keep your seatbelts fastened.
give good news. It’s hard not to feel like you are When September 11th happened, I thought now people know what cancer patients deal with every- Such an announcement, of course, would be ludi- day when a renegade fireball hits their lives. I have crous. No customer would take the risk. Fortunately, the privilege of talking to these people. The fire- commercial air transportation is remarkably safe. Health fighter heroes have fascinated many. I get to see a care is quite unsafe; patients just do not get the statistical announcement upon entering the health care system.
Hospital-acquired infections (called nosocomial infec- A HOSPITAL CRITICAL CARE NURSE
tions) are estimated to affect 2 million American patientseach year, leading to 90,000 deaths (Burke 2003). Not all I took care of a breast cancer patient who had plas- of these infections are preventable, but many are through tic work that failed. Going into surgery, she thought improved safety practices such as proper hand hygiene of that she would have her breast removed and then caregivers, raising the head of the bed for patients on reconstructed. She developed bleeding and they mechanical ventilators to lower their chances of getting couldn’t reconstruct. Now she has a whole other pneumonia, proper administration of antibiotics prior to burden. She not only has cancer, but she also isleaving without a breast. I spent a lot of time with surgery, and putting patients in single-occupancy rooms her, mostly listening and we had some “spa” so they are not exposed to the germs of a roommate time—(that’s what I call it)—washing, rubbing the (Berry et al. 2004; Berwick 2004; Burke 2003; Trampuz feet, washing or braiding hair, mild massage. I took care of her for three days in a row—three 12-hour Millions of patients are also harmed by medication shifts; I was ready for the patient to leave; you can’t errors (Institute of Medicine 2006). Such errors include administering the wrong drug, the wrong dose of the rightdrug, or administering the wrong combination of drugs.
The number of medicines some patients take and the MEDICAL ONCOLOGIST
number of different caregivers serving one patient can cre- The patient I most enjoyed taking care of here was ate confusion, as can the many drugs with similar names.
a Mayo doctor. This person brought knowledge to Handwritten prescriptions also can lead to mistakes.
the table. He listened to my advice, I gave him Drs. Robert Wachter and Kaveh Shojania (2004), authors choices, and he made decisions. He chose treat- of Internal Bleeding, the Truth Behind America’s ment at various times, and chose not to have treat- Terrifying Epidemic of Medical Mistakes, describe a ment other times. He lived his life and used his study in which they asked 159 physicians to look at a time as well as possible. He was an opera buff. He handwritten prescription. Half of them thought it was for would say: “Doctor, you have to keep me going for Plendil, a calcium channel blocker, one third thought it the next opera.” We were both fighting an enemy—his disease. This person was able to live hard and was Isordil, a drug for angina, and the rest thought it was fight hard for the three years he had once he got the Zestril, a blood pressure drug. This was an actual pre- disease. This person took advantage of the time he scription that was written for Isordil but filled as Plendil.
had and that was very satisfying for me.
Berry, Bendapudi / SERVICE RESEARCH IN HEALTH CARE Applying bar-coding technology in dispensing and breast cancer and is just the first step in the screening administering drugs to hospital patients and computer- ized order entry significantly lower the incidence of med-ication errors, but these are not yet widespread practices.
Clinicians Are Stressed
Communication errors of one type or another frequently contribute to errors in diagnosis and treatment. One study Serving acutely ill people is exceedingly stressful of 75 error reports from 18 family physicians in five states work. We have studied many kinds of service providers, found that 80% of the errors were initiated by communica- but never have we studied service providers who are as tion failures such as misinformation in medical records or visibly tired and fatigued on the job as doctors and nurses missing records, poor communication among clinicians, treating people with acute illnesses.
mishandling of patient requests and messages, and inade- The physical stress of the work can be daunting.
quate reminder systems (Woolf et al. 2004). The National Hospital nurses commonly work shifts for 12 or more Quality Forum has identified 27 “never events” for hospi- hours with little downtime. They are on their feet much tals, that is, adverse events that are totally preventable and of the time, do considerable “heavy” work such as lifting should not occur. Minnesota was the first state to publicly or turning patients or helping them to the bathroom, and release a report on how many times a never event occurred may walk the equivalent of several miles while gathering in a Minnesota hospital. The information compiled needed supplies and medications (Hendrich, Fay, and between July 2003 and October 2004 indicated that 99 Sorrells 2002). A busy physician may start and end the events were reported, resulting in 20 patient deaths and four “regular” workday doing hospital rounds, see 25 to 40 cases of serious disability. Of the 99 events, 52 occurred patients in the outpatient clinic between hospital rounds, during surgery, including operating on the wrong patient or return a dozen patient phone calls after evening rounds, wrong body part or leaving foreign objects in the patient and then be awakened in the middle of the night by a (Minnesota Department of Health 2005).
phone call concerning a patient having difficulties. It was Donald Berwick, MD, cofounder and president of the instructive for us to eat with Mayo Clinic physicians, Institute for Healthcare Improvement (IHI) and a noted which we did frequently. Most of them have learned to health industry reformer, wrote a request for proposals eat very fast because they know their pagers can sound at (RFP) for a total knee replacement he needs and published any moment, calling them back to a sick patient.
it in a leading medical journal. He begins his RFP with Following are excerpts from detailed notes one of us these words: “Don’t kill me” (Berwick 2005). Berwick’s took while observing a live-donor liver transplant. The IHI embarked on an unprecedented campaign in 2004 same surgical team performed two back-to-back surg- called “100,000 Lives.” Collaborating with industry asso- eries—harvesting the organ from the donor and transplant- ciations and government agencies, the campaign per- ing it into the recipient. Time was of the essence, with no suaded more than 3,000 hospitals to implement some or all opportunity to rest between the two surgeries. The precise of six changes based on best available evidence that could time was noted at various intervals during the procedures: save patients’ lives. The goal was to save 100,000 livesover the following 18 months. In June 2006, the results This is a big procedure today—the epitome of were in: An estimated 122,000 lives had been saved, per- transplant surgery technology, skill, and a pioneer- haps the clearest documentation yet of how a service ing spirit. A male (J) is donating about 60% of his designed to help can needlessly harm, and how much liver to a female co-worker (D). This is a story of opportunity exists to improve the quality of this service.
Harm to patients is not always as overt as a botched surgery or medication error. Kahn and Luce (2003) con- This is a stressful operation for the team. Taking ducted an experiment with women in a mammogram out part of the liver of a healthy person is no walk context that showed patients receiving a false-alarm test on the beach. It has to be perfect. Dr. M can’t be offeven slightly in dividing the liver.
result experienced more stress and were more likely to Dr. M is doing the resection assisted by Dr. J delay future mammograms than a control group receiving and Dr. A. Both Drs. M and A wear magnifiers.
normal results. Delaying future mammograms does not Operating under three lamps, they can see about as occur with false-alarm patients under two conditions: if patients are told they have an increased risk of develop- Dr. M had ultrasound images taken of the liver.
ing breast cancer or if they receive information that a pos- The radiologist comes in to take a look at the itive mammogram result does not necessarily indicate images and Drs. M and A go to the monitor to JOURNAL OF SERVICE RESEARCH / November 2007 review the image together and discuss. Mayo teamwork Emotional stress is an inescapable companion to serving people who are seriously ill and undoubtedly contributes It’s now 10:45 a.m. and Dr. M is ready to cut the to the physical stress that accompanies such work. Dr.
liver. The map has been drawn using the advice of Richard Hollis (1994, p. 1) captures the emotional con- the radiologist looking at the ultrasound images.
This is the most delicate part of the operation; you can feel the atmosphere in the room change.
It is the patient who carries the burden of illness, but the compassionate physician shares that bur- At 12:10 p.m., Dr. M says, “So far, so good.” den, lifting it when possible and lightening it when The concentration, the focus, the stamina required that is all that can be done. This sharing of the bur- of the surgeon in a procedure as complex as this is den has always been the hallmark of the medical quite remarkable. These surgeons need to prepare themselves physically and emotionally like athletes.
The liver comes out at precisely 1:14; it’s drained of blood by Dr. A as Dr. M closes the A powerful source of emotional stress for clinicians is patient. The liver is tied in a wrapper and put in the delivering bad news to patients and families. Other kinds of service providers deliver bad news to their cus- At 1:40, Dr. M calls the donor’s father to tell tomers—“The flight is delayed” or “The product is sold him his son did very well and to tell him he would out”—but the information typically is not life changing; call him again when the transplant is completed.
in health care it often is. Based on behavioral science The donor’s liver will regenerate in 2 to 4 weeks.
findings, Chase and Dasu (2001) offer several principles It is now 2:00 p.m. and Drs. M and A are opening to improve service encounters. The first principle is to the recipient. At 2:50, the diseased liver comes out “finish strong.” But how does a doctor finish strong when and at 2:53, the donated liver is placed in the body.
informing a patient that he or she is paralyzed from the It is 3:15 p.m. and Drs. M and A are hooking up accident, has had a stroke, or has a terminal disease? In the veins to the new liver—the portal vein and thehepatic vein.
commenting on a Journal of Clinical Oncology article At 4:33 p.m. Dr. M says: “OK, that’s a finished (von Gunten 2002) proposing how a doctor might best product.” The clamps come off at 4:43 and Dr. A inform a patient that death is near, Groopman (2002, and Dr. J close while Dr. M gives medication dosages to his physician assistant and then dictatesfor the medical record. The procedure is done at Today, after caring for patients with cancers for more than 25 years, I have told nearly 500 people Dr. M takes the team to meet the family of the that they were going to die; rarely has such a con- recipient and explains what occurred. He states versation gone as smoothly or the conclusion been “both of them did great” and says they can see D in about 45 minutes. At 5:35, Dr. M and the teambegin hospital rounds.
What is service communication quality in medicine when the news is bad? It is not an easily answered ques- The remarkable physical intensity required of the tion. Patients differ in how much they really want to surgeons is evident in the liver transplant transcript.
know about their prognosis, and they may be vague in What may be less apparent is the emotional intensity.
conveying what they want to know. And even if a patient Losing concentration for just a moment can harm the does not want the entire truth, is it good service to with- patient; the slightest carelessness can lead to catastro- hold it? Sometimes a patient will ask a question such as phe. Fatigue is inevitable, but its negative consequences “What are my odds of remission, Doctor?” while the doc- are unacceptable. The emotional pressure is palpable. In tor mentally juggles, in real time, the average statistics an interview with the primary surgeon, Dr. M, 3 days from the literature, his or her own personal instincts with prior to the described transplant, he indicated that live- this patient, his or her own personal style and preference donor transplants are extremely stressful for him in addressing such questions, and the fact that the because he is performing major surgery on a healthy patient’s spouse had earlier requested that the doctor not disclose the dire prognosis. Clearly, this type of service Emotional exhaustion in the workplace is posited to situation is different in kind and degree from what be partially a result of emotional display frequency, dura- researchers study and report on in business-oriented tion, and intensity, as well as the variety of emotions to be service literatures. In medicine, bad news commonly is displayed (Morris and Feldman 1996). Without a doubt, far more consequential and relationships among clini- many clinicians would be high on each of these dimensions.
cians and patients far more personal.
Berry, Bendapudi / SERVICE RESEARCH IN HEALTH CARE A medical oncology nurse practitioner at Mayo Clinic They also wanted an apology. Most physicians in the explains how she approaches the “bad news” service: study wanted to apologize for a mistake but were con-cerned that their statements could increase their vulnera- I try to set the stage for patients with suspicious bility in a legal proceeding. This study exposes the strong tests or symptoms. I don’t like going for the dra- emotions physicians can experience when patients have a matic moment. I suggest to patients that they bring bad outcome, when the possibility of having made a mis- their spouse when they come back. When I go in take arises, and/or when the doctor is accused of mal- the room I have a plan. Patients remember the practice unjustly. As one physician respondent stated, “If moment when they hear bad news and I want to something goes wrong with a patient . . . the things handle it as well as possible. I say a prayer before Iwalk in the room and try to center myself. The that come to the doctor’s mind are ‘Was it something I harder part is the patients I’ve come to know. The prescribed? Was it an instruction I failed to give? Did I do doctor comes in afterwards, but I deliver the hard something wrong?’ You get that sinking feeling probably news to the ones I know well. It is a tearful time.
on a daily basis almost” (Gallagher et al. 2003, p. 1003).
Another cause of emotional stress for health care providers is the possibility or actual occurrence of a med- HEALTH CARE: AN OPPORTUNITY FOR
ical malpractice claim. The service quality literature SERVICE RESEARCHERS
stresses the importance of reliability (e.g., Zeithaml,Parasuraman, and Berry 1990) and recovery when fail- The health care services sector offers talented acade- ures occur (e.g., Tax, Brown, and Chandrashekaran mics an area of research with high potential for making 1998), while acknowledging the inevitability of service significant contributions. In addition to the social, psy- failures (e.g., Keaveney 1995). As noted earlier, medical chological, moral, and economic impact of health care, it errors are common, yet service recovery is more difficult also is an intellectually challenging field of study. The to pursue in practical terms because the errors may harm problems are perennial (mortality and suffering) but also patients and may result in a malpractice action.
mutable (technology, advances in science, and social Individuals providing other services do not normally get mores continually affect the delivery of health care). A sued when they make a mistake. In health care, the indi- goal of this article is to provoke further interest and vidual may be sued along with the institution. Moreover, research in health care service. Toward this end, we have many malpractice claims are pursued in the absence of created Table 1, which summarizes promising areas for definitive medical errors (Studdert, Mello, and Brennan inquiry categorized by the health care service dissimilar- 2004). In the 1990s, approximately 70% of U.S. mal- ities discussed. These inquiry areas are neglected or practice claims resulted in no payment, and defendants underresearched and would benefit from study by service won the majority of cases going to trial (Data Sharing researchers in management, operations, and marketing.
Project Information Manual 2001).
Health care service aligns well with the research training Medical malpractice has become a crisis in American academics receive in business school PhD programs.
health care and by all accounts is exacting a considerable Health care also fits the purview of business disciplines emotional and financial toll on physicians. Many doctors given the complex service provider, consumer, organiza- in high-risk, high-liability specialties such as emergency tional, technological, productivity, and safety issues it medicine, neurosurgery, and obstetrics and gynecology presents and its pervasive economic and social influence.
are closing their practices, moving to a state with lower The health care system differences in various coun- malpractice insurance costs, refusing to perform certain tries offer an excellent opportunity to compare and con- procedures or serve sicker patients, and practicing defen- trast system effects on a wide variety of issues. A commonly sive medicine by ordering extra diagnostic tests or refer- asked question is which country’s health care system is ring for a second opinion (Studdert et al. 2005).
the best? It is not an easily answered question despite Apologizing to customers for service failures is stan- published data that rank countries on various criteria such dard recommended practice in the service recovery liter- as costs, survival rates (e.g., breast cancer), avoidable ature. It also is recommended in some medical literature events (e.g., smoking rates), and process indicators (e.g., (Gallagher et al. 2003; Kraman and Hamm 1999). A cervical cancer screening rates) (Hussey et al. 2004; study of patients’ and physicians’ attitudes concerning Reinhardt, Hussey, and Anderson 2004; Schoen et al.
disclosure of medical mistakes that caused harm found 2004). For example, Canada’s nationalized health system that patients wanted to know what happened and why, costs far less per capita than America’s (Reinhardt, Hussey, what it would mean for their health, and how the problem and Anderson 2004). Yet, Canadian citizens may have to would be corrected for them and prevented in the future.
wait several years before they can have what is classified JOURNAL OF SERVICE RESEARCH / November 2007 Promising Areas for Scholarly Inquiry in Health Care Service Provision
1. Customers have some combination of illness, pain, uncertainty, fear and perceived lack of control.
a. How can health care services be delivered to increase patients’ perception of control?b. Would increased perceived control in nonmedical decisions (e.g., when meals are served, adjusting room lighting, choosing music when undergoing a medical procedure) improve clinical outcomes and/or patient satisfaction? c. What differences occur, if any, in how patients evaluate the quality of service in extended service encounters (such as a hospital stay) compared to brief service encounters (such as an office visit)? d. What is the role of learned hopefulness in patients’ evaluations? How does hope affect patients’ evaluations of risks and payoffs of medical 2. Customers may be reluctant coproducers because health care is a service they need but may not want.
a. What can clinicians do to increase the ability and the motivation of reluctant coproducers?b. What role can technology (such as telemedicine) and customer communities (such as support groups) play in enhancing the patient c. Is patient satisfaction always the appropriate metric when clinicians focus on needs rather than wants? What other metrics should be d. What influences surrogate coproduction such as when a family member or agent of the patient must make difficult choices about a loved one’s care? Do current models of risk-reward decision trade-offs and attendant satisfaction (Bendapudi and Leone 2003) apply when the decisionmaker is the agent versus the actor? 3. Customers relish privacy physically, emotionally, and spiritually.
a. What are predictors of customer self-disclosure?b. How does self-disclosure manifest in different cultures that place differing levels of emphasis on privacy?c. As patients develop closeness with a specific clinician, how can this trust be “transferred” to others in the focal health care system 4. Customers need “whole person” service.
a. How should clinicians be trained to read patients’ needs for psychosocial support as well as medical care?b. Given that patients may face difficult trade-offs between sacred values such as health and well-being versus secular values such as frugality (Tetlock 2003), what can be done to help them make sound financial decisions as well as medical ones? c. What differences occur, if any, in how patients evaluate the quality of medical service when they have a serious illness compared to when 5. Customers are at risk of being harmed.
a. How can patients best be motivated and educated to evaluate safety information across complex health care services?b. How can policy makers best communicate risk to different populations with varying needs and abilities for cognitive processing (Vidrine, c. How do patients determine whether a medical problem was caused by a medical error? How is blame apportioned in a patient’s mind? What 6. Clinicians are stressed physically and emotionally.
a. What can be done to reduce burnout among clinicians?b. What impact does the “acting” that clinicians engage in when interacting with patients have on their emotional well-being (Hennig-Thurau c. What conventional health care delivery processes can be restructured or reengineered to reduce the physical strain of being a clinician?d. What nonclinical training do clinicians need to be effective in a role that requires they interact not only with patients but with families, other health care providers, insurance companies, government agencies, and the broader community? as elective surgery even if they are in considerable discom- Enormous sums of money are invested and spent in fort. Insured Americans could usually have the same creating and consuming a health care service crucial to surgery in a matter of days or weeks. The background and people’s well-being. Yet, health care is fraught with prob- perspective of service researchers would be useful in com- lems. Purchasers face continually rising costs for a parisons of these two health systems. Which of these service that is too often inefficient, ineffective, and dan- health systems is best is probably not the right question; gerous. Providers frequently endure considerable physi- the better question is what can the United States and cal and emotional stress, which can manifest itself in on-the-job fatigue and mistakes, job-related burnout, and Berry, Bendapudi / SERVICE RESEARCH IN HEALTH CARE the decision to leave their profession prematurely.
Data Sharing Project Information Manual (2001). Rockville, MD: Although health care shares common characteristics with Physician Insurers Association of America.
Duhachek, Adam (2005), “Coping: A Multidimensional, Hierarchical other services, it also has uncommon characteristics that Framework of Responses to Stressful Consumption Episodes,” set it apart; studying health care service reveals its salient Journal of Consumer Research, 32 (1), 41-53.
Eurobarometer (2006), “Medical Errors.” Retrieved January 30, 2006, from http://ec.europa.eu/health/ph_information/documents/eb_64_ No other service sector affects the quality of life more than health care. No other service commands more Gallagher, Thomas H., Amy D. Waterman, Alison C. Ebers, Victoria J.
resources or is more challenged as it faces the future.
Fraser, and Wendy Levinson (2003), “Patients’ and Physicians’ Health care needs the expertise, objective point of view, Attitudes Regarding the Disclosure of Medical Errors,” Journal ofthe American Medical Association, 289 (February 26), 1001-1007.
and fresh ideas of service scholars in operations, man- Groopman, Jerome (2002), “Dying Words,” The New Yorker (October agement, and marketing. As a field of inquiry, health care poses many questions that service researchers could pur- Hawkins, Lee, Jr. (2005), “As GM Battles Surging Costs, Workers’ Health Becomes Issue,” The Wall Street Journal, CCXLV (April 7), sue. As professionals, we have an opportunity to help shape the future of health care service delivery.
Heffler, Stephen, Sheila Smith, Sean Keehan, Christine Borger, M.
Kent Clemens, and Christopher Truffer (2005), “U.S. HealthSpending Projections For 2004–2014,” Health Affairs—WebExclusive, W5 (February 23), 74–85.
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———, ———, William M. Sage, Catherine M. DesRoches, Jordon Peugh, Kinga Zapert, and Troyen A. Brennan (2005), “Defensive Leonard L. Berry (PhD) is a distinguished professor of mar-
Medicine among High-Risk Specialist Physicians in a Volatile keting and holds the M. B. Zale Chair of Retailing and Malpractice Environment,” The Journal of the American Medical Marketing Leadership in the Mays Business School, Texas Association, 293 (June 1), 2609-2617.
A&M University. He is also a professor of humanities in medi- Tax, Stephen S., Stephen W. Brown, and Murali Chandrashekaran cine in the College of Medicine. During the 2001-2002 acade- (1998), “Customer Evaluations of Service Complaint Experiences:Implications for Relationship Marketing,” Journal of Marketing, 62 mic term, he served as a visiting scientist at Mayo Clinic, studying health care service. He is the founder of Texas A&M’s Tetlock, Philip E. (2003), “Thinking the Unthinkable: Sacred Values and Center for Retailing Studies and is a former national president Taboo Cognitions,” Trends in Cognitive Science, 7 (July), 320-324.
of the American Marketing Association. In 2007, he received Trampuz, Andrej and Andreas F. Widmer (2004), “Hand Hygiene: A the AMA/McGraw-Hill/Irwin Distinguished Marketing Frequently Missed Lifesaving Opportunity during Patient Care,”Mayo Clinic Proceedings, 79 (January), 109-116.
Educator Award. Professor Berry’s books include Discovering Vidrine, Jennifer I., Vani Nath Simmons, and Thomas J. Brandon (2007), the Soul of Service, On Great Service, Marketing Services: “Construction of Smoking-Relevant Risk Perceptions among College Competing Through Quality, and Delivering Quality Service.
Students: The Influence of Need for Cognition and MessageContent,” Journal of Applied Social Psychology, 37 (1), 91-114.
von Gunten, Charles F. (2002), “The Art of Oncology: When the Tumor Neeli Bendapudi (PhD) is an associate professor of marketing
Is Not the Target: Discussing Hospice Care,” Journal of Clinical and the founding director of the Initiative for Managing Oncology, 20 (March 1), 1419-1424.
Services at the Fisher College of Business, The Ohio State Wachter, Robert and Kaveh Shojania (2004), Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes.
University. During the 2007-2008 academic term, she will be the chief customer officer at Huntington Bank. She served as a Wennberg, John E., and Elliott S. Fisher (2006), The Care of Patients visiting scientist at the Mayo Clinic in 2001-2002 studying with Severe Chronic Illness, An Online Report on the Medicare health care service. She is the recipient of the highest teaching Program by the Dartmouth Atlas Project, The Dartmouth Atlas of awards from the Academy of Marketing Science and The Ohio Healthcare 2006, Hanover, New Hampshire: Center for TheEvaluative Clinical Sciences, Dartmouth Medical School.
State University. She is actively involved with businesses Woolf, Steven H., Anton J. Kuzel, Susan M. Dovey, and Robert L.
through board service, consulting, executive education, and Phillips, Jr. (2004), “A String of Mistakes: The Importance of

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