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Health Care: A Fertile Field for Service Research
The online version of this article can be found at:
can be found at:
Journal of Service Research
Additional services and information for
A Fertile Field for Service Research
Leonard L. Berry
Texas A&M University
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
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
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
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
—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
) 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
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
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
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
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.
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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
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, 32 (1), 41-53.
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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
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.
Hendrich, Ann L., Joy Fay, and Amy Sorrells (2002), “Courage to
Heal,” Healthcare Design
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ABC News/Kaiser Family Foundation/USA Today
Gremler (2006), “Are All Smiles Created Equal?” Journal of
(2006), “Health Care in America 2006 Survey,” October 15. Menlo
Park, CA: The Henry J. Kaiser Family Foundation.
Adams, Jon and Michelle Biros (2002), “The Elusive Nature of
Responsibility,” Obstetrics and Gynecology
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Hussey, Peter S., Gerard F. Anderson, Robin Osborn, Colin Feek,
Bendapudi, Neeli and Robert P. Leone (2002), “Managing Business-to-
Vivienne McLaughlin, John Millar, and Arnold Epstein (2004),
Business Customer Relationships Following Key Contact
“How Does the Quality of Care Compare in Five Countries?”
Employee Turnover,” Journal of Marketing
, 66 (2), 83-101.
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——— and Robert P. Leone (2003), “Psychological Implications of
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Customer Participation in Coproduction,” Journal of Marketing
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Kahn, Barbara E. and Mary Frances Luce (2003), “Understanding
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Extreme Honesty May Be the Best Policy,” Annals of Internal
———, Derek Parker, Russell C. Coile, Jr., D. Kirk Hamilton, David D.
O’Neill, and Blair L. Sadler (2004), “The Business Case for Better
Macinnis, Deborah J. and Gustavo de Mello (2005), “The Construct of
Buildings,” Frontiers of Health Services Management
, 21 (Fall), 3-24.
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England Journal of Medicine
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——— (2004), “Some is Not a Number, Soon is Not a Time,” keynote
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Forum, December 14, Orlando, Florida.
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Morris, J. Andrea and Daniel C. Feldman (1996), “The Dimensions,
Chase, Richard B. and Sriram Dasu (2001), “Want to Perfect Your
Antecedents, and Consequences of Emotional Labor,” The Academy
Company’s Service? Use Behavioral Science,” Harvard Business
of Management Review
, 21 (October), 986-1010.
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Cmiel, Cheryl A., Dana M. Karr, Dawn M. Gasser, Loretta M. Oliphant,
Health Division (2006), OECD Health Data 2006
and Amy Jo Neveau (2004), “Noise Control: A Nursing Team’s
Approach to Sleep Promotion: Respecting the Silence Creates a
Raghunathan, Rajagopal, Michel T. Pham, and Kim P. Corfman (2006),
Healthier Environment for Your Patients,” American Journal of
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Cutler, Ben (2003), “Putting Pricing in the Picture: Shielding
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JOURNAL OF SERVICE RESEARCH / November 2007
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Cascade Analysis in Describing, Counting, and Preventing Medical
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Errors,” Annals of Family Medicine
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. New York: Free Press.
———, ———, 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
, 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
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
(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
, 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
Endoscopische Thoracale Sympathicotomie Informatiebrochure HyperHidrosisKliniek Informatiebrochure HyperHidrosisKliniek Endoscopische Thoracale Sympathicotomie bij de HyperHidrosisKliniek De chirurgische behandeling van overmatig zweten van handen en/of oksels (hyperhidrosis palmaris/axillaris) Het is goed u te realiseren dat voor u persoonlijk de situatie anders kan zijn dan beschreven
Aquarium Fish and the Veterinarian (Or, I flushed them down the toilet, too) Zoo/Exotic Pathology Service Lecture given at the U. C. Davis Avian/Exotic Animal Medicine Symposium 1993Aquarium fish medicine is a challenging and exciting area of veterinary medicine. It isfortunate that as veterinarians, we are uniquely trained to work-up diseases and attempttherapies in many animal species. Th