Soldier, doctor, patient, customer.

The baby needed milk. So, I broke from my usual pattern and stopped at the grocery store in uniform. Searching the aisles, I was stopped by an elderly couple, both of whom held out their hands, shook mine, and thanked me for my service. I was reminded of what a privilege it is to serve my country; to sacrifice for my country. The hardships seemed small and insignificant, while the honor seemed immense. I stood straighter, and was reminded of the pride I had the first time I put on the uniform, joining a long and grand tradition. I was reminded that there are easier jobs, there are better paying jobs, but there very well may be none better. I work with the best of the best and care for our country’s brightest and bravest. I had a routine appointment. The waiting room was full and lived up to its name as I waited to be seen. Despite the delay I was content. I had a good book, I was getting worldclass health care, and I was not asked to pay a cent. Everyone in the clinic was hard at work and I did not mind the quiet time to sit and read. Looking around, the facility could have been newer, fancier, and brighter. There could have been more doctors, nurses, and medics to tend to me. But, then my country has better things to spend its money on. I thought about the soldiers in harm’s way all over the world who need armor and ammo. I thought about the roads to be repaired, schools to be filled, scientific research to fund. To serve my country on this day means waiting quietly, thanking my provider, and returning to work. The Customer Satisfaction Survey arrived a few days later. It seemed base and transactional. It did not call me a soldier, but a patient. It did not remind me of the army value of selfless service or that I had volunteered to serve my country. In its bureaucratic way it asked if I was made to feel like the most important person in the clinic that day. It did not ask simply if my care was adequate to meet my needs, but if my care met my wants and desires. It seemed to belittle the personal relationship I have developed with my provider and asked me to judge them on a professional level as if I had the knowledge and experience to understand their job. What might I want from my provider? I want a provider that can keep me in the fight and preserve the fighting strength of the force while spending as few taxpayer dollars as possible. We are strong not because we are an army of one, but because we are an army of many. In green, I am no more important than the soldier to my left or right. Customer Satisfaction Surveys have the potential to improve the health care environment by finding ways to improve provision of care and efficiency as well as identifying and rewarding top performers. But they also have the potential to harm. A recent study showed increased mortality in those patients who were more satisfied with their care, suggesting that care that is satisfying to the patient may in many cases not be in their best interest. Satisfaction surveys focus attention on the individual and their individual experience, isolating them from the community and shared civic engagement. They can breed a sense of entitlement in beneficiaries and destroy the sense of community and shared sacrifice that often arises in difficult times. They can push providers to provide “satisfying” care rather than evidencebased care, especially when survey results are tied to facility and provider reimbursement. We should expect compassionate and evidence-based care from our providers, but satisfaction surveys fail to provide the benchmarks that would be necessary for patients to truly understand the quality and implications of their care. High-quality, patient-centered care and patient safety should be our goals. Patient satisfaction, while being far easier to measure, is a poor proxy for patient-centered care, and bears only a passing correlation to quality care, if any at all. Striving for patient satisfaction may in fact jeopardize global patient safety as the demands for medically unnecessary tests and treatments are granted to garner higher scores. Narcotic painkillers now kill more Americans than heroin and cocaine combined, a fact that should weigh heavily on anyone asking providers to strive first for patient satisfaction in an era in which every discomfort, no matter how minor, must be measured, recorded, and treated. In the military, we are asked to preserve the fighting strength of the force and be good stewards of public 30505 Saint Andrews Drive, Georgetown, TX 78628. doi: 10.7205/MILMED-D-13-00582