Improving Communication: The Puke or Shoot Continuum


No one likes to be sick and let’s face it… puking is the worst. Second to that I guess, is getting puked on. If any of you have had kids or been around them, especially if one of them gets car sick easily, then you know what I mean. This picture was taken on the turnpike in Oklahoma, right before my little guy got sick.

So, why in the world would I start off a blog on Physician Communication talking about puking?

In the previous blog, I discussed the most powerful and important tool for improving physician communication. Coaching for communication can support, encourage and help physicians improve their connections with patients. In this blog I will talk about some of the common aspects of traversing a common trajectory I like to call the Puke or Shoot Continuum. Read on to see if you may have been on this same journey…

After speaking to many groups about physician communication and patient experience (especially when I had the distinct privilege of being the first or one of the first people to speak to the physicians about CMS, public transparency of these data, what the HCAHPS or CG CAHPS surveys are; the questions, the wording, the scoring methodology, etc.), I began to notice a pattern.

One of two things would happen: They’d either “shoot the messenger“ or “puke on the data”!

I saw how groups had to go through various stages of the acceptance process (spoken like a social worker, I know). It takes some talking to help groups get over their frustrations and doubts to the point where they were ready to make changes and hear how they could improve. Sometimes a group can move through this process in one meeting or conversation. Sometimes it takes a series of conversations over time.

Please hear me on this…I LOVE working with physicians and other care team members. I don’t say any of this to disparage, or stereotype. I just am calling out a pattern that I have seen time and time again. As I work with groups all over the country, when I describe this Puke or Shoot Continuum, it resonates. I find that this gives those of us working in this space a language for our common experiences.

I call this path to performance “The Puke or Shoot Continuum.” Here are some points on the spectrum.

  • Don’t shoot! In this stage people tend to either “shoot the messenger” or “puke on the data.” And let’s be honest, sometimes it’s both of these in the same conversation. This is where a lot of the frustrations often surface about frustrations with CMS, public transparency, the survey tools, etc. I find in this phase it’s best to help just forge ahead and calmly present the rationale behind the surveys and the payment structure. Check out our short video on YouTube with one way to explain this to a group: What the Heck is Value-Based Purchasing?
  • “My patients are different!” This is where some will make the case for exemptions, declaring that their patients are sicker, more negative, or should be otherwise excluded from the CMS and public reporting. I had one neurologist in a Midwest town look me straight in the eyes and declare that his patients in his practice were in more pain than any other patients of a neurology practice anywhere else in the country! I find that by letting folks be heard with their concerns and then talking about the national movement and transparency of the data to compare patients from all regions can help.
  • “Show me my data!” This is when physicians want to see how they specifically do, not as a group, a hospital or a division. Although HCAHPS asks questions about doctors (plural), groups are able to achieve huge success with transparency of data through customized physician-level reports or use of an Enterprise Data Warehouse to get at individual physician-level data.
  • “Tell me what the patients say!” I love it when a group gets to this point because they are coming around and want to know what their patients are saying. This is where the value of talking to patients about the specifics of physician communication—through focus groups or Patient & Family Advisory Councils—can project that patient voice which so readily resonates with physicians.
  • “Fine, just tell me what to do.” This is my favorite point: when a group is ready to hear how they may make an impact and are open to the various strategies that can help improve their communication with patients. At this point it is crucial to be ready with the 2-3 improvement strategies you’d suggest that the group employ to help improve their communication.

So how about you? Does this continuum resonate with you? Please leave a comment and share with us about your journey with this.  One of my favorite CNOs called me and said “Janiece, I think we got through the ‘Shoot the Messenger’ phase but now we’re stuck on the ‘Show Me My Data’ phase!” Together we talked about some tips for how to help her Med Exec group get “unstuck” as we worked out a model for attribution of the HCAHPS data at the physician level.

Be sure to check out our final blog in this series, The Path to Performance: Tips for Traversing the Trajectory where I’ll share some key strategies that help to get groups through this Puke or Shoot Continuum and still move on to improvement in physician communication.

Janiece Gray

I began my career as a social worker and later, with my Master of Health Administration (MHA), directed operations at Allina Health in Minnesota. I later directed patient experience at Allina. My background and experience give me strengths in approaching healthcare opportunities and challenges through a systems lens – with unique strengths, challenges and activation points. My experience is also informed by leadership roles leading performance improvement in patient-centered care and patient experience departments. Working in the client role with healthcare consulting firms inspired me to address some unmet needs in the industry, and to co-found DTA Healthcare Solutions. I have a Lean Six Sigma Black Belt, and find that the discipline of practice translates to healthcare work very well.

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