Significance of Serenity Prayer and patient satisfaction

I’m a fan of the Serenity Prayer: “God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.” The words are simple but meaningful. The first segment offers comfort, while the second inspires strength to overcome obstacles. The final phrase is the most difficult to achieve.

The prayer itself could be applied to the controversy surrounding its origin. Although it seems biblical, most sources credit Reinhold Niebuhr, a protestant pastor who was born just outside of my St. Louis hometown and died in 1971 at age 78. Mr. Niebuhr is said to have first used the prayer during church group services in the late 1930s. It spread like wildfire via the United Services Organization to World War II troops and then to Alcoholics Anonymous followers. Fame generated an ironically intense dispute about authorship, mostly potentiated by Mr. Niebuhr’s daughter, whose efforts seem hyposerene.

In recent years, I’ve been citing the Serenity Prayer more often - to myself, co-workers and patients - usually as an attempt to counteract frustration. Some days, everyone seems frustrated: Colleagues feel underpaid, overworked, unappreciated, challenged by bureaucracy, or burdened by personal problems. Patients are suffering from or worried about a disease. But the degree of frustration seems much more related to the person than the magnitude of the problem. This becomes a professional issue when it impacts the increasingly important quality health measure known as “patient satisfaction.”

Patient satisfaction is particularly important to hospital administrators and government bureaucrats. This measure is a global assessment based on a vague combination of ease of access (wait time for an appointment and in the office waiting room), and expectations, confounded by advertising and medical naiveté. Parameters like friendly staff, popular magazines and comfortable waiting rooms are important. Quality of care carries much less weight. Nonintervention and prevention seem to be especially undervalued recommendations that may even negatively impact satisfaction.

Next: The challenge and significance of active nonintervention

Active nonintervention

One of my biggest challenges comes when attempting to provide realistic expectations about the relative risks and benefits of treating ditzels. “Ditzel” is a medical term, but the origin is obscure. Ditzels are not unique to dermatology. Other specialists define ditzels as follows:

• Radiologists: very small nodules in the lung … usually benign … presenting the dilemma of how to deal with these tiny lesions.

• Pathologists: specimens submitted for histologic examination that do not usually pose a diagnostic dilemma but are time-consuming.

• Surgeons: Small specimens with limited educational potential … no suspicion or history of malignancy. They often have few possible diagnoses and a reduced billing charge because of limited complexity .… They slow you down … as you struggle to get the “right” wording and obsess over whether what you see is pathologic or normal.

My definition of a ditzel is a skin finding of minimal consequence that cannot be quickly and easily changed. Many ditzels resolve spontaneously. The ditzel challenge for dermatologists is to help patients understand and accept their clinical insignificance. For pediatric dermatologists, the person who needs help is the parent rather than the patient, complicating the goal of achieving acceptance.

Next: Leaving yourself open to criticism

Open to criticism

Warts, molluscum, spider angiomas and small birthmarks are common ditzels. One of my mottos is: “The treatment should never be worse than the disease.” So, when I provide education about therapeutic options for ditzels, merely mentioning the Serenity Prayer usually gets me an understanding nod from the parent, and protects my patient from a painful procedure.

I have also been blindsided by idiosyncratic parental hostility. Anger more often comes from medically unsophisticated parents who are probably hungry and tired of waiting, but also disproportionately frustrated about a relatively trivial problem that bothers them much more than their child. Rather than accepting the thing that cannot be changed, these parents seem to misinterpret my bias towards active nonintervention as a sign that I am somehow withholding an easy fix.

In these cases, mention of the prayer seems to grant them the courage to criticize my knowledge base, doubt my best intentions and demand a different answer. I know that in some situations, aggressive behavior can change outcomes, but for a ditzel in my clinic, attack only provokes suppressed, conflicting reactions: aggravation (go somewhere else) and apprehension (will they complain?).

Circumventing hostility

I’m also pretty sure that plenty of snacks, prizes and entertainment would be very effective ways to circumvent hostility and promote patient satisfaction. I have made suggestions to my hospital administrators about incorporating these features in the clinic waiting room. If patients and parents were highly satisfied on their way into the exam room, we could better focus on medical care. Until then, God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.

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