What’s Next?: Closing The Expectation-Performance Gap


Leonard Zwelling

In any business endeavor, or any human interaction, there is an inherent gap. Those involved come with expectations of some result from the business transaction or person-to-person interaction. Then there is what actually happens. That gap between expectations and performance is as good a definition of satisfaction as I can imagine. Total satisfaction, as Stephen Levine taught me, is the “absence of desire.” In the case of a product, if that product does everything that you thought it would and you paid a reasonable price for it, you are satisfied. In the case of a human interaction, you bring expectations and hopes to the interaction. If you walk away with what you had wanted, you will be satisfied. If you walk away with less than what you wanted, you may be a little less satisfied. You get the idea.

One of the tools for closing the expectation gap is price. If expectations are high and the price for the service is high, the deliverable better be good. Conversely, if the price is low, you may be more forgiving as to the quality of the deliverable with reference to expectations.

A great deal of effort in modern medicine is being placed on the results of patient satisfaction surveys. These templates attempt to assess the size of the expectations-performance gap.

There seems to be a major effort underway to close a perceived significant gap between what patients come to MD Anderson expecting and what they take away when the interactions are over. Why should such a gap exist?

I actually think it is quite simple. MD Anderson has been victimized by its own success and its ad campaign that suggests that not only will MD Anderson make cancer history, MD Anderson will make YOUR cancer history. And that doesn’t happen all that frequently and it is very unclear that it happens with greater frequency at MD Anderson than at any other cancer center. It is certainly unclear whether or not outcomes are the same at all MD Anderson sites around Houston let alone the rest of the world. There is a great gap of knowledge as to how good MD Anderson really is and whether or not the bragging about making cancer history is really relevant or even true.

Assuming this satisfaction gap is real at MD Anderson, how might it be closed?

First, alter expectations by giving patients a true assessment of the benefit they are likely to derive by coming to Anderson particularly before they mortgage the house and fly in for a four-week stay in Houston. A patient from West Virginia with advanced lung cancer should not be expected to derive a great deal of benefit from a visit to the Anderson clinics although he might. It is unlikely that his cancer will be made history. As long as the patient understands the likelihood of deriving any benefit in terms of life quality or quantity based on an analysis of prior clinical experience of like patients at Anderson, then the patient is in the optimal position to decide what to do and at what cost to him or his family.

Second, Anderson could analyze its own survival data and post to a web site the likely results of a visit to MD Anderson for a patient with a particular diagnosis. The same should be done for all of the NCI-designated cancer centers.

If that were done, then each patient could adjust his or her expectations based on the best available data and know what the likelihood of derived benefit will be from a visit to 1515 and at what cost.

Having just taken the patient satisfaction survey for my last visit to Anderson, I cannot say that these ideas are being incorporated in the process to assess the gap.

Lowering expectations to reality and making transparent what reality is would go a long way toward closing the gap.

Despite what Dr. DePinho promised, it is not likely that MD Anderson, or anyone else, will be making cancer history in the next five years. Perhaps an advertising campaign extolling the virtues of MD Anderson’s care quality (measured in some way) and/or better outcomes (we know how to quantify this) would fix expectations at the proper level and make satisfaction at results more frequent. Why the heck not try that?


LZ’s letter to NY Times on its web site June 25:

To the Editor:

Re “A Doctors’ March on Washington” (Op-Ed, June 16):

While sympathetic to the case made by Dr. Danielle Ofri for a broad political statement in Washington, I must disagree with this idea. As someone who has been on both sides of such actions, I have found them ineffective.

I have lobbied on Capitol Hill on behalf of several of the large physician groups during yearly meetings of these groups in the capital. I have also been a Senate staffer being lobbied by similar groups during the first phases of the discussion of the Affordable Care Act.

It was not the one-time statements, large or small, that had an effect on the final legislation, but the efforts of skilled, professional lobbyists making constant contact with congressional offices and offering actual legislative language that had the real impact on the final legislation.

Lobbying effectively is not a one-time, big-event process. It’s a day-in, day-out presentation of a logical and focused case that wins the day.

A march on Washington by doctors may attract news coverage for a day. Speaking with a single voice for patients’ rights and for social justice continuously will be far more effective. The insurance and pharmaceutical industries have figured this out.
The writer is a retired oncologist.

Leonard Zwelling