Everyone likes a clean car. It’s a great feeling to come out of the car wash or the detail place with your shiny wheels and a little scented evergreen tree hanging from the mirror. That car you were thinking about selling now seems to be more desirable. At least until the next thunderstorm or unconcerned pigeon passes overhead, all is right with the world.

Russ’ Car Wash, the place I took my ’66 Impala when I was 16 and still go to now, believes this so much that their motto is “A Clean Car Is Worth More.” I believe that as well. And for $10—$5 on Wednesdays—it’s worth it to me to have my car washed.

Now, if I sent a 5-year-old out to wash my car in return for a large chocolate chip cookie, I would probably not get my money’s worth (or cookie’s worth) and would not be happy with the job. That is, if I want anything above 3 feet to be clean.

I would be at the point where spending a few extra bucks returns quite a bit of satisfaction. There is, however, a point of diminishing returns. If I spent $200 for a team of detailers to find every water spot and every piece of lint, the extra cleaning may not really mean that much in the end. This is especially true if the kids and the dog ride regularly.

Close scrutiny of the practice of emergency medicine is much like having your car washed. Some scrutiny is entirely appropriate and desirable. Reasonable feedback about patient satisfaction helps us to adjust our behavior, and this leads to happier patients and, in turn, happier hospital administrators.

Feedback about productivity is equally helpful. This process can bring to light issues regarding effectiveness of charting and speed at which patients move through the department. Most physicians have no desire to be the laggard, and are eager to improve when this information is presented in the appropriate manner and setting.

Use of best practices to improve these important areas of our work has been shown to be beneficial to everyone involved. Just as in car washing, however, there is a point at which increasing the depth of scrutiny fails to bring about significant gains or, worse, becomes counterproductive.

If a doctor is in the 90th percentile in patient satisfaction scores, is there really a reason to hound this doctor about a few mediocre scores or an occasional complaint? Does this relentless emphasis on the negative have a negative effect itself?