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?

I believe it does. Pointing out the negatives without providing some positive feedback from the vast majority of satisfied patients diminishes the value of the desired behavior and creates cynics out of former believers.

This positive reinforcement does not need to cost much. Just an occasional thumbs-up or a quick Happy-Gram does it for me. For others, money may be a significant motivator—that’s not to say that money wouldn’t motivate me, too. Being left alone regarding trivial matters goes a long way as well.

In spite of our education and compensation, everyone enjoys a pat on the back occasionally for a job well done. When this does not happen, human nature begins to take hold, and we ask ourselves why we are knocking ourselves out if all that is received is negative feedback.

In order to have a few higher percentage points of patient satisfaction or a few dollars more in billing, there will be costs unless there is some positive feedback. So what does this high-scrutiny environment cost?

These costs are difficult to measure but certainly have a high value. Cynicism can spread through a group like gastroenteritis through a kindergarten class. It kills esprit de corps and poisons innovation and spontaneity (and nap time).

Apathy, the ugly stepsister of cynicism, is never far behind. Suddenly, the desire to serve on hospital committees or volunteer to do extra work with students plummets like the popularity of Congress.

Finally, unhappiness sets in, and previously content physicians are reading the last few pages of newspapers such as this one. The weather is nice in Virginia, isn’t it?

Clearly, scrutiny of our practice is not the only factor in physician happiness, but it is an important part of the puzzle. As reimbursements fall and patient census goes up in many parts of the country, desirable physicians will be looking for greener pastures. The question hospitals and groups need to ask themselves is, What is the cost of making these doctors unhappy?

Are the cynicism, apathy, unhappiness, and physician turnover worth a couple of percentage points or a few extra bucks in billing? Is it worth the cost of recruiting or the inherent instability that high turnover can bring to a group?

There was some dew last night. I’m not washing the car. It’s not quite as shiny, but I’m happy until some bird dumps a load on my windshield.

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center. Your feedback is welcome at David.Baehren@utoledo.edu.