This is Scott
Selinger and welcome to another edge-of-your-seat-amazing talking blogpost -
ABC’s for ECP’s, the podcast on behalf of the Northern California’s chapter of
the American College of Physicians Council of Early Career Physicians. Today
I’d like to talk a little bit about this new world of patient satisfaction
scores.
I really like my new
car. I got it a few months ago and it’s been working great. But
then a few weeks ago I folded the back seat down and now it won’t come back up.
So like most men, I hit it a few times and then decided to take it to the
dealership. It was a pretty easy, seamless process of getting in and out
but there were a few snags.
For instance, they
told me I needed a new part and they’d call when they got it in - but that
didn’t happen and when I called 2 weeks later I found out that the part I
needed had been there for 10 days.
And then there was
the little issue of the fact that when I got the car home, the seat was still
broken. I brought it back, saw a different service advisor, who
apologized profusely, and they got it fixed the same day.
The kicker was, every
time I was there, I was reminded before I left that “by the way you might be
getting a survey …” at which point I cut them off and just gave them a thumbs
up and said “all 5’s guys!” because I really wasn’t interested in hearing the
spiel – the surveys they send out are based on top box scoring, so if they get
anything except a 5 out of 5, they get dinged, even if they had nothing to do
with the dissatisfying issue.
This is getting to my
main point about patient satisfaction surveys and its effect on us as
physicians. This is something I slowly started hearing more about towards
the end of residency, but at the time the satisfaction scores at the resident
clinic were abysmal and we felt sort of resigned to that because a lot of the
dissatisfying factors were systems issues beyond our control. That’s if
you can imagine patients being dissatisfied by frequently seeing random
doctors, long wait times, bedside manners that were still under construction,
and frequently being told that they didn’t need antibiotics for their cold or
opioid pain medications for their headache.
But now that I’m out
practicing, I’m realizing how huge an issue this is. I’m still trying to
figure out when someone needs steroids and when they need antibiotics or the
best way to convince them they need to quit smoking or lose weight and
honestly, sometimes this weighs on my mind especially when I have someone
demanding something I know is unreasonable.
With all the money
that is tied to patient satisfaction scores between Medicare reimbursements
based on it as well as organizations and practitioners trying to maintain
patient loyalty and the insurance money that comes along with it, it’s no
wonder it frequently feels like our profession is starting to more resemble
that of the service industry, but saddled with the complexities of human health.
To tie back to the car problem I had, a colleague of a colleague now
routinely, in her follow up emails to her patients, has a little tagline at the
bottom talking about what they should do if they get a survey! Patient
satisfaction scores are now commonly being tied to physician pay and
advancement or retention at their current job, the theory being to incentivize
us to make that extra effort to make sure our patients are satisfied by their
medical care.
And in theory this
sounds great because why shouldn’t patients have an exceptional experience
every time? Why should they expect any different of us than they do of
their mechanics (and I don’t mean to pick on mechanics - I’m just still a
little miffed at mine). Well, there may be a few reasons, just because
our profession is a little different than many others in the service industry.
A study[1] just
published a few weeks ago in the Journal of Patient Preferences and Adherence
(which I, like I’m assuming many of you, didn’t realize existed until today)
surveyed about 4000 doctors in a state medical society about exactly this which
came back with 155 responses. Granted, that’s a small number, but there
are some disturbing statistics from it.
First, 78% of
respondents said that these patient satisfaction surveys affected their job
satisfaction moderately to severely, with 28% of people saying they had thought
about leaving the medical profession because of them.
Second, just over
half of respondents said that they had inappropriately prescribed an antibiotic
or narcotic or ordered an unnecessary lab test because of the patient
satisfaction surveys.
Finally, while there
were 6 neutral or positive comments given on patient satisfaction rankings,
there were 47 negative comments and I do appreciate the fact that they
published them. They are actually divided up into 5 themes including the
two I just mentioned as well as:
- that they’re a poor way to evaluate the quality of medical
care,
- that there’s too much weight on them and not enough
administrative effort to improve medical outcomes
- that they’re perceived as a conflict of interest
So
that’s one side of the coin, and it is a very striking viewpoint from the
healthcare providers, but that study of course needs to be taken with a grain
of salt as it is a small number and certainly could select out for the most
dissatisfied people to respond.
But
what about from the patient side? Is there validity to these viewpoints?
Well there was another larger study about two years ago[2] published
in JAMA that looked at patient satisfaction surveys from 52,000 respondents
over 7 years. While high patient satisfaction was associated with less
frequent ER visits, it was also associated with greater inpatient use, higher
overall healthcare and prescription drug expenditures, and increased mortality.
There was commentary both ways when this article came out and to date as
best I could see, there hasn’t been another large study published regarding
this, but if you could tie it to the study looking at the physicians
perspectives on these surveys, it’s not hard to believe this data might be
real.
So
what are we supposed to do with all this information? There’s been so
much change in what the role of a physician is supposed to be. We’ve gone
from a paternalistic approach more to one of shared decision making. But
is the heavy weight of patient satisfaction surveys unbalancing the power of shared
decision making? And aren’t we now being asked to be more paternalistic
to society by reducing health care expenses, antibiotic and opioid
prescriptions, and be more dogged about preventative cancer screenings and
weight loss?
I
think the missing part of the equation is time and communication and we
definitely do need to be able to clearly communicate our thoughts with
patients. So far, I’ve seen great feedback from people when I’ve actually
stopped and instead of auto-refilling medications I don’t think are appropriate
or ordering easy labs I know aren’t indicated, I explain to them why doing so
would give me that gnawing pit in my stomach that knows when I do something
wrong. We’re all so rushed these days, I think this gets lost and I’ve certainly
been guilty of it on occasion, but this has to be a point where we hold the
line. This is why most of us went into medicine in the first place - to
help people and to be educators, not to be vending machines.
I
haven’t gotten a call for a survey for the car dealership yet. I’m
conflicted though and I actually feel differently now than when I started
writing this. If I give my honest opinion, which was my emotional urge
and first reaction, it’s going to bring down someone’s score, it might get him
disciplined or he might take a salary cut - it could contribute to his getting
fired. And the errors made were system errors too - probably nothing to
do with the guy I dealt with. Giving anything but 5’s would just seem
spiteful. I guess I’ll wait and see …
I
know I covered a lot of ground here and I’m hoping you have a few opinions to
share (and at this point I feel like I know who all of “you” are as I haven’t
seen too many downloads yet) so as always, we’d love to hear your feedback on this, so if you have any
burning questions or comments, you can post them on the blog at
canocecp.blogspot.com, our podcast page on itunes, our facebook page or email
them to canocecp@gmail.com. And if you have time, be sure to head on over
to our facebook page for the Northern California Chapter of the ACP Council of
Early Career Physicians so you can find out more about the events going on in
the chapter.
[2] Arch Intern Med. 2012 Mar
12;172(5):405-11. doi: 10.1001/archinternmed.2011.1662. Epub 2012 Feb 13.
The
cost of satisfaction: a national study of patient satisfaction, health care
utilization, expenditures, and mortality.
