This is ScottSelinger 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 ofthe American College of Physicians Council of Early Career Physicians.  TodayI’d like to talk a little bit about this new world of patient satisfactionscores.

I really like my newcar.  I got it a few months ago and it’s been working great.  Butthen 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 thedealership.  It was a pretty easy, seamless process of getting in and outbut there were a few snags.  

For instance, theytold me I needed a new part and they’d call when they got it in - but thatdidn’t happen and when I called 2 weeks later I found out that the part Ineeded had been there for 10 days.  

And then there wasthe little issue of the fact that when I got the car home, the seat was stillbroken.  I brought it back, saw a different service advisor, whoapologized profusely, and they got it fixed the same day.  

The kicker was, everytime I was there, I was reminded before I left that “by the way you might begetting a survey …” at which point I cut them off and just gave them a thumbsup and said “all 5’s guys!” because I really wasn’t interested in hearing thespiel – the surveys they send out are based on top box scoring, so if they getanything except a 5 out of 5, they get dinged, even if they had nothing to dowith the dissatisfying issue.

This is getting to mymain point about patient satisfaction surveys and its effect on us asphysicians.  This is something I slowly started hearing more about towardsthe end of residency, but at the time the satisfaction scores at the residentclinic were abysmal and we felt sort of resigned to that because a lot of thedissatisfying factors were systems issues beyond our control.  That’s ifyou can imagine patients being dissatisfied by frequently seeing randomdoctors, long wait times, bedside manners that were still under construction,and frequently being told that they didn’t need antibiotics for their cold oropioid pain medications for their headache. 

But now that I’m outpracticing, I’m realizing how huge an issue this is.  I’m still trying tofigure out when someone needs steroids and when they need antibiotics or thebest way to convince them they need to quit smoking or lose weight andhonestly, sometimes this weighs on my mind especially when I have someonedemanding something I know is unreasonable.  

With all the moneythat is tied to patient satisfaction scores between Medicare reimbursementsbased on it as well as organizations and practitioners trying to maintainpatient loyalty and the insurance money that comes along with it, it’s nowonder it frequently feels like our profession is starting to more resemblethat 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 nowroutinely, in her follow up emails to her patients, has a little tagline at thebottom talking about what they should do if they get a survey!  Patientsatisfaction scores are now commonly being tied to physician pay andadvancement or retention at their current job, the theory being to incentivizeus to make that extra effort to make sure our patients are satisfied by theirmedical care.

And in theory thissounds great because why shouldn’t patients have an exceptional experienceevery time?  Why should they expect any different of us than they do oftheir mechanics (and I don’t mean to pick on mechanics - I’m just still alittle miffed at mine).  Well, there may be a few reasons, just becauseour profession is a little different than many others in the service industry.

A study[1] justpublished 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 whichcame back with 155 responses.  Granted, that’s a small number, but thereare some disturbing statistics from it.  

First, 78% ofrespondents said that these patient satisfaction surveys affected their jobsatisfaction moderately to severely, with 28% of people saying they had thoughtabout leaving the medical profession because of them.  

Second, just overhalf of respondents said that they had inappropriately prescribed an antibioticor narcotic or ordered an unnecessary lab test because of the patientsatisfaction surveys.

Finally, while therewere 6 neutral or positive comments given on patient satisfaction rankings,there were 47 negative comments and I do appreciate the fact that theypublished them.  They are actually divided up into 5 themes including thetwo I just mentioned as well as:

- that they’re a poor way to evaluate the quality of medicalcare,

- that there’s too much weight on them and not enoughadministrative effort to improve medical outcomes

- that they’re perceived as a conflict of interest

        Sothat’s one side of the coin, and it is a very striking viewpoint from thehealthcare providers, but that study of course needs to be taken with a grainof salt as it is a small number and certainly could select out for the mostdissatisfied people to respond.

        Butwhat about from the patient side?  Is there validity to these viewpoints?Well there was another larger study about two years ago[2] publishedin JAMA that looked at patient satisfaction surveys from 52,000 respondentsover 7 years.  While high patient satisfaction was associated with lessfrequent ER visits, it was also associated with greater inpatient use, higheroverall healthcare and prescription drug expenditures, and increased mortality.There was commentary both ways when this article came out and to date asbest I could see, there hasn’t been another large study published regardingthis, but if you could tie it to the study looking at the physiciansperspectives on these surveys, it’s not hard to believe this data might bereal.

        Sowhat are we supposed to do with all this information?  There’s been somuch change in what the role of a physician is supposed to be.  We’ve gonefrom a paternalistic approach more to one of shared decision making.  Butis the heavy weight of patient satisfaction surveys unbalancing the power of shareddecision making?  And aren’t we now being asked to be more paternalisticto society by reducing health care expenses, antibiotic and opioidprescriptions, and be more dogged about preventative cancer screenings andweight loss?

        Ithink the missing part of the equation is time and communication and wedefinitely do need to be able to clearly communicate our thoughts withpatients.  So far, I’ve seen great feedback from people when I’ve actuallystopped and instead of auto-refilling medications I don’t think are appropriateor ordering easy labs I know aren’t indicated, I explain to them why doing sowould give me that gnawing pit in my stomach that knows when I do somethingwrong.  We’re all so rushed these days, I think this gets lost and I’ve certainlybeen guilty of it on occasion, but this has to be a point where we hold theline.  This is why most of us went into medicine in the first place - tohelp people and to be educators, not to be vending machines. 

        Ihaven’t gotten a call for a survey for the car dealership yet.  I’mconflicted though and I actually feel differently now than when I startedwriting this.  If I give my honest opinion, which was my emotional urgeand first reaction, it’s going to bring down someone’s score, it might get himdisciplined or he might take a salary cut - it could contribute to his gettingfired.  And the errors made were system errors too - probably nothing todo with the guy I dealt with.  Giving anything but 5’s would just seemspiteful.  I guess I’ll wait and see …

Iknow I covered a lot of ground here and I’m hoping you have a few opinions toshare (and at this point I feel like I know who all of “you” are as I haven’tseen too many downloads yet) so as always, we’d love to hear your feedback on this, so if you have anyburning questions or comments,  you can post them on the blog atcanocecp.blogspot.com, our podcast page on itunes, our facebook page or emailthem to canocecp@gmail.com.  And if you have time, be sure to head on overto our facebook page for the Northern California Chapter of the ACP Council ofEarly Career Physicians so you can find out more about the events going on inthe chapter.
[1] Patient PreferAdherence. 2014Apr 3;8:437-46. doi: 10.2147/PPA.S59077. eCollection 2014.

Impactof patient satisfaction ratings on physicians and clinical care.

Zgierska A1, Rabago D1, Miller MM2.

[2] Arch Intern Med. 2012 Mar12;172(5):405-11. doi: 10.1001/archinternmed.2011.1662. Epub 2012 Feb 13.

Thecost of satisfaction: a national study of patient satisfaction, health careutilization, expenditures, and mortality.

Fenton JJ1, Jerant AF, Bertakis KD, Franks P.