Op-ed: Patient satisfaction doesn’t mean the best medical care

A version of this op-ed was published on March 15th, 2010 in the USA Today.

If you recently saw a doctor, you might subsequently receive a survey in the mail asking whether your physician was friendly, spent enough time with you, or showed the appropriate level of concern for your medical issues.

Patient satisfaction surveys are being increasingly used in hospitals nationwide. Press Ganey, a leading organization measuring patient satisfaction, counts more than 10,000 medical institutions in the U.S., and over 40% of hospitals, among its clients.

Happy patients are obviously important, but doctors often have little idea of how patients perceive them. Gauging patient sentiment with satisfaction scores is a useful way to point out deficiencies and improve the patient experience.

In fact, doctors who consciously try to improve their patient interactions are sued less often. According to a study funded by Press Ganey, and published in the public health journal Medical Care, physicians with low patient satisfaction scores were more likely to be involved in malpractice lawsuits.

Patient satisfaction also translates into higher hospital revenue, so it’s no surprise that administrators pay close attention to these numbers, with high scores often finding their way into marketing campaigns.

But can focusing too much on patient satisfaction actually be detrimental?

No correlation to care
Studies from both the Annals of Internal Medicine and the British Medical Journal did not find a strong correlation between patient satisfaction and the quality of care. In other words, just because you’re satisfied with your doctor doesn’t necessarily mean he’s a competent physician.

More worrisome is that hospitals and health plans are increasingly using satisfaction scores in part to determine physician compensation.

The Center for Studying Health System Change estimates that patient satisfaction scores factored into how nearly a quarter of physicians are paid. But paying doctors to keep patients happy gives them a reason to acquiesce to patient demands.

If a medically unnecessary test or drug is requested, for instance, an added financial incentive encourages physicians to comply, rather than risk angering the patient.

Impacts decisions
Already, more than 80% of doctors, according to a survey from HealthLeaders Media earlier this year, said patient pressure influenced their medical decisions. And in primary care, linking bonus pay to patient satisfaction could cause physicians to be more selective in who they see, subtly keeping patients who they know will score them well, and referring disagreeable ones to other providers.

Quality health care sometimes means saying “no” to patients, denying them habit-forming pain medications that can feed an underlying, destructive drug addiction, or refusing to order unneeded CT scans that can facilitate harmful radiation exposure.

But Edwin Leap, a nationally recognized physician columnist at Emergency Medicine News, notes that doctors “are constantly under the microscope to give patients what they want, since ‘giving people what they want,’ has been tragically, and falsely, equated with good medicine.”

Satisfaction scores give patients a needed voice to express their concerns, which can help medical professionals improve their patient relations. But it’s a mistake to use patient satisfaction as a doctor’s financial carrot.

After all, a totally happy patient isn’t necessarily one who has received the best medical care.

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  • http://nostrums.blogspot.com James Dougherty

    I saw a lawyer in the ER once. Classic ankle sprain. Exam consistent, no suspicion of fracture. He insisted on an X-Ray (Me: “X-Rays not always definitive.” Him: “how can you tell unless you do one?”, etc) It was like being in the courtroom already.

    It took me 30 minutes to figure out how to handle this, by continuing to discuss with him. Turns out he was deploying to SW Asia in 2 days. So I did the film. He was so convinced it would be abnormal, I couldn’t help being a little smug when I told him it was normal.

    Bottom line, you could call it defensive medicine, or you could say that there were circumstances that justified going a step further (he was going to be out in the desert…any F/U needed was not going to happen.)

    He was satisfied, I was satisfied. The lesson learned was that there’s a way to balance “best medical care” and “patient satisfaction.”

    PS: this was back in the day when you could still rely on clinical judgment, pre every-bump-on-the-head-gets-a-CT.

  • W

    “Satisfaction scores give patients a needed voice to express their concerns, which can help medical professionals improve their patient relations.”

    Satisfaction surveys I’ve received are standardized forms that limit responses to selecting a “1-5″ score. Only a few of the questions even involve the doctor/patient interaction, with very limited room for any specifics. I think characterizing them as a “needed voice” is a bit generous.

    I learned the hard way that faithfully filling out these things (and supplementing them with a more thorough letter to the Patient Relations office) can work against you…even if your naive intention is only to provide some real feedback for potentially improving care, based on one person’s opinion in one set of circumstances. But I’ll never do it again.

    I have a great deal of respect for the hands-on side of medicine. I dislike and distrust the administrative side rather intensely. Should I have any concerns about treatment in the future, I’ll try to discuss them only with the physician. If he or she is receptive, wonderful. If not, it’s up to me to decide whether the issue is important enough to make changes. No harm, no foul.

    Surveys by administrators? Useless.

  • paul

    i’m pretty sure the main conclusion of any study funded by press-ganey will be that press-ganey should continue to exist.

  • SmartDoc

    Dissatisfied patients = lawsuits

    Really dissatisfied patients = big lawsuits plus nightmarish investigations into complaints trade to quasi-totalitarian state medical boards

    Caveat doctor.

  • Laurel

    I once has a less than ideal encounter with a doctor. I was so upset, I wrote a letter to the patient representative of the clinic. Not only were my concerns belittled, I was treated differently afterwards by the providers in the clinic. My reasons for the complaint was to voice my pain and perhaps enlighten my doctor about my needs. The doctor and the clinic were unwilling to have a honest discussion about the issue. I would guess most of the doctors reading this think I am an unreasonable patient and deserve the treatment I got. Even after extensive therapy dealing with the incident, I still an unable to form any type of bond with my new doctor and only make appointments for things I clearly can’t treat on my own.

    The surveys where they ask you if the medical assistant smiled are a waste of time. Medicine has lost its compass, instead its focus is on superficial things instead of what really matters. I want a doctor that cares, even when things go wrong.

  • Jerome Frnka

    I agree that ratings of 1-5 have very little merit. I am a multi-complex patients and those I have a quite large regimen of physicians. Whenever one of them spends sufficient time with me to arrive the proper course of treatment, I make it a point to write a lengthy review in which I describe very aspects of my visit. My major problem lies with those physicians who do not spend sufficient time or perform tests the results of which have valuable diagnostic values.
    Recently, a urologist arrived at a completely erroneous diagnosis which jeopardized my renal function. HIs diagnosis was based on supposition and conjecture with no supporting medical evidence. When I saw a more experienced urologist, he spent sufficient time to arrive at a valid diagnosis. Hence I wrote a very complimentary review of his work.

  • Braden DeLoach, MSII

    I agree with the first two comments.

    A patient’s concerns should be brought to the physician. If a patient doesn’t feel comfortable with sharing how they feel about their medical care with their physician then perhaps they are seeing the wrong physician or need to work with the physician on developing a better relationship.

    As a physician, even though time may be a valuable resource, it is very important to tell the patient not only what you are thinking but why you are thinking it and what evidence supports your thinking, all in addition to the benefits and risks. If you can not convince the patient (particularly a lawyer that has had a fair amount of training in understanding a line of reasoning) that your line of thinking is correct then give the patient the benefit of the doubt then document the conversation.

    In the ER, where building a patient-Doctor relationship is more like speed dating, Dr. Dougherty brings up an important point. The patient knows more about what is going on in their life than the doctor ever will. Getting a social history or in this case, a social future, is just as important as understanding the injury. Inability to F/U certainly justifies a patient wanting you to take the extra step. If you knew you were right and the extra test proves your were right, it may give you that smug “I told you so” feeling that gets you through the day, but knowing that you not only treated a patient’s injuries appropriately but also put your patient’s concerns at ease should be paramount.

    The bottom line here is that patient’s need to engage their doctors and doctors need to be willing justify their actions not to a court but to the patient that is sitting in front of them. Being able to take care of an injury or disease but failing to convince the patient of it is certainly better than failing to treat the disease but convincing the patient that you did, however in both instances it is incomplete medical care

  • Yious

    Getting the right diagnosis is obviously the most important thing for me but I recently went to a local hospital b/c of chest pains and was VERY satisfied with my care just b/c the doctors listened to me, asked me questions, took action quickly, and were honest with me at the end when they gave me some chest doctors to see because they werent sure

    I appreciated that.

  • cynical doc

    “Dissatisfied patients = lawsuits”

    satisfied patients= medical board taking your medical license away for over-prescribing narcotics

  • jsmith

    This is all so hard and nebulous. Why we get paid the big bucks.
    When I started at Kaiser in 1989 I once had a pt get very mad at me. She had a 1 cm diameter non-specific rash on her arm and I told her it would get better on its own. She wanted a medicine, and I told her none was necessary. She got mad and complained to my great boss at the time, who patiently explained to me that 1% hydrocortisone to the arm bid for 5 days would a)not hurt the pt and b)get the pt out of my exam room so we could both get on with life. An important conversation in my professional life. You gotta be gentle with people.
    Of course you also have to draw the line somewhere. Personally I draw it at opioids and benzos, unnecessary antibiotics (we’ve all seen C. difficile colitis) and radiation exposure.

    • Anonymous

      Sadly, it seems that some doctors are drug pushers, and many patients like it that way. Opioid narcotics seem to be prescribed far too commonly, with result that plenty of leftovers find their way to those who are addicted due to abuse.

  • Leon

    @She got mad and complained to my great boss at the time, who patiently explained to me that 1% hydrocortisone to the arm bid for 5 days would a)not hurt the pt and b)get the pt out of my exam room so we could both get on with life.

    Care like this has lead us to patients demanding unnecessary treatment. Perhaps if your boss would have said no, this patient would have learned something valuable. Instead, we have a bunch of patients call the shots and doctors worrying about patient satifaction scores.

  • DJ

    What brain cell came up with this idea of tying reimbursement to ‘satisfaction’?
    It’s the business world influencing and corrupting medicine. People, this will just cause doctors to lie to patients! : “You’re not morbidly obese!” or,” You don’t have a problem with_______(fill in the blank); “Here, let me write a prescription for you. Will that make you happy? Have a nice day!… Sounds like retail, not a professional. No!… professionals may have to tell you the ugly truth about something you may not want to hear…something that’s ‘good’ for you instead.

    Sheesh. No wonder it’s hard to doctors to do primary care. No intelligent person would put up with this idiocy. This will further drive them out.

  • http://www.pulseuniform.com Penelope

    Satisfaction and wellness are different things to consider, though there will always be satisfaction if there is wellness but it doesn’t mean that you are well even if you are satisfied with your doctor. Sometimes I despise surveys, I remember it like a school card. Some students don’t care if they will learn or not but what is important to them is to have a high grade even to the point of cheating, sometimes surveys are like that. I totally agree with you that satisfaction with the doctor doesn’t necessarily mean he’s a competent physician. I’m still convicted that competent doctors are those who are honest enough to say no to their patients and to tell their patients the truth without even getting extra money from them.

  • http://SusanaMayMD.com Susana May, MD

    I don’t know where the authtor of the op-ed practices, but it certainly doesn’t remotely resemble the reality of practicing in a managed care enviornment. If a patient needs a CT, one has to go thru incredible lengths to get it approved by the insurance. Want a brand-name drug? Forget about it! Unless the patient is willing to pay, they usually get the more ‘cost-effective’ care. I am proud to have high patient satisfaction despite the increasing difficulties. I certainly wish somebody would pay me more for my effort!

  • http://www.cedarhillpt.com Paul Weiss

    Interesting read…especially after just watching the video of the magician regarding the placebo effect. It has me wondering if there is an effect of patient satisfaction with their clinician and their treatment outcome.

    My other thought…many of the issues of patient satisfaction mentioned relate to “giving the patient what they want”. Much of that stems from misinformation the patient brings into the clinic with them. (I.e. demanding antibiotics for a viral infection.) Public health education could go a long way in correcting people’s misconceptions. The other part of it seems to stem from patients not trusting in their physician. (If the doctor tells someone they don’t need an antibiotic for a viral infection, why don’t some patients believe this?)

  • http://www.facebook.com/barrientoshollis Anna Barrientos-Hollis

    I think were all off here a bit on the purpose and intent for patient satisfaction.  There is a huge oppurtunity in helathcare for patients to better understand (keeping them informed) and to meet their personal needs afterall they are the customer.  If your all about quality and current with best practice good for you but from a patients perspective ITS EXPECTED so their are no bonus points for that.  How about simple common courtesy and compassion irregardless of who they are where they came from or what disease/illness they have.  And if you don’t think they should have an antiobiotic then that’s fine after explaining, giving rationale, and options to seek elseware is all you can do.  Patient satsifaction will not increase by giving them the meds they want its about patient education when you choose not to write the sript and it’s about speaking to them at eye to eye level.  CREDO (Compassion Respect Excellence Diversity Ownership) behaviors are what their looking for and as a nurse leader in the healthcare orgainization if my pay refelcts patients satisfaction for where I work then the it should be used as the physicians financial carrot as well!