How patient satisfaction can kill

How patient satisfaction can killPatient satisfaction is all the rage.

Medicare is beginning to tie patient satisfaction scores with hospital reimbursement, and doctors across the country are under pressure from administrative executives to raise patient satisfaction scores.

High scores are even used by hospitals as a powerful marketing tool.

But, in the end, are patient satisfaction scores hurting patients?

I wrote about the issue previously, saying that patient satisfaction scores reward rich hospitals, as well as a previous USA Today op-ed, warning that catering to patient demands may not be in their best interest:

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.”

So it comes as no surprise that a recent study from the Archives of Internal Medicine has confirmed most physicians’ fears.

According to the study,

compared to the least-satisfied patients, those who were most satisfied with their healthcare were on more prescription medications, made more doctor’s office visits and were more likely to have had one or more hospital stays, despite the fact they were in better overall physical and mental health. Also, despite the greater attention and all those prescription drugs they got, the highly satisfied were more likely to die in the few years after taking the survey than were those who pronounced themselves least satisfied with their physicians’ medical care.

As emergency physician WhiteCoat aptly puts it, “High satisfaction with a health care facility means that you’re more likely to be admitted, you’re more likely to pay more for your care, and you’re more likely to be discharged in a body bag.”

Not only are satisfied patients more likely to die, they cost more:

Overall, the most satisfied patients incurred 8.8% more healthcare expenditures than did the least satisfied and spent some 9.1% more on prescription drugs than did the least satisfied.

Our health system provides overwhelming incentives to “do more.”  The flawed fee-for-service payment system gives a financial carrot to order more tests.  The emphasis on patient satisfaction pressures doctors to acquiesce to demands for medications.  And finally, the malpractice system punishes doctors for not ordering, or not referring, enough, never for overuse of medical resources.

We need are more incentives to do less.  Reward doctors for sticking to evidence-based clinical guidelines.  Back them up for saying “no” to patients, at the risk of lower satisfaction scores.  Educate the public that more tests can, in fact, be harmful.

And now, patients need to know that a hospital with a high patient satisfaction score isn’t necessarily a good thing.

The Archives study shows that patient satisfaction raises health costs and kills patients.  How much more data do we need before realizing that patient care and patient satisfaction cannot be mixed?

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://www.thehappymd.com/ Dike Drummond MD

    Great … great post Kevin. And doesn’t it feel good when you have the research proven facts to back up our gut feelings. As someone just said on your facebook page: “I bet Michael Jackson was very satisfied with his doctor’s care !”

    In many cases, someone, somewhere has to say no. It is often not the doctor and no one wants it to be the insurer or, heaven forbid, the government. As payment mechanisms drift toward reimbursement for patient satisfaction … we will be talking about this and studying it in much greater detail in the years ahead.

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • Anonymous

    So predictable and so sad. Now that the “patient satisfaction” industry has taken root, we will continue to waste billions and billions of dollars on this each year, money that could have gone towards providing genuine health care.

    • Anonymous

      Now that the “quality” people are done plundering healthcare, it’s time for the “satisfaction” people to raid it.

  • Anonymous

    So treatments used to satisfy patient are bad for patients?

    Or people who are sicker are more satisfied with their care?

    Or medical care in general is bad for your health and those that not satisfied avoid medical care?

    Or do doctors with a tendency to satisfy patients have inferior clinical skills?

    Or is there some other factor that contributes both to patient satisfaction and more treatment?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Let me contribute something from the beleaguered EMR industry and generally from software firms.
    It is a well known fact in our industry that a company lives or dies by customer satisfaction scores (seriously :-)). Surveys are continuously conducted, measured, benchmarked and so forth. The strange thing is that a product with no problems and no bugs and no customer calls, usually scores much worse than a product that has lots of problems and generates lots of calls, if the calls are handled courteously and workarounds are provided and bugs are fixed in a timely manner. A strong human relationship develops between the suffering client and the account manager, and a perception that the vendor is very helpful is created. So basically the more you screw up, the happier your customers are if you are nice and responsive to them (until you “kill” them, of course).
    This is exactly what you are seeing here.

    • Anonymous

      The difference is that we are dealing with a human life (your mum, your child) and not a product. There are ethical and moral crossings that other industries do not need to be concerned about. 

      • Anonymous

        like invester divedends? CEO’s high salaries? bean-counter management is a real killer for care givers. in 38 years of healthcare i’ve seen less than a hand full of physicians that at least thought they had the best interest of the patient and or outcome of there illness. it is down hill from there.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        True. The point was that customer satisfaction is rarely indicative of “quality” and many times it is indicative of the opposite.
        There has got to be a different objective measure somewhere….. The problem is that nobody knows what that is so they pick this very poor surrogate, just so they can say they have a measure and because it sounds good to the uninformed.

  • Anonymous

    Nice post. You nailed it.  Next precert I have to fill out will say: “The patient really, really, really wants this medicine. You don’t want them to be unhappy, do you?”

  • Craig Koniver, MD

    This is an interesting junction in health care delivery, but I don’t think the full story has been written yet–I believe we are at the beginning of this story, not the end. 

    Certainly doctors who cater to patients just to keep them happy are clearly doing these patients a disservice (as well as the practice of medicine). But on the outpatient side, where most of medicine takes place, doctors do need to undertand that many, many patients are tired of being corraled through the exam room with only 10 minutes or less being given to them.

    The idea of patient satisfaction to me, misses the point. Far better for hospitals and the like to measure how well patients feel “taken care of” as opposed to satisfied….there is a distinction indeed.

    It is time for doctors to wake up to this reality that their reimbursement will be tied into (on some level) by how well they connect with their patients and not just rely on the the thinking that “if only the patient followed my advice…”…….health and medicine are not the same and patient’s want a role negotiating this and most of all want to feel connected to their doctors….

    http://www.newrulesofmedicine.com

  • http://EasyOpinions.blogspot.com/ Andrew_M_Garland

    Correllation is not causation. What is the supposed mechanism that relates great care to more death? I don’t believe that hospitals and doctors are medicating people to death in order to please them, or that more medication is more pleasing, other than narcotics.

    How about this. People with real and often severe illness are treated well by doctors who understand their medical condition. The patients are grateful for the deserved attention, but unfortunately die at a higher rate than people who are healthier.

    People who are seeking narcotics or who are not seriously ill pester doctors for attention. The doctors are reluctant to give treatments for mild or non-existent illness, and those patients complain regularly about how bad their doctors are. These patients do not usually die.

    This mechanism would explain the results. Does it apply? I suppose we will not know, because people are willing to accept statistical analyses without identifying the mechanism of causation.

    One thing we do know, is that satisfaction scores are worthless as currently collected. That didn’t need to be verified by a study; many doctor’s blogs report the idiocy of patient complaints.
     

  • http://makethislookawesome.blogspot.com/ PamC

    I’m surprised to find such propaganda on this site. That first quote is a doozie. Here’s counter-evidence:  “Despite all they hype and propaganda, both the FDA and the National Institute of Health state that: “Studies have shown that properly managed medical use of opioid analgesic compounds (taken exactly as prescribed) is safe, can manage pain effectively, and rarely causes addiction.” (A Guide to Safe Use of Pain Medications, FDA) But for some reason we’re all being taught that if you take a nice, church-going housewife and give her oxycontin, she’ll turn into a back-alley dealing junkie with a spike in her arm. But this simply isn’t true.”

    Second, wouldn’t it be more likely that because of a good relationship with their doctors, their patients may be willing to do more risky procedures than they would do with a doctor they didn’t trust so much? Couldn’t that be a cause of an increased risk for death? This study shouldn’t be used as a justification to be an a$$hole or withhold services (though, wouldn’t *that* be great for the bottom line?).

    • Anonymous

      The article is simply saying that if patient satisfaction becomes your primary goal, you do more harm overall.

      No, gone are the days when doctors took on risky procedures. If the insurance company will not pay for it, we will not do it.

    • http://twitter.com/USMCShrink Kevin Nasky, DO

       A lot (increasing number?) of physicians are shying away from prescribing any controlled substances. With increased law enforcement focus on shutting down “pill mills” (watch for definition of “pill mill” to expand), you can’t blame docs for simply wanting to dodge that conundrum altogether and simply refuse to prescribe narcotics. It’s only going to get worse.

  • Payne Hertz

    Logical deductions from this article include:

    If you like your doctor, he sucks.
    If you hate your doctor, he rocks.

    Medical care is inherently bad for you so the more you get of it, the worse off you are.

    Doctors have no ethics, and can be expected to commit fraud by ordering unnecessary treatments just to get a high satisfaction score.

    Patents don’t want their doctors to be honest with them, but to give them whatever is mentioned on some handout they got from the internet.

    Failure to assess and treat chronic pain is a good thing.

    —Is it possible you might see a higher incidence of both satisfaction and death (which seems a contradiction in terms) with patients who have doctors who take their complaints seriously (doing necessary tests,  identifying illnesses that might lead to death and admitting to hospital where appropriate) versus those that blow their patients off, leading to poor satisfaction and a greater number of patients who die unseen and untreated at home, albeit with less testing, drugs and hospitalizations? (since dead people don’t do surveys how did they assess when someone died? Those who die at home and fail to complete the survey may be less likely to be detected than those who die in the hospital. They mentioned that mortality data was only available on a subset of patients, meaning satisfaction data and mortality data appear to be derived from two unequal groups.

    I think the findings here are suggestive but a little too weak to be jumping to conclusions.

     

  • Anonymous

    i get it, however the bills that patients recieve should reflect value. patients can be treated with honesty and proffesionalism. bedside manner does need to be frank and not have the soap opera tinge to it. a patient might appreciate the honesty if they actually recieved a bill that reflected economy. prescriptions shouldn’t be marked up expotentialy, a forty dollar meal should be decent and etable,a patient should be able to know up front what it is going to cost and have choices. over ordering- high frequency of meds,therapies like bi-pap should be stopped. dr.s all to often have a mind set of initial orders that are four times what the patient needs and further more all should be reduced as a pt. improves. hospitals could be a lot cleaner and yes even dr.s could decrease hospital aquired infections. the pt. that  dictates their own care? a psych consult should be immediate.

  • http://www.facebook.com/people/Jackie-Swenson/100000046998781 Jackie Swenson

    As a ‘patient’ who’s been through 5 life-saving surgeries in a 20 year span, I have to say that patient satisfaction is influenced by the outcome as well as the way my physician treats me.  I’d had a nice and gentle gynecologist who directed me (over the phone) to the right medical specialist.  I’d had a heavily accented neurologist who emphasized how crucial it was for me to seek a particular neurosurgeon outside the ‘network’.  I’d had a wonderful general surgeon who talked me out of having a mastectomy only to have the recurrence missed for four years…  But I still liked her and trusted her with the second surgery… (She was more upset than me when the recurrence was confirmed – all the pevious mammograms had been misread until I went to her directly…)

    I love all my doctors – except the ones who disregard my concerns and complaints.  One family doctor – believing that I was ‘over-stressed’ from work – dared to suggest for me to move to another state (Arizona or Nevada, to be exact!) to avoid the ‘allergy’ problem that is rampant in our region.  The ‘allergy’ symptoms turned out to have been caused by a 4x5x6.5 cm life-long brain tumor!

    19 years later, another family doctor – a reputable one who’d taken good care of several of my family members – sent me to see a psychiatrist when I ‘demanded’ to have an MRI!  I’d been mostly under the care of my oncologists for the previous 8 years, and he never did learn about my brain tumor history…  [Even though I'd spent more than 15 minutes filling out the patient information package ...]  He’s still our family doctor because we know he’s a good doctor.  Everyone makes mistakes – patients and their doctors need to communicate well to keep those mistakes from happening.

    ‘Statistics’ don’t tell the full picture…  ‘Data’ can be easily manipulated…

  • Anonymous

    You are splitting hairs when you try to differentiate between “taken care of” and patient satisfaction. All patient satisfaction surveys I have seen address both. 

    The real wake up call for physicians is that even the most skilled and knowledgeable amongst us   are only as good as the patient (customer) thinks they are. Reminds me of when I fly commercially…..Since I hate turbulence, no matter how minor, the best pilots are the ones who get me there without a bump inflight. I give them all 5′s. The bad pilots are the ones who makes me hold my seat all the way. I would pay them less if I had my way. 

    What did you ask?….weather conditions?….Oh I don’t know, I never look outside. 

  • http://twitter.com/TheUnorthodoc Doc Cory

    Well-said, Dr Kevin.

  • Anonymous

    Kevin, I’m of two minds on this topic, given that there seems to lurk here a groundswell of support for this thesis from docs who are only too willing to once and for all be rid of this pressure to “satisfy” their pesky patients.

    Patient satisfaction can be a double-edged sword.  For example, we’re only now starting to hear from women who have undergone invasive and disfiguring breast cancer surgeries to remove masses found via screening mammography (I was one of these) who were then told: “Great news! It’s not cancer!” to which we are expected to be duly grateful to the brilliant docs who treated us based on unnecessary and misleading screening diagnostics. Score one for patient satisfaction (actually relief!)  Oh, except for that permanent disfigurement, of course . . .

    On the other hand, I’ve had both the best of care and worst of care from the same E.R. two weeks apart – the first visit was with an E.R. doc who told me quite clearly that my chest pain, nausea, sweating and pain radiating down my left arm were just due to GERD. Patient satisfaction score: (surprisingly!) High, because I was relieved (and also embarrassed for having made a fuss over nothing).  Two weeks later: same E.R. but different E.R. doc, and a revised diagnosis of “significant heart disease” and emergency treatment. Patient satisfaction score: also High, because I was immediately whisked upstairs to experience world-class life-saving cardiac care.  Cost of providing the wrong diagnosis: low.  Cost of providing appropriate care two weeks too late: catastrophically high.

    On the other hand, we know that patients do march into their physicians’ offices demanding unnecessary things like antibiotics for sore throats – and many docs feel compelled to provide them. If they refuse, by trying to educate the patient on the sound science behind their reasoning, they risk patient dissatisfaction. More on this at: “When Patients Demand Treatments That Don’t Work” at http://ethicalnag.org/2011/10/30/patients-demand-treatment-dont-work/

  • Anonymous

    Kevin -

    Thanks for the linkback.

    I echo the sentiments from a couple of the prior comments.

    Andrew is right. We can’t equate correlation with causation. The high satisfaction scores don’t *cause* patient deaths or higher costs. The study only showed that the two metrics are somehow related. Higher satisfaction correlates with higher death rates – especially in healthier patients. There is some other set of intervening factors that likely have “caused” the increased likelihood of death and increased costs.

    I also agree with Dr. Koniver that this is the beginning, not the end, of this saga.

    Finally, I think that the people who should sit up and take notice of this study should be the people who rely upon satisfaction data: hospital administrators and patients.

    The data are faulty, people. Wake up already.

    Administrators and hospital boards should be held legally liable for relying on this often specious data and putting their heads in the sand when they *know* that the results end up harming patients.

    Patients need to learn that high satisfaction ratings have little to do with the practice of good medicine. If you want a physician who looks like Dr. McDreamy, thinks like Dr. House, and comforts you like Dr. Phil, you’re going to be disappointed. I would never take my family members to several physicians I know who have very high satisfaction scores. Some physicians who have mediocre satisfaction scores (a rating of “very good” which puts them in the lowest quartile of scores) are outstanding clinicians and are good with patients as well.

    A “4″ out of “5″ on these surveys is a failing grade, but the surveys and the hospitals don’t tell you that. If the surveys simply asked “was your doctor courteous?” and gave a “yes/no” response, the survey companies couldn’t make hundreds of millions of dollars each year comparing and publishing statistically insignificant results between hospitals.

    If patients want to continue relying on these numbers, at least at your eulogy your family can tell everyone that you died “satisfied.”

  • Brad White

    Good article Kevin.  I have seen safety procedures bent or outright broken is order to comply with patient wishes.  I love good customer service, but airline passengers get no say in air safety procedures, why do we let patients impact ours?

  • Anonymous

    As a patient, I’m confused by the doctor responses here.  It seems like you’re suggesting that a disliked doctor will give you better care, and patients should be wary of the ones that are liked.

    • Anonymous

      No, they are just saying that there is much more to evaluating a doctor than his patient satisfaction scores.

  • http://twitter.com/KarenSibertMD Karen Sibert MD

    Good care doesn’t always involve the greatest degree of charm or likeability.  Foreign doctors may be unfairly discriminated against by patients who don’t relate easily to them.  Now we’re being rated according to patient satisfaction with pain management.  This can backfire–patients who have had lung resection for cancer, for example, can’t tolerate excessive narcotic medication because they can’t tolerate much respiratory depression.  Sometimes safety has to take precedence over complete comfort.  Turning medicine into a popularity contest is an ominous trend.

    Karen Sibert blogs at http://apennedpoint.com/

  • http://pulse.yahoo.com/_AHJLBFNNBNL7SVEXJCRGWDZTBI Braidz

    Here is my experience. It is only anecdotal evidence (anecdata!), but I think it’s highly relevant …

    I have atrial fibrillation (+ some other diagnoses). One of the times I was admitted to the hospital, I also had intermittent fever/joint pain, which I had been treating at home with Aspirin. I also had long bouts of coughing.

    Once admitted to the hospital with Afib, I received a shot of blood-thinner (Heparin), so I could no longer receive aspirin, since that also is a blood-thinner. OK, I could understand that, but I needed relief for my joint pain/fever. So I suggested a shot of something stronger. But no, I couldn’t have that. They only gave me tylenol/paracetamol, and I lay there writhing in pain. I also had a persistent cough, and was refused any medication for that. These long bouts of coughing made the Heparin shots (in the skin of the belly) painful, so they hurt for hours afterwards (instead of the usual half a minute before the pain subsided). I was unable to sleep at all that night, but I didn’t dare ask for a sleeping pill after having already been refused effective medication for pain/coughing.

    And here’s my point: REFUSING TO GIVE ME EFFECTIVE SYMPTOM RELIEF ULTIMATELY PREVENTED EFFECTIVE TREATMENT — in a number of ways:

    - The third time I was supposed to get a Heparin shot, I refused it, because my persistent cough had still not been attended to. (Coughing, and subcutaneous injections in the belly, are a TERRIBLE combination!)

    - The blood thinners (stronger than I had been taking before) were used as a reason for not giving me effective pain relief. THEN later, they wanted to start me on Warfarin/Coumadin/Marevan. Do you think I consented, after such a terrible introduction to stronger blood-thinners? No, I did not!

    Later, I finally DID start on Warfarin/Coumadin/Marevan. I had to, because of a mini-stroke. But now that Aspirin would be a danger to my life because of these other blood-thinners, our family doctor (thankfully) prescribes medium-strong analgesics (Codein with Paracetamol(Tylenol)). It’s not an ideal solution, and sometimes it gives me a mild headache/nausea. But it’s better than having REAL pain, and it’s better than refusing blood-thinners/getting another mini-stroke.

    So I hope people (especially hospital staff) understand that lack of symptom-relief CAN interfere with effective treatment!

    • josie boyle

      It is interesting you cannot see the link between the refusal of blood thinners when suggested with ultimate outcome of  having a stroke.  This is why they were giving you the shots, as a bridge to the Warfarin building adequate levels in your system to prevent a stroke.  You interfered with your own treatment by refusing therapy, which may have extended your illness.

      • http://pulse.yahoo.com/_AHJLBFNNBNL7SVEXJCRGWDZTBI Braidz

        In fact, I DO see the link you were talking about — and that was my whole point! Don’t you see?? Because, as I stated quite clearly in my reply, the lack of symptom relief made the treatment too painful for me to accept. Which, in turn, relates to my main point, which is that lack of patient satisfaction (owing to lack of symptom control) can be dangerous and can affect outcomes. And I think I’ve clearly demonstrated that such was the case here. Far from being an optional luxury, patient satisfaction/ symptom control are sometimes essential for outcomes, is what I was trying to convey.

        COMMUNICATION / INFORMATION:
        I also want to mention that there were some HUGE communication issues during that stay at the hospital, which, for the sake of trying to “keep it short”, I did not mention in my first reply here. These unanswered questions which I had, have later been explained to my satisfaction. 

        One thing I never got an answer to until AFTER my hospital discharge was why, after going back SPONTANEOUSLY from Afib to a normal heart rythm (instead of needing electroversion like I needed the previous time), they STILL wanted to give me more aggressive anticoagulation therapy. After all, they had not seen this as necessary after the electroversion the previous time! I also wondered, since I previously had an episode of hemorrhage during dental surgery (admittedly because of Aspirin, which no one had given any instructions about not taking before the dental surgery), and since later dental surgery had to be done with special precautions in case of another hemorrhage — why it would then make sense to anti-coagulate ME using something stronger. (I had also had small episodes, even when I had not taken Aspirin, which I saw as proof that I bled more easily/ longer than the average person.)

        As I said, these questions and others have since been explained to my satisfaction. Not by the staff at the ward where I stayed then. (The doctors who did rounds were out the door before that was ever possible!) But I got satisfactory answers from a specialist (a hematologist) whom I have had the privilege of knowing at the hospital where I work. But I wonder what would have happened if I had not myself been a hospital employee, and thereby not had access to specialists who could explain this to me. And where do non-hospital employees/ people who don’t know any specialists in the relevant field go to have THEIR questions answered, if they have not succeeded in asking for and getting sufficient information?

  • josie boyle

    One of the largest issues I see in the emergency department related to patient satisfaction is the prescribing of narcotics for pain.  The provider and I can will treat the patient with respect, address all the medical complaints (dental pain), make a referral and compassion fill their antibiotic, but if a Percocet prescription is not attached to the discharge paperwork, watch out!  Recently, one of our providers was cornered in a room by an angry patient because the provider pulled up his “care everywhere” and found the patient “seeking” at numerous facilities.  When the provider brought this up, the patient yelled, postured violently and would not let the provider out the room.  When the tech forced the door open, the patient left, yelling obscenities, carrying his patient satisfaction survey in his hand to be filled out and returned anonymously.  I am not sure why this person has any right to effect our reimbursement as a facility.

  • Anonymous

    Healthcare is so emotionally charged that I just can’t think it’s fair to only use patient satisfaction scores to determine reimbursement… it almost seems unethical to me and I’m speaking from a patient’s perspective. 

    I’m all for the patient being heard, but how in the world can you tell what is fact when you only have “one side of the story” and emotions can be swayed so easily?  I remember being taught how to find the truth in what people tell you about experiencing the same situation… you compare the stories and see what is common. 

    Granted, I haven’t always had what I feel is the best service (mainly in regards to common courtesy that should be prevalent in any working environment with people), but I can understand you need to have more than one perspective and I really think the doctor’s perspective also needs to be accounted for (if not other perspectives as well) if you’re going to require emotional standards for reimbursement.  It’s only fair.

  • Anonymous

    I suggest that “every visit” to a health care professional be rated for satisfaction by the patient. This concept is long overdue. Every health care professional needs to be scored and these scores need to be published on the Internet so we can weed out the quacks. Too many health care consumers have been abused for far too long. We have an medical industry that does everything possible to protect their quacks. It’s time for them to come clean. We have doctors that are nothing more that drug pushers in the name of weight loss. We have doctors that are on the pharma payroll resulting in patients never getting an RX for a generic medicine. We have doctors that commit Medicare fraud by double and triple billing on a routine basis. Will a rating system completely end this abuse? Nothing is perfect. But, the more shysters we can expose, the more money consumers will save over the long haul. 

    • Anonymous

      Good idea. I propose that we incorporate your suggestions and take them a step further. 

      Let’s rate every visit by a patient for satisfaction by physicians and nurses and publish *those* on the internet so that we can weed out the drug seekers and health care abusers and so we can stop providing them medical care. 
      Too many doctors have been abused by patients for far too long. We have a system that does everything possible to protect the drug seekers and health care abusers. It’s time for them to come clean. 
      We have patients that are nothing more than drug seekers in the name of selling prescriptions.
      We have patients that demand prescriptions for name brand medications because they are mentally ill or because they can sell name brands for more money than generics.
      We have patients who commit Medicaid and Medicare fraud by doctor shopping for medications on a regular basis.
      Will a rating system completely end this abuse? Nothing is perfect. 
      But the more health care abusing patients we can expose and refuse to provide treatment to, the more money that consumers will save over the long haul. 

      And if patients who are legitimately in pain get inaccurately labeled as a drug seeker like Payne Hertz mentions below, I guess that’s just collateral damage, right? 

      Why didn’t I think of your idea sooner?

      • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

        One problem with these rating sites is it only works one way.

        Privacy rules prevent the physician from telling the other side of the story.

      • Anonymous

        Seems to me that EMR could weed out most, if not all, of the “drug seekers” you claim are having such a huge impact on illegal drug trade. The problem is, we have way too many computer neanderthal docs in the medical industry that have a strong aversion to using a keyboard instead of a pencil. Either that, or they are just too cheap to spend the money to convert. I don’t see Visa or Mastercard having overwhelming problems with fraud. The medical industry has PhDs and MDs with all of their education and expertise and they can’t figure out how to stop prescription fraud? Get real! Fact is, corrupt doctors want to stop RX fraud because the kick-backs are just too darn good! Medicare? Medicaid? Don’t make me laugh! EMRs would clean that up overnight! Bunch of shysters! Duh? Why didn’t I think of that sooner? Duh?

        • Anonymous

          Not much for drawing analogies between two comments, huh?

          As an apparent computer expert, please explain how patient information in one EMR helps to “weed out” drug seekers when such information is contained in a different EMR in a different hospital or a different state.
          VISA and MasterCard track five metrics for each purchase: date, location, amount, account, and item purchased. Each patient visit is comprised of hundreds if not thousands of metrics. One CT scan or MRI is hundreds of MB in size as opposed to one credit card transaction which is a few hundred thousand times smaller. Where will all this data be stored? Comparing the two systems is inappropriate.

          And it is the medical industry’s MDs that need to figure out how to fix EMRs? Brilliant. Lets make taxi drivers figure out how to fix crumbling roads and blog commenters figure out how to fix bugs in the blogging software. Users of a product should obviously be responsible for fixing that product.

          Oh, and thank you for your brilliant, scintillating, and well-researched expose on why doctors want to perpetuate prescription fraud … because Stark laws and other federal regs are so easy to circumvent.

          I so look forward to your next syllable. Try not to make it “Duh,” will you?

          • Anonymous

            “hundreds if not thousands of metrics” DUH? Since when does removing a wart or dispensing a flu shot or, at the very worst, referring a patient to a specialist require “hundreds if not thousands of metrics”. Face it, you can’t defend it any longer. Primary care is a scam! If Willie Sutton or Al Capone were alive today, they wouldn’t be robbing banks or bootlegging whiskey, they’d be doctors doing primary care! DUH! Any more pearls Mr. Einstein?

    • Anonymous

      It cannot be a matter of black and white, yes or no.  Without a narrative, there is nothing useful to come from these surveys.  This is a disservice to practitioners and patients alike.  And, frankly, how many people who were not killed by treatment, or by their illness, are NOT going to say they had a “good outcome,” regardless of the quality of care.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      My 84 year old mother is prescribed lasix ( furosemide) 80 mg per day to treat her high blood pressure, recurrent volume overload, congestive heart failure and pulmonary edema by her physicians. When she takes her lasix or any other loop diuretic she voids for hour upon hour and is a prisoner of the rest room . Her orthopedic injuries make getting to the bathroom quickly difficult at best. She is supposed to wear incontinence protection ( adult diapers and pads) which she does. She is supposed to weigh herself daily and contact her physician for changes of weight within certain parameters.  When she has an appointment outside the home she does not take her lasix. When she feels she needs to be mentally sharp she stops her antidepressants.She has been educated on the risks and dangers of this numerous times by her primary care doctor and her cardiologist. She does it anyway. She repeatedly ends up in the ER in pulmonary edema and congestive heart failure. Sometimes her legs swell and she gets soft tissue infections called cellulitis and again ends up in the hospital. As an internist/ geriatrician I have explained the situation to her repeatedly. She is a willfully non compliant individual. She is furious at her doctor for prescribing the diuretic. Her doctor would receive poor patient satisfaction scores from her.  Her doctors would get even worse outcome scores. As a patient she is not atypical of American citizens who think they can stop their long acting antidepressants on Friday so they can drink alcohol on the weekends or use recreational drugs, or the patients who repeatedly for no common sense reason abruptly and repeatedly stop and alter therapy without discussing the risks with their doctors first.   If you choose to look at two simple questions such as ” are you well?” and ” did you have a good outcome?” you will be declining to see many fine practitioners. 

      • Anonymous

        I agree completely with your comment. There will always be patients that will never be satisfied, just as there will always be patients that are completely satisfied. Most patients will fall somewhere between the two extremes. Whether we like it or not, patient surveys are in our future and will be required, at least in the world of ACOs. As proposed in the new Affordable Care Act, ACOs are challenged to meet very high standards if they wish to participate in cost savings resulting from improved care coordination. There are actually 63 specific measures being proposed, which fall into 5 domains. One of those domains deals specifically with patient/caregiver care experiences. The measures that ACOs need to report on, in this domain, are:
        1. getting timely care, appointments, and information
        2. how well your doctors communicate
        3. helpful, courteous, respectful office staff
        4. patient’s rating of doctor
        5. health promotion and education
        6. shared decision making
        7. health status/functional status
        My very simple two question survey is contained in item #7 of this list.

  • Anonymous

    Satisfaction with a provider isn’t necessarily grounded in his/her acquiescence to a patient’s petulant demands. It’s about communication (in BOTH directions) and a provider’s willingness to hear what the patient has to say and respecting a patient’s right to disagree, decline recommendations, and request alternative treatment plans (or none at all) without feeling like the patient is disobeying a stern parent. Yes, educate, Yes, document, but then move along in partnership with the care recipient. This shouldn’t be an adversarial relationship.

    • Anonymous

      But sadly, it so often is just that – an adversasrial relationship.  Ironically, I awoke this morning, having been tolerating several rather nasty symptoms for a while, wishing I could advertise for a physician with whom to form a partnership for care.  Where both could speak freely, without either jumping to conclusions immediately. I think patients are, too often, seen as the enemy, a frustration to physicians and other medical staff.

  • Anonymous

    Have learned, through hard experience across multiple practice settings (including correctional) that I’m doing something wrong if all my patients are happy with me.

    If my patients’ ways of doing things works so well, they probably don’t need me.  When I suggest things they need more than they want, “opportunities” for dissatisfaction arise.

    Not keen on a blunt, unforgiving, insensitive bureacratic instrument tying physician income to patients’ subjective experiences of pleasure.  Talk about a powerful setup for unintended consequences!!!!!!

  • http://twitter.com/ChrisJohnsonMD Christopher Johnson

    For better or worse, we are now apparently stuck with satisfaction surveys becoming equated with quality of care. One of the things I dislike about the burgeoning industry of patient satisfaction surveying is the bogus statistics that go with these surveys. I’ve sat through several presentations by representatives of these survey companies. They show graphs comparing institutions or doctors with each other. They blithely show bar graphs with no error bars and drawn using numbers that make no pretence of being a truly representative sample of the total data set. Using such “data,” which a statistician would laugh out of the room, they assert, on the basis of miniscule absolute differences in the raw scores, that doctor A is obviously doing better than doctor B when it is clear that a.) the sample of patients is clearly not random, and b.) even if they were, the confidence intervals certainly overlap.

    Patient satisfaction is clearly important, but the tools being pushed to measure it, don’t — at least not accurately. I’m sure they’re fine at the margins, at distinguishing the awful docs from the wonderful ones. But most of us fall somewhere in between, in the mushy middle.

  • http://pulse.yahoo.com/_AHJLBFNNBNL7SVEXJCRGWDZTBI Braidz

    Comparing patient satisfaction scores for different hospitals is like comparing apples and oranges. After all, there is a diversity in the clientele which hospitals have, and in the tasks in which they specialise. So, I do not envy those of you who are doctors and who now suddenly are in the situation of being rated in this way. Many people have, in their comments further down, already given an excellent rundown of the numerous reasons why this rating system is seriously flawed.

    Further down, I wrote a comment (because I felt that I had to) about one subject which was touched on here — pain and other unpleasant symptoms, particularly in connection with treatment. These opinions I expressed were NOT meant as an endorsement of this reimbursement system — even though do I stick to what I wrote about pain/symptoms. Regarding reimbursement, I think patient satisfaction at best would need to be one of many criteria.

    This problem could lead to a flight of physicians to other areas (geographic) and to other types of jobs/hospitals, depending on where it is easiest to get high patient satisfaction scores — wherever that is!

    I have not lived on your side of the Atlantic for years. So, thankfully, I have not experienced firsthand the effect of the “War on Drugs” on management of pain and other symptoms. For all of you to be expected to be the “gatekeepers”, so to speak, for drugs — and THEN at the same time be rated for patient satisfaction without regard for the many reasons behind — that’s just bad!

  • Anonymous

    Patient satisfaction is like putting a band-aid on stage four lung cancer. What our health care system needs is an Occupy Movement. Better yet? What our health care system really needs is an Arab Spring! Consumers are tired and angry! They have been abused and ignored for too long. Consumers need to use their power at the voting booth and rock the health care world. It’s time to burn America’s Status Quo Health Care System in effigy! 

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      How about a few practical solutions other than your canned lets have ACO’s and bigger more efficient systems Dave?

      What would you do about educating students in school about nutrition, exercise, biology and health? How would you deal with reproductive health and contraception.? Who would pay for it and how?  What would you do about at home nutriiton and education and physical and mental health checkups? Do you have an opinion or suggestion on the increasing diagnosis of autism and Attention Deficit Disorders in children?  

      What would you do and how do you propose without wrecking the comedy to curb the plethora of alcohol and its relaitonship to fun and sexual satisfaction advertising in the media and its effect on accidents, addiction and health?

      What do you plan to do about the aging baby boomers and their chronic illneesses? The hundreds of thousands of returning war veterans physically and emotionally scarred but expected to enter a difficult and competitive workforce and rejoin their pre service lives as if nothing had happened.

      You are big on revolutions and short on practical solutions.   Do you actually have an original idea on anything sir?

      • Anonymous

        Everything you propose assumes that the entire blame for our broken health care system is the patient and not the provider. I could waste my time shooting holes in your “theories” all day long, however, it would only be casting pearls before swine. The fact of the matter is, health care in every other industrialized nation in the world ranks better than our broken and failed health care system here in America where we supposedly have the “best health care in the world” (that’s is, if you can afford it). Besides, where else in the industrialized world do they spend nearly 18 percent of GDP on a health care system that has completely faied the consumer? Do these other nations do anything special with regard to education in all of the “bad behaviors” that you mention? Huh? I think not! So, I’m big on revolutions and short on practical solutions? Well, aren’t you the educated one? Are you the highly successful Boca Raton Concierge Doctor? Didn’t you spend endless hours studying the practice of medicine? Tell us doc, why don’t you stop casting blame on your patients and begin to police your own corrupt industry? Huh?

        • Anonymous

          Practical Solution #1: Flush expensive concierge medicine down the toilet! Primary care is nothing more than an expensive version of military triage. The VA does primary care better, more efficiently, more effectively and for 1/3rd the cost. We need more mid levels doing primary health care in an ACO environment and less expensive over-educated prima donnas!

          • Anonymous

            I know I’m wasting my time, but:

            You do understand that NONE of the countries you admire for having better, less expensive health care than the US have done so with ACOs.

            They ALL have achieved that admirable goal with a large, well-paid supply of primary care PHYSICIANS.

          • Anonymous

            Countries that have better, less expensive healthcare have a great deal of government involvement.  I haven’t seem many physicians advocate for any of these types of systems-single payer or a national healthcare system.  In a market based system, do you really think the primary care physician will thrive?

          • Anonymous

            Not sure what you mean by a “market based system.”

            In this country, over half of health care is purchased by the government. Those not covered by these plans generally have to take the coverage chosen by their employers, in regional markets increasingly dominated by a single insurer.

            I don’t think this is “market based,” but whatever it is, every primary care doc I know in private practice is turning away patients on a regular basis.

            Several of the more successful European plans require the mandatory purchase of private insurance chosen from a large selection, and rely on small-office based primary care docs for the bulk of health care services.

            So, I guess I’m really unclear what your argument is.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    This is a wonderful article. There are areas of patient satisfaction that should be calibrated. Ease of getting an appointment. Timeliness of the visit. Was the doctor on time. If the doctor was not on time, did the doctor or his staff take steps in advance of your arrival or once you arrived to keep you informed about the delay?  Did they offer to re schedule you?  Was the staff pleasant and professional. Did the staff protect your privacy.  Did the doctor give you his or her attention during the visit.? Was the doctor through and complete in the evaluation of your concerns?  Did the doctor address all your problems and questions and give you an opportunity to ask questions?  Did the doctor or staff provide you with educational material or resources to learn more about your disease? Did the doctor explain clearly how you should followup on this visit and communicate with the office?  If the doctor suggested a referral , did the doctor offer to contact the consulting physician on your behalf to alert that physician as to why you were being referred there and to provide that consultant with the pertinent and available medical data needed to asses your problem?  Was the office clean and professional?  These are the type of items that can and should be calibrated and recorded .  Often a patient will disagree with the suggested treatment.  An example would be use of antibiotics for treatment of a viral illness such as a simple cold. Patient satisfaction can not simply be a record of the patient not getting what they wanted even if the patients expectations were inappropriate for the medical condition they have.
    I would use the same criteria for institutions including cleanliness, response to calls from your room for attention. Protection of your privacy while caring for you. These are items that individuals should be able to judge and report on that do not require a nursing or medical school education 

  • http://pulse.yahoo.com/_AHJLBFNNBNL7SVEXJCRGWDZTBI Braidz

    A member of my family ALMOST had a lung resection for cancer. Reading what you say here, gives me an additional reason to be glad that the decision was made not to operate, for the purpose of preserving his remaining lung function. (COPD, and right around the cutoff point for operating or not operating.) In fact, it turned out that the doctors had also decided that the operation could not be done, and I think they were relieved to hear that he also had come to the same conclusion on his own.

    When I now read here that patients who have had this operation cannot get adequate pain relief, then I am, as I said, relieved that no operation was performed! Granted, patients have different priorities. Some patients in the same situation would say, “Do whatever it takes…”, and I also respect that.

    But I think one very important thing is to be UP FRONT (before the operation!) about the possibility (or lack thereof) for pain management after the operation. Then each individual patient can make decisions based on what is acceptable for him/her.

  • http://www.facebook.com/lbertybell Mark Bell

    This is an interesting study -
    and of high quality. The study does not address overall benefits of evidence-based MD medicine
    (and in fact it says it does not). But the study does find that the most
    satisfied patients do die at a higher rate.

    First, let’s take a
    look at how they measured “satisfied.” It was mostly based on these
    questions: “…how often in the past 12 months patients’ physicians or
    other health care providers performed the following: (1) listened
    carefully, (2) explained things in a way that was easy to understand,
    (3) showed respect for what they had to say, and (4) spent enough time
    with them.” These are clearly valuable things in any relationship.

    So why might these people die at a higher rate? The authors thought it
    might be because highly satisfied patients are more likely to be granted
    their requests for specific drugs or elective procedures (at a greater
    cost), and that there could be iatrogenic mortality from them. The
    authors concluded that they really had no idea why they found what they
    did, and more research was needed to explain their counterintuitive
    findings.

    I can offer an explanation that they touched on but did not explore – confirmation bias.

    That is the well-known tendency to interpret evidence in a way to
    confirm one’s beliefs. If you buy an expensive thing, your tendency is
    to appreciate it and justify it to yourself and others. You do things
    which sustain the satisfaction.

    Satisfied patients (of any
    healing discipline) tend to offer justification for their health care
    decisions. If they are under care for a condition which ends up killing
    them, and they believe in that care, they’ll receive more care than the
    average person does. Believing in it, and receiving more of it, they’ll
    rate it more highly than the person receiving less care. And I can
    almost guarantee they’ll come to terms with their misfortune more easily
    than those who are dissatisfied.

    So: belief. Is not the study
    really about belief, then? One can read it so. What it does not say, by
    itself, is anything at all about the effectiveness of allopathic
    medicine.

    This is the study itself: http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.1662

  • Anonymous

    Another way to look at this study is that we actually show some sense of urgency and expedite treatment when patients suffer a true emergent medical condition.   This communication of concern during the last, terminal years or events is perhaps evident in this study.  If you run the stats in your facility, most will find that about 5% have drug problems.  We cannot discount everyone else.   I do agree that there are too many questions.  We also know that some people will never give the “Top Box” number unless there is perfection but we cannot fully discredit these scores.   

  • http://twitter.com/TristaKoch Empowered Practice

    In my experience, most customer satisfaction or dissatisfaction comes down to the communication and bedside manner of the doctor and/or staff, not the patient’s success or failure of obtaining medications or surgeries that they sought after. When the medical professionals communicate openly and honestly about the patient’s health situation and all options, then the patient feels satisfied with the care they received. This would include all communication experiences from the moment they schedule and appointment or are admitted to the time they walk out or are discharged. Was the receptionist smiling while talking over the phone to schedule the appointment, was the patient greeted upon arriving to the appointment, did the nurse apologize for the wait if there was one, did any waiting times get communicated in advance, did all the patient’s questions get answered, was there good followup and follow through, etc? Patients want to be educated and well informed about their health and know that the doctor is willing to collaborate with other specialists if need be. 

    -Trista

    With all that being said, I will not disagree that med or surgery-seekers give high ratings when they get what they want and low when they are told no. 

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