Customer service has limits in the exam room

Health reform includes measures to link hospital reimbursement to patient satisfaction measures.  Through both public and private insurers, this trend is likely to spill over into the outpatient setting in the very near future.

Aside from creating redundancy in the market (with some very rural exceptions, patients can act as agents of their own satisfaction by voting with their feet), there are serious limits to physicians as agents of pure customer service.  Our roles supercede service to the sole patient sitting on the exam table, and attaching payment to patient evaluation endangers the complex responsibilities that physicians — especially primary care providers — owe to the community at large.

As primary care physicians, we are charged with negotiating sensitive and intimate health concerns.  Control of elevated weight and blood sugars that patients would prefer to ignore, for example. We handle a myriad of difficult topics with the best aplomb we can muster, but these discussions are not always met with open arms.

We guard the continued utility of antibiotics beyond this generation’s coughs and colds.  In refusing Z-paks for viral illnesses, we may be engaging best practices, but we rarely leave  happy patients who expect an anti-bacterial cure for their viral sniffles.

We are the sentinel in the battle against a growing national addiction to narcotic pain medication.  Deciding when to write another script for Vicodin and when to transition to non-narcotic modalities is an art that takes both training and courage, but with an epidemic-sized population hovering on the edge (or already over the abyss) of addiction, few patients are satisfied when a request for opioids is denied.

We are the unwitting actuaries of the health care budget. We are torn between the newest, most heavily marketed drugs and tools, and the driving push to curtail spiraling costs: to employ the cheapest evidence-based medications, to grudgingly abide by insurance company prior authorizations, to realize that sometimes the most expeditious answer also places the most burden on the health care dollars that we all rely on as the bulge of the baby boom generation passes through the snake’s belly.

Moreover, outpatient physicians choose who we care for.  Under reimbursement schemes that punish providers for problematic interactions, the most likely outcome is that problematic patients will find it difficult to retain medical homes outside the home of last resort: the emergency department.  We all know these patients: chronic narcotic seekers, unstable psychiatric patients, those who inhabit the nebulous borderlands between volitional bad behavior and true mental illness.

Maintaining equanimity in the office in the presence of such patients requires subtle skills such as setting boundaries, establishing protocols and limitations, negotiating the news that needs will be met but impulses and whims will not be indulged.  The physicians most willing to take on such patients should not be doubly punished for the ruckus that frequently arises around them.  They should be afforded the additional resources it takes to stabilize such individuals and minimize their disproportionate impact on the hospital system.

Linking reimbursement to patient satisfaction hobbles physicians’ ability to uphold high standards and to broach difficult terrain when necessary.  Applied with a broad brush, tying reimbursement to patient satisfaction harbors the potential to interrupt the integrity of the doctor-patient relationship and compromise the larger promise made by physicians to uphold the health of the nation.

Julie Craig is a family physician who blogs at America, Love It or Heal It.

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  • Adrianne Stone

    This reminds me a great deal of the problems that public school teachers face, especially In urban areas. These teachers get the kids that no one else, not charters nor public schools nor anyone else, wants to teach and who have been neglected educationally their whole lives. These kids come to them with emotional and behavioral problems, sometimes even cognition issues, and almost always way behind in their learning.

    Then those same teachers are judged by their ability to get their kids to be able meet some arbitrary standard on standardized tests, when they had all the cards stacked against them in the first place. Even more so when compensation is tied to it.

    Having worked in the system this was one reason I was Not in favor of the government getting more of their hands on it. People make decisions like this that touch everyone involved without thinking through the ramifications.

    • Steven Reznick

      Teachers are the most maligned group in America. Until students and their families create an environment at home that encourages education and achievement, nurtures it , rewards it and demands it , the teacher will continue to be the whipping boy for parents and politicians trying to explain why math and reading scores stink. I remember having a miserable teacher in junior high school who made my life and my classmates lives in this Algebra class miserable. My parents attitude was that this was an obstacle that I had to overcome to be successful. They worked with me after to school to help me achieve the classes goals. They found me a tutor who could help bring me up to speed. They expected me to achieve and excel and having a historically poor teacher was not going to be used as an excuse. I thank them for their attitude and I am appreciative that they held me to a higher standard. It was not an unrealistic standard just a standard they thought I could reach and exceed. Teachers do not have the luxury of having this type of family support in today’s world and they receive far too much criticism because of family and student failings not educators.

    • Julie Craig, MD

      Adrianne, yes I think your analogy is very apt: this is a very similar approach to the No Child Left Behind legislation. Instead of shoring up areas of weakness, it serves only punish areas that are usually weak because of structural issues that are usually already very entrenched, and not amenable to amelioration by punishment. Yes, every office should be courteous, on-time, etc, but much of dissatisfaction comes from issues like too little time available for the doctor-patient interaction – a function that is likely to become only worse if punitive measures are taken which further cuts reimbursement.

  • Steven Reznick

    Its all about health education which begins at home and is continued during the schooling years. Much of the common sense health teaching has been eliminated from the schools due to budget constraints. It is tough to satisfy an under or poorly educated public in health care matters.
    There are clearly customer service issues that can be addressed. Being considerate of the patients time is very crucial especially if you are running behind. Informing the patients in exam rooms that you are running behind and giving them the opportunity to wait or re schedule is just simple courtesy. Calling the patients further down the schedule and telling them of the delay and giving them the chance to come a few minutes later or re schedule is within the grasp of most practices. Returning phone calls in a timely fashion and communicating lab results in a timely fashion is within the realm of all practices to do regularly. Training staff in customer service so that phone calls are answered quickly by a human being, patients are not automatically placed on hold without asking their permission to do so are simple customer service items that are achievable. Greeting patients with a smile when they enter and sign in works as does removing the glass barrier that separates the reception staff from the patients in the waiting room. These are not difficult or expensive perks just items that must be taught, reinforced and rewarded by the doctor(s) or administration. Treating patients the way you wish to be treated goes a long way towards meeting patient satisfaction issues.

    • rswmd

      I agree with everything you say, but you haven’t addressed the big problem.

      Should physicians have their payments for services already performed reduced by 25-30% based on anonymous comments on surveys that the docs aren’t allowed to review or contest (especially when, as in our practice, 99% of the complaints are about insurance issues that we have no control over)?

      What other profession would be willing to work under these conditions?

      • Steven Reznick

        Of course physicians should not have their fees reduced by even 1% for customer service reviews. On the other hand if physicians are concerned about this then let them bet on themselves, set up a direct pay practice or concierge practice and send a note to the insurers that they are opting out of their contracts after the 90 day notification period. You want freedom from bureaucracy go out and earn it or take it !

        • Julie Craig, MD

          I do not believe that concierge practices are answers to the larger questions posed by the crises in our health care system. They may answer some questions for physicians, but that is a one-dimensional answer. As noted in my original post, much of my concern is for more global issues: what happens to the cost of care when the incentive for physicians is stronger than ever to lower the threshold for firing difficult patients. Concierge care does not answer this question; it exacerbates that particular problem.

          • Steven Reznick

            We do not fire the most difficult patients. In fact in most concierge practices in my community, we take on the most complex and difficult cases that traditional practices forced to see high volumes of patients for short single problem directed visits can not handle or do not want to handle. As an outgrowth of concierge medicine we have seen the development of the direct pay practices which accept no insurance and charge a reasonable flat fee for a visit. The model is still evolving based on the needs of the market. The model evolved out of a failure of the AMA, ACP or American Academy of Pediatrics or Family Practice developing a successful reimbursement model for physicians in their societies. If anything , the ACP ignored its original white papers on Internal Medicine and has decimated the generalist.
            Concierge and direct pay practices have several things in common. They have built a successful niche and beach head because the patients like them. The physicians running them believe in health care being a relationship between the doctor and the patient not run by the employer or the insurance company administration. The doctors setting them up have the wisdom foresight and courage to take risk and bet on themselves. When they set up these practices under the direction of trained consultants they find a home for those patients deciding not to join. In many cases the concierge and direct pay physicians permit a fare share of pro bono or scholarship patients to the practice. Yes their panels make them only available to smaller numbers but those smaller numbers receive the attention and care that every American deserves !.

  • Rolf Olsen

    All of the issues you’ve raised are certainly important. But while effective ‘customer service’ contributes to ‘patient satisfaction,’ it is not the same thing.

  • W Joseph Ketcherside, MD

    Everything you describe in the post is true, but I think there are some more basic considerations. There are a lot of physicians who don’t get to the subtleties above. They interrupt patients before they get the story, perform a cursory exam, refuse to answer any questions, provide no diagnosis other than “Looks like you are doing OK now”, and promise to send a letter to your doctor. This was my father’s exact experience with a specialist to whom he was referred after a critical hospitalization for sepsis. He is a retired college professor who had a lot of very good questions about why he ended up in the hospital and how to care for himself properly. He got absolutely nothing from this encounter.

    This physician does not deserve to be paid at all for this visit, forget a 1% ding. Funny, the only people I see who question the concept of being penalized for providing poor care are other physicians. I have been in medicine for nearly 40 years. It’s time for physicians to realize we aren’t any more “special” than anyone else.

    • Julie Craig, MD

      Very fair question. But the critical question is, how do you propose to differentiate this type of interaction from complaints that are punitive in nature – ie. because a patient disagreed with reasonable actions on the physician’s part? As I mentioned in my original post, this is mostly where market-driven factors come in: if a physician is not good, don’t go back (or if there was truly negligence involved, any individual can file a complaint with the state board of medicine). If a physician is truly not good, a critical mass can invoke that principle and that forces change on different level. But I cannot think of a single business model (car repair, plumbing, accounting, legal services, retail, etc) in which the payer gets a discount if the customer is unhappy with the service provided. Even workers who operate on tips still get a base wage that cannot be modified, and restaurant customers are still obligated to pay the cost of food even if they short the server on the tip. You are very correct that physicians should not be treated differently than other providers of services – yet this is a model that is almost uniquely being applied to health care.

      • W Joseph Ketcherside, MD

        Not true at all. If you have a valid complaint about a restaurant meal or service it is common for them to comp you a dessert or not even charge. Service providers discount unhappy customers all the time. You need to find a new garage ;~)

        My point is that physicians fail regularly on the basic services part. We are worried about the occasional crazy with a punitive complaint, and I know those happen. Somehow other businesses manage to survive those. And most people who read them can see through them. When the complaint details a lack of concern for time, poor communication skills, poor follow-up, well that’s obviously not a “punitive” complaint.

        I do not accept the premise that we should not measure physician performance just because the perfect measure hasn’t been invented.

        Regarding your suggestion to just not go back – Part of the problem is how people get to a specialist. Your PCP sends you to the one they use. Dad’s in a small town an hour away from a larger city. The urologist he saw is the ONE who comes to his town. He didn’t get an opportunity to shop. When he asked around after the bad experience, a couple friends told him they would never see this urologist again because of the way he treated them. So this guy’s issue has been known for years. And yet this PCP keeps sending people to him. You know that who we refer patients to is often based on habit, personal relationships, being in the same building or group – things that are not related to actual quality of care.

        Sure, if they kill a couple of our patients we notice. But I have seen some really awful docs keep plugging along because people keep sending them patients right up until they lose their privileges or the state takes their license.

        It is not enough to just practice technically correct science as a physician. We care for people, and owe them respect as well. If a physician can’t communicate effectively they will not get all the information they need to get the right diagnosis, and the patient won’t get all the information they need to follow care advice.

        It’s time physicians saw some of the same market factors that impact the rest of the business world. Do good work with high customer satisfaction and you will thrive. Don’t and you won’t.

        As for this urologist, he’s soon to have a conversation with a physician family member, maybe he’ll spend more than 3 minutes with me. Looking forward to getting his note and seeing how he coded it, and comparing to Dad’s version. Wonder if there’s any upcoming going on. And of course he’s about to meet social media and doctor rating sites. Promised Dad I would show him how to fill out a valid, non-punitive, accurate customer service rating on a physician.

        • southerndoc1

          “It’s time physicians saw some of the same market factors that impact the rest of the business world”
          If we want to bring market factors into medicine, it has to be a two-way street: physicians would have to be given the ability to set their fees, charge extra for extra services, and so on.

          • W Joseph Ketcherside, MD

            Absolutely agree! Good service should be rewarded. Better docs should be paid better. In the current system the insurance companies and Medicare pay the same amount to everyone for a given billing code. Where’s the incentive to do a better job? And lousy docs should go out of business like any other business failure.

    • southerndoc1

      “It’s time for physicians to realize we aren’t any more “special” than anyone else.”
      So you think everyone should have their pay adjusted after the fact based on anonymous surveys?

      • W Joseph Ketcherside, MD

        I think physicians should be paid based on the quality of care they provide, not the number of bullet points they put into a note.

  • meyati

    There’s a site called Rate My Doctor. The main thrust of feedback is if the doctor is on time, does the doctor explain the proposed prescription regime, is the doctor friendly, is the nurse friendly. Some friends and I went into it, and we decided that we’d pick a doctor with the lowest ratings. Some of the worst doctors we’ve met had the highest ratings. One wanted to treat the symptoms of thyroid problems and kept ignoring lab results until my TSH was out of range. The survey asked if the doctor ran lab work that you requested, but nowhere did it ask if the doctor could read lab work- and the list like that kept going. There’s more to being a doctor than being a smiling robot that’s on time.

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