Is the goal of patient satisfaction to make patients happy?

The link to a recent article in Forbes magazine entitled, “Why Rating Your Doctor is Bad for Your Health“ keeps showing up in my inbox with the subject, “thought you would find this interesting.” The reason is because I’m responsible for overseeing education and training related to physician communication and patient satisfaction for a large national hospitalist practice.

The article isn’t so much interesting as it is unfortunate.  Its premise, based on comments from physicians, is that, “many doctors, in order to get high ratings (and a higher salary), overprescribe and overtest, just to ‘satisfy’ patients who probably aren’t qualified to judge their care.” And physicians report that this is taking place in an effort to meet patient satisfaction goals.

While it’s true that patients may be unable to judge certain aspects of clinical quality, there’s one thing they are quite capable of noticing (apparently a lot better than us physicians): a bad attitude.

The patient satisfaction mission is a critical one and our understanding and support of it is essential to the care of our patients and the credibility of our profession.

Before expanding on that point, let me try to establish some “street cred” by sharing that I’m a working hospitalist in addition to my administrative responsibilities and personal interest in patient satisfaction (which, for the purposes of this commentary is best referred to as the “patient experience” – I’ll explain below).

Much of what I hear from physicians about patient satisfaction is negative. And I do understand why. The government’s HCAHPS survey methodology and the Value Based Purchasing program are imperfect systems leaving obvious room for improvement. Additionally, hospital administrators sometimes have unrealistic expectations or misunderstand the limitations of these surveys. However, I believe these evaluation tools and their results can foster improved patient care. And with greater clarity regarding the goal of the patient experience mission and physicians’ role in it, I hope to convince my colleagues of the same.

What’s the goal?

One thing it isn’t, is making everyone satisfied (or happy). And that’s the reason why the term “patient satisfaction” misses the mark. For one thing, trying to make everyone happy is a losing battle.  The reality is that our recommendations sometimes collide with patients’ expectations. And this is where our expertise must show.  We physicians are charged with synthesizing many variables to determine what the correct care is for our patients. Effectively communicating the rationale for such care to patients so they can understand our recommendations is a responsibility we all signed up for and must abide by.

The goal of the patient experience mission is to ensure that all our patient interactions culminate in decreased patient anxiety, increased patient understanding and hopefully improved patient compliance and outcomes. And we shouldn’t lose sight of the fact that each of these outcomes is a valid end-point in its own right.

Yes, there are patients and families that are demanding and the final risk/benefit analysis may dictate that we provide something that isn’t absolutely necessary but not overtly harmful. I have ordered an MRI for an inpatient with back pain and at best a marginal indication for it. It was an unnecessary expense (to the hospital and the health care system), but a necessary maneuver to avoid further inefficiency in the patient’s care and the potential utilization of other costly resources within the hospital. But these are the vast minority of situations and to focus on them misses the point.

If we’re preemptively over-ordering, over-prescribing or simply taking orders from patients solely to improve survey scores or to generate a chunk of bonus money, we have only ourselves to blame. And again, we are missing the point.

The vast majority of patients are appreciative of our explanations and expertise when we take the time to listen carefully and make the effort to explain things clearly. This leads to better patient experiences and it can only help patients’ survey ratings of care. Care that accomplishes these goals is achieved through superior communication, which informs our role in improving the patient experience.

What’s our role?

It goes without saying that physicians are responsible for providing the most effective and evidence-based medical care at all times. But accurate clinical decision making must be accompanied by communication that addresses what I refer to as the patient’s “core concerns”:

What is happening to me?

Will you listen/talk to me?

Will you look out for me?

By offering clear explanations, listening compassionately and acknowledging patients’ predicaments with empathy and caring statements, we can restore a degree of autonomy that will allow patients to trust that we have their best interests in mind at all times. This is our role in improving the patient experience.

Patients surely have the ability to judge whether we’ve addressed the “core concerns.” And we should keep asking them how good a job we’re doing of it. After all, we’re healing people, not fixing computers.

The public will forgive us the occasional disgruntled patient who cannot be convinced of our best intentions, but they will never forgive us for misunderstanding the patient experience mission and failing to do the right things while under our care.

Mark A. Rudolph is Vice President, Patient Experience & Physician Development, Sound Physicians. He blogs at The (in)Patient Experience.

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  • http://twitter.com/ARamsteadCopy Amelia Ramstead

    Excellent thoughts. Yelp and other similar sites are surely doing more damage than good.

    • Suzi Q 38

      I think that Yelp can be even more damaging, because people actually read what people write about their experiences with certain doctors and hospitals.

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    Well stated article. We should never equate patient satisfaction with our acquiescence.

    I find there are 2 types of patients when it comes to satisfaction “grading.”

    1. Patient is rational and wants good care but has enough insight to know what they “dont know.” – These patients may think they want a particular medication or procedure but with proper time and education a good doctor can give them guidance that they respect and accept (or at least make an educated choice.)

    2. Patient is convinced that they are right and are unwilling (or do not have the insight) to truly understand their problems and needs. These patients will often be irrational and they will never be happy with anything less than the doctor just “giving them what they want.”

    Patient number 2 is the major problem. they are your “doctor shoppers” and often heavy users of medical resources.
    Unfortunately, they to are most likely to post “grades” and comments on the internet about physicians.

    • doctor.rudolph@gmail.com

      Thanks for your comment, Brian. I find that the patients in the second “bucket” you mentioned are often dissatisfied with virtually any outcome! You do what you can with these folks. And the rest will be grateful for the additional information and communication we offer them.

  • CaliforniaMFT

    Physicians can easily increase their patient ratings by doing two things: 1. Spending more time with patients 2. Listening to them/being present.

    I’m a psychotherapist who recently had to make the very difficult decision to have Nissen fundoplication. Although there was clear evidence that I had severe, intractable GERD, none of my doctors nor the surgeon could guarantee the outcomes of the surgery.

    So, ultimately, what was the deciding factor? The surgeon. I was referred to him by my physician. The surgeon spent 45 minutes on my first consultation, answering my entire two-page list of questions. He did not rush. He was very honest about what I could and could not expect from this surgery. He listened very carefully when I talked about a previous failed surgery (for another issue) and to all my other concerns. He took my pain very seriously. He was very present. My second consultation with him was similar. I decided to do the surgery based on the way he treated me.

    The surgery turned out to be one of the best things I’ve ever done in my life. Not only do I have a normal stomach for the first time in my life, but my asthma decreased by 90% and I’m no longer disabled by the damage done by my reflux.

    Had my surgeon pushed me out of the office without answering all my questions, ignored my concerns, or typed on his computer instead of listening to me, I wouldn’t have had the surgery, and my health would have continued to deteriorate.

    So, slow down, listen, and pay attention. It’s good for both the patient and the doctor.

    • doctor.rudolph@gmail.com

      CaMFT – that’s a great story, thanks for posting. I think one can extrapolate your experience to the many patients who may benefit from a chronic pharmaceutical treatment for diabetes or heart failure, but without solid trust in their physician or provider, they may see it as another annoying pill to take and not feel appropriately compelled to be compliant. Providers clearlyt have a role in their patients’ compliance with recommended therapies.

  • Suzi Q 38

    It sounds crazy, but I hate to fill those evaluations out unless I have positive things to say. I view this as way too much “big brother” watching, as if I were a spy for the administration. Sometimes, I am annoyingly too positive with some evaluations, because I know it may help a doctor or nurse.
    The problem with this realization though, is that I hesitate to complain.

    As much as I complain about a physician at home, I am reticent to complain about him or her on the Press Ganey evaluation. I have a few ideas about how they could have made a better diagnosis in a more direct way, thereby preserving my mobility. At this time the evaluation sits, all alone, unanswered on my office desk. I realize that if I answer truthfully, a few doctors may be reprimanded.

    Part of me wanted to try taking my suggestions to the patient advocacy department. She listened intently to my story and problems and wanted me to file a grievance. I told her I would think about it, as I am concerned that there were so many errors in my case that someone may lose their job.

    If anyone has any ideas about how I can convey my disappointment about my past medical treatment at one of the best cancer hospitals in the state, please let me know.

    I think the sad error is that no one was in charge of me; no NP or PA, or PCP. The specialists are highly credentialed from really good medical schools but did not talk to each other. For example PT was concerned about me, but did not know the newly hired neurologist, so they did not talk with them about my care. There was also very little time to talk with me. The doctors were not used to a person like me asking questions about certain tests to decide why my thighs were weak after my hysterectomy.
    It took a year and a half for me to escalate with several more symptoms for them to take a too little too late diagnostic tests that I was asking for a year ago.

    I finally moved on, but I hesitated because to the money and time it takes to start all over again at another teaching hospital. I ended up having my surgery at another hospital to save what was left of my mobility.

    How do I complain about my thoughts and how it all occurred without a couple of doctors getting in real trouble and possibly losing their jobs?

    I am waiting to complain because I have the hopes that I will be better and there will be a “happy ending.”

    On the other hand, I don’t want this type of non-communication between my doctors and various departments and the patient to continue with other patients.

    • doctor.rudolph@gmail.com

      Suzi – you should definitely share your thoughts with the patient advocacy department of the hospital. That’s what they’re there for!

  • nat

    I believe both articles (yep, even the Forbes one) have valid points. I am a primary care doc, see patients, teach and am medical director. I have several concerns with Press Ganey and various ways to measure patient satisfaction:

    1. The cost and usefulness of data. How much $$ do these surveys cost? What NEW information are we getting? What do I want as a patient? Probably much the same as Dr. Rudolph. Caring, be seen when I want to be seen, personal touch, be able to contact or be contacted by my doc, etc. So far, not much new information there. I believe we can be more cost effective at getting information and have better real data. That may mean free text as well as likert scales in the surveys.

    2. The current system is built against changing to a more patient friendly environment. As a doc, I (and I believe many docs), have been advocating for patient satisfaction for years. Our current system, pay for performance, pay per RVU, ‘your goal is to be at 75% MGMA’ etc. work against the premises of patient satisfaction. Many of the “touches” that increase satisfaction cost money, do not generate immediate RVUs. I would LOVE to spend 45 minutes with my patients. My bean counters – would hate it and then ask me why are your patient #s low? Hello double book time. Change is on the horizon and I am both scared and excited to see where we might end up – hopefully more humanities in medicine.

    3. Lack of response or change to the surveys – this is the perception. I have free texted comments and always left my name and contact information requesting a call/email back, and I have never heard from any hospital, business, corporation when I filled out their quality satisfaction surveys (except for getting their spam). My patients say the same thing, even when I encourage them to fill out surveys and write in comments. Hospitals groups and Press Geney absolutely need to streamline their data gathering to quicker and then also make changes and publicize them. Show your patients WHY it is important to give feedback and what changes have resulted from that feedback. Respect your respondents.

    To any quality folks who read this – I believe / hope that most docs want the feedback (not I say feedback – NOT simply a score)- I thrive on it and constantly want to improve. Make it useful, pertinent to them and what they can affect, supportive systems, and timely and you will have docs / providers / patients / staff jump on board with patient satisfaction.