Patient satisfaction is underrated

Through three years of medical school, I’ve seen disgruntled physicians repeatedly slam the recent movement toward patient satisfaction. In our family medicine clinic, a copy of Dr. William Sonnenberg’s essay “Patient Satisfaction is Overrated” hangs on the door to remind attendings, residents, and students of the unfair pressure to keep patients happy despite their demand for antibiotics, imaging studies, or narcotics.

The only way to keep the patients satisfied, the argument goes, is to give in to unreasonable requests. “The mandate is simple,” the author suggests: “Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission.”

But the options are not simply give in to pressure or say “no” and lose patient trust. There is another path that is harder, takes more time, and is particularly challenging for young medical students and doctors: to improve communication.

“Patients aren’t the best judge of what is best for them,” Dr. Sonnenberg writes. This is true, but a physician’s calling includes not only judging what is best for patients, but also helping patients seek out accurate information, educating them, and developing the relationships and trust that ensures they understand the reasons for and against any treatment.

The author concludes with, “We should try to be kind to our patients and take time to understand them, but we must resist these misguided pressures and do the right thing. Sometimes patients have to be told ‘no,’ and the leadership in health care must understand this.”

This takes too narrow a view. Physicians must understand there is more than one way to say no. And going against patient wishes does not always lead to poor satisfaction.

A physician’s job requires — and patient satisfaction flows from — education, empowerment, and encouragement for patient decision-making within the health care delivery system. It’s explaining why his symptoms appear viral and explaining why antibiotics simply won’t help. It’s explaining that narcotics addiction is an illness in its own way, and there are other ways (e.g. rehab programs, exercise, counseling, withdrawal prophylaxis) to address the problem.

Patient satisfaction is linked to many other qualities a physician may possess, not just her prescription rates. It depends on her communication skills, the amount of time that her patients perceive she spends with them, and that she provides adequate explanations for the causes of pain or illnesses. Patient satisfaction and treatment compliance have been shown to relate directly to a physician’s empathic behavior. Improved communication is even linked to improved health outcomes. The pressure to keep patient-satisfaction levels high should not be seen as “misguided,” but as a call to arms to focus on a new skill set in an overburdened health care system. These surveys strive to keep doctors’ eyes on the patient rather than the computer.

There are ways to go against people’s wishes and still keep them happy. Kindness, respect, and understanding go a long way. Countless primary care physicians serve as the patient heroes who display these qualities. These are the role models for future physicians, and they must be acknowledged and celebrated. Health care leadership can put an emphasis on these qualities, seeking to strengthen the communication skills that define the patient-physician relationship.

This is admittedly no easy task. Personalities differ, and a doc will not get through to every one of his patients. A patient upset that he didn’t go home with amoxicillin may cause a good physician to receive a lower “score” than he deserves. But this can be mitigated or avoided by what doctors should be doing with every patient: seeking to improve creating intimate connections with diverse people. Physicians help patients understand their disease and treatment options as much as simply trying to treat them.

Doctors must see the new reality of the field of medicine not as creating perverse incentives away from proper treatment, but instead as an interpersonal challenge to connect with and educate all patients, including — especially — difficult ones.

In order to truly improve health care, the medical system must refocus on the relationships between doctors and patients, and less on doctors as intervention providers. Doctors exist for the patients, and to share some of life’s most intimate moments with them: life, death, birth, sickness, and recovery. To aid them when they need it most. To optimize their long-term health. To improve their quality of life, and to work to keep them healthy, educated, and satisfied. Patient satisfaction is underrated.

Justin Berk is a medical student. 

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  • PrimaryCareDoc

    This is rich, coming from a medical student. Come back and talk to us after you’ve actually been in practice for a few years. Come back after you get a “dashboard” of your satisfaction scores presented to you every month and they are all red, because anything below a 4.7 on a scale of 1-5 is in the “red zone.” Come back after you are told by your corporate overlords that you’d better get into the green zone if you don’t want a pay cut (green zone is getting a 5 on everything).

  • Dr. Drake Ramoray

    I will let Kevin refute your points.

    http://www.kevinmd.com/blog/2012/02/patient-satisfaction-kill.html

    In addition Doctors have less and less time for patients. Patient satisfaction scores is just another reason to hurry off after writing a script, especially when corp med links doctor compensation to satisfaction scores.

  • Dr. Ivo Robotnik

    Patient satisfaction (at least as defined by corporate med) IS overrated, as evidenced by the studies showing worse patient outcomes for higher satisfaction survey scores. C’mon man

    • Justin Berk

      The argument is that there is a way to increase satisfaction scores without worse patient outcomes: Instead of caving to ABX demands, seek to improve communication. There are some amazing physicians that do this, and though naive or idealistic, those are the docs that I think have the right idea.

      • Dr. Ivo Robotnik

        I didn’t mean to come off as harsh, but it seems I did. I think there’s a discrepancy between what you are talking about and what we are now essentially being graded on. We’re often talked down to by administrators, policymakers, and other such soulless individuals about patient satisfaction scores, which probably contributed to my vitriol. These ‘patient satisfaction’ scores have very little to do with what we consider patient satisfaction. They’re little more than bubbles that people circles after they leave the office or hospital. We’re being push to make sure they circle all the 5′s instead of all the 1′s. Something as silly and insignificant as that is becoming an increasingly ‘important’ part of healthcare. What you and I consider patient satisfaction isn’t the same as the suits at the top.

        Your suggestions on improving patient care aren’t wrong; they’re what most of the docs on here have angrily expressed often. We need more time with our patients. More time to find out. More time to explain. More time to communicate. But time is the very thing that we’re getting less and less of each year. Patients complain that we don’t spend time with them, and the overlords dictate that we need to see more patients. It is impossible to effectively communicate and develop a relationship with the time we are given.

        But, like you, I’m an idealist. Don’t lose that idealism, because we’re gonna need it if we have any hope of turning things around. And we will.

  • azmd

    Oh, are medical students being rated on patient satisfaction scores now? That;s interesting.

    • Justin Berk

      I wish I had a must-useful tips list. I don’t. But some of the most impressive mentors I’ve had can do it. I don’t think it’s easy, but that’s what I, and hopefully other medical students, will continue to strive to develop as we enter the field.

  • John C. Key MD

    So much wrong with this post it is hard to be succinct. I really think naivete and its cousin, inexperience, does it best.

  • http://www.thepatientdoc.com The Patient Doc

    Three years ago before I graduated residency, I would have agreed with him 100 percent, but after my first 2 years of practice dealing with horrible administrators, and patients who thought my office was Burger King and they could ” Have it their way”, spending extra time trying to educate patients who would tell me they didn’t care, then going home and crying, I changed my view. I will agree that we need to work on the doctor-patient relationship, and create understanding between both parties. I speak as a doctor and a patient with lupus, and I see both sides, and truthfully I’d rather have my rheumatologist do what’s right ( like temporarily boost up my steroids) the have her give in to my complaint that I don’t want steroids cause it makes me fat.

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

    The term “patient satisfaction” is now obsolete. They changed it to patient experience, but, strangely enough, the surveys haven’t changed that much.

    I am starting to think that this entire experience/satisfaction thing, the way it is currently implemented, deployed and utilized, is intended to divert patients’ attention from proper medical care, to the color of the carpets and the contrived customer-friendly tone of staff…. It’s cheaper that way…

    • Arby

      I think you nailed it here. Also, this is why I think more and more alternative medicine is creeping in. Why pay a physician to treat us if someone at a support staff wage can wave their hands over us and make us feel loved.

    • buzzkillerjsmith

      Figuring out what proper medical care consists of is hard. Better to evaluate whether the receptionist was perky enough.

  • azmd

    One of the biggest things wrong with healthcare today is the overwhelmingly large number of people involved who don’t do the work (and in many cases have never done it) weighing in with ideas on how the work can be done better, cheaper, faster, more safely, etc., etc.

    This would be fine, except that it is people like this who are creating the healthcare policies which are driving the nails into the coffin of our profession.

    • Justin Berk

      As someone who is about a year out from entering the profession, I’d like to think that my voice does have some resonance. If that’s not the case, then I apologize for wasting the time it took you to read the article.

      In a profession that seems more and more disgruntled I would (and do) hope that medical student idealism would be encouraged.

      • Arby

        Speaking as a hopeless idealist, the more you are, the harder you fall when you find out that those that have no ideals except their own self-serving nature, lie to you, and for their own ends, with many harmful effects to patients and physicians alike.

        I hope you go into this with eyes wide-open so that you don’t lose your idealism. I’d really rather not have a bitter doctor. And, for those that truly have ideals and can still manage to live them, I applaud you.

        • http://www.thepatientdoc.com The Patient Doc

          Justin I still want to have those ideals, and maybe part of me still does. But basically I was belittled and insulted in my last job for those ideals. I think it’s great that you feel the way you do,more of us should, but keep in mind that not everyone will appreciate that mentality, especially money driven administrators.

      • azmd

        I would certainly encourage medical student idealism to the extent that it leads you to pursue a clinical practice, preferably one in primary care, and to involve yourself in advocating for our profession to return to a place in which we are given the resources we need to genuinely have relationships and good communication with our patients.

    • AGM

      Right, so I feel like there are really two issues at hand here. One is that to some extent what and how things can be done better, faster, or cheaper is often a matter of evidence. Certainly, anyone (including patients, students, physicians, scientists, etc.) can participate in that discussion, and weigh in with whatever evidence they have.

      A second is about the sorts of tradeoffs a particular physician or physicians as a whole will have to endure for those improvements. That is probably not a discussion non-clinicians should be engaged in. Unfortunately there are almost as many pictures of the ideal medical profession as there are clinicians.

      Nevertheless, I’m not sure there is a necessary tension between a patient’s feeling of well being and their health. I don’t think the article meant to lay blame on clinicians. It might just as easily (and more likely) be a problem about the way the system is constructed… something that society and physicians should try to change to make it easier for physicians to provide the care they want to provide.

      • azmd

        I didn’t see the article laying blame on clinicians. I did see it laying out a simplistic, and non-achievable solution to the feelings that patients have about not receiving adequate care–just communicate with them better!

        In my opinion, speaking as both a physician and a patient, that stance is insulting to both physicians and to patients. It is insulting to patients, because many of us are aware we are getting substandard care due to grave deficiencies in the U.S. healthcare system. Having my doctor follow a “customer-service” type script is not going to get me better care. Allowing my doctor to have more than 10 minute with me (or with my child) to think things through, maybe even look a couple of things up, would get me better care.

        Making sure that my doctor has gazed soulfully into my eyes at the end of the appointment and said “Have I answered all of your questions?” Is not the same as making sure that he has given me good care.

        • AGM

          I definitely think you are right about that. It seems like you are saying something very similar to what the article said (but doing a better job articulating the point). There is no doubt it begins and ends with a somewhat simplistic thesis. However, for example, he does say:

          “Patient satisfaction is linked to many other qualities a physician may possess, not just her prescription rates. It depends on her communication skills, the amount of time that her patients perceive she spends with them, and that she provides adequate explanations for the causes of pain or illnesses.”

          I think that captures what all of us would like to see in our personal healthcare relationships. I do think we have a particularly strong negative response to “patient satisfaction”. It has become a loaded term that implies customer service.

          It just seems like the author probably needs an editor (and some nuance) more than he needs a verbal bludgeoning.

          • Justin Berk

            Eh- More than an editor, perhaps a different audience.

          • AGM

            On the up side, it seems to have turned from destructive to constructive criticism.

          • azmd

            Actually, I think this is exactly the audience you need. We all care very much about our patients and our profession and have some valuable insights about why your ideas are good, but not practical, and what needs to be done about it.

  • azmd

    Communication is easy, especially for those who have received training in how to communicate effectively. I would disagree that it is cheap, because in order to genuinely communicate with your patients (and not just give them the token “let them talk for one minute at the beginning of the visit without interrupting them” before you scramble through the rest of your seven minutes with them) requires time, and time with a doctor costs money, which third party payors don’t want to pay, which is why we’re all in the predicament that we’re in now.

    • http://www.thepatientdoc.com The Patient Doc

      I agree. Spending extra time educating/counseling patients cost me a lot of time which made adminstration pretty angry. I’m not too familiar with billing, but isn’t there a way to bill for extra time, or for counseling. I would see counseling codes, but I don ‘to really know how that works.

      • azmd

        Yes, I also spend quite a bit of time listening to/educating my patients. I am quite aware that this has earned me a little bit of a reputation for being “inefficient.” It seems that spending time with your patients is a quaint, outdated value, although no one will come right out and tell you that. They will just suggest that you “work smarter” by “communicating better” so that you can somehow speed up the patient encounter and get on to the next 39 of them.

  • Justin Berk

    As we discussed, this is not a causal connection and my argument is that there is a way to improve patient satisfaction without the unnecessary tests, costs, mortality. It’s not “Give Norco or lose satisfaction points.” The third option is teach physicians (and medical students) how to communicate saying no while maintaining a strong patient-doc relationship. It’s a hard thing to do, but can be developed.

    • azmd

      That’s assuming that there’s a doctor-patient relationship to begin with, either a potential one or a pre-existing one. However, one of the practice venues in which patient satisfaction surveys are being used most destructively are in EDs, where by definition there can be no real patient-doctor relationship. Also, trends in our healthcare system increasingly undermine the doctor-patient relationship in ways that the individual doctor has no control over, for example having the patient see a mid-level practitioner rather than their MD if they come in for a “non-complex problem.”

      I don’t think anyone here disagrees that improved communication could lead to improved care and improved patient satisfaction. The issue is that, as a rather savvy medical student has pointed out in a subsequent posting, our healthcare system increasingly rewards doctors who provide machine-like care (rapid, “efficient” and standardized) while giving lip service in the form of patient satisfaction surveys to the type of care that the patient is actually seeking: personalized and thoughtful.

    • SteveCaley

      Remember, in a therapeutic relationship, such as primary care, there can be cycles over the years. I came in to pick up patients from a doc who had been there for 35 years, and retired. My patient satisfaction surveys were not as good as his – they wondered why.
      Duh.
      They had been seeing him for up to 35 years, that’s why. It took a while to build a relationship with them. But in a three-month snapshot, I wasn’t doing as well as he did, on the ol’ patient approval MBA metric.
      Duh.
      The point is, the doctor/patient relationship according to whom? a pay-for-performance surveyor? A bad metric provides nonsense.

  • Justin Berk

    I think you’re probably right about the term. But I do hope that an emphasis on patient satisfaction, at least in concept, puts a focus back on to patient care: treating the patient and not the disease.

  • Justin Berk

    Totally appreciate this response and I definitely’ won’t refute inexperience. Perhaps my views will change in 5 years. But I do see unique physicians that can accomplish the goal of satisfaction and quality care without refilling Norco and ABX all day – that’s the physician I hope to be in 5 years and those are the physicians that should be celebrated within the profession.

    • azmd

      And are those unique physicians seeing their own patients, in eight minute increments, doing their own EMR charting, their own prior authorizations, their own meaningful use paperwork?

      To the extent that you are seeing attendings in an academic setting who enjoy a reduced clinical caseload and the assistance of medical students and residents to deal with prep work and paperwork, you may not be getting an accurate impression of what is realistically possible in a community clinical practice today.

  • Justin Berk

    1) I don’t believe there is, but that is the argument often cited – in the Sonneberg essay and all around KevinMD.

    2) Ha – perhaps it was taken down. And I didn’t mean for the essay’s posting to be a condemnation on our institution’s clinic. Many of the FM residents and attending I’ve worked with have been the mentors that I’ve seen do it right: building a therapeutic relationship, sitting down and explaining why antibiotics won’t work for this virus, and finding a balance where patients speak highly of their physician without receiving any unnecessary treatments. But it seems that the dichotomy of “do-what-they-want” or “do-real-medicine” is getting louder in the profession.

  • Thomas D Guastavino

    Perhaps a real life example may demonstrate reality vs theory. Some time ago I was one of only a few orthopedists that still saw medicaid patients electively. It soon became apparent that in this population there were an inordinate number of chronic back pain patients that had been on narcotics for a long time by their primary. Beyond the fact that it took a long time to try and unravel their history, and get paid practically nothing for it, we always gave these patients the benefit of the doubt and never assumed they were just drug seekers. Alternatives to narcotics were discussed and offered. The majority of the time this worked but there were always patients who became belligerent and demanded the narcotics.
    Over time the amount and intensity of the belligerency became much worse, at times these patients threatening our staff. Nasty phone calls and and letters soon followed threatening everything from physical harm to malpractice suits to having our licenses revoked.
    We no longer see these patients. Besides the threats, the very idea that our livelihood may become dependent on patient satisfaction surveys from patients like these became to much to bear.
    Until the powers that be wake up and realize the importance that motivation and secondary gain have in patient recovery and satisfaction, our only recourse will be to avoid patients like this in the first place.

  • http://www.CommunicatingWithPatients.com/ Edward Leigh, MA

    Dear Justin: Thank you for writing this article. You bring up many great points. As with any new initiative, the patient satisfaction topic has some bugs to work out. Over time, we will find a way to best utilize patient satisfaction data. However, I do firmly believe we are taking a step in the right direction. Communication is the key. I have been in healthcare 20 plus years and know patient meetings are short and we must quickly establish rapport and encourage patients to follow our recommendations. Using the right words in the right way makes a dramatic difference. Justin, I wish you all the best with your studies and future work as a physician. Yes, practicing medicine is challenging, but don’t ever lose your wonderful enthusiasm. Keep engaging, Edward Leigh, MA, Founder & Director, Center for Healthcare Communication

    • Justin Berk

      Thank you for the nice comments. Much appreciated.

  • medicontheedge

    The general population wants it’s healthcare delivery like their fast food: quick, cheap (out of pocket, anyway), and without any effort on their part. Healthcare corporations, hospitals, clinics, ED’s, etc, are actively MARKETING this way. So “customer” satisfaction surveys are part of that campaign. I wonder when they will begin to give out a free CT scan when you do the on line survey? *snort*

  • Karen Ronk

    Can someone please explain when and how these patient satisfaction surveys (I guess that is the right word?) come into play? I have seen many healthcare providers over the last 18 months and have not been asked to fill out anything. Do they only occur in large “corporate med” settings?

    Sounds to me like they are no different than the “Customer Satisfaction” surveys that are everywhere in corporate America today. In which case they are probably useless, arbitrary and just plain annoying.

  • http://www.thepatientdoc.com The Patient Doc

    I write a blog about being a doctor with lupus and seeing things from both perspectives, with the hopes of creating understanding between the two. After reading some of these comments, I wonder if it’s too late. Have we been so abused my patients, administration, life in general, that we’ve given up on making things better. I hear it from the other side too, with patients complaining that they no longer trust their doctors. I don’t know how this breakdown in the doctor-patient relationship started, but there must be a way to fix it. There should be a way for us both to be satisfied.

  • Justin Berk

    Thanks for you nice comments.

    Hopefully even the most pessimistic doctors can eventually be reminded why they joined the field of medicine — just like the difficult patients that take some extra time and patience. Even if means naive med students have to take a few punches.

    I hope that I, and my young colleagues, are constantly reminded.

  • http://www.mywhitecoatisonfire.com/ Lumi St. Claire

    There are a lot of really valuable comments here that speak to a tremendous issue which is the MEASUREMENT of patient satifaction. For those of us who are routinely subjected to Likert scale assessments from patients, we know that one (rightfully or inappropriately) disgruntled patient can mean devastation for an overall average, which can be used in making weighty decisions regarding things like compensation and advancement.
    I know it was extremely refreshing for me in my new job to receive the usual email with our deparmental scores, and then an actual assessment of which scores were lowest and why -some of which could be addressed at the physician level and some which were completely out of our control and depended on things like scheduling programs and administrative staffing. And an actual acknowledgement from our higher ups letting us know they understood the issues we had no power to change.

  • buzzkillerjsmith

    Some day Justin will be running something. Pandering can be a good career move. I hope to be retired by then.

  • http://batman-news.com Barbara F

    Justin: You sound like an excellent and compassionate physician-in-the making. Do not let the negativity you encounter change the path you are following, because in the long run, right is always right. I’m not clinical – I’m an inhouse physician recruiter with a physician-led health system that has fully embraced the “patient experience” and from my perspective, we are much farther ahead of our competition, and our patients are healthier and happier, because of it. When I hear physicians talk about “horrible administrators” and “corporate overlords”, and spew such negativity about their careers, colleagues, and patients, I see physicians who are in the wrong place for the wrong reasons. When you complete residency, look for a position where physicians lead, and you will find your philosophy and idealism valued and welcomed. As Gandhi said, “be the change you hope to see in the world.”

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