We shouldn’t focus exclusively on patient satisfaction

“Patient-centered.”

It sounds so right, doesn’t it? Right up there with mothers and apple pie. If only family medicine were so simple.

report by ABC News told the story of a doctor at a VA hospital in Kansas City who claims she was forced to leave her job because she tried to limit prescriptions for opioid pain medications to reasonable amounts. Patients complained, so she was canned.

She claimed that some patients received prescriptions for 900 narcotic pills a month. Some patients were “lethargic, not functional.” Patients who wouldn’t accept the gradual tapering of the narcotic doses would threaten her, “cussing, cursing, lashing out, complaining to the administration …”

In a separate announcement, the VA admitted there’s a problem with opioid prescribing nationwide and says it will improve the situation in part with “physician education.”

From a different environment comes stories of ER doctors prescribing Vicodin “goody bags” for patients complaining of any sort of pain. This approach decreased patient complaints and increased patient satisfaction scores, so hospital administrators were giddy.

These reports come in the midst of other findings that deaths from prescription drugs are now greater than deaths from heroin and cocaine combined.

The patient-centered medical home advocates have it wrong. They push for high patient satisfaction scores the way a retailer would obsess about customer satisfaction ratings. Unfortunately, my world in family medicine is so much more complex than running a Target.

We shouldn’t focus exclusively on patient satisfaction. We really need system-centered care by system-centered physicians. Most of the time this will correlate perfectly with patient satisfaction: patients who feel like they were listened to and that their physicians simply cared for them.

But at key moments, the highest form of family medicine is to piss off a few patients. Those who demand narcotics for iffy indications, demand antibiotics for colds, and demand MRIs for simple sprains are but just a few examples. This isn’t to suggest that the family physicians should be jerks about the encounters. There are polite and tactful ways to say no. But no matter how nicely it’s said, if a patient has made up his mind that he will not be satisfied until he gets his narcotic, he will leave the physician encounter not just dissatisfied, but often burning mad.

The PCMH pushers make no acknowledgment that these types of encounters occur and make no effort to reward ethical family physicians for making good decisions to protect patients from harm to themselves and protect the medical commons for everyone. In fact, they have created incentives for physicians to do the wrong thing.

This is one more reason the current PCMH model should be dumped into the trash heap of innovations that just don’t work.

Richard Young is a physician who blogs at American Health Scare.

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  • toolate

    Give me an X. Give me an R.

    What’s that spell?

    It spells being called in to the principal to be chastised after the pt. complained because I said no – compassionately, btw. It spells the end of me.

  • PrimaryCareDoc

    Spot on. Thank you for this. This captures perfectly what we in the trenches have to deal with on a daily basis.

  • Richard_Young_MD

    Craig,
    I haven’t seen great rigorous evidence one way or the other. Who in the world would fund it? There is no National Institute of Family Medicine or even Primary Care for us to tap into. There has been at least one study that showed that when doctors took time to explain to patients why they weren’t getting the antibiotics they requested, patients were just as happy as just receiving the prescription, and clinic re-visit rates were lower in the extended explanation group. Of course, no one pays us to take the time to have the conversations. We are incentivized to do the quick approach, which is to just write the prescription.

  • medicontheedge

    One of the ways our ED deals with the chronic drug seekers, and the chance that they may drive our all holy Press-Ganey’s down is to have “care plan” orders for those patients, that address their issues. Patients with “care plans” are left off the survey lists. As are the mentally ill “frequent flyers”.

  • Judgeforyourself37

    Don’t blame President Obama, cynholt, as Press Ganey has been used in the years predating the Obama administration.. I have been retired for ten years and Press Ganey was the “gold standard” for assessing patient satisfaction then and in years prior, too. As for the over prescribing of narcotics, that, too, has been the standard far before our president was elected in 2008. Eight years ago, 2006, when President Bush was in office, I fx my leg and although my pain was alleviated by Ibuprofen, I was asked at least five times if I needed a stronger medication, such as Oxycodone. Oxycodone was the medication of choice and frankly, it has been given out too freely for at least fifteen or more years. My friend had a lumpectomy and was barraged by the anesthesiologist to take Oxycontin, prior to her surgery, being a nurse, and having taken that drug after a partial lobectomy in 2001, she knew that it was highly addictive and refused. She was harassed by the doctor to allow him to administer it. She still refused as having had a prior lumpectomy, she knew that Oxycontin was contraindicated for that type of procedure.

  • Doug Capra

    The main point is valid. Balance is necessary. But why is it that when we talk about patient satisfaction the argument so often get’s reduced to the drug seeking patient or the patient in pain. Certainly that’s a problem. But is that the “profile” of what it means to be “patient?” Consider the millions of patients who are treated every day for various reasons, most not life-threatening or for severe pain. The kind of treatment most patients want is basic — compassionate, empathetic, respectful, dignified, humane. There are ways to deliver that service even if you can’t give patients everything they want because of what they medically need. Those who deliver medical services in the field are often part of a huge system whose pricing is behind most individual bankruptcies in this country. It’s not the caregiver’s fault — but for what these services cost people — it is not unreasonable for them to demand at least the same kind of respectful, dignified, and humane service they can get form AT&T, Apple or Costco.