Hold off on patient satisfaction scores until they are done right

We’re living in a world or ratings. Books get rated on Amazon, dry cleaners get rated on Yelp. Doctors are getting rated, too — not only on web sites, but also in ways that end up dictating how much money we can make, or whether we can keep our ability to work in a hospital. Is this a good way to improve medical care or medical outcomes? Is it even fair?

We already know that ratings don’t reflect good medical care. In fact, patients who rate their doctors the best have shorter lifespans. They get more tests, more scans, more antibiotics — which may make them happier, but also makes them sicker.

You do not want a doctor who does what he thinks is going to make you post a positive review. You want a doctor who listens carefully and helps you make the best medical decision. Even if that means you don’t get an antibiotic.

But there may be an even worse, more odious problem being caused by the reliance on ratings to determine income. As Daniela Drake has written, quite bluntly, in he Daily Beast, minority doctors are likely to suffer the most under Affordable Care Act provisions that tie payments to patient satisfaction scores. The bottom line: Patients are far more likely to rate a doctor positively if they are of the same race. Black doctors, if you look at the statistics quoted in that essay, are going to get royally screwed. They may be doing great medicine and helping their patients, but if they don’t get the ratings, their income will drop. Not only that — but it becomes less likely that they’ll be hired by hospitals, because they need to get those high satisfaction scores too.

Paying doctors more for doing good medicine makes sense, but only if you’ve got a good way to measure doctor performance. Measurements ought to reflect whether good medical decisions are being made, and whether docs are helping their patients by following good medical practice. Some elements of being a good doctor are going to be hard to measure, like listening skills and empathy and caring. But it’s clear that patient satisfaction, as it’s measured now, isn’t measuring good doctoring. Let’s abandon patient satisfaction scores, at least until we figure out a way to do it right.

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

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

    Here is an idea for the many patients on this blog who have repeatedly asked how they can help their doctors: refuse to fill out those incredibly dumb surveys. Just don’t do it. And ask your friends and family to stop doing it as well. Post on Facebook. Email it. Tweet it…. and let’s end it.

    • Arby

      There is a large percentage of surveys that are never filled out. Especially though email. I even think (when some of them have been handed to me by staff) that they are probably rated on the percentage of them filled out, too.

      So, the next time I am at the hospital I will let the patient advocate know how insulted I am to be asked to complete them.

    • DoubtfulGuest

      I’m also concerned about what Arby is saying. Overall, I agree it’s just better not to play the game.

      My two main issues are: 1) Assuming that dissatisfied people take more initiative with surveys than satisfied people, because the satisfied ones are out enjoying their lives…Is it better to keep giving individual docs perfect scores at times we feel those would apply? To balance out the nasty comments from others? Or not?

      2) I’d love to try Arby’s suggestion of going to the patient advocate and saying I don’t want this interference in my doctor-patient relationships. But is there any possible blowback for my doctors if I do that?

      It’s a conflict between how does this affect all our doctors long-term vs. how will this affect MY doctor next month?

      • Arby

        I won’t answer the surveys all 5′s when they are not, but I also think they will ignore my protest by not filling out a survey because so many will just not take the time to fill one out.

        My doctor needs to do what is best for me, not pander to me. So, to me personally, I am left with only one choice and that is to tell the administrators that is a ridiculous way to measure a physician’s performance. I get how a survey could be used to work with the bottom performers to improve their people skills, but the way the survey is used it appears to punish even great physicians on subjective grounds.

        I hadn’t thought about the blow-back on physicians from lodging my complaint with management and I think I have too many of them in the system for them to single one out. However, I did consider blow-back on me as a patient. This is why you see in my comment I didn’t advocate every one taking my stance.

        • DoubtfulGuest

          Well, I’m seriously thinking of following your lead. I just like to make informed decisions and wondered if any doctors here had opinions about patients trying that. Or any background information to consider. I’m happy to do it if it would help.

  • Arby

    I am trying to figure out a way to request patient satisfaction questionnaires for administrators of health care organizations. It would have questions like how many hours do you require of my physician in a day, what unreimbursed time do you expect from them, how many patients per hour must be seen, what metrics are they expected to meet (HIV, Hep C tests) even if they don’t apply in my situation. What justifies their salaries.Things like this. Any ideas?

    • DoubtfulGuest

      Brilliant. I see another KMD group project in the making. Perhaps this one will get one step further than last time…;)

      • Arby

        The idea didn’t come from this board originally. It came from watching a physician arguing with a former reporter and mouthpiece for the new “physician leaders” on thehealthcareblog(dot)com, and losing badly. It made my blood boil and made me want to ask this reporter what benefit these administrators bring to my healthcare.

        I have no illusions about this board and any grass-roots efforts. I only wanted ideas for other questions to ask the suits and then I will take it and run with it myself, similar to what Margalit is advocating for in her newest article. Patients need to be in the fight or we lose.

  • Suzi Q 38

    I have filled them out before.
    The doctor was terrible, so I scored him accordingly.
    I gave him lowest scores possible.

    It have nothing to do with prescriptions that were not written or tests that were not needed.

    He wasn’t listening to me when I told him my symptoms. I worsened under his care.
    I almost diagnosed myself, and he still wouldn’t listen to me.
    I finally “bailed” on him and went to another hospital and doctors who not only listened to me, but believed what I said and treated me accordingly.

    I was glad to have the survey to tell my story and give him a score deserving of his work or lack thereof.

  • Joe

    This is interesting. One thing we have noticed from our own surveys here is that black patients are far more likely to refuse care from a black physician, especially if the physician is from Africa, Haiti, etc. I wonder if the geography makes a difference. We are a very poor, rural community.

  • chaplaindl

    These are a couple of the questions on the HCAHPS survey: “How often did your doctor listen carefully to you?” “How often did your doctor explain things in a way you could understand?” The survey is about specific behaviors. I don’t understand the objection to these questions. Are the physicians on this blog saying they are not willing to be evaluated by patients based on whether they listen carefully and explain things well? The criticism would make more sense if it were clear that those criticizing these surveys could describe which questions they consider to be unfair, or not an accurate measure of patient satisfaction. Then it would be clear that they have actually read the surveys they are criticizing.

    The authors of the study who found a correlation between patients being healthier and their relative dissatisfaction with their physicians were careful to say that the study did not provide sufficient data or even the type of data that could demonstrate causation. Yet blog after blog suggests doing away with patient satisfaction measurements based on the study as if it did demonstrate causation. Undergraduates who have studied science or logic would know better. An equally plausible alternative explanation of the data in the study is that persons who are ill spend more time with their physicians of necessity and develop a closer relationship with their physicians than persons who are well. Therefore they have more opportunities to be satisfied with their care.

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