Conning the Unsatisfied Patient (May 19, 2015)


This isn't the first time I've written on the subject of "patient satisfaction". But I was prompted to do so again, and in more depth, by a particularly condescending and idiotic article on the subject I ran into recently. The author mewled on for a couple of pages about how IMPORTANT it is to get down to a patient's level and presented a few obvious suggestions to her fellow doctor gods and goddesses on how to do so. In other words, bless her heart, she exemplified the reasons that patient satisfaction has ended up becoming such a big issue in conventional medicine.

Making customers happy has always been important in business. But traditionally it has not been a high priority in the practice of medicine, and that is putting it gently. Those of us who have been on life’s journey longer than we generally care to admit can remember quite clearly how common it once was to be treated indifferently, and even contemptuously, by the medical professionals who were supposedly caring for you.
 
This attitude was commonplace and if it was never exactly acceptable, it certainly was universally tolerated. You saw it not just in hospitals and but frequently in the doctor’s office as well. “We’re getting sick people well, not catering to their whims” would have been a good way to summarize the attitude. And the public generally went along. 

But as medicine became more and more of a business, particularly a big corporatized business, someone finally came to the realization that there might, just MIGHT, be some competitive advantage in trying to please the customer. This re-casting of the patient as a health care consumer has gotten to the point where receiving a telephone survey asking you to rate your recent doctor’s visit (as though s/he was a Comcast customer service representative) is a common thing. And it’s not just the health care companies that care about this. The results of patient satisfaction surveys are now one of the criteria that Medicare uses to decide how much to reimburse a hospital for its services. Bad patient satisfaction surveys, lower reimbursement rates.

Press Ganey is the largest company in the patient satisfaction evaluation business, and if you have ever received a telephone survey asking you about your recent hospital stay or office visit, they are most likely the boys behind it. Their promotional materials are all about “patients’ perceptions of their care”, and you need to look at that little phrase closely. It is very telling. Not the QUALITY of patients' care. But their PERCEPTIONS of it.

At first glance this sounds like a great thing, particularly to anyone who has ever burnt out a call button during a hospital stay trying to get some help getting to the bathroom or who wondered why, if for some reason they weren't going to make it into surgery that day after all, someone hadn't brought them some FOOD. And by the time they leave the hospital, up to 90% of hospital patients still don’t know who their supervising physician was, for pete’s sake. But it has its downside as well, which can be briefly stated in a phrase that sums up one of the great bummers of human existence. And that is this -- what you Like is not necessarily what is Good for you.

Americans are more satisfied when they get a lot of medical care. People with respiratory infections who receive a prescription for antibiotics are more satisfied – even if that infection is viral and the antibiotic will be useless at best. When one hospital found out that patients who left the hospital with a prescription for hydrocodone were more satisfied, because apparently who doesn’t love opiate painkillers, guess what everyone got upon leaving that hospital? And doctors who make a point of telling their patients they need to quit smoking, lose weight or exercise, quickly see their patient satisfaction scores drop – and their bonuses, and maybe even their jobs, disappear.

Medicare is no longer going to pay a hospital with a low patient satisfaction score as well as one with a high score. That will motivate a hospital administrator to improve patient happiness with the hospital, and not necessarily the standards of care of that hospital. Of course sometimes the two overlap. A hospital that is too noisy to sleep in, or one that doesn’t make it clear to the patients it is discharging what they are supposed to do next, is going to have poorer outcomes as well as angrier patients. But if giving away free painkillers gets you more love and cash than cutting down the number of infections patients acquire in your hospital -- and costs a whole lot less to implement-- what’s a business going to do? Because never forget, in America, medicine is a business and the bottom line is king. Because if it isn't, soon there's no business.

I once knew a nurse who told me about a surgeon at the hospital where she worked. This guy was terrible. His patients needed followup surgeries to correct the mistakes that he made on them the first time more often than not. But he was a charming man with an amazing bedside manner, and his patients loved him and referred all their friends to him. Because he did take the time to treat his patients like human beings. At least when they weren’t on the operating table.

So this is the thing. There are a million ways to make a patient happy without making him or her better. In fact, one study found out that patients who were the most satisfied with their medical care had a HIGHER death rate than those who were less satisfied. What does THAT mean? This is my guess. It’s what I said earlier – what you like isn’t necessarily what is good for you. Americans (as opposed to other nationalities) tend to like a lot of health care. We’re happier when we get more tests, more prescriptions and more appointments. And in a country where the third leading cause of death is medical error (have I ever mentioned that before?) unnecessary treatment spikes your odds of an adverse event.

I think I can safely say that there is one thing no patient satisfaction questionnaire is ever going to ask you, and that is whether the visit fixed your problem. And there is really only one reason you should ever be ultimately satisfied with your care, and that is if it gets you better.  

Are you BETTER? Is your problem gone, or improving? Do you know what to do to alleviate it, and are you doing it? If the answers to those questions are “no”, why are you satisfied with your care when it clearly is not doing the job?

There’s always been a lot of money in telling people what they want to hear, of course. And there IS a lot to be gained from doctors finally starting to really listen to patients. So a little attention to patient satisfaction, particularly when it improves hospital cleanliness, wait times, noise levels, patient understanding of what is happening and communication with all members of the staff, is surely a fine thing.

But, like most blessings, this one isn't unmixed. So my suggestions are to take advantage of this historically new focus on communication and make sure you know what’s going on with your health and medical care. If they won't tell you, find someone who will. If you are going into the hospital, focus your research and your choice of institution on how good their outcomes are in your area, not on how good they are at handholding and chitchatting about your dogs or grandchildren. And until your problem is fixed -- and not before -- don't be too satisfied.  

--dr. diane holmes
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