Is "All 5's!" the way to go?

ABC's for ECP's

This is Scott Selinger and welcome to another edge-of-your-seat-amazing talking blogpost - ABC’s for ECP’s, the podcast on behalf of the Northern California’s chapter of the American College of Physicians Council of Early Career Physicians. Today I’d like to talk a little bit about this new world of patient satisfaction scores.

I really like my new car. I got it a few months ago and it’s been working great. But then a few weeks ago I folded the back seat down and now it won’t come back up. So like most men, I hit it a few times and then decided to take it to the dealership. It was a pretty easy, seamless process of getting in and out but there were a few snags.

For instance, they told me I needed a new part and they’d call when they got it in - but that didn’t happen and when I called 2 weeks later I found out that the part I needed had been there for 10 days.

And then there was the little issue of the fact that when I got the car home, the seat was still broken. I brought it back, saw a different service advisor, who apologized profusely, and they got it fixed the same day.

The kicker was, every time I was there, I was reminded before I left that “by the way you might be getting a survey …” at which point I cut them off and just gave them a thumbs up and said “all 5’s guys!” because I really wasn’t interested in hearing the spiel – the surveys they send out are based on top box scoring, so if they get anything except a 5 out of 5, they get dinged, even if they had nothing to do with the dissatisfying issue.

This is getting to my main point about patient satisfaction surveys and its effect on us as physicians. This is something I slowly started hearing more about towards the end of residency, but at the time the satisfaction scores at the resident clinic were abysmal and we felt sort of resigned to that because a lot of the dissatisfying factors were systems issues beyond our control. That’s if you can imagine patients being dissatisfied by frequently seeing random doctors, long wait times, bedside manners that were still under construction, and frequently being told that they didn’t need antibiotics for their cold or opioid pain medications for their headache.

But now that I’m out practicing, I’m realizing how huge an issue this is. I’m still trying to figure out when someone needs steroids and when they need antibiotics or the best way to convince them they need to quit smoking or lose weight and honestly, sometimes this weighs on my mind especially when I have someone demanding something I know is unreasonable.

With all the money that is tied to patient satisfaction scores between Medicare reimbursements based on it as well as organizations and practitioners trying to maintain patient loyalty and the insurance money that comes along with it, it’s no wonder it frequently feels like our profession is starting to more resemble that of the service industry, but saddled with the complexities of human health. To tie back to the car problem I had, a colleague of a colleague now routinely, in her follow up emails to her patients, has a little tagline at the bottom talking about what they should do if they get a survey! Patient satisfaction scores are now commonly being tied to physician pay and advancement or retention at their current job, the theory being to incentivize us to make that extra effort to make sure our patients are satisfied by their medical care.

And in theory this sounds great because why shouldn’t patients have an exceptional experience every time? Why should they expect any different of us than they do of their mechanics (and I don’t mean to pick on mechanics - I’m just still a little miffed at mine). Well, there may be a few reasons, just because our profession is a little different than many others in the service industry.

A study^[1] just published a few weeks ago in the Journal of Patient Preferences and Adherence (which I, like I’m assuming many of you, didn’t realize existed until today) surveyed about 4000 doctors in a state medical society about exactly this which came back with 155 responses. Granted, that’s a small number, but there are some disturbing statistics from it.

First, 78% of respondents said that these patient satisfaction surveys affected their job satisfaction moderately to severely, with 28% of people saying they had thought about leaving the medical profession because of them.

Second, just over half of respondents said that they had inappropriately prescribed an antibiotic or narcotic or ordered an unnecessary lab test because of the patient satisfaction surveys.

Finally, while there were 6 neutral or positive comments given on patient satisfaction rankings, there were 47 negative comments and I do appreciate the fact that they published them. They are actually divided up into 5 themes including the two I just mentioned as well as:

- that they’re a poor way to evaluate the quality of medical care,

- that there’s too much weight on them and not enough administrative effort to improve medical outcomes

- that they’re perceived as a conflict of interest

So that’s one side of the coin, and it is a very striking viewpoint from the healthcare providers, but that study of course needs to be taken with a grain of salt as it is a small number and certainly could select out for the most dissatisfied people to respond.

But what about from the patient side? Is there validity to these viewpoints? Well there was another larger study about two years ago^[2] published in JAMA that looked at patient satisfaction surveys from 52,000 respondents over 7 years. While high patient satisfaction was associated with less frequent ER visits, it was also associated with greater inpatient use, higher overall healthcare and prescription drug expenditures, and increased mortality. There was commentary both ways when this article came out and to date as best I could see, there hasn’t been another large study published regarding this, but if you could tie it to the study looking at the physicians perspectives on these surveys, it’s not hard to believe this data might be real.

So what are we supposed to do with all this information? There’s been so much change in what the role of a physician is supposed to be. We’ve gone from a paternalistic approach more to one of shared decision making. But is the heavy weight of patient satisfaction surveys unbalancing the power of shared decision making? And aren’t we now being asked to be more paternalistic to society by reducing health care expenses, antibiotic and opioid prescriptions, and be more dogged about preventative cancer screenings and weight loss?

I think the missing part of the equation is time and communication and we definitely do need to be able to clearly communicate our thoughts with patients. So far, I’ve seen great feedback from people when I’ve actually stopped and instead of auto-refilling medications I don’t think are appropriate or ordering easy labs I know aren’t indicated, I explain to them why doing so would give me that gnawing pit in my stomach that knows when I do something wrong. We’re all so rushed these days, I think this gets lost and I’ve certainly been guilty of it on occasion, but this has to be a point where we hold the line. This is why most of us went into medicine in the first place - to help people and to be educators, not to be vending machines.

I haven’t gotten a call for a survey for the car dealership yet. I’m conflicted though and I actually feel differently now than when I started writing this. If I give my honest opinion, which was my emotional urge and first reaction, it’s going to bring down someone’s score, it might get him disciplined or he might take a salary cut - it could contribute to his getting fired. And the errors made were system errors too - probably nothing to do with the guy I dealt with. Giving anything but 5’s would just seem spiteful. I guess I’ll wait and see …

I know I covered a lot of ground here and I’m hoping you have a few opinions to share (and at this point I feel like I know who all of “you” are as I haven’t seen too many downloads yet) so as always, we’d love to hear your feedback on this, so if you have any burning questions or comments, you can post them on the blog at canocecp.blogspot.com, our podcast page on itunes, our facebook page or email them to [e-mail]. And if you have time, be sure to head on over to our facebook page for the Northern California Chapter of the ACP Council of Early Career Physicians so you can find out more about the events going on in the chapter.

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[1] Patient Prefer Adherence. 2014 Apr 3;8:437-46. doi: 10.2147/PPA.S59077. eCollection 2014.

Impact of patient satisfaction ratings on physicians and clinical care.

Zgierska A1, Rabago D1, Miller MM2.

[2] Arch Intern Med. 2012 Mar 12;172(5):405-11. doi: 10.1001/archinternmed.2011.1662. Epub 2012 Feb 13.

The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality.

Fenton JJ1, Jerant AF, Bertakis KD, Franks P.