Tuesday, April 01, 2014

Patient Satisfaction: A Good or Bad Thing?

I read this article on Medscape recently, which I thought was thought-provoking. After all, I have been on the receiving end of something like this before. It's a bit long, but worth the read:

Editor's Note: 

This article first appeared in the Fall 2013 issue of Keystone Physician, a publication of the Pennsylvania Academy of Family Physicians.
I recently was at the Scientific Assembly of the American Academy of Family Physicians (AAFP) in San Diego, giving a lecture to a large audience of Academy members on respiratory syncytial virus (RSV) bronchiolitis. I mentioned why I thought identifying the RSV virus was important. I stated that if you tell the family the infant has RSV and that there is the expectation that cough will last 1-2 months, this may forestall them going to the ER or urgent care center. In those assembly lines of healthcare, they will be told that their child has "bronchitis" and will receive the inevitable azithromycin script. This will make the parents happy, free the healthcare provider of the need for further explanations, and result in a satisfying visit for the administrators of that facility. The trouble, of course, is that an antibiotic has again been used to treat a self-limited viral infection.
A physician came up to me afterwards and agreed with me but said that he had no choice. He works in one of those venues and is subject to surveys to measure "quality." For him, quality is measured in 2 ways: The first is by getting the patient door-to-door in 45 minutes, and the second is by a Press Ganey survey to see if the patient was happy. Because of these measures, he is forced to abandon his role as a responsible steward of antibiotic use to keep his job and get a bonus.
Another physician in the audience told the crowd that he was able to increase his satisfaction score by 7% simply by prescribing an antibiotic to all patients who call with a complaint of cough, sore throat, or sinus headache. One doctor reported to the media that he had to give Dilaudid® for minor pain because his Press Ganey score was low the previous month.
I believe that this little-known company, Press Ganey, from South Bend, Indiana, has become a bigger threat to the practice of good medicine than trial lawyers. They are the leading provider of patient satisfaction surveys for hospitals and physicians. For the past decade, the government and healthcare administrators have embraced the "patient is always right" model and will punish providers that fail to rate well in these surveys. Press Ganey's CEO, Patrick Ryan, said, "Nobody wants to be evaluated; it's a tough thing to see a bad score, but when I meet with physician groups I tell them the train has left the station. Measurement is going to occur."[1] Obamacare has budgeted $850 million in reduced Medicare reimbursement for hospitals with lower scores.
The mandate is simple: Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission. One emergency room with poor survey scores started offering hydrocodone "goody bags" to discharged patients in order to improve their ratings. And doctors face the reality that uncomfortable discussions on behavioral topics -- say, smoking or obesity -- come with the risk of a pay cut. If you tell a patient that their knee pain is related to weight, that their smoking is worsening their child's asthma, or that they can't lose weight because of French fries and not a glandular problem, your ratings and pay will take a hit.
Overtreatment is a silent killer. We can overtreat and overprescribe. The patients will be happy, give us good ratings, yet be worse off. We must have the ability to deny treatment for a patient's own good. Patients aren't the best judge of what is best for them. Several years ago, an elderly female patient wanted me to write a prescription for tamsulosin because she got a coupon in the mail. It did not matter that she lacked a prostate.Satisfied patients are not healthy patients. In a paper published in 2012, researchers at the University of California, Davis, using data from nearly 52,000 adults, found that the most satisfied patients spent the most on healthcare and prescription drugs.[2]They were 12% more likely to be admitted to the hospital and accounted for 9% more in total healthcare costs. Strikingly, they were also the ones more likely to die.
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 healthcare must understand this. Take heart in the words of Mark Twain: "Always do what is right. It will gratify half of mankind and astound the other."

While I am all for consumer satisfaction, and this includes healthcare, I do think the are numerous caveats and problems with this system. I hear it all the time, from my ER and hospitalist colleagues. From the negative reviews from patients I personally have gotten, for "not prescribing Testosterone treatment because I didn't feel good" (despite having normal levels to begin with). Or because "Dr. Vagus practices based on science only, and didn't want to give me pills to help me lose weight and feel better".  While satisfaction is important, it is also subjective. And in situations of disease prevention, the patient might not necessarily see the end result of our intervention (by not having a heart attack), instead looking at parameters which might not be concordant to our medical goals. In my case as an endocrinologist, it's usually something related to weight, or libido, or hair, or sexual performance, or something like that. And so, if the system evolves into one that rewards physicians based on satisfaction surveys, it's not surprising to have things backfire.
Sure, I could do what that other group of "hormone experts" in town are doing; non-fellowship trained practitioners (some not even doctors) prescribing all sorts of supplements to make one have enhanced libido or sexual prowess, or to make an 80-year old man ripped like good ole Arnie (or that octogenarian you see in the airline magazines). But is that why we are here? Is that what our Oath was about? To satisfy the patient? And not to save lives, or enhance health?
I shudder to think about what kind of healthcare we will end up delivering.


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