Here is a link to an article in the Atlantic, The Trouble With Satisfied Patients. The gist of the article is that often hospitals with the highest patient satisfaction demonstrated some of the worst patient outcomes.
I first discussed the patient satisfaction issue a few months back in a post entitled How Satisfied Are You? In it I had linked to another article in JAMA that pointed out that patients who are more satisfied with their care spend more money on that care and are more likely to die.
How can this be?
Is it possible that we are emphasizing the wrong things when we are talking about and measuring patient satisfaction?
Case in point: When my son was born I took him to the hospital to get his second newborn screen done, the one that checks for certain genetic and metabolic abnormalities and that is required by the state. I held him as the woman stuck his foot and squeezed it hard milking enough blood out of the wound to fill up the required bits of paper. He screamed bloody murder until he was hoarse and his face was beet red. It seemed to take an eternity, an eternity of having my own heart torn to shreds as I watched him suffer. I know how this works. I know it is necessary. Yet I experienced a very visceral hatred of that woman for hurting my baby, the depth of which shocked even me. Was she incompetent? No. But if you had sent me a survey to ask if I was satisfied with his care, I would have marked an unequivocal, very emphatic “NO” even though there was no way she could have done her job better.
Another example? I hear patients complain all of the time about not getting a response when they need assistance getting to the bathroom. One just a few days ago was telling me that he ended up soiling himself and the bed because after two whole hours no one responded to his pleas for help. This is from a hospital with an agressive PR campaign and a community perception of excellent care. If patients are happy with their care, they think they are getting better outcomes than they really are. Smoke and mirrors. This hospital has a cadre of employees that visit patients during their hospitalization in order to identify unsatisfied patients and give them coupons for discounts at the gift shop or cafeteria. Screw that, I say. Just help them to the dang bathroom for crying out loud! The hospital should not be intended as a resort. It is for healing and should in the process of that maintain dignity and humanity whenever possible.
When the push to start measuring patient satisfaction started a few years ago, I was totally behind it. I liked the shift from the perception that we were doing the patient a favor by deigning to see them to a more customer service oriented approach. At the time it seemed the focus was on providing quality care in a more humane way. I like that. I like that a lot. I am not afraid of being measured over it. But over the years the focus is slipping into something not quite so positive… I DO care when patient satisfaction is costing people their lives. So should you.
5% of my salary is tied to patient satisfaction. Right now in our organization there is an emphasis on patient wait times. Generally I run on time or pretty close, but there are days when I just cannot win no matter what I do. In fact, a couple of years ago the “random” survey was inexplicably sent out to a ton of patients who were seen the day after Christmas. We worked in a lot of people who needed to be seen that day and as a result we were running over an hour behind. The survey asked patients how long they had to wait, not whether or not they were happy about getting in to be seen. We took a huge hit on that time thing despite the fact that patients said they were overall very happy with their care. Should we have refused to see those patients in order to preserve our numbers? I have been told yes. I am certain that is not the right answer.
Have you received a survey in the mail about your visit to a physician or hospital before? There is a lot secrecy I think about how those things are scored. Did you know that for a score to count positively, you have to mark “exceeds expectations”? Anything less counts negatively. Even if you mark “good”. If you exceed expectation on everything isn’t that just average? Aren’t we setting ourselves up for failure? And in order to stave off that perceived failure is it possible that we are pouring resources into things that are not actually improving patient care?
Another consideration: Is it that patient satisfaction as it is currently measured is mutually exclusive of the most competent doctors? Can the two not mutually exist in the same person? Perhaps. Some of the most brilliant minds are just not capable of being hand holders or shoulder huggers. Do we want to exclude brilliant minds from practicing because of this? I am not sure that is in anyone’s best interest, either. I have seen and heard of more than one physician forced out of a hospital system because of low satisfaction scores. They were excellent physicians who had saved many lives. Will they be replaced by more personable doctors who are less competent? In some cases, yes.
So, what do patients want? What do they need? Do they want to be seen within fifteen minutes of their appointment time every time? Or do they want a physician who feels free to take their time, listening to complaints, coordinating care collaboratively? Do they want someone to help them get to the bathroom or just someone at checkout who says they hope you will fill out the survey saying that they have provided you with “excellent care” because using the same verbiage that is on the survey results in higher scores?
So do I care about patient satisfaction? Sure. But I am not going to be losing sleep over it. In the end I expect my patients to be treated as I would expect my own family to be treated. That does not mean handing them a cup of coffee at the door. That means making sure their referrals and procedures are scheduled in a timely fashion, that bloodwork and imaging results are communicated to the patient, that we minimize medication errors, and that we smile when we do all of this because it is a pleasure to serve our patients.