Pleasing the patient vs. saying no

The patient in Dr. William P. Sullivan’s emergency room in suburban Chicago asked him to write a note excusing her from work because of an unsightly pimple on her nose. He said no, but later he wondered: Would the refusal, even if it were clinically and ethically appropriate, result in a ding to his department’s patient satisfaction rating?

“People get mad and you think, ‘Great. There goes another bad score,’” he said.

The anecdote is recounted in an American Medical News story that explores what seems to be a source of growing tension between doctors and patients: providing care that’s appropriate vs. pleasing the patient.

This is by no means a new issue. Doctors have always had to deal with patient expectations for care that are not necessarily warranted – antibiotics for a viral infection, for instance, or imaging tests with a low likelihood of yielding any useful information. What’s different these days is that physicians, and the organizations they work for, are increasingly being graded on patient satisfaction and paid accordingly.

From the American Medical News article:

Nearly two-thirds of hospitals, health systems and large physician groups have annual incentive plans for doctors, said an October 2011 report from the Hay Group, a Philadelphia-based management consulting firm. Sixty-two percent of those use patient-satisfaction metrics as a factor, up from 43% in 2010, said the survey of 182 health care organizations covering physicians in 144 medical specialties. Many set base pay lower and require doctors to meet performance metrics to earn hefty incentive pay.

“Bonuses of less than 5% don’t get anybody’s attention. Make it 5% or 10% or 15%, and that’s a sufficient financial opportunity to get your attention,” says Ron Seifert, vice president of the Hay Group. “We’re going to see more of this.”

To add to the motivation to get serious about patient satisfaction, Medicare also has begun paying for and publicly reporting performance measures. Patient satisfaction ratings account for 30 percent of the overall score; hospitals and physicians who fall short will see a percentage of their payments withheld. In other words, if patients are unhappy with the care they’re receiving, the penalty to providers will be a smaller paycheck.

Is patient satisfaction such a bad thing? It’s no secret that health care hasn’t always been well attuned to the patient’s perspective. In many ways, the emphasis on patient satisfaction is a long overdue effort to place the focus of health care where it belongs: on patients themselves. If providers consistently receive low scores from patients, it’s probably a sign that there are some issues in need of addressing. Tying it to financial incentives simply puts more skin in the game.

There’s valid debate, however, over the extent to which patient satisfaction ratings accurately reflect quality of care and how much they should influence the size of the provider’s paycheck. Are patients receiving quality care when the doctor agrees to their request for a CT scan for a headache, even though the imaging study is expensive, exposes the patient to radiation and is probably unnecessary? What about people who are likely to be unhappy regardless of the quality of the care they receive?

The connection between the doctor’s refusal of an inappropriate patient request and the likelihood of a low patient satisfaction score in fact is not entirely clear. That’s why a Wisconsin physician who specializes in addiction medicine is designing a study to examine this relationship more closely.

Dr. Aleksandra Zgierska, an assistant professor with the University of Wisconsin School of Medicine and Public Health, told American Medical News that decisions about prescribing narcotic pain medicine are a “day-to-day conundrum” in her practice. “The challenge is how do we discuss this with the patient so the patient doesn’t leave unhappy… Saying yes is easy. I know from firsthand experience that it’s very tempting,” she said.

Her study will look at the prescription of opioid pain medications and whether it correlates to patient satisfaction ratings.

Of the handful of other studies that have explored this issue, the one that has received the most attention appeared earlier this year in the Archives of Internal Medicine. It found that patients who gave the highest satisfaction ratings also had higher prescription drug costs, were more likely to be hospitalized and had worse outcomes – but the researchers could not definitively establish why this was the case. Although it might be assumed (and this indeed was the conclusion that many people seemed to draw from the study) that these patients were happier because they were receiving lots of prescriptions and hospital care, whether it was warranted or not, this remains just that: an assumption.

Turning down requests for inappropriate care may in fact not be the no-win situation that doctors fear, the American Medical News article suggests:

Experts agree that saying no does not have to mean an unhappy patient. They say that listening with empathy to a patient’s concerns, reviewing options in an evenhanded, nonjudgmental way, emphasizing the undue risks of nonbeneficial interventions, asking the patient to defer a decision, and even sitting down with the patient – instead of standing – can help.

It’s possible that many patients might actually welcome the discussion and ultimately leave the exam room feeling better informed about the decisions that were made.

The real issue seems to be one of balance. How can providers deliver quality care without compromising for the sake of a good patient satisfaction score? How can the patient experience be meaningfully valued without compromising other important measures for how providers ought to be paid? Regardless of the imperfect metrics that currently exist, these are questions that demand some thought.

2 thoughts on “Pleasing the patient vs. saying no

  1. Physicians are trained professionals. It’s their job to do what’s best for a patient, not pander to their uninformed insecurities. As a patient, I expect my doctors to assess my condition, explain what’s going on and direct me in the best way to remedy whatever problem I might have. I don’t expect them to ask me how they should treat me. This idea that “the customer is always right” is better left on a sales floor, not in a medical facility.
    Personally, I think this issue is one that needs to be focused on the patients, not the doctors. Why do patients go to a doctor and believe their care is sub-par because they weren’t given a prescription or a series of expensive tests, or if they’re told that nothing’s wrong? What can be done to change that?
    If health care facilities want to rate their physicians, I think that peer review would be far more meaningful. The average patient simply doesn’t have the expertise to be given so much control over their physicians.

  2. This is quite the conundrum, and Katie’s point of view, while not necessarily a minority, is certainly not as vocal as the opposition. Patient satisfaction has always been important — patients are human, and deserve all respect — but in the not-too-distant past, all we had to worry about as providers was what the patient told to local friends. Now, a disappointed patient might post something on Facebook for hundreds of friends, might file a complaint with the medical board or the hospital, and will almost certainly get some sort of follow up about satisfaction from someone. The old system of paternalism without explanation was definitely wrong, but so is “the patient knows best”. As a provider, I try to treat everyone with the respect I would want, and answer all questions honestly. I do not order tests or treatments that are not indicated, but it’s surprising how often a patient has a valid reason for wanting something that they only tell me after I say something like, “the chances of that helping are miniscule”. I’ve been doing this long enough to know for sure that there is something to be learned from every encounter.
    When I am a patient, I expect the same thing. I expect to have my concerns listened to, and if I want something, as a patient, I expect to understand why it’s a bad idea if it’s not delivered. When there is mutual trust and respect, it’s hard for both the patient and the provider to not to be satisfied.

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