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Last Updated: May 8, 2015

There has been quite a lot of discussion recently on patient satisfaction and attempts by Medicare and other insurers to use it as a measure of quality of care in hospitals as well as in the outpatient environment. Hospital and clinic administrators are beginning to use tools to track patient satisfaction and medical providers are encouraged to make efforts to improve their patient's satisfaction with the care they relieve.

First, I want to stress that I like and want my patients to be happy with the care they receive. But using patient satisfaction as a measure of quality of care is problematic, and the purpose of this article is to illustrate how and why this is a bad idea.


On Patient Satisfaction and Quality of Medical Care

Satisfied patients use more healthcare resources but die sooner.

Why Patient Satisfaction Does Not Equal Quality Care

Physicians and medical providers are often faced with the difficult decision of choosing between doing the right thing or offering their patients what they want, even when it is not in their health interest.

Let me illustrate with a few examples why I think striving to make patients happy does not produce better quality medical care.

Use Of Pain Killers and Other Controlled Substances

Each physician (especially those working in primary care) has a significant number of patients that present with pain and want pain medications. A subset of these patients have unreasonable expectations about their treatment, often fueled by addiction to narcotics. For example, a patient may have had surgery for a shoulder problem 3 years ago. After surgery, his pain was treated with narcotics and he became addicted to these medications and used various forms of opiates, either from their doctor or off the street, ever since then. They now return to their primary care doctor asking them to continue to write oxycodone or similar narcotics for "chronic pain". The initial shoulder injury has long healed, but they still claim they have severe, "10 out of 10" pain and the orthopedist assured them there is nothing else they can do but take pain medications. And they make it quite clear that nothing short of a narcotic would be adequate. If patient satisfaction becomes an essential component of measuring quality of care, there is very little the physician seeing this patient can do to achieve superior scores on this measure, other than giving narcotics for a condition that does not require it, to a patient whose major issue is addiction.

And the scenario above is not at all uncommon, which makes it likely for a physician who is doing the right thing and refuses to write narcotics or other controlled, habit-forming medications for inappropriate circumstances to accumulate poor patient satisfaction scores, and thus be penalized for delivering quality care.

Saying No To Unnecessary Tests

Here is another common scenario that is likely to generate low patient satisfaction scores, despite maintaining quality of care. A middle-aged lady presents to her doctor with low back pain. The pain is quite severe, and it was triggered by moving heavy furniture the day before. She has no neurological signs (such as radiation of pain down their legs, or tingling, weakness, incontinence, etc.). Due to the severity of her pain, and because she had a relative that had a low back disc herniation that required neurosurgical treatment, she wants an MRI of her low back "to make sure nothing is broken there". Despite her physicians' reassurance that a more appropriate course of action is to get an X-ray, try anti-inflammatory medications and physical therapy for a while, she is adamant that she needs an MRI. "I know something is out of place in my back, and only an MRI will show it".

Saying no to unnecessary laboratory and imaging tests is not only the right thing to do, but would saves tax-payers and the system a lot of money and resources. And yet, doing so would almost invariable (except maybe for the most charming/persuasive of physicians) generate poor satisfaction scores.

Telephone Consultations

Seeing patients in the office is only part of medical care. Physicians in general, and primary care doctors in particular, spend every day significant amounts of time over the phone discussing with patients, pharmacies and other providers issues related to lab results, medication refills and other aspects related to patient care. It is not uncommon for me to spend up to two full hours a day dealing with such communications. While most are necessary and appropriate, some are not. Sometimes doctors receive calls from patients who self-diagnose themselves with bronchitis, for example, and ask for antibiotics to be called into their pharmacy, without being seen. While such a practice would save these patients the effort and cost of a doctor visit, it is not safe. Antibiotics are powerful medications, and their use need to be carefully weighed against their side effects, risks of resistance and clinical need. Refusing to prescribe medications in such a manner is likely to generate low satisfaction scores, while quality of care is enhanced.

Saying No To Disability Requests

You don't have to practice too long, as a physician, before you realize there are many people who don't like to work and seek your authority to use any real or imagined ailment they may have as a means to obtain assistance under disability laws. I remember the case of a young patient whose only health problem was addiction to methamphetamines and occasional seizures induced by abusing this drug. She thought this was good enough reason to request disability benefits, and kept coming back to me to request my support for it.

Saying no to unsubstantiated requests for disability is very likely to result in low patient satisfaction scores, but it will most definitely save the society a lot of money.

Taking Away Driving Privileges

In a country like the US, where the ability to drive a car is such an important part of daily life and individual independence, having this privilege taken away can be quite traumatic. Yet there are circumstances when, as a physician, I have to advise patients it is better to give their care keys away. Sometimes I have had to call DMV and ask them to revoke a patient's driving license, as they were not willing to give their keys away. Again, such encounters are not likely to reflect high satisfaction scores when these patients are solicited to rate their experience with their doctor, yet the quality of care has not been compromised in any way.

Satisfied Patients Die Sooner

I know some of you may be thinking: "Sure, you are a doctor, no wonder you are biased when it comes to patient satisfaction". I understand that. I want to say two things to answer this.

First, I don't want to give the impression here that I don't value patient satisfaction, or that it should be completely disregarded. What I'm trying to say is that, while patient satisfaction is important, it is not the best measure of quality of care, and in some instances, some of which I tried to illustrate above, it can actually be counter-productive to use it for such a purpose.

Second, I would like to quote a large study just published in the Archives of Internal Medicine, entitled The Cost of Satisfaction. Nearly 52,000 people were followed for 7 years, during which time their satisfaction with their medical providers was measured, as was their use of medical resources and mortality rates. The results? Not very reassuring:

"...higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality". (emphasis mine)

If you care curious about the exact figures in the study above, satisfied patients were 26% more likely to die sooner.

Dr. Gily Ionescu MS, MD.

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