By James Borders, MD
Patient “satisfaction” now factors into the amount of fees that hospitals receive from government payers. This policy, a feature of the Affordable Care Act, requires the withholding of a percentage of total Medicare reimbursements that can be earned back by hospitals achieving high scores in areas of patient satisfaction on surveys mailed to patients after leaving the hospital. By making hospital personnel and services accountable to meet patients’ expectations, so goes the reasoning, care quality and safety in the hospital should improve. Most of the survey questions administered by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey pertain to nursing care, but several of the 32 questions inquire about perceptions of the care rendered by the physician treatment team.
An article in the April 2015 issue of “The Atlantic” entitled “The Problem with Satisfied Patients” raises concerns about treating patients as customers whom we desire to please. Physicians eager to please patients may avoid giving unwelcome advice and may order imaging and other tests that may not be indicated. The error of asking patients about being satisfied with the degree of pain relief was recognized, leading to its removal from HCAHPS surveys, as the truth emerged about the harm of using a pain scale as the “fifth vital sign”, a known contributor to the epidemic of opioid use disorder.
Dr. Emery Wilson, speaking to the 2000 graduating class of the University of Kentucky College of Medicine, cautioned graduates to not camouflage incompetence with a good bedside manner. Research at the University of California-Davis published in 2011 found that higher patient satisfaction scores were associated with higher inpatient utilization, greater total healthcare expenditures, and higher expenditures on prescription drugs. During over 140,000 person-years of follow-up from 2000 to 2006, the most satisfied patients had a 26% greater mortality risk. This statistic remained despite excluding patients with poor self-rated health and 3 or more chronic diseases.
Press-Ganey, the company who provides the patient satisfaction surveys used by the Centers for Medicare and Medicaid Services (CMS), continues to revise and update the surveys based upon ongoing research. That research clarifies that a major factor in patient dissatisfaction is poor communication between patients and healthcare providers. Long wait times in emergency room waiting rooms are often cited as a classic example of a source of displeasure to patients. However, research finds that patients are satisfied with waiting if healthcare personnel regularly and compassionately update them while they wait.
Patients most often base overall healthcare perceptions upon the quality of interaction with whom they encounter when receiving healthcare. Even in oncology, patients have statistically improved outcomes if they are given the facts with warmth, empathy, respect, and appropriate encouragement. Patients deserve the truth and handle it surprisingly well if it is properly communicated. Working with the facts, patients can and should be equipped to partner with their physicians in developing a care plan.
In 1982, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research urged the adoption of shared decision making (SDM) as a way of improving informed consent to medical treatments. Despite these many years since that report, this goal remains elusive. Medical ethicists lament the excessive pendulum swing in the model of medical decision-making away from physician paternalism toward patient autonomy. There is a need to standardize informed consent to a “best practice” that encompasses a fair and truthful discussion of the pros and cons agreed upon by a broad scope of skilled providers and settings. Consideration must be given to the timing and setting of the discussion prior to medical or surgical procedures to assure that the patient is not unduly influenced by time urgency or family considerations. It is easy to forget that the language of medicine is foreign to the medical layman, and patients need our guidance and patience in these discussions. How often are we asked, “What would you do if I were you or someone in your own family?” It is unloving and unwise to refuse to attempt an honest and sincere response.
We can never hope to fully satisfy all of our patients’ desired health outcomes. Such a goal is neither safe nor realistic. However, we can consider that we have contributed to a positive patient experience if it can be defined as having created a successful acceptance of the facts-favorable or unwanted- made more palatable when delivered with kindness and compassion.
James Borders, M.D.