Satisfaction – not a useful quality measure


Category : Medical Rants

You can’t always get what you want
You can’t always get what you want
You can’t always get what you want
But if you try sometimes well you might find
You get what you need

Dr. Lisa Robinson, a Robert Woods Johnson Clinical Scholar at U Penn, has a brilliant piece in the New Yorker magazine – WHEN DOCTORS TELL PATIENTS WHAT THEY DON’T WANT TO HEAR.

I urge you to read the entire piece, but here are some highlights:

In October, 2012, Medicare débuted a new hospital-payment system, known as Value-Based Purchasing, which ties a portion of hospital reimbursement to scores on a host of quality measures; thirty per cent of the hospital’s score is based on patient satisfaction. New York City’s public hospitals recently decided to follow suit, taking the incentive scheme one step further: physicians’ salaries will be directly linked to patients’ outcomes, including their satisfaction. Other outpatient practices across the country have also started to base physician pay partly on satisfaction scores, a trend that is expected to grow.

Satisfaction on the surface should be a great quality measure.  It should reflect bedside manner, which we all know is most important.  But, as my son often says “on further reflection”, the evidence argues otherwise.

Consider, for example, a recent study among patients with chronic kidney disease: the more knowledge patients had about their illness, the less satisfied they were with their doctors’ communication. Another study’s title asks, “How does feeling informed relate to being informed?” The answer: it doesn’t. The investigators surveyed over twenty-five hundred patients about decisions they had made in the previous two years, and found no over-all relationship between how informed patients felt and what they actually knew.

Communicating accurately may decrease satisfaction:

…But it is the second finding that suggests why paying based on patient satisfaction isn’t the way to get us there: the more people understood about the grim nature of their prognosis, the less they liked their physicians.

She finishes this essay with this telling conclusion:

But do higher scores on a satisfaction survey translate into better health? So far, the answer seems to be no. A recent study examined patient satisfaction among more than fifty thousand patients over a seven-year period, and two findings were notable. The first was that the most satisfied patients incurred the highest costs. The second was that the most satisfied patients had the highest rates of mortality. While with studies like this one it is always critical to remember that correlation does not equal causation, the data should give us pause. Good medicine, it seems, does not always feel good.

But will anyone take the Rolling Stones classic advice?

Comments (9)

Has the ACP, the AMA, or any other medical society, taken a position opposing the use of satisfaction scores in determining physician payment? If not, it’s fair to assume their support for these policies. Thanks

That is incorrect logic. Unless they specifically approve, then we just do not know. These data are relatively new, perhaps the article will start a groundswell to oppose such measures.

This is obvious to nurses and physicians, people who actually take care of patients. Medicine is not a commodity like other services, and “consumer” satisfaction can’t be measured by “end user” questionnaires. Eventually, everyone dies, and patients often can’t be satisfied in the same way a Snickers bar satisfies. The delusion that quality can be linked to “patient satisfaction” can only be taken seriously by those who are far removed from patient care. Really a joke, but the jokesters hold the money and power.

Well said ErnieG;

How can I satisfy someone as I tell them that they have poor prognosis related to their advanced lung cancer? The hospital bathrooms can be spick and span ….majority of health/hospital care is not elective like going to a hotel/movie/dinner; it is a compulsion and can never be satisfying, especially with bad prognosis.

[…] Satisfaction – not a useful quality measure ( […]

Robert –
Any post that quotes Mick Jagger is an automatic like!

This may be an attempt to capture some of the negatives patients feel about their medical experience. Often we find rushed doctors who over schedule, being assisted by staff that is trying to keep up with the doctors, with the result being short answers, not much in the way of service, and a general feeling of abandonment by patients’ doctors.

Amidoc made the point that the doctors on this blog care about their patients, want to offer the best service possible, and are looking for other doctors, and patients, to have this discussion. I believe this to be true.

The problem is the countless other doctors who use the doctor shortage, or other excuses, as a reason to be rude. They are rude to their patients and rude to their staff. This is picked up on by the patients and will be translated into poor satisfaction scores.

Doctors are very happy creating their own little world and do not want to engage in any discussion that will challenge they way they do medicine. This link may be of interest:

My reality is that doctors, and only doctors, can sign the paper work for any test, medication, or other medical care, not pharma.

It may be important to remind ourselves that on this, and on some other blogs, there is an extraordinary group of people who may not always agree but are interested in the discussion. This does not translate across all of medicine and certainly does not translate to patient interaction and satisfaction.

It really is impossible to measure the intangible.

Steve Lucas

Before we went on this route, did we ask the patient what will make him satisfied? We have assumed a lot of things in VBP based on the hospitality industry. Medicine is not tourism.

If I am a patient, this is what will make me satisfied-
1) evaluation at a reasonable time ( heart attack – right way; sleep apnea- 2-3 months)
2) correct diagnosis or strive for one- ( empiricism with caution)
3) treatment plan based on common sense; if multiple options, shared decision making
4) ability to follow up with questions on phone, email with expectation of timely response

I urge us all to think – what will make us satisfied from our clinics, doctors and hospitals. I am sure everyone’s list will be different but something like above will be top 4-5 things.

Adding to the list unspoken but understood is treating the patient with respect. I am not a widget, nor am I the guy in room three.

Additionally I am tired of hearing about silent killers, and while everything is alright now, we need to test today. There is a palatable sense that doctors are afraid patients will not agree to a test so fear and a false sense of urgency will somehow compel compliance.

As a business person I know that to create the capacity necessary for a test on demand system there will be a large amount of excess capacity that will be filled by unnecessary testing in order to justify the time and equipment involved. Balance is key.

The items listed so far along with the word RELAX would be a good stating point in improving patient satisfaction. Patients do pick up on a hospital or doctor’s office vibe and will reflect that in the way they react.

Bob C. has written time and time again about coming into a patient’s room and sitting at the bedside, taking the patients hand and asking questions, allowing the patient to answer. Then to everyone’s shock and horror the patient tells you what is wrong. All those rush rush test and hurried conversations go out the window.

The patient is simply happy that someone took the time to listen, and that is patient satisfaction.

Steve Lucas

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