I'm Not Leaving Without My Z-Pak
How much unnecessary prescribing results directly from patient demand is unclear. However, no one disputes the fact that patients who don't get what they want are often unhappy. This is commonplace in medical care, whether the patient is asking for a pain medication, an unnecessary MRI, or antibiotics. Some patients will never be satisfied with rational explanations, polite demurrals, or reasonable alternatives.
Knowing this, why is there so much concern about patients' reactions when clinicians just say "no" to antibiotics? Worries about patient satisfaction were among the most frequent clinician reactions to the survey findings. In a nutshell, many clinicians fear the consequences of patient dissatisfaction over not receiving an expected antibiotic prescription, provoking them to prescribe nonindicated drugs. An emergency medicine practitioner explains: "Prescribing unnecessary antibiotics is quicker than taking the time to explain properly, and customers who don't get antibiotics are much more likely to complain. Good medicine is taking a back seat to 'the customer is always right' mentality now prevalent in healthcare."
Some clinicians describe having been threatened with poor satisfaction ratings, and accused of providing substandard care on the basis of race or insurance status, when they declined to hand over the prescription. "It is very hard to get a patient out the door of the ED without a prescription for an antibiotic," maintains an emergency medicine clinician. A nurse practitioner frames the reality of the issue this way: "Giving antibiotics makes the patient happy, and a happy patient is a happy administrator."
The clash between patient satisfaction and good medicine has consequences that go beyond the potential risks to patients of taking unnecessary drugs. Readers also mentioned the following:
The patient goes elsewhere and gets what he or she wants;
When the patient gets antibiotics from another provider, you are labeled incompetent, especially when the patient is "magically cured" 3 or 4 days after getting antibiotics;
The patient gives you/your clinic a poor satisfaction rating, or complains to administration;
The patient doesn't return to you the next time he or she wants antibiotics (or possibly ever); and
You lose your job.
Several clinicians report that they have indeed lost their jobs following complaints from patients who didn't receive antibiotics. For example: "I am in the waning days of employment at a privately owned urgent care center. One of the reasons cited for my departure was my reluctance to provide antibiotics 'on demand.' I was told that I was not responsible for antibiotic overuse and resistance. Needless to say, I am leaving, in no small part due to the emphasis on patient satisfaction over standards of care in this and other matters."
Has Placating Patients Gone Too Far?
Such anecdotes are concerning, but how likely are clinicians to be reprimanded, sanctioned, or disciplined for refusing to practice inappropriate medicine? Does patient satisfaction, in the absence of incompetence, really drive medical practice to the extreme of termination? Are clinicians, as an emergency medicine practitioner fears, "being held captive by satisfaction surveys"?
Physicians maintain that they are, and a recent Web-based survey of members of a state medical society suggests that patient satisfaction surveys contribute significantly to job dissatisfaction, attrition, and inappropriate clinical care among some physicians. Specifically:
59% of respondents reported that their compensation was linked to patient satisfaction ratings;
78% said that patient satisfaction surveys moderately or severely affected their job satisfaction;
28% had considered quitting their job or leaving medicine;
20% said their employment was threatened because of patient satisfaction data; and
50% believed that pressure to obtain better scores promoted inappropriate care, such as unnecessary antibiotics.
Dr. Bartlett does not mince words in his views on this issue. "The use of patient satisfaction scores to evaluate physicians is just plain wrong, not to mention the fact that there is a direct correlation between patient satisfaction scores and mortality. The happier the patients, the more likely they are to die."
Sparse evidence suggests that patients are less satisfied if they don't receive expected, hoped for, or requested antibiotics.[1,4] However, another study of parent requests for antibiotics for their children with viral respiratory illnesses found that parental dissatisfaction was not influenced by the failure to receive expected antibiotics, but by poor communication during the visit. According to patient satisfaction surveys, patients don't even acknowledge putting pressure on physicians for antibiotics. An older survey found no correlation between patient satisfaction and receipt of an antibiotic prescription. Instead, satisfaction correlated most strongly with the quality of the physician-patient interaction.
When clinicians give in to patient demands for antibiotics, it isn't always a matter of "if I don't prescribe them, someone else will," although that sentiment was heard many times. Some clinicians have resisted, finding themselves undermined by their colleagues. A nurse practitioner has had to suffer the imputation that because she is a "nurse" she didn't know what she is doing, when, after declining to prescribe unnecessary antibiotics, the patient went to a physician and received the desired prescription.
Brad Spellberg, Professor of Medicine at the Keck School of Medicine of the University of Southern California in Los Angeles, believes that "concerns about patient satisfaction are valid but the real driver is fear. If physicians knew the diagnosis they were treating, they would be able to explain that antibiotics won't help and are dangerous when treating viruses, cause side effects, and make the patient's normal bacteria antibiotic resistant. Patients want something to make them better. Clinicians can offer symptomatic relief, and if they knew that the illness was viral, that is what they would do. They just don't want to be wrong and miss bacteria."