COMMENTARY

Is Placating Patients Putting Medicine in Peril?

Brandon Cohen

Disclosures

May 12, 2014

In a recent article by Dr. William Sonnenberg, healthcare professionals questioned the value of working to gratify patients. But the question went beyond whether patient satisfaction mattered, and turned to the question of whether the drive to placate patients was actually harming medical care in the United States. In particular, the reliance on postvisit survey results, such as Press Ganey scores, to evaluate doctors and hospitals was widely denounced.

Dr. Sonnenberg began the discussion with an impassioned essay, commenting, "We must have the ability to deny treatment for a patient's own good. Patients aren't the best judge of what is best for them." The responses flowed freely and were overwhelmingly supportive of the author's view.

The prevailing sentiment was that healthcare was turning into just another service available for purchase. Patients were compared with customers at banks, spas, hotels, and fast-food restaurants, demanding specific treatments and giving low scores to clinicians who did not comply.

"You are now a provider, so your patient is a consumer. It's your job to make them consume," quipped an emergency department (ED) physician.

"The mandate is simple," continued Dr. Sonnenberg. "Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission."

Others soon chimed in with horror stories about what some providers were doing to placate the demands of patients. Overprescribing antibiotics and overusing expensive procedures were mentioned, along with the disinclination to mention such touchy subjects as obesity or smoking to patients who might become offended and lower a clinician's ratings. One physician described hydrocodone "goody bags" given to departing patients, and a nurse even reported feeding cake to a patient with diabetes -- all to gain more favorable scores.

"Hospitals and practices have focused on patient satisfaction, and in turn created a nation full of addicts and lots of drug resistance," wrote a nurse.

The lack of feedback from the surveys was also condemned by another ED physician:

We are not given access to just who the dissatisfied patient was...or why they were dissatisfied. We can never learn from our mistakes, and we cannot defend ourselves by pointing out just why the drug-seeking or antibiotic-demanding patients were unhappy with us.

An internist pointed out some of the ugliest possibilities of relying too heavily on survey results:

You only have to be a minority doctor to see why the Press Ganey score is heavily stacked against you. If you [work] in a predominantly majority area where the battle lines have been framed on the basis of friends and enemies...for minority doctors, the Press Ganey score has really been a major disaster.

And a family practitioner described how the practice could be forced on an unwilling doctor: "My former employer told me that I had to become more sensitive to what the patients want and give in sometimes, even if it's a poor medical decision, just to keep patients happy.

Many were defiant and vowed to stay true to their principles, such as this ED physician:

It will cost me income, contracts, and ultimately even drive me out of medicine, but I'll do it as long as someone will have me and I can make a decent living. I try to treat every patient as I would treat a family member, but that implies doing what's best, not what's expedient.

A physician's assistant went even further, viewing any kowtow to popular opinion as a "violation [of] the oath they took when they became physicians to do no harm."

But a few respondents were willing to see at least some value in considering patient satisfaction scores. A family practitioner wrote:

We need to educate [patients] so that they can make better decisions and better evaluate the care they receive. Patients know what is important to them, and they are teaching us (the physicians) what that is. Ratings should be used to help us provide better -- not worse -- care, and providing quality, evidence-based medical care will ultimately lead to higher patient satisfaction through better outcomes.

Some commenters saw no option other than to try to game the system. One ED physician reported that at his hospital, they were careful to enter conditions, such as mental illness and drug addiction, that might disqualify particularly unhappy patients from filling out evaluation surveys.

An internist reported a simpler method to boost his popularity. "My scores took a jump 10 years ago when I started wearing one of those disgusting white coats."

It is unlikely that evaluations of this type will disappear any time soon. On the basis of this discussion, it appears that healthcare professionals are genuinely frustrated by this practice and will have to figure out creative ways of dealing with the problem.

The final word goes to an internist, who reported a situation in which he found himself forced to refuse the stated wishes of a patient. "Several years ago, an elderly female patient wanted me to write a prescription for tamsulosin because she got a coupon in the mail. It did not matter that she lacked a prostate."

The full discussion of this topic is available here.

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