Patient Satisfaction and Quality of Care: Are They Linked?

An Expert Interview With Joshua J. Fenton, MD, MPH

Linda Brookes, MSc; Joshua J. Fenton, MD, MPH


June 11, 2014

In This Article

They Can't Always Get What They Want

Medscape: In your original paper, you mentioned the possibility that too much emphasis on patient satisfaction measures could lead to "unintended adverse outcomes." There has been a lot of discussion about overtreatment,[20] such as overprescribing of antibiotics,[21] and ordering unnecessary tests. Patients ask for these things, even when they aren't necessary, and are more satisfied when they get what they think they need. Do providers modify their behavior based on patient satisfaction scores?

Dr. Fenton: That was one of our concerns about the results of our study. We observed an association between higher patient satisfaction and higher healthcare utilization, and yet there was also an association between higher satisfaction and patient mortality. It was an observational study, so is it impossible to determine whether the associations were causal. It does raise some concern that the high utilization among the more satisfied patients may not have been for high-value care.

Ours was not the first study to point to the problem of low-value care in healthcare. The studies from the Dartmouth Atlas of Health Care have been widely cited for pointing out, for example, that approximately 30% of healthcare expenditures in the United States are probably wasteful and for either discretionary or inappropriate care.[22] So there is a dynamic in US healthcare that drives excessive healthcare utilization, and we are concerned about that. An overemphasis on patient satisfaction could make this worse.

Most primary care providers are concerned about the perverse incentives that satisfaction metrics could introduce into the clinical encounter. I'm particularly wary about the push to maximize satisfaction, as if the goals should be to get every patient to rate every encounter as "excellent."

Some encounters are bound to be challenging for both the patient and the clinician. When difficult issues are raised, such as a patient's ability to drive, a possible substance abuse issue, or perhaps poor exercise habits, patients may have an affective response that leads to lower satisfaction. Yet compensation schemes that unduly award maximum satisfaction would discourage these important conversations.

There is a major difference between the doctor/patient relationship and the relationship between a business and a customer. Of course, many primary care encounters, as well as those in other settings, are driven at least to some extent by consumerist behavior on the part of patients. Patients ask for this or that test, treatment, or referral, or a brand-name drug advertised on TV. Perhaps they want an antibiotic when in fact they have a common cold. In these situations, the doctor would ideally respond to patients' requests empathetically in a manner that addresses their concerns. But a denial of patients' requests, even if respectful and empathetic, obviously risks dissatisfying the patient. In essence, we want physicians to care about satisfaction, but not too much.


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