The Pros and Cons of Patient Satisfaction Measures

A Primary Care Debate

Bradley P. Fox, MD; William R. Sonnenberg, MD; Charles P. Vega, MD

Disclosures

July 08, 2014

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Bradley P. Fox, MD: Welcome to Medscape Family Medicine. My name is Brad Fox. I am a family physician in Erie, Pennsylvania, and a former President of the Pennsylvania Academy of Family Physicians. I currently serve on the Advisory Board for Medscape Family Medicine.

Recently, Medscape Family Medicine republished an editorial[1] from Keystone Physician journal that was written by Dr. William Sonnenberg. As President of the Pennsylvania Academy of Family Physicians, Dr. Sonnenberg addressed the idea of using patient satisfaction as a guide for physician evaluations and payment. He argued that this is not a good way to evaluate physicians and judge them for payment -- and in addition, it may actually be detrimental to patient care.

With me today are 2 of my colleagues. Dr. Sonnenberg is the author of the article and a family physician in Titusville, Pennsylvania. He is the immediate Past President of the Pennsylvania Academy of Family Physicians and currently is Chairman of the Board of the Pennsylvania Academy of Family Physicians. In California, Chuck Vega is a fellow member of the Medscape Family Medicine Advisory Board, and Clinical Professor of Family Medicine at University of California Irvine as well as the Residency Director. Welcome, gentlemen.

Charles P. Vega, MD: Thank you.

Dr. Fox: Bill, I want to turn to you first. When you wrote this editorial, did you have any idea that it would get more than three quarters of a million hits on Medscape, that you would be quoted in Forbes magazine and in 2 other magazine articles, and that you would become a trending person on Twitter?

William R. Sonnenberg, MD: No, not at all. I think the Keystone Physician has a circulation of about 4800. I was a little shocked and surprised, but pleased. I had a feeling it was one of my better pieces of writing, but I was just surprised that it went this far.

Dr. Fox: Where did you come up with the idea for the article, and what did you base it on, Bill?

Dr. Sonnenberg: I was giving a lecture in San Diego on bronchiolitis, and perhaps I got carried away at the talk. I said that we need to pin down a diagnosis in these patients because if we do not, parents will be taking their children to emergency wards or urgent care centers, where they will be given the obligatory prescription for azithromycin, which seems to make everyone happy.

Afterward, a bunch of doctors who work in urgent care centers came up to talk to me. They said, "Look, we know what we are doing is wrong, that it is bad medicine. But our performance is judged largely by 2 parameters. First, do we get the patient door to door in 45 minutes? Second, do we keep the patient satisfied?"

In my opinion, looking at the quality of medical care is like judging a work of art; it is very subjective. But the administrators grab on to 2 statistics. They look at the clock. Is the patient in and out, door to door, in 45 minutes? And they look at the doctor's satisfaction score.

Many times, you see unintended consequences. You see a satisfaction survey that may have been well-meaning when it was developed. It was embraced. It was endorsed. It became part of the metrics of a physician's success, and it has led to unintended consequences -- namely, that physicians are afraid to deny requests for antibiotics.

They have also become afraid to not prescribe the opiates that patients ask for. I believe this is partly responsible for the epidemic of opiate use we see. The use of hydrocodone in the past 20 years has skyrocketed. Prescribing hydrocodone has increased 5-fold, and I believe this focus on patient "satisfaction" is part of the problem.

I do not believe this survey has been validated. Does asking patients to complete Press Ganey surveys and accepting this kind of input from patients result in a better quality of medicine? Does it have an outcome advantage? I do not believe that has been proved, and that is why I wrote the article.

Dr. Fox: Chuck, you have said that you would look at the other side objectively and perhaps see an advantage to surveying the patients, using an objective survey, and taking those results to try to evaluate physicians and their quality of care. Can you speak about the other side of that point?

Dr. Vega: I actually agree with Bill. The evidence for satisfaction as a strong metric for improving the quality of care for major hard outcomes, such as mortality, myocardial infarction, and incidence of cancer, is fairly weak. I think Bill referenced an article from 2012 by Fenton and colleagues[2] that showed increased patient satisfaction was associated with a higher risk for mortality, which is a completely counterintuitive result. Certainly, mechanistically it is very hard to explain how that happens. There are probably a lot of confounding factors that go into an outcome like that.

On the other hand, there is evidence that increased patient satisfaction is important for improving patient adherence. Patients are more likely to take their pills, more likely to try to quit smoking, and so on, and those are good. But overall, I believe it is worthwhile to pull back and look at that entire concept of patient satisfaction. When patients come to see me -- and hopefully when they come to see any clinician -- there is something therapeutic just in that visit, just in that relationship. Being able to talk about your symptoms is valuable; to have someone listen to you in an empathic manner, to get a plan of care, and to arrive at some kind of solution together.

Moreover, take a look at some of the key buzzwords in medicine these days: There is "patient-centeredness," and there is "accountability." You want to be patient-centered and accountable, and at the same time you really believe in the therapeutic relationship. I think we all do. In that case, patient satisfaction has to be part of that metric for how we measure ourselves as a profession. It is better for our profession, and particularly better for patients. And overall, it is better for our society.

Dr. Fox: The question becomes this: If patient satisfaction may or may not be a partial metric that, according to some data, may worsen outcomes, how can we incorporate patient satisfaction into quality care? Is there an answer? Bill, you seem to think there is not. Chuck you seem to think there is. Chuck, I am throwing the question to you first.

Dr. Vega: I do not think that the link between patient satisfaction and higher risk for inpatient stay or death has been proven, because otherwise, we should try to dissatisfy as many patients as possible -- and that does not seem correct, does it?

But at the same time, it is part of the metrics. It should not be the only metric. Bill mentioned the others. We are all accountable to those, in terms of patient volume, and other metrics of quality care, which I think are much more important than any board scores you achieve. But what matters is how we apply the metrics, and I believe we need to apply them in a smart way.

Different practices have some latitude in how to apply the results. If you want to kick out those confounding outliers, you can. Right now, the effect of patient satisfaction on income is about 3% of a primary care physician's salary and 2% of a specialist's salary. This is not a major chunk of a physician's salary, or anywhere close.

I believe the smart application of these important metrics will help us all move forward to make medicine better.

Dr. Sonnenberg: I believe a metric like that goes beyond salary. Physicians are generally a very competitive lot, and if you look at a survey and see that you are in the lower 10% or 20% of a given metric, you will try to do things to increase it. The trouble is, the way these are measured does result in unintended consequences. Patient satisfaction parameters are too underdeveloped to throw immediately into the hands of our administrators.

For example, Press Ganey itself says that a valid survey needs to include at least 30 patients. Yet they produce outputs and give reports to these organizations that say this or that physician is doing poorly. They may not divulge that only 5, 6, 7, or 8 responders were included, which does not make it a valid survey.

At the present time, this is being used poorly. It should be kept out of the hands of nonclinical people -- hospital administrators, managers, and others. They do not understand the metrics and are using them poorly. They are hurting people, making it difficult for us to cut back on antibiotics and opiates. They should stop using invalid surveys.

Dr. Fox: From the standpoint of looking at your own surveys, I know both of you get your results, and I know both of you look at them. Have you found yourselves consciously doing certain things and questioning whether you are doing these because of the survey? Are you thinking, "Well, it isn't going to hurt anything, so why not?" Be honest, and then tell me whether you know colleagues who are also doing this. And what is your answer when they ask, "How should I approach this? What should I do when the insurers are telling me they are watching me? When my employers say they are looking at me? When my colleagues tell me they are looking at me, on the basis of my patients' satisfaction surveys?" Bill, I am going to throw it to you first.

Dr. Sonnenberg: First, I have a kind of luxury. I still work for myself as a solo practitioner, so my metric is whether patients actually show up at the office. Yes, insurance carriers look at it periodically. Sometimes I agree, and sometimes I disagree with the results.

Once I was dinged for something I believe is distinctly unfair. Years ago, a patient had an x-ray in the emergency ward; I received the result 3 days later. I called the patient promptly when the x-ray showed up on my desk. The patient yelled and screamed and gave me a bad report, and I ended up getting certified for 1 year instead of 2 years. It did not matter that what I did was logical, proper, and the best anyone could have done. They did not care; they saw the and dinged me for it anyway.

Dr. Vega: Those stories are not uncommon, and they are unfortunate. But if you apply this system in the right way, those outliers could be kicked out of the analysis.

I will offer another story. I have a patient who was started on fertility treatments. I am not a fertility specialist, but when she couldn't get a refill on her fertility medications, she called my office. I asked her why she had not talked to her specialist. She said that she had called that office 3 times without a response and that she just wanted me to prescribe these drugs. I told her that this was out of my realm of practice, it is very specialized; it can change week to week. I called the specialist's office. I got nothing. It took me 3 calls to get through, and finally she restarted the treatment, but meanwhile, she had lost approximately a month.

We all know physicians like that. It is great to assume that we are all wonderful, super physicians who are on top of everything and meticulous every moment of the day, and that we have great people skills. We can be there when our patients are suffering and celebrate with them when they are doing well. But we know that is not the case. It is time for us to hold accountable, in some way at least, those who do not meet the standard, who fall below the standard.

If nothing else, patient satisfaction surveys can identify that approximately 10% of physicians who are really outliers. For those who are doing an outstanding job, those with uniformly great reviews, the narratives are very important. It does not come down to just numbers. Those who are not responding to patients, who are providing terrible customer service -- no one wants those physicians practicing. At least they want those practices to become much, much better and I think that is in all of our interests.

And if we don't do this now, when are we going to do it? We have to start rolling this out, because it has been something we have been talking about for decades, and yet we keep putting it off and kicking it down the road, because of the application issues. It is a tough fight. I see that. There are challenges. But this fight is a fight worth having at this time.

Dr. Fox: You both say that maybe there is validity to patient satisfaction, and I feel the same way. But by using this survey, we are validating Press Ganey as an agent of patient satisfaction. Would it be smart for our own organization -- the American Academy of Family Physicians -- or another medical organization to put together its own process that does not look only at the 37 patients out of the 1200 I saw this quarter who are "valid," but instead takes a more real-time or medically sensitive approach? What do you think of that idea?

Dr. Sonnenberg: That may be useful. Perhaps we could approach Press Ganey and challenge the questions they ask. If you look at the questions, they are kind of banal and primarily address the style of the physician rather than the quality of the medical care. Make sure the questions are better, more clinically relevant, and get to the core of whether this patient received good therapy.

Second, the results should be more transparent. When these surveys are put out on an individual physician, they do not note that the number of survey responses is not statistically valid for reaching a conclusion about that physician. That is one of my big complaints. When 8 patients respond to one of these surveys, it is not a statistically valid response. It takes 30 patients for the results to be statistically valid. They are not providing that information. We need to point this out. We need to say, this is where you are wrong.

Dr. Vega: I think Press Ganey took advantage of a situation. They saw this as an evolving field and put resources into it, and they have been successful. Why? Because they started it, they ran the show, and that is why they are so prevalent in this area. The questions they ask, as far as I know, are basically right out of the Agency for Healthcare Research and Quality. They include issues about respecting your patients: Does the physician explain things in a manner you can understand? These are desirable, particularly from the patient's viewpoint. If quality is a work of art, it seems that those are a really nice substrate to begin your opus of patient care.

In terms of statistics, one thing we lack is a decent knowledge of statistics. I am not a statistician. I would depend on someone to provide that service, and if the Academy can do it, that is outstanding.

I do not believe anyone will ever come close to fully agreeing on this. There will always be different opinions about what to stress and what is important. But if you can agree on some simple metrics and apply them locally, that may work.

We need to have a broad template of questions that are fair and speak to patient-centeredness and how to apply those in your local system, your local practice, and your local academy. That is important to try to achieve as we move forward.

Dr. Sonnenberg: As far as quality is concerned, in my opinion, it is like saying the Mona Lisa is a bad painting because the security guards in Paris treated you rudely. This does not make it a bad painting. I do not believe the survey that is being used measures quality of medical care well.

One humorous anecdote I heard was that to get rid of the outliers, make sure you put down an abuse diagnosis in the coding. If you put down an abuse diagnosis -- alcohol or drug abuse -- those statistics are automatically excluded by Press Ganey. I have heard that this is a way to game the system.

Dr. Fox: Basically, we have agreed to agree and agreed to disagree on the topic of including patient satisfaction in the quality metric. We do need to have a relationship with our patients; we need to keep our patients as part of the team. Transparency and patient-centeredness are important. But there is also the question of how you do it, and where a focus on satisfaction may sacrifice the ability to adequately care for your patient.

In closing, where do you think this is going? What are your suggestions as we look forward to the future of medicine and the future of the patient-centered medical home?

Dr. Sonnenberg: Reluctantly, I have to cede some ground. Patient satisfaction is important, and someone has to actually look at it and make sure it does occur. At the present time, patient satisfaction is being used poorly as a measure of quality care. It is not ready for the administrators or the bean counters to use. I believe it should be taken out of their hands and improved before putting it out there as a valid metric. Patient satisfaction will have to be included in the future, but right now, it is leading to a slew of unintended consequences that are deleterious to the population at large.

Dr. Vega: I would suggest that asking patients whether they feel they are being treated with respect is an important outcome measure, or asking them whether they believe that having things explained to them in a way they can understand is a measure of the quality of their physician. I am convinced that the physicians who do that are truly embraced and are more successful in practice.

In the same way, patient satisfaction will be increasingly embraced as a metric. It has to be. I believe the application will evolve and will involve more input from physicians. We are actively trying to prepare our students and residents for that here at UC Irvine, and I am proud of that. I want to be on the vanguard of this movement, because it is the right thing to do. It will have bumps and unintended consequences; everything does, along the way. But, we are on the right path.

Dr. Fox: I thoroughly enjoyed this conversation, gentlemen. We probably could talk for another hour on the topic, but we are limited.

For those of you watching on Medscape, I hope you have appreciated this. The link to the original article on patient satisfaction will be posted, if you have not yet read the article/editorial. Please send us your comments. We are compiling some of the comments for another article we will publish in the future.

Gentlemen, thank you for your time this morning and I look forward to seeing you in the future.

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