Researchers Uncover Secrets of Patient Satisfaction

Laird Harrison


June 01, 2017

Listening Leads to Higher Satisfaction Scores

Sometimes the best treatment an orthopedic surgeon can give a patient doesn't involve a scope, a shot, or a pill. Sometimes it's just a listening ear. "You have people come to you and say, 'Fix me,'" explains hand surgeon David Ring, MD, PhD, associate dean for comprehensive care at Dell Medical School in Austin, Texas. "What they really mean to say, is 'Help me.'"

It took Dr Ring years of research to gain that insight, and months of working with a communication coach before he knew how to make use of it. Often, it means guiding patients to new understandings about their lives. Physicians who learn to do that will not only get better results but also enjoy their work more, he says.

It's also the best way to get high marks on patient surveys, he adds, something few physicians can ignore these days. Increasingly, payers are making reimbursement decisions on the basis of quality measures. Instead of paying for services, they want to pay physicians for making patients healthier. But that means gauging patients' health. So along with measurements of pain and function, many are asking to see results of patient satisfaction surveys.

For example, the Centers for Medicare & Medicaid Services lists the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) among the options that medical practices can use to measure the quality of their care. Eventually, these measures will determine reimbursement levels.

"Depending on what practice or institution you work for, they're probably already collecting CG-CAHPS scores on you," says Dr Ring. "It's a fact of life for most of us."

And gathering this information isn't just one more exercise in satisfying the bureaucracy, says knee surgeon Khalid Azzam, MD, an assistant professor of orthopedic surgery at Indiana University School of Medicine who has researched patient surveys. "It helps you make fine adjustments to the way you practice, whether that includes the patient's flow into the practice or following up with the patients afterward."

Filling out surveys in private allows patients to give useful comments they might not make out of politeness when face-to-face with their doctors, says Dr Azzam. Orthopedists may also use the surveys to gauge the quality of a prosthesis or the way it is implanted, he adds.

Dr Azzam's practice asks patients to fill out surveys before surgery and then during regular follow-up intervals, usually at 4 weeks, 4 months, and every year after surgery. It provides tablets at follow-up appointments on which patients can enter their comments and ratings.

Collecting the information can prove challenging. Dr Azzam finds that the most satisfied patients don't feel much incentive to return for a follow-up appointment, so they don't fill out surveys. "We do our best to make sure patients know the importance of coming to their follow-up appointments, in case there is a problem with the joint, so we can fix the problem," he says. "Our support staff reminds patients to come back on an annual basis, even if they're satisfied."

Why Are Patients Dissatisfied With Their Joints?

The bigger puzzle, though, is why so many patients say they're not satisfied with their new joints. Among total hip and total knee patients, about 80% say they're happy. By comparison, surgeons say that at least 95% of total hip and knee patients have had completely successful procedures, says Dr Azzam.

"There is a small proportion of patients who, despite a well-functioning knee, are not totally happy, and we're trying to figure out why," Dr Azzam says.

Do some designs or surgery techniques end up with a knee that feels more natural or normal to the patient? These are questions we need to answer.

At the 2017 annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), Dr Azzam presented an analysis of 414 surveys from his own practice. The survey showed that one surgeon in the practice got better ratings than the other, suggesting that the latter person had some work to do.

More intriguing, only 47% of respondents felt that their prosthetic knee felt like a healthy, natural knee all the time, whereas 42% said it felt that way some of the time. Why? "Is it a patient variable, such as general health or an activity level?" Dr Azzam wonders. "Is it overall psychic well-being, or is it a surgery or implant design? Do some designs or surgery techniques end up with a knee that feels more natural or normal to the patient? These are questions we need to answer."

Researchers exploring similar questions have examined the relationship of survey answers and demographics. Some have identified male sex, age older than 50 years, a shorter length of stay, and better health status and education as factors boosting scores on surveys. Other studies looking at demographic factors have not shown any correlation with survey responses.[1] Research on patients' expectations have also produced contradictory results, says Dr Azzam.

But studies of tertiary clinics in multiple countries have found a more consistent correlation between patient satisfaction and aspects of nursing care, such as careful listening and a relatively high ratio of nurses to patients. These outranked physician care, admission process, physical environment, and cleanliness in some of the studies.

Zeroing in on physicians, other studies have shown that interpersonal skills, including attitude, ability to explain care, respect for patients' preferences, and involving patients in decision-making were, more important factors than clinical competence.[1,2]

Showing Empathy and Choosing Words Wisely

For Dr Ring, one aspect of physician comportment stands out above all others: empathy. In a study he presented at the 2016 AAOS annual meeting, he found that patients who rated their hand surgeon highly for empathy were also likely to give that surgeon high marks overall. The patient's age also mattered, but waiting time in the office, duration of appointments, time from booking until appointments, second opinions, resident/fellow involvement, management, and health literacy did not.

"People don't necessarily come to us because of their pathophysiology," Dr Ring says. "It's not a matter of what disease they have; it's 'How can I be myself?' It's 'How can I do my job? How can I do things I enjoy, or do things that give me meaning and purpose?'"

Medical school teaches aspiring doctors to push aside such thoughts and to look at the human body as a machine, he says. "You almost get dehumanized." That training was reflected in surveys conducted by the AAOS in the 1990s[3] that showed patients considered orthopedic surgeons to be "high-tech, low-touch," Dr Ring says.

I thought I could tell people straight out what I knew, but it came out too blunt and it made them angry.

But knowing that psychological and social factors are influencing patients' perceptions of their health is only the first step toward responding to these needs. Dr Ring discovered this in a former position at Massachusetts General Hospital when he tried to bring up these factors with his patients. "I thought I could tell people straight out what I knew, but it came out too blunt and it made them angry," he says. "So I had complaints coming into our office of patient advocacy."

Enhancing Your Communication Skills

Eager to address the problem, Dr Ring began reading about communication skills and working with a psychologist, Larry Harmon, PhD, who has also researched patient surveys. Dr Harmon sometimes attended patient visits with Dr Ring to coach him on better communication. "I practiced and worked on it as much as I practiced surgery or medicine," says Dr Ring.

Rather than blurting out recommendations about resiliency and coping skills, Dr Ring now thinks carefully about the message he wants to deliver, taking into consideration the patient's health literacy. "I also craft it for hopefulness and optimism," he says.

Typically he boils his message down to three to four bullet points, pausing between sentences to see whether there are questions, and waiting for the patient to acknowledge. After speaking for about half a minute, he invites the patient to "tell me your questions." Even the conventional way of phrasing this invitation, "Do you have any questions?" can be off-putting, because it implies that the conversation might be at an end, he says.

The AAOS offers some resources for members who want to improve their communication skills; these include a list of mentors, an information page on nonverbal communication and a page on interview skills.

Dr Ring put these techniques to work in a recent visit with a patient who had been referred for cortisone shots to treat pain in his shoulder. The man, a construction worker in his 60s, didn't think the shots would work. "My knees and my shoulders are trashed," he said. "I'm going to get my knees replaced, and they tell me I need to get my shoulders replaced."

Rather than preparing a syringe, Dr Ring invited the man to keep talking. The man said he was having trouble eating and also acknowledged that he needed to stop smoking and lose weight. "He was expressing vulnerability and desperation," Dr Ring says. "He was telling me that he had lost his meaning and purpose in daily life."

Even the conventional way of phrasing this invitation, 'Do you have any questions?' can be off-putting, because it implies that the conversation might be at an end.

Dr Ring considered his options. Many doctors would have given the cortisone or written a prescription for an opioid and sent the man on his way. In the past, Dr Ring might have told the patient why drugs were only a short-term solution, and he would have explained about catastrophic thinking. This was the approach that often infuriated his patients at Massachusetts General. "You're telling me it's all my head?" they used to say.

This time, Dr Ring offered sympathy. "I can tell how hard this has been for you," he said. "It's even affecting how you eat!" He told the man how impressed he was that he was still doing construction work past the age when so many people switch careers. Then he guided the conversation toward solutions: "What do you think would make a difference here?"

The man talked about how he had lost weight and quit smoking in the past. He realized he might not need joint replacements after all. Together, doctor and patient discussed short-term and long-term plans. "He recognized that he could do a lot himself," says Dr Ring. "I kind of left it at that."


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