I posted an article to Facebook yesterday regarding patient satisfaction, and to be honest, I was somewhat surprised at just how many people – both medical and non-medical – responded to it. The article was about the “Cost of Satisfaction” out of UC Davis and was published in 2012. The gist of the article? That happy patients don’t have better outcomes and incur more expenses. It’s an opinion that many in the medical community have held for a long time – that increased patient satisfaction scores don’t necessarily correlate to quality care. It’s true that satisfied patients are more adherent to physician recommendations and generally are more loyal to their physicians, but higher satisfaction scores often correlate to physicians giving into patient request for “discretionary services” that may be of little or no medical benefit (for example, MRIs for low back pain). In fact, some of these services can be harmful by leading to overtreatment, for example.
The researchers at UC Davis actually searched the data and corroborated what many had suspected. They ultimately found that higher patient satisfaction was associated with lower emergency department use but higher inpatient utilization, greater total health care expenditures, and higher expenditures on prescription drugs. The most satisfied patients also had a significantly greater mortality risk compared to least satisfied patients, when controlling for a multitude of variables. Satisfaction directly correlated with the extent to which physicians were willing to fulfill patient expectations.
I’ve commented before on the danger of “patient satisfaction surveys”, and though I think they have some merit, I dont think they should be used as a strong regulatory tool (the Affordable Care Act withholds 1% of total Medicare reimbursements for the worst performers). But as I’ve said before, we shouldn’t be shifting our focus away from patient’s health in order to be people pleasers. “Patient satisfaction” is one word away from “customer satisfaction” but patients aren’t customers, and most physicians don’t consider themselves customer service providers. As Dr Gregory Patrick points out in his opinion piece in the Pittsburgh Post-Gazette,
Anyone working in customer service knows that customer satisfaction depends on saying ‘yes.’ Saying ‘no’ to a customer does not raise customer-satisfaction scores. An inconvenient truth in grading doctor-patient interactions along a provider-customer axis: The customer is not always right.
The inconvenient truth is that due to the information imbalance in medicine between patient and provider, the patient actually cannot always be right. At my institution, we’ve toyed with idea of doing a study looking at trauma patients who leave the hospital “against medical advice” and finding out what ultimately happens to them. In other words, do patients actually know what is in their own best interest? Ultimately, the answer is no – human beings constantly do things that harm their own health, but not knowing what is in your own best interest isnt necessarily a bad thing. After all, that’s why physicians and other health care providers have dedicated years of their lives to obtaining a medical education and honing their craft – because patients don’t and can’t always know what is wrong with them and what they need from the health care system. I’m by no means advocating a return to paternalist medicine where the doctor is always right, but similarly we shouldn’t be saying that the patient is always right either, especially not for the sole purpose of making them happy.
The higher mortality rate that the UC Davis researchers discovered is particularly disturbing, although logic tells us that an increased utilization of health care resources is likely to lead to an increased number of patient safety events or medical errors. The problem of errors and adverse events in the health care system has been well documented by the Institue of Medicine. One could argue that these events are also likely to impact patient satisfaction ratings as well, with far dire outcomes. Instead of focusing our energy entirely on whether our patients are happy, perhaps we should be spending more time ensuring their safety.