Highly Satisfied Patients May Not Be Getting the Best Care

Patients who report being highly satisfied with their doctors are not always getting the best care and, surprisingly, are about 26% more likely to die than people who feel more ambivalent about their physicians.

In a study published in the Feb. 13 issue of the Archives of Internal Medicine researchers from UC Davis found that in a nationally representative sample of more than 50,000 patients, higher satisfaction was associated with a 12% lower use of the emergency department. That’s clearly a good thing. But, it was also associated with a higher elective hospitalization rate, and a 9% increase in health care expenditures, including on prescription drugs. And then there’s that higher risk of dying. The most satisfied patients—even though they were often the healthiest at the beginning of the study—were more like to die than the least satisfied patients. What’s going on here?

Patient satisfaction data has become increasingly important as these measures are used to help consumers choose providers and, in some cases, to determine physician compensation. As the UC Davis researchers report, “Patient satisfaction data may empower consumers to compare health plans and physicians, and both the Centers for Medicare & Medicaid Services and the National Committee on Quality Assurance require participating health plans to publicly report patient satisfaction data. Health plans use patient satisfaction surveys to evaluate physicians and to determine incentive compensation, and consumer-oriented Web sites often report patient satisfaction ratings as the sole physician comparator.”

That’s giving a lot of weight to a subjective measure that relies on what other, smaller studies suggest is a “tenuous link” between patient satisfaction and the quality of care and health outcomes. This is especially true when it comes to older, vulnerable patients, where studies have found that “patient satisfaction had no association with the technical quality of geriatric care.”

This doesn’t surprise me. In my brief personal experience working as a patient representative at a hospital, patients were pretty clear about what they considered a satisfying experience. They didn’t want to wait too long in the emergency room, they wanted doctors and nurses to treat them kindly and with respect; they wanted prompt pain relief and they didn’t want to be discharged too soon or before they felt their medical problems were fully addressed. Often, patients indicated on surveys that they were dissatisfied with care when they felt slighted, ignored or when some of their personal effects went missing.

These are the kinds of experiences that are important to many patients. They represent what we think of as “customer service,” the same kinds of qualitative measures consumers use to rate cable providers, auto dealerships and vacation resorts. In a commentary accompanying the Archives study,   Brenda Sirovich, an assistant professor of medicine at Dartmouth Medical School writes; “While most Americans may accurately assess how well their washing machines, their hair stylists, or even their airlines are performing, their evaluations of physicians and health care interventions may have limited validity.”

The truth is, in many cases patients aren’t informed enough to know whether they are getting evidence-based and/or appropriate care. The Archives study found that patients “often request discretionary services that are of little or no medical benefit, and physicians frequently accede to these requests, which is associated with higher patient satisfaction.” Take the example of acute sinusitis. For many years it was a given that when a patient walked into a doctor’s office suffering from the telltale signs of head pain, stuffy nose and fever, he or she almost always left with a diagnosis of sinusitis and an antibiotic prescription. Now, based on recent studies  that doctor would be practicing better medicine by telling the patient that Tylenol will help ameliorate the bothersome symptoms, but antibiotics are not necessary and may be harmful. But if he does that, the doctor runs a real risk of having a dissatisfied patient who will take his business elsewhere—and perhaps comment about his dissatisfaction on any number of physician-rating websites.

The Archive authors found that, “Physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services, such as advanced imaging for acute low back pain.” This catering to patient requests or expectations leads to over-use of expensive services and an increase in health care costs. But there is a darker side to trying to please patients by providing more discretionary services; more testing and more interventions leads to over-diagnosis and over-treatment that can harm patients—leading to poorer outcomes and even premature death.

The problem is that many patients equate what turns out to be potentially excessive care with a doctor being thorough. They are grateful that he or she has “found something” and has taken aggressive steps to treat the problem. Sirovich, who calls this a “positive feedback loop” writes; “Numerous studies have found that patients are consistently highly satisfied with one of the most common downsides of medical care—false-positive test results and the downstream events that follow.”

A prime example of this feedback loop is in screening for prostate-specific antigen (PSA). Sirovich explains: “Regardless of the true net effect (beneficial or harmful) of screening, a physician ordering a screening PSA receives a favorable result: he can reassure the patient with a ‘normal’ PSA result; celebrate with the patient who has overcome a ‘false positive’; or (most compelling for the physician) offer potentially life-saving treatment to the patient whose prostate cancer was ‘caught early’—notwithstanding the likelihood that the patient’s outcome may be worse because of early detection.”

What emerges from the Archives study and Sirovich’s excellent commentary is that patient satisfaction surveys may not be a very good metric for evaluating a physician’s ability to provide the best care. As the study authors conclude; “Without additional measures to ensure that care is evidence based and patient centered, an overemphasis on patient satisfaction could have unintended adverse effects on health care utilization, expenditures, and outcomes.”

The authors aren’t recommending that we scrap the whole idea of considering patient satisfaction when determining the quality of care. But they believe, as do I, that the metrics of measurement be re-examined so that doctors aren’t afraid to speak honestly to patients and to sometimes tell them “no, this test (or procedure or medication) you want is a waste of money and may even harm you.” Doctors should also be able to approach uncomfortable subjects with patients, including substance abuse, psychiatric issues, and failure to adhere to treatment with worrying they’ll receive a bad satisfaction report. Rating doctors is not the same as rating a washing machine.

At its heart, the message from this study is that doctors and other health care providers need to work harder to get the message across to their patients that more care is not necessarily better care. They need to inform them about the true risks and benefits of screening tests and treatments, and must involve patients more in decision-making that allows them to help direct their own care.

Punctual service, a friendly, respectful manner and a comfortable waiting room may be valid indicators of a patient’s satisfaction with his or her doctor. But they should not be the only metric available to patients who are trying to choose a provider. Especially if these satisfaction surveys implicitly reflect a doctor’s willingness to acquiesce to a patient’s demands without explaining risks and benefits of a particular test or treatment option. The Archives study suggests that to do so would do nothing to promote value in health care and would actually be harmful to patients in the long run.