Oh Henry
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Well it’s that season again when contracts come up for renewal. Administrators are working hard to glean data from patient satisfaction reports and emergency physicians are working just as hard to dismiss them as worthless. It’s amazing how quickly we come to be at each other’s throats. When did we get to the point where we were no longer on the same team? When did we get to the point when it was one against the other? The Romans had a great phrase that the medical community would be wise to embrace: “Non mihi, non tibi, sed nobis.” Not me, not you, but us.

It is amazing the extreme positions which people take with regard to patient satisfaction surveys. Let me just begin by saying that I think they tend to be weak science representing small amounts of data. They neglect to ask certain key questions and they tend to lump or split doctors from the group. Having said that, do I think they’re important? In short, when your job depends on it, it becomes important. The hospital administration, who is in many ways our ultimate boss, believes in these surveys and will use them at will. So the smart doctor will pay attention and take them seriously, learning how to interact with the nursing staff such that the patient care is seamless.

When it comes down to it, you might as well “teach to the test.” Take advantage of the fact that the questions are known in advance. Words and phrases can be used in your patient interactions which directly reflect the questions which are going to be asked on the survey. It’s going to be a part of the program, so use the program to your advantage. Virtually all of the surveys try to ascertain whether the physician cared about the patient as a person. They try to find out whether or not the doctor was solicitous of the patient’s pain. They seek to find out if the doctor put the program together for discharge. Is there anything wrong with these things? I think these are important factors. It seems as though we have fallen into a defensive posture, where anything that comes out of the patient surveys has to be wrong and cannot relate to the actual quality of care which the patient has been given. To read some of the columns, it would seem that to get a great Press Ganey score you would need to be an inferior doctor intellectually. Nothing could be further from the truth. In my 34 years of emergency medicine experience, there have been very few physicians who have been fired for lack of medical knowledge. This isn’t rocket science. The two most important elements in an emergency physician are a dedication to getting the work done and the ability to make the patient feel that they’ve been cared for. The physicians who complain that the patient satisfaction surveys unfairly discriminate against them better put this into some kind of perspective. It is not a badge of honor or a sign of brilliance to have bad patient satisfaction scores. The best physicians I’ve worked with, from a scientific standpoint, also had great patient sat scores. They were able to marry the two together.

To be fair, satisfaction surveys judge physicians – and nurses -- by a set of criteria which were never taught in medical or nursing school. In the health care professions, getting the right answer was always the way to go. In the actual practice of medicine, it is much more important to find an answer which is able to accommodate the needs of the patient sitting in front of us. This does not mean that we should do things which are inappropriate. We should not give out medications which are unnecessary and we shouldn’t do testing that isn’t scientifically needed. But we ought to take the time to explain to people why we are doing certain things. And if this is communicated with empathy, it will almost always be a success. For instance, it is inappropriate for the physician to ever mention that the expense of a test or medication is the reason we aren’t getting it. Everybody believes in cost savings…on somebody else. Nobody believes in cost savings on them or their loved ones. The best phrase to use to help you take complete control of the doctor-patient situation is merely to say, “This is what I would do with my own family member.” That will do more to reassure a patient than all the studies, all the graphs, all the protestations which we use to try and discourage unnecessary care.

Many intelligent emergency physicians protest that administrations rely too heavily on patient satisfaction scores. This is indeed a major problem, one that needs to be addressed. What we need is to come together and ask for the quid pro quo. If emergency physicians are always to ask about the pain, then administration needs to do whatever it can to get patients upstairs quickly. If EPs are going to be careful to protect a patient’s privacy and treat them decently, then the hospital needs to do whatever it can to get them into a bed, registered and ready for care in a expeditious manner. If EPs are going to put together the discharge package in such a way that the patient can understand it, then the hospital must provide specialists who are going to take care of cases in a timely manner. This is a joint undertaking. I realize that frustration levels are often high in emergency departments, but the great emergency doctor is able to separate out his anger and frustration at the system and is able to care gently for the patient who presents in front of him.

Most people know the attitude of the doctor or nurse taking care of them. It’s not your words, it’s your attitude. The patient immediately senses if you are working in their best interest or not. Let’s stop the name calling. Let’s stop the war. Let’s start using patient sat surveys for what they’re really good for: looking at both the system and physician interpersonal actions. They are both represented in the  patient satisfaction numbers. Emergency physicians need to not be so defensive that we cannot learn from these studies. By the same token, the hospital has to understand that it is equally complicit in patient satisfaction by the very systems it sets up and puts into action.

Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.

 

Comments   

# Mark Jaben, MD 2009-02-12 21:27
No one doubts that useful information can be gained in patient satisfaction surveys, The problem is that their main use is not in a collaborative effort to solve issues, but as a bludgeon to command and control.

Healthcare is the only business in America with two bosses, each with a different motivation and incentive. Administrators are focused on the finances and told they are bad if the hospital is not making money. Doctors, who are focused on their patients, control the utilization of resources and are told they are bad if they miss any diagnosis.

In the economically difficult times m edicine has experienced for at least the past 10 years , administrators have increasingly pursued a command and control style in hoping to meet their objectives. But this is a flawed strategy because it ignores the other boss. Because hospital boards hire the administrator, they are inclined to side with their choice when decisions that inevitably pit finances against good patient care compete. And as the balance between administrations and doctors has tipped over the past 10 years, finances usually win out. Doctors have, in many cases, abdicated their institutional responsibilitie s. We have all let this get horribly out of whack without realizing the consequences.

There must be a healthy tension between these groups, operating in balance, and appreciating the essential role each plays for the other in their institutions. Healthcare institutions must foster the attitude and create the beaurocracy that bring these bosses to the table as collaborators, each with a necessary perspective toward achieving the real goal of healthcare, which is the caring for health
The enlightened board, administrator and medical staff will realize that this balance is essential and necessary if the institution hopes to make good decisions on the behalf of its patients.

Maybe then, these surveys can be used for their intended purpose.
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# Dr. Henry missed the boatMarcus Ma, MD 2009-02-19 14:35
I think Dr. Greg Henry missed the boat on patient satisfaction scores. After 14 years of practice in emergency medicine, I find that patients are coming in with high demands and expectations. Many times I find myself jeorpardizing my practice if I tried to meet these demands and expectations. For example, I had patients with chronic pain who felt that they should be coming in to emergency room for shots of dilaudid pr prescriptions for percocets twice a week, and sometimes more frequently. Or, a 26 year-old woman who threatened to contact the media and her lawyer because she tried on two consecutive days to get admitted for heroin addiction. (There was no indication for admission and the detox physician refused to admit her both times.) Or, a 50 year-old man who demanded a MRI of his back for "chronic back pain" because his family physician was not working fast enough to get it scheduled so he came to the ER to get it done.

Patients are using emergency rooms today for their primary care needs on a regular basis. I sent many patients home "dissatisfied" because I failed to meet those needs, and not because of my care or treatment.

Lastly, emergency physicians are not doing enough to deter patients from using our emergency services irresponsibly. Because of our failure, we are creating huge problems with overcrowding of emergency rooms across the country.

If you want to do patient satisfaction surveys, at least you can do is to screen the patients you survey, or take surveys of patients with true emergencies who get admitted. If we want to continue to "satisfy" patients and run emergency rooms as clinics, then I suggest that we all go back to residency for training in family practice or internal medicine.
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# Press-Ganey has trumped truth-tellingMark Hatcher, MD 2009-02-19 14:37
"Give me truths, for I am weary of the surfaces, and die of inanition."
Emerson

I have been an avid reader of your magazine since its inception. Topics are timely and relevant to those of us "in the trenches" of our nations' emergency departments. Having seen extensive changes in our field over the past three decades the battles we are fighting now seem to me the most relevant. Dr. Henry's insights have always proven to be thoughtful and timely and I always enjoy reading his columns and editorials. I have respected his comments over the years and respectfully thank him for his years of service to our profession.
However, our profession is currently engaged in its most far-reaching political struggle to date. Press-Ganey is the standard-bearer of the cultural assault on medicine. Who decides what quality care is? Press-Ganey is an assault on the ability of physician's to tell the truth to their patients. Our society is currently reaping the consequnces of years of relativism. My truth is as important as your truths. The individual has been empowered to make decisions without regard to consequences. The expectation of personal responsiblity is nonexistent. If absolutes do not exist then everyone is allowed to state his or her truths regarding worldviews, ethics, behaviors, and now medicine.
I practice in a high-volume(85K patients/yr) trauma center. All of us who work in these settings have become adept at identifying and managing acutely ill or injured patients. As all of us know, however, that the majority of these patients have no need of the interventions modern medicine has to offer. These patients suffer from self-limiting illness, chronic illness, or psychic imbalances. Ten years ago I could sit with these patients and (hopefully with empathy) tell them that no testing or interventions would be needed.
Now these patients come armed with unreasonable expectatons as to the content of their emergency department "experience". Many of us have the opinions of these patient/custome r interactions directly tied to our paycheck. The patient has been empowered to determine the quality of the care they receive. Having received one too many "the doctor did nothing for me" complaint letters, I have now joined the ranks of those looking for diseases that are unlikely to be present. Press-Ganey has trumped truth-telling.
Who can argue with Dr. Henry's statements that patients want to feel cared for and taken seriously, or that we can improve our interactions with patients? Yes, our attitudes, both spoken and unspoken, speak volumes and can set the tone for the ER visit.. However, our Press-Ganey world has introduced an era of inauthentic patient-physici an interactions. The majority of ER testing that is currently performed has little or no impact on patient outcomes and subjects our patients to inappropriate risks.
The expectations of pharmacotherapy likewise has damaged the relationship we have with our patients. Let's be honest. Most painful conditions are self-limited and can easily be managed with rest and Advil. In fact most conditions we treat could be managed with OTC medications. Most of our injured patients leave with a Rx for a narcotic so that they will be happy with their visit. We as a profession are directly contributing to significant narcotic abuse in our culture. The larger issue relates to the development of a part of the culture that is unable to deal with the minor inconveniences that occur in life without some form of anaesthesia. Does everyone really need to leave the ER with a prescriptiuon?
I half-jokingly used to tell my colleagues that the best medical training I received was my time as a waiter at a busy steakhouse in Indianapolis. Now when I say this I am no longer joking. Yes, I still manage the chaos of my busy ER with fluency and expertise. Sick patients receive timely and professional care. But now I am more bogged down with the excess testing and cajoling that is required by the modern patient. The non-acute patient takes up a large part of my time and the department's limited space.
I have accepted Press-Ganey as a fact of modern ER life, but I have done so reluctantly. I had anticipated that the eloquent, politically-act ive members in our profession would fight the battle to limit the relevance of Press-Ganey in the arena of healthcare. They have not. To the great impoverishment of our profession and our culture we have entered into an age of "diagnostic relativism" and we wil be the poorer for it. This should give us pause.
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# Residency- trained and board-cerified EMD (and proud of it)T. E. Marchiondo 2009-02-21 11:31
I've been practicing emergency medicine for 17 years and would like to know why Press-Ganey isn't shoved down the throats of every specialty as much as it is ours. I would also like to know why our jobs in the E.D. are totally dependent on it, especially when we work with others who see half of the patients that other E.D. docs see and in some cases are downright dangerous, yet their jobs are intact because their patients are "happy". I do find that docs with consistently higher Press-Ganey scores order more unnecessary tests and prescribe more unneeded antibiotics and narcotics than others whose scores aren't as high. We in emergency medicine are held to a higher standard than any other specialty which gives them the excuse to do little or nothing for their patients. Are their patients giving them high scores and are their jobs on the line? Of course not, because they are not held to a standard as high as ours. How many times have we seen patients in the E.D. who have been evaluated by their doctors over the phone or who have been told by them to just "go to the emergency room" for things such as chronic problems and out-patient testing? We must ask ourselves how many times can we order the same normal tests over and over again for the same chronic problem in the E.D. before it becomes abnormal. Is this acceptable, cost-effective, common-sense medicine that will help cut down the waste and abuse in a system that costs 2.3 TRILLION dollars a year and is breking the back of our faltering economy? How long can the system coninue to practice this way and where will the money come from and who will pay for it? The answer is that we all are paying and so are the future generations that are yet to be born. Why is it up to the E.D. to solve all the world's problems?
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# ED Medical DirectorTim Lewis, MD 2009-03-18 04:36
While I respect the opinions of other writers, I have to say, "way to go Greg." There is no correlation between test ordering and over use of analgesics to patient satisfaction. Patients want what we all do: to be kept informed, be respected, and be treated with dignity. Dr Marchiado is right, CAT scans and opiates are not a substitute for connecting with our patients. Those who falter under this notion risk driving up costs and will not find success in patient satisfaction.

Press Ganey is an imperfect tool and it high scores are not equivalent to quality. However, we as emergency physicians can not effectively argue against treating patients with dignity and respect, keeping them informed, and practicing golden-rule interpersonal skills. That is what patient satisfaction is about.

I think we are better off find ways for our teams to succeed than to fight the liabilities of the measurement tool.
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