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Sat Scores Are Harmfully Misleading
by William Sullivan, DO, JD
Does patient satisfaction matter? The answer is a resounding “yes.” In fact, as the director of an emergency department, feedback from dissatisfied patients has provided both me and our group with an early warning about several physicians who were not performing up to our standards.
However, when we attempt to quantify patient satisfaction, the whole concept falls on its face. Even my ten-year-old son knows that you can’t predict the frequency of colors in a three pound bag of M&Ms just by grabbing a handful off the top. Yet satisfaction survey companies routinely make similar assertions every day by performing advanced statistical calculations on the results of 40 surveys from 6000 patient visits. Then they misuse data even further by creating numerical data about specific physicians from 6 or 7 survey responses.
When hospitals or contract management groups then tie our compensation or even our employment to monthly “numbers” that don’t come close to meeting statistical significance, they are misusing the statistics and detracting from the proper practice of medicine . . . and the satisfaction survey companies are laughing all the way to the bank.
It would be great to measure a physician’s quality of care and to reward those who practice high-quality medicine. Unfortunately, the concept of “quality” is a lot like the concept of “justice” – we know it when we see it, but no one can properly define it. Some companies instead take a variable that can be measured and then use “experts” to make everyone believe that the measure reflects something else. In essence, satisfaction survey companies have taken a big pot of “patient satisfaction” and slapped the label “quality” over the front of it. Then, by showing hospital administrators and hospital boards how competitor hospitals are “performing better,” the companies have gotten full scale buy-in from their clients. It’s like a modern day reincarnation of the Emperor’s New Clothes.
Satisfaction survey companies know that hospital boards and hospital administrators want something that sets their hospital apart. There’s this “Top 100” and that “Top 100” plastered on billboards all over town. Patient satisfaction companies give hospitals yet another metric to brag about. We’re in the 95th percentile! That’s great. Funny how we don’t hear about all of the patients in those communities who have developed MRSA due to unnecessary antibiotic prescriptions, who will develop cancer because they have been over-radiated with CT scans, and who make regular treks to emergency departments for their narcotic fix – all in the name of patient satisfaction. Just make sure you give us all “5”s so our numbers are better than our competitor’s numbers next month.
The problem with grading patient satisfaction is that the scores cater to the difficult patients. A vast majority of our patients are reasonable and well-adjusted. With our employment and our compensation hinging on every “5” we can get, doctors are reduced to giving patients whatever they want, regardless of the medical appropriateness.
But the emergency department doesn’t see that many of those types of patients, right? The last shift that I worked, I evaluated five patients with acute exacerbations of chronic low back pain and two patients with chronic toothaches. I treated their pain, but several were unhappy because I would not refill their opiate prescriptions. I made sure I addressed all of the bullet points for the satisfaction surveys and I had a nurse in the room to witness my interactions with the patients.
I review all of the complaints that come to our emergency department. Before Press Ganey, we had an in-house survey system that gave us similar grades, but that could also be correlated with the patient visit. It was interesting to find that patients who didn’t get what they wanted frequently graded physicians low in all categories, not just a few. When I asked nurses if the doctors were “rude” or “insensitive” as the patients had alleged, frequently the response was “no”. The patients were just angry and the survey was the best way to express those feelings.
Is anyone naïve enough to believe that I will receive all “5”s from patients who don’t get what they want? It is a statistical fact that survey distributions are bimodal. Really happy and really unhappy patients are the ones who complete the surveys. Even worse, with a few swipes of a pencil, one really unhappy patient can take a doctor who is in the 100th percentile with four patients and drag that doctor to the first percentile. In other words, turn away the patient who wants a Z-pack for his cough at the risk of your income . . . even your job.
Emergency physicians can always use guidance on how to communicate better. Patient feedback is a tremendous asset in this regard. But using statistically insignificant data to measure an unrelated set of data in order to create some illusion that one hospital or one physician is “better” than another demeans our profession and is harming our patients.