I just bought a brand new car. As I was about to drive away, the dealer reminded me that I would be receiving a survey in the mail. He asked that I be sure to fill it out and send it back as his, “future depends on it”. I could not help but think of many of my colleagues who say the same thing to their patients upon their discharge.
Emergency medicine is the youngest specialty and we (and those before us) have fought long and hard to gain acceptance and legitimacy. We demand to be taken seriously, yet we have become beholden to outside forces that dictate our every move. How can we expect to be taken seriously, let alone take ourselves seriously, when we allow patient satisfaction (“patient sat”) surveys to tell us how well of a job we are doing? I am not implying that we shouldn’t care about what our   patients think of us, but rather that our number one priority should be to provide good, honest, care and do the best, at all times, for all our patients. Hospital administrators place excessive stock in these scores, and to what end? I can see rationale for clinical outcome measures as we should always strive to improve upon our mortality and morbidity rates, but not only do patient sat surveys not improve care, they threaten to bring the system to its knees. Here’s how:

Problem #1: 
You can’t please everyone
Let’s face it, sometimes EPs have to be the bad guys, and there’s no way around it. We have to tell the drug addicts that they won’t be getting any more Percocets. That’s not going to go over well. We have to tell the patient with the hangnail that he’s going to be waiting for hours, or worse, that he shouldn’t have come to the ED in the first place. He may be a bit frustrated. What happens when it becomes our priority to make these individuals happy? When we bend our knee to patient sat surveys we risk becoming beholden to drug addicts and serial abusers of the system.

Problem #2:
Don’t mess with triage

If you really want to improve your EDs patient sat numbers, you should focus your attentions on those patients who will actually receive a survey, right? The problem is that patients who are admitted, i.e. the sickest patients, don’t receive surveys; it is the less acute patient who gets one. Therefore, patient sat surveys put direct pressure on EPs to see the sickest patients last and the less acute first. Rather then educating the people who inappropriately utilize our services the surveys simply encourage them to keep coming back.

Problem #3:
Legitimizes system abusers

We have a national problem in the United States — ED overcrowding—due in no small part to individuals using the ED for primary care services, knowing that they won’t be turned away. Patient sat surveys send a clear message to these system abusers that the ED is here to serve them, in whatever capacity they choose. “Thank you for seeking care at our hospital,” we say, “we want to know what your experience was like in our ER for the toe pain you have had for six years. How were you treated? Was the waiting room nice? Was the triage staff appropriate? Please come back and see us again!”
Problem #4:
Salaries tied to surveys

I care about my patient sat survey scores because I am told to by my boss. More important, however, my bonus is directly tied to my patient sat scores. So now my salary is, to a great extent, being determined by drug addicts and other abusers of the system who know nothing of the quality of care I provide. All they know is that they spent four hours waiting to be seen only to have me tell them that their “cold” is indeed just that. They want their antibiotics and/or Percocets and, of course, are not happy they waited and left empty handed.

Problem #5:
Misspent funds

Hospitals are going bankrupt (see Prince George’s County hospital in Maryland) because of declining or non-existent reimbursements. And yet emergency rooms are bursting at the seams with individuals seeking routine care. And still, hospitals spend millions every year on patient sat surveys. Can these expenditures be validated with real results or are we just throwing money at the problem? I submit that patient sat scores tell us nothing of real use, and we ought to redirect these funds.

Problem #6:
Sat scores have become a game

What does it say about patient sat scores that emergency departments hire “Patient Sat experts” who teach physicians little tidbits to get their scores up. This entire scoring system has become a game. These consultants feed us lines to say, tell us to hold the patient’s hand, bring them a soda, a  sandwich, and legitimize their complaints and those of their family. Basically, give the patient what they want, anything to get your scores up. Many EDs even pay people to make follow-up phone calls to raise their scores. When did patient satisfaction become so much like the scoring on American Idol?
It’s time for a change!
What gets my ire up are hospital administrators and their lobby groups. They are the first ones to stand up and complain about ED overcrowding, yet they directly encourage it by relying heavily on patient sat scores. You want to cure this problem? First, eliminate patient satisfaction surveys. Second, institute advanced triage. Put a nurse, PA, NP or EP in triage (depending on comfort level) to do a medical screening exam. I know we already triage, but we need to take it one step further. Those who are sick or potentially sick should be brought right back to the ED; those who are not should be educated! They should be told that the ED is happy to provide treatment, but that there is a co-pay, payable in advance. They should be provided with a list of alternative free clinics in the area for them to consider. By doing this, the overcrowding problem is fixed, EMTALA’s requirements are satisfied and the liability is not any worse than it is now (patients were screened, offered admission to the ED and given alternative, more appropriate venues at which to seek care).
All of that said, we cannot legitimately stand up and complain about any of this because we have sat back and watched it happen. Our complacency implicates all of us and we have thus lost the moral high ground. We are being encouraged to prescribe inappropriate medications, change the way we triage and treat patients, perform minimal to no real education and encourage people to keep coming back to the ED for their primary care. This, I am sorry to say, is the reality of modern, community emergency medicine. We should be ashamed of ourselves for allowing our profession to sink this low, for allowing administrators to dictate how we practice, how we prescribe and how we care for our patients. Mostly, we should be ashamed for what this has done to our emergency rooms in the guise of increased wait times, overcrowding, hospital closures and, according to every recent study on the subject, wholly inadequate preparation for any natural or man-made disaster. In short, we have failed the American people, and I for one am ashamed and embarrassed. We have no one to blame but ourselves. This was not what I signed up for when I entered the field of emergency medicine, I will tell you that.
I would argue that as the “front line” in the health care system, we have a greater responsibility to the population as a whole. If the politicians and hospital administrators will not fix this problem, we need to stand up, exercise some leadership and do so ourselves.
Ron Elfenbein, MD, assistant director at Harbor Hospital in Baltimore, recently campaigned to become a Maryland state delegate.


# Benny Mullins MD 2007-09-15 19:08
Amen! We, as you state, are encouraged to be unethical. JCAOH, administratorts and lawyers are destroying medicine, not insurance companies.
# You Nailed It.Scott G. Shelp, RN CEN BA 2007-09-18 11:30
Dr. Elfenbein, you're sure to get much criticism from more "politically correct" professionals in our arena, but you've raised valid points. We are here to make people healthy, not happy. Ideally, they'll be happy about that, but sometimes they'll get answers they don't want to hear. While we welcome feedback on our courtesy and efficiency, satisfaction surveys will always be tainted by patient's (sometimes unrealistic) expectations about what the ED can provide them. Keep speaking out!
# NiceAaron 2007-09-22 16:14
I've been waiting to have my views expressed so well. Community EM is not what we're teaching residents how to do. It also seems almost universally shocking to the new grads that this is what EM actually is. I keep hearing "why did I choose this specialty again?"
# unbiased evaluatorsRyan 2007-09-28 19:47
Excellent article. Dr Elfenbein, if you read your comments, hopefully you can respond to this.
Does a consulting group exist that shadows doctors to evaluate their care? For example, if an experienced ED nurse were to solicit herself as an evaluator of care, would that be beneficial. Instead of handing out Press-Gainey reports on X number of paients and receiving variable feedback, perhaps a person who is familiar with "appropriate and compassionate" care may be a better evaluator than the patient themselves. By silently shadowing a group of physicians over the course of a week or a few days, that evaluator may be able to give an unbiased impression of the care provided. This would not only be more valid, but more consistent. Obviously, an intrusion into the doctors world, but no more so than a regular nurse to the patient. Patient wait times compared to averages, nurse to patient and doctor staffing ratios, etc could all be included. Perhaps even triage scores all graphed on a chart in a final report. How much would it cost? Not sure. How valuable would it be? Who would it be valuable to: the hospital, the physician, the group administrator, the patient population at large? Could it do a way with the patient assessments?
Perhaps this already exists, but I haven't seen it. We hire expensive consultants for all kinds of things (patient flow, revenue cycle, billing and coding), would we hire an appropriately paid unbiased reporter to give us feedback (valuable feedback) on our compassion and service. While all that is important, maybe it could acheive my dream goal and get rid of the Press-Gainey once and for all.
# ED doc grandfather'd diplomat ABEMLynn E Taylor MD 2007-09-30 21:09
Amem brother..... could not have expressed the travesty of sat scores much better myself...lost count over 16 yrs ago the number of people that should not be in the ED that are the most vociferous and unjustly so... I do catch myself bending over backwards to explain(at the expense of precious time) the reasons for a treatment(or lack or) to avoid complaints or bad reports because of my concern someone will misunderstand my intentions.... Since I do locum tenens, all it takes is one complaint!!! I look very forward to retirement!!
# ER gruntRick Herndon D.O. 2007-10-02 20:23
Maybe some genius should develop a sat. survey for the poor slobs who work in every ED in this country to really know how bad it is! It doesn't seem that as a speciality, EM will be able to keep some of the best people over the long term.
# Doctor Satisfaction Surveys?Cindy, MD 2007-10-03 07:30
In my experience with patient sat scores, patients gave low scores when they didn't get what they want (e.g. they wanted me to go give patient information to family members over the phone which is a HIPA violation, they wanted admission but didn't meet admission criteria, they wanted refills of pain medications which were not indicated in the their treatment, etc). When teaching residents, I often say that our job is to determine what a patient needs, but sat scores have indicated to me that we are suppose to determine what they want and try to please them. I often wish that we had doctor satisfaction surveys where we could document any ill personal interactions with patients (as you medicalegally cannot do this on the chart).
# ARNPAngelo M. Mishio 2007-10-04 06:07
Dr.Elfenbein- your contention is that pt sat surveys are going to bring down the ED system. Isn't that a being a bit overdramatic? You state, "pt sat scores tells us nothing of real use." Have you ever looked over a survey? One that was perhaps filled out about you? You would be surprised what they tell you. I have and have changed my practice for the better. Your contention that pt sat surveys are "putting pressure" on ER docs to treat less acute pts before the "sicker ones" is a stretch. Is a survey that indimidating? Come on. Your whole commentary was looking at ER pts through the eyes of an ER doctor. Have you ever been an ER pt? How about a family member? Your whole perspective will change. It's true you cann't please everyone. Yes there are drug seekers, system abusers, and when the shift is busy its hard to be kind and patient. But you know what? You don't have to go through this. If pt sat surveys are ruining your career this much why don't you quit? As you say, "it's not what you signed up for." But then again, that new car you just bought, will not pay for itself. We all get paid good money, I might dare to venture and say great money. Shouldn't we be expected to give good customer satisfaction? Yes, I said it, customer satisfaction. Why are we fighting this? This is a whole paradigm shift that has been going on in the US healthcare system for years, decades. Why not embrace it? Is that not your expectations when you/your mom/dad, whoever, sees a doctor? To be seen timely, and professionaly? The other day I was talking to an ER physician and his family member went for outpt bloodwork. They had to wait close to 45 minutes, so they complained and left. What was his expectation? The issues involving overcrowding, uninsured, ect within the ED are a lot larger,more important, and having very little to do with pt sat surveys. Why not address these issues in a future article? And step down from the soapbox. Pt sat surveys are here to stay, and thankfully will not be the end to ER medicine.
# Response to ARNP?Ron Elfenbein 2007-10-16 23:14
Dr. Mishio,
Thank you for your comments. I think you missed the entire point of my article. Yes, I have looked at surveys about myself and yes, I have learned some things. I never opined that these surveys are useless, just that the hundreds of thousands of dollars spent on them might be better directed elswhere (like more nurses -which EVERY study shows makes patients happier, or working monitors, more techs, more stretchers, nicer waiting rooms, etc..)-There, I just solved your satisfaction problem and saved however many hundreds of thouands of dollars your department spends on the surveys- I will wait for your check.....

Is not the point of the EMERGENCY ROOM to service Emergencies? Are we not the "final safety net" in the health care system? As I stated in my article, these surveys merely justify the visits we all see for such ridiculous things as: "I want a pregnancy test" or " I have had this pain for 12 years but it was convenient for me so I came in today".. I argue the ER is not the appropriate venue for this and these surveys merely encourage this sort of behavior. What percentage of patients do you see that really need to be in the ER? National polls estimate this number to be lower than a third... Yet, you want to encourage them to keep coming back???

We saw 1/3 of this nation's population in the ER last year...A THIRD.... We saw them in fewer departments, with fewer beds, fewer nurses and fewer resources. I would argue sir, that this is NOT sustainable and our system is in danger of imminent collapse. We are woefully unprepared for any disaster as we are already operating so close to the edge. How can one argue against this?

Of course we should all strive to be nice, to be appropriate and to be "efficient". However, do the ends justify the means? Again, I argue that these surveys are simply justifying patients' inappropriate use of our services. Further, these surveys, or the threat of the surveys, keep us and the nursing staff from educating our patients, as I also suggest in my article. Rather than explaining to our patients that it is not appropriate to call 911 for a pregnancy test or for "I have a cold", we are worried they might get a survey so we "skip" that all important step, prescribe inapproriately because we "want to make the CUSTOMER happy" as you suggest..Again, do the ends justify the means?

Would you agree that there is an overcrowding problem in this country's ERs? Again, my contention is that we are the final safety net and that as such we need to treat emergencies, not "you were more convenient". How anyone can argue with this point, I fail to understand...

And no, thanks for suggesting it, but I have no plans to retire anytime soon. The "customer is always right" model works for retail and perhaps you are happy working retail, I, however, believe our patients and our nation deserve better.
# Patient and Retired 21 year Healthcare EmployeeBarBara 2009-02-03 15:39
I have read a lot of your comments but I failed to see any mention of the perception of the patient when entering the ER. If you have indifferent ER Techs that do the initial triage and then stick the patient in a room and forget about them,
it will hit the patient satisfaction scores dramatically! Physicians, you can give the very best of care in the ER, but a lot of the time the patients perception of their care is tainted by the emergency room staff. You need to find a way to make the emergency room staff accountable for their behavior! You also need to see the entire patient satisfaction survey results. When management ignores the complaints of the patients, of course, you get low scores. But instead of placing the blame on the physician, look at the staff!!
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