It isn’t much of a case, but it created questions in my mind.
A mom brings her 8 year old daughter to the hospital for a nonproductive cough. No fever. No runny nose. Just a cough. The patient had started school again this week, and so the microbiome in her nasal passages had thus begun mixing with all of the other microbiomes on school lunch tables, desks, and childrens’ shirt sleeves. The end result was that now she was coughing for a couple of days – like a majority of other children in the school.
The child looked fine. I told the mother that she likely had a “head cold” and that it would have to run its course.
The mother wasn’t convinced.
“How do you know she doesn’t have the flu”?
“Well, I don’t know for sure, but even if she did have the flu, it wouldn’t change the management right now. It would still have to run its course.”
“I want her tested for the flu.”
“Influenza testing really won’t help us much. The test itself has a high false negative rate, meaning that even if the test is negative, a large percentage of people still end up having influenza.”
“I want her tested for the flu.”
Fine, I thought. It’s your money.
Forty five minutes later, results from the influenza swab came back negative.
“So like I was saying before, this is something that will have to run its course.”
“You said that the test wasn’t accurate. There are a lot of kids in her school with influenza right now. I want her to get Tamiflu.”
“Tamiflu isn’t going to help. It is only effective within the first 48 hours. You said the cough started two days ago.”
“You know, I have always had good things to say about this hospital and I’ve never had this many problems with a doctor in the emergency department before. It hasn’t been 48 hours and I want her to get the Tamiflu.”
So I gave the woman a prescription. Let her spend the $120 for a drug that won’t work.
Then I began thinking. Would some bean counting clipboard carrier claim I provided unnecessary care?
So what do you think? Knowing that rapid influenza testing has a significant false negative rate and knowing that influenza is widespread in the country, but also knowing that a patient has mild symptoms …
Is it unnecessary care to provide anti-influenza treatment to someone who tests negative for influenza?
Yes (76%, 185 Votes)
No (24%, 57 Votes)
Total Voters: 242
By the way, after the visit, a pharmacist called and said that the patient was requesting a different medication since the patient was on state “insurance” and the “insurance” didn’t cover the cost of the medication.
Unfortunately, there isn’t anything else that works which was covered.
UPDATE 1/15/2012Thanks for the votes and comments.
When thinking about this situation, three issues came to my mind.
First, Tamiflu is approved by the FDA for acute uncomplicated influenza when symptoms have been present for not more than two days. It is also approved for prevention of influenza. From a technical perspective, a Tamiflu prescription was indicated if the child had influenza or if the child was being prophylaxed against influenza. The indications for use do not contain a description of any symptoms that must be present before Tamiflu is prescribed. If influenza is diagnosed or being prevented, Tamiflu is indicated.
Second, diagnosis of influenza in an inexact science. Rapid influenza testing is notoriously inaccurate. If the test is positive, there is a high likelihood that influenza is present (although about 1 in 50 patients with positive results do not have influenza). However, if the test is negative, one third of children and about one half of adults will still have influenza. A negative influenza test by no means excludes a diagnosis of influenza. Between 30 and 50 percent of influenza cases are asymptomatic and it is difficult to distinguish between a common cold and influenza early in the course of the disease.
Third, Tamiflu probably doesn’t work. A Cochrane review found that Roche funded all of the studies demonstrating Tamiflu’s efficacy, that Roche hid a majority of the data from studies about the effectiveness of Tamiflu (and still won’t disclose it), and that the study data that was released had significant bias. See also this article from Forbes.
Putting all of these facts together, then we need to consider why most people in this case thought that prescribing Tamiflu was “unnecessary”.
Was it unnecessary because Tamiflu doesn’t work? Then anyone who prescribes Tamiflu is providing unnecessary care.
Was it because the patient tested negative for influenza? How do we accurately diagnose influenza in order to prescribe the medications, then?
Was it because the patient’s symptoms weren’t severe enough? What symptoms are needed before Tamiflu can be appropriately prescribed?
In the end, when dealing with this patient’s mother, I decided that the prescription of Tamiflu ends up being an issue of medical discretion. Most people probably wouldn’t have given the medication to their children for those symptoms, but if she wanted it that bad, the medication was technically medically indicated and not prescribing the medication would have resulted in even lower patient satisfaction scores. So I gave her the prescription.
The incentive to improve patient satisfaction favored prescribing Tamiflu and I had no disincentive for doing so. If the patient’s mother wants to pay for a useless medication that has many side effects in order to treat mild symptoms – after knowing these facts – why should she be prevented from doing so. This is just one example of how emphasizing patient satisfaction adversely affects medical judgment, encourages testing and treatment which is of questionable benefit, and drives up the cost of care.
“Unnecessary care” is going to be a catch phrase in the next few years as government and insurers try to decrease expenditures in medical care by refusing to pay for testing or treatment which is deemed “unnecessary.” When you hear this phrase, ask yourself who is making the determination, how the determination is being made, and who stands to benefit.
Survey “response rates have been dramatically declining over the past decade,” says Paul Alexander Clark, founder of SmartPatient, a health care analytics company. He should know: Until 2007 Clark was in charge of Press Ganey’s patient-satisfaction improvement group. The response rates, he says, are now “too low to produce reliable results.” Insiders have known this for a decade. “This is a dirty little secret in our industry,” a senior Gallup executive wrote in a 2002 letter to the CMS chief. “At those levels the standard rules of probability don’t exist. … This means you may or may not be tracking real patient attitudes.”
The article also states that “flawed survey methods and the decisions they induce, produce billions more in waste.” That’s $280 billion in waste according to estimates in the article. Wasted money so that hospitals don’t lose a percentage of their Medicare payments – government cuts which will total $1 – 2 billion under government mandates geared to save money. The thing is that a substantial portion of the $280 billion will be paid for care to Medicare and Medicaid patients. So the government is paying out a large percentage of $280 billion for increased medical care … to improve patient satisfaction … so that it can save $2 billion. They don’t call it the Affordable Care Act for nothing.
Oh, and when the government was asked for its comments to the Forbes article, it “declined several requests to comment on the record.” Imagine that … refusing to comment on wasteful spending using an unreliable process which is associated with increased patient deaths.
Press Ganey’s CEO, Patrick Ryan’s answer to this stinging criticism of his company’s methods? “Suck it up.”
However, when you look at reviews of Press Ganey by its employees on GlassDoor.com, it is difficult to tell whether or not “suck it up” is advice for physicians who are the brunt of inaccurate statistics or whether it is a directive on how Press Ganey should run its business. Out of 16 Press Ganey employee ratings, only 25% would approve of Mr. Ryan as CEO.
Let’s put this into perspective. The average doctor approval rating in Press Ganey’s surveys is in the 85% range – more than a 4 on a 1-5 scale. Mr. Ryan’s approval rating is in the 25% range — 0.25 on a 0-1 scale. Doctors get chastised for scoring more than 4 on a 1-5 scale while Patrick Ryan smugly smiles with his rating of about 1 on a 1-5 scale. If a doctor had a 25% approval rating in a hospital setting, that doctor would be fired. Done. And the doctor would have trouble finding another job, too. Patrick Ryan? He’s still working his magic at Press Ganey.
But that’s not all. On GlassDoor.com, employees have repeatedly stated that Press Ganey management is “sucking up” the entire company.
For example, one employee review notes that “The current senior managment comes accross as clueless. They have exciting visions with no ablitiy to execute on them.”
Another employee review states that “Press Ganey sells a product that it doesn’t even believe in enough to use internally.” That’s right, folks, Patrick Ryan wants everyone else to “suck it up” and to believe his company’s surveys are statistically accurate, but he allegedly won’t even use those same surveys for his own company. Kind of like Congress exempting itself from the requirements in the Affordable Care Act. This same employee suggests that Mr. Ryan’s approval rating is “generous” and likely from “lemmings of the new leadership” adding high survey marks to “boost the numbers” and skew the survey results.
Anot her employee states “It’s disheartening to be lied to on a daily basis by a group of individuals” at Press Ganey. If Press Ganey’s management lies to its employees, does anyone expect that Press Ganey will be telling hospital administrators the truth when trying to sell its product?
Yet another employee review states that upper management is “unethical” and that there have been 4 CEOs at Press Ganey in three years. Wonder why.
I could keep going on, but you can click on the link above and read the company reviews yourself. It’s actually entertaining to read how many people think that Press Ganey is a poor company.
Suck it up, indeed.
The emperor’s clothes are gone. Everyone sees it yet few are willing to admit it. Patient satisfaction metrics are associated with higher costs, higher death rates, and a former Press Ganey executive has admitted that survey response rates are too low to produce reliable results.
Why are we still using them? One reason might be that the hospital administrators encourage the surveys because the surveys are associated with higher medical spending … to the tune of $280 billion dollars.
It’s OK that satisfied patients are more likely to die.
It’s OK that survey statistics are unreliable.
Hospital administrators know that they can drive doctors to perform more expensive and discretionary testing at their hospitals by catering to patients with satisfaction surveys.
Think about this next time you or a family member has a bad outcome from your hospital care … or the next time you get a resistant infection from discretionary antibiotics prescribed to make you more satisfied … or the next time that a family member dies from an overdose of pain medication that was prescribed to increase patient satisfaction.
You or your family member might just be satisfied to death.
If that happens, you can always take the advice of Press Ganey CEO Patrick Ryan — “suck it up.”
We were away for the weekend, but in a restaurant, I caught glimpses of this segment on 60 Minutes called “The Cost of Admission.” Couldn’t hear the conversations in the restaurant, but luckily CBS posted the entire report online. If you didn’t see it, you really need to watch the video and/or read the transcript.
In summary, 60 Minutes spent a year investigating irregularities in hospital admissions. Administrators at Health Management Associates and at EMCARE (one of the national emergency medicine contract groups) were accused of putting pressure on emergency physicians to admit at least 20% of patients that came to hospital emergency departments. For Medicare patients, the “benchmark” for admissions at one hospital was allegedly 50%. The 60 Minutes expose also included spreadsheets showing comparisons of different physicians’ admission practices and text from e-mails saying such things as “I have been told to replace you if your numbers do not improve.”
HMA held a conference call disputing the allegations and stating that they “take all allegations regarding compliance very seriously.” HMA allegedly had outside experts review the data (not the medical records?) and the experts determined that “the data simply do not support the allegations.”
Now HMA is being investigated by the US Department of Justice for Medicare fraud. I predict that HMA will make a large settlement with the government to drop all charges (without admitting wrongdoing, of course) and that things will return to business as usual shortly thereafter.
With things like this, I can’t really blame patients for thinking that medical care is “all about the Benjamins.”
I was surprised by the tenacity of a mother whose 12-year-old child had twisted her ankle while running in gym class.
The exam showed minor pain and no soft tissue swelling. Perhaps a little point tenderness over the distal fibular growth plate. X-rays showed open growth plates (see orange arrows), but no other injuries. I discussed the possibility of a Type 1 Salter Harris injury and the generally excellent outcomes. I recommended rest, ice, and crutches. Asked the tech to place an air splint on the patient’s ankle.
“She can’t use crutches. She needs a wheelchair. And an air splint isn’t going to protect her ankle well enough.”
“Why can’t she use crutches?”
“The last time she injured her ankle, the orthopedic specialist told her she needed a wheelchair. He wrote her a prescription for the wheelchair. She was in it for at least a month in school.”
I looked through our medical records. No previous visits. Turns out the incident the mother described occurred in another state.
“I can’t comment on what happened before or the reason that the orthopedist believed she needed a wheelchair for a month, but it looks like she’s more than capable of using crutches now. We’ll show her how to use them before we discharge you.”
The patient apparently was on board with the mother’s plan. Even though she could hop on one foot from the wheelchair in the room onto the bed without problems, she nearly fell over twice when they were crutch-training her. One time, she landed on her bad foot and screamed in pain. That sent mom into a rage.
So they got what they wanted. Short leg splint. Wheelchair for two days. Mandatory orthopedic follow-up within that time period.
Then comes the Press Ganey comment several months later.
“Doctor was rude and dangerous. Wouldn’t listen to me when I told him that my daughter needed a wheelchair for her injury. Missed an obvious fracture through both bones on my daughter’s x-ray. Tried to get her to walk on her bad leg and when she did, she fell, causing a worse injury to her ankle.”
Of course, there is no way to respond to these untrue statements. And the complaints are taken as true by hospital administrators.
In retrospect, I probably should have just admitted her and put her in traction for a couple of weeks.
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.
By the way, the “Death Knell” article is now number two on the list when you do a search for the term “Press Ganey”. The “Flunking Own Rating Scale” article I wrote is number three on the list. Clicking on the link to this article a lot will make it climb in the “Press Ganey” search term rankings as well.
What you’re getting at, is the core of why patient satisfaction scores in the ED are so soul crushing to some of us and what is so fundamentally different psychologically and philosophical about being a physician in the ED, compared to any other setting.
Outpatient physicians have always had their own version of “Press-Ganey”. So does every business in a free market. In their case it’s “name”, “reputation”, and “practice building”. If their patients don’t like them and aren’t “satisfied”, they go elsewhere and the practice, and ultimately the docs pocketbook, suffers. If their patients are satisfied, the physician benefits with a more robust practice and fatter wallet. This is like any other “business”. The better a business is at providing a product or service, the better off the business is. This is how it should be. Doctor makes patient happy, happy patient makes doctor happy. It’s a positive feedback loop. (Although a physicians practice is more than “just a business”, it is a professional practice held to ethical standards, it has to pay the bills, with dollars and cents, according to the rules of business.)
However, the ED is like no other business in the world. In the ED, you’re swamped no matter what. You have no control over your workflow. There’s essentially no risk, ever, of not being busy enough to “put food on the table”. Being overwhelmed with patients is the rule. Whether or not there are too many patients to see, or twice as many patients than you can see, or three times as many patients as you can see, does not affect your pocketbook, and does not increase your job satisfaction. In fact, the busier it gets in the ED and the more”customers” there are, the worse the job satisfaction. It’s a negative feedback loop. Unlike the outpatient doc, where the more satisfied the patients are, the busier the practice is, the healthier the pocketbook is and the happier the doc is. In the ED it is the exact opposite. In fact, you are grinding the machine to increase the job satisfaction (and profits) of someone else such as an administrator that you might not have even met or barely know.
This is why outpatient physicians in private practice (and all good businessmen including hospital CEOs), especially ones in their earlier years building a practice (or business), just don’t see what all the complaining is about. To them, “patient satisfaction” is their lifeblood. Without it, they can’t pay their staff, their practice overhead or their own salary let alone have any profits left over. This is a crucial difference. Another crucial difference is that when they reach the point of saturation, there are several protective mechanisms not available to ED physicians, that keep the work load and stress load to a manageable level:
So I happened to be looking through my blog stats to see which posts are most interesting to you all lately.
One of the stats on the blog is search terms that cause people to end up on my blog. Some of them are amusing, such as “How do I disimpact myself” [ANSWER: You don't] and “Why do hospitals want JCAHO accreditation anyway?” [ANSWER: It beats the heck out of me, too]
I have become one of the de facto resources for people who want to know whether they need antibiotics to treat strep throat and for demonstrating what an infection of lice looks like … which is just wonderful because after I published to the world that my kids just got over lice, the search rank will probably go up even higher and I will soon be known as the Head Louse King.
But I found it most amusing that my blog is the third on the list of Google search terms when someone does a search for “Press Ganey.” The article that pops up is “A Death Knell for Press Ganey” which I wrote in February.
I flipped through the pages of results and happened across a page titled “Press Ganey Reviews.” What the heck, I thought. Let’s see how Press Ganey’s ratings stack up.
According to Press Ganey‘s own ratings scale, it fails. Using ballpark estimates on a 1-5 scale, doctors and hospitals have an average rating of about a 4.3 or so. Drop to the 3.5 range on the 1-5 scale and you’re scraping the bottom of the barrel in the ol’ percentile rankings.
Press Ganey’s rating on a 1-5 scale is a rocking 2.8.
When compared to the scale that Press Ganey uses for hospitals and doctors, Press Ganey’s ratings flunk. And only 33% of employees approve of Press Ganey’s president Robert Rob Draughton. Allegations of nepotism, poor pay, high employee turnover in the comments section of the reviews (.pdf file in case site is removed). One employee stated that “Management does not take feedback.” A company that earns millions of dollars on feedback from other entities doesn’t take feedback on itself?
If Press Ganey were a doctor, it would be out on its ear.
For those of you who believe that patient satisfaction ratings are a detriment to health care and to our patients, a study published yesterday in the Archives of Internal Medicine titled “The Cost of Satisfaction” is a must-read.
Not only does “satisfaction [have] little or no correlation with Health Plan Employer Data and Information Set quality metrics,” but, according to the results of this study, hospitals that push to have the highest satisfaction scores may be harming or even killing their patients.
Noting the “tenuous link between patient satisfaction and health care quality and outcomes” the authors found that patients who had the highest satisfaction were more likely to be admitted to the hospital, spent more on health care, spent more on prescription drugs, and were 26% more likely to die than those who had the lowest satisfaction. When study authors excluded data for patients who rated their health as “poor” or who had a “substantial chronic disease burden,” they found that with “healthier” patients, the association between high patient satisfaction and increased patient deaths became even higher.
Next time you see a hospital brag about its high patient satisfaction scores, remember what this study shows: High satisfaction with a health care facility means that you’re more likely to be admitted, you’re more likely to pay more for your care, and you’re more likely to be discharged in a body bag.
Still think “satisfaction” and “quality” are synonymous?
See more medical news from around the web over at the Satellite Edition of this week’s Update at ER Stories.
The story of “Dr. Douchebag” and why morale is declining in many of this country’s emergency departments. Even if you say “thank you, sir” for the abuse, your job may still be threatened because of bad Press Ganey scores.
Indiana woman awarded $1.5 million after surgeon did not operate on abdomen soon enough. Two days after initial presentation, she required emergency surgery for ischemic bowel requiring that a large portion of her intestines be removed.
Sorry, Grandma, I know that your bone cancer is causing you excruciating pain, but you can’t have any more pain medication. As Florida cracks down on doctors who treat chronic pain patients, the patients are having more difficulty getting their medications. Where do the patients end up? In the emergency departments.
When pill abusing patients go to the emergency department and don’t get their medications, some become abusive and violent.
Now some Florida hospitals are implementing a “chronic pain management plan” which requires doctors to “help educate patients about the dangers of abusing prescription drugs and addiction.” Got that, Granny? You have bone cancer and you have six months to live, but abusing oxycontin is dangerous and can kill you.
As part of the “plan,” emergency physicians then will “refer the patient to a primary care physician” – who has already been “cracked down upon” and who won’t prescribe the pain medications, either.
End result? In an attempt to curb abuse by criminalizing the prescription of pain medications, Florida is now affecting the ability of patients who are legitimately in pain to receive necessary treatment. Cancer pain patients in Florida now more likely to get bounced around the system and die in pain.
And people blame the physicians instead of the legislators.
Patients gone wild in Pennsylvania. Woman gives medical staff hard time in ED, pulls out IV, threatens to infect everyone around her with HIV, kicks a security guard in the cha-chas when trying to escape, then is wheeled out of the hospital by police kicking and screaming in a wheelchair. Initially charged with three felonies, but those charges were dropped by persecutors er, um prosecutors. Of course, if the security guard was an off duty police officer, the patient would be doing 20 to life in Leavenworth.
Patients gone wild then … police gone wild? Patient becomes combative in emergency department. Police called, then allegedly “strike the patient, place him in a headlock, pull and twist his head and forced handcuffs on him with force and violence.” Another officer allegedly “pushed the handcuffed man over a metal chair arm with the force of his weight pressing upon him.” The officers could face jail time and fines if found guilty.
Patients gone wild — Twilight Edition. Toledo woman allegedly tries to steal baby from hospital. When ED nurse approaches her, the woman turns around and bites her. Then she hisses, turns into a bat, and flies away.
While many patients can’t afford health care at all, some hospitals cater to the ultra-rich, charging them between $450 and $4,500 per day in order to have a butler, swank hospital rooms, and an exclusive menu. Meanwhile, other patients wait in the emergency department for days before a hospital bed opens up. Oh, and medical residents aren’t allowed on the units, either — only attending physicians.
Kevin Pho from Kevin, MD wrote an article in USA Today providing some suggestions on how to reduce malpractice lawsuits. Some people commenting on the article demanded that physicians’ hours be cut back so that they aren’t overworked while trying to pay for their “expensive houses, cars, and boats” (see comments section).
I say “be careful what you wish for.”
In other countries, people are demanding that physicians work more hours because patients can’t get the care they need when the doctors work banker’s hours.
If you haven’t read the first part of this two-part series, which was published before the primary results were known, please go here to review it.
The final results in the New Hampshire Republican presidential primaries have been published and I’m confused.
Based upon the sample from Dixville Notch, each candidate should have received one portion of the votes, but when a larger sample size was taken, the candidates all received different portions of the vote. None of the final results were even close to the predicted results from Dixville Notch.
Jon Huntsman’s scores were off by 31%
Ron Paul’s scores were off by more than 100%!
Rick Perry’s scores were pretty close, but he still got votes even though the survey said that he wasn’t supposed to get any votes at all.
Rick Santorum should be happy. The initial survey said that he would get 0.000% of the vote. He ended up with 9.4% of the vote. What a massive error that was!
Dixville Notch Predicted Percent Vote
Actual Percent Vote
1/9 = 11.1% of vote
9.4% of vote
2/9 = 22.2% of vote
16.9% of vote
1/9 = 11.1% of vote
22.9% of vote
0/9 = 0% of vote
0.7% of vote
+ “a lot” %
2/9 = 22.2% of vote
39.3% of vote
0/9 = 0% of vote
9.4% of vote
+ “even more” %
Now you can see from the sample of an actual Press Ganey report in the previous post, a difference in a “mean score” of less than 1% can make the “percentile rank” change by 5 points or more. What happens when the mean score changes by 100% or more? Disaster.
So it seems that the scores from small sample sizes in Press Ganey surveys are pretty much like random number generators.
Kind of like administrators praising and demeaning staff based upon how many blue Chevrolets drive past the hospital between 3PM and 4:30PM on Tuesday afternoon. If there are 5 Chevys, you’re the best. If there are 0 Chevys, you’re fired.
If administrators and hospital boards can’t see the problems with basic statistics, how are they supposed to run hospitals effectively?
Make sure to leave a copy of this post on your administrator’s desk or under your administrator’s door.
We need to bring some accountability to those who manage our profession.