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BMI Measurements Inaccurate But Still A Government Gold Standard

Saturday, June 14th, 2014

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Everyone needs to read this NY Times article and then think about how inane the concept has become.

The Body Mass Index or “BMI” is used as a measure of a person’s body weight. If your BMI is between 18.5 and 25, you’re normal. More than 25 and you’re overweight. More than 30 and you’re obese. The measurement is based on a person’s weight and height, but it was originally created in the 1800s to measure human growth – not as a measure of a person’s ideal body weight or health. More recent studies show that people considered “overweight” using the BMI measurement are healthier than those who are at the lower end of the “normal” measurement. One study shows that likelihood of death increases with a BMI of less than 23. BMI doesn’t account for the distribution of body fat (abdominal fat is less healthy), BMI falsely classifies muscular individuals as “obese”, and even the CDC has recommended that doctors not use BMI as a diagnostic tool.
Yet what is one of the things our government requires that doctors calculate on every patient’s chart in order to meet “meaningful use” criteria?
You guessed it.
A BMI measurement.

This is what happens when inmates run the asylum.

The reason that we are being required to measure BMI isn’t because a patient’s BMI has any meaningful clinical use … it’s that the BMI can be measured. If it can be measured, it can be tracked. If it can be tracked, then people (essentially health care providers) can be manipulated and penalized if some arbitrary number on a meaningless scale isn’t reached.

Think about it. If we tried to find other substitutes for “health”, they would be difficult to calculate. How many calories does a patient eat? How much alcohol does a patient drink in a day or week? How much exercise does a patient get each day or week? There’s no standard way to objectively quantify or objectively measure any of those criteria.

Instead the government sticks with something easy to measure – even though it has no bearing on a patient’s health. With a little propaganda, the government can make all the patients who don’t know any better think that BMI really is a useful measure of health. Then, if the BMI isn’t calculated and put on the patient’s chart, it gives the government a means to reduce or deny payments to the healthcare providers.

Calculating a BMI and asserting that it is a representation of health is like measuring the number of clouds in the sky at 3PM each day and claiming that a higher number of clouds is an accurate representation of good government.

The scary thing is that another industry has been making similar assertions for years and certain village idiots just continue to believe the misinformation.

Patient satisfaction scores have long been asserted to be a surrogate measure for healthcare quality. Of course, those assertions are made by corporations which receive hundreds of millions of dollars each year from hospitals so that they can compare one hospital to another … on a statistically invalid and entirely misapplied metric. Studies prove that higher satisfaction is associated with higher healthcare costs and almost double the amount of patient deaths. Recall the story about the Texas neurosurgeon who maimed and killed patients yet who had great Healthgrades.com scores (which were suddenly removed by the Healthgrades staff when the story broke). Healthgrades knows its data are inaccurate, but persists in collecting and disseminating inaccurate and potentially dangerous information.
Junior high statistics classes teach twelve year olds that inadequate sample sizes automatically prevent you from making valid conclusions from the results. Want a real life example? Open up a pack of skittles, take out 5 pieces of candy, note the proportion of colors, and then see if those proportions match the proportions of colors left inside the pack.

Despite the woefully inadequate sample sizes and scientific evidence showing that these measures have no bearing on patient outcomes, the same government that relies upon BMI measurements as a representation of health is going to rely upon patient satisfaction scores as a measure of healthcare quality … and will reimburse hospitals less for care when they have lower satisfaction scores. Hospital administrators and hospital governing boards swallow this obviously inaccurate and misleading information like high school kids sucking beer through a beer bong — all in the name of profits with little regard to the adverse effects on patient health.

It is refreshing to see that hospitals are starting to be held accountable for these decisions. It is easy to prove administrative negligence and hospital board liability when bad faith actions harm patients so that hospitals can earn more money.

After all … the sun is shining. That means that BMI measurements and payment for satisfaction are bad government policies that no one should follow.

I’m a scientist. I know these things.

The Effectiveness of Advertising

Wednesday, June 11th, 2014

A cute little 6 year old boy was brought from home. He had autism and didn’t communicate much.

His mother stated that he would occasionally just stop eating and drinking. Then he would get dehydrated. Then he’d get constipated. Then it would be a big problem to attempt to get him un-constipated. He had to be hospitalized for dehydration a couple of times and he had to be manually disimpacted once. The mom estimated that he had gotten significantly dehydrated 4-5 times in the past few years. So the patient’s pediatrician sent him to the emergency department to get some IV fluids in order to attempt to avoid the progression of events.

I examined the boy and he did seem behind on his fluids. He hadn’t urinated since he had woken that morning and his mucous membranes were tacky.

I asked him “Won’t you drink some juice for me?”
He said “Dehydrated. Need fluids.”
OK. Interesting vocabulary for a six year old.
“I know you need fluids. Could you drink some fluids to make you feel better?”
“No. Dehydrated. Need fluids.”
The nurse brought him some juice. He turned his head away and got upset when it was offered to him.
“Dehydrated. Need fluids.”
“We’ll have to stick you with a needle to give you fluids if you won’t drink.”
“Dehydrated. Need fluids.”
His mom interjected. “He’s really good about IVs.”

Difficult situation. On one hand, the kid did seem dehydrated. But the source of his dehydration seemed entirely psychogenic. It was almost as if he wanted an IV. On the other hand, if he did have some underlying desire to get IV fluids, would giving him IV fluids just encourage him to stop eating and drinking on a more regular basis?
Then you weigh the upsides and the downsides.
Potential Upsides: IV fluids seemed to be what the primary care physician, the mother, and the patient wanted. Little harm. Hopefully a quick disposition after receiving the fluids.
Potential Downsides: Probably overkill. Would be the first point of contention if the kid kept refusing oral fluids and required hospitalization. There’s no guarantee that the kid would start drinking again after he was “tanked up.” Probably would result in unmet expectations if wasn’t done, which would likely result in complaints to the administration and possibly negative Press Ganey scores.
As an aside, this situation perfectly demonstrates the perverse notion of HCAHPS and patient satisfaction ratings. If you don’t give the patient a desired treatment that is of questionable medical benefit, you get bad reviews from the patient and the government or hospital penalizes you. If you do give the patient a desired treatment that is of questionable medical benefit, you get accused of providing “unnecessary care” and the government or hospital penalizes you. You’re put in a no-win situation where you’re guilty of some misconduct regardless of what path you choose. But that’s another story.

In the end, the potential downsides won out. The kid got an IV.

So they sat there watching TV as he got a few fluid boluses. The patient sat there intently watching the shows and even more intently watching the commercials.
“He LOVES watching TV commercials,” his mom said.
He finally urinated which was my cue that his tank was full.
The mom asked if I was planning on doing any blood tests.
“Not really. They aren’t likely to change our treatment course. Besides, kids are pretty resilient.”
Then the patient chimed in. “High cholesterol. See your doctor.”
“Wow. You did see your doctor today,” I quipped.
“High cholesterol. See your doctor.”
So I asked him “What would your doctor give you for high cholesterol?”
Without missing a beat, he said “CRESTOR!”
I looked at the mom. She shrugged and smiled.
“Well, it’s time for you to go home and drink some Gatorade.”
His eyes opened wide “Yeahhhh. The THIRST Quencher.”
“Yeahhhh,” I echoed.

Now why didn’t I think of that before we started the IV?

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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.

Anatomy of a Tragedy and Healthgrades.com

Sunday, September 8th, 2013

Saul Elbein deserves a shout out for the article he wrote in the Texas Observer titled Anatomy of a Tragedy. If you haven’t read the article, you need to go get a cup of coffee, sit down and take it all in. I disagree with his suggestion that the problems raised in the article may have been the price of living in a “free market”, because a free market system would require more transparency, but I won’t let my disagreement with him on this point overshadow an excellent article.

The article chronicles how a neurosurgeon in Texas permanently injured and likely even killed multiple patients during surgery and how the Texas Medical Board failed to timely respond to complaints that were raised. As a result, the neurosurgeon, Christopher Duntsch, continued operating on patients and patients continued having bad outcomes from his surgeries. The article also shows the down side to tort reform in Texas – noneconomic damages are limited to patients who have been permanently injured and to families whose loved ones have died due to the physician’s malpractice.

One of the issues raised in the article that I wanted to expand upon was why patients kept going to Dr. Duntsch for surgical procedures. After all, this doctor reportedly maimed patients during surgeries. Who would go to him knowing that information? Obviously his quality as a physician was substandard, right? Healthgrades.com Duntsch Patient Satisfaction Ratings

Maybe not. Check out Dr. Duntsch’s profile on Healthgrades.com. What you would have seen before Healthgrades.com reomved the information was that the same doctor who was reported to have caused the deaths of several patients and who reportedly permanently injured multiple other patients was rated as a 4.3 out of 5 in patient satisfaction. Dr. Duntsch rated above the national average in every one of Healthgrades’ patient satisfaction survey details except the total wait time in exam rooms – where he rated the same as the national average.
Now Healthgrades.com has decided to remove all of the satisfaction information from Dr. Duntsch’s profile, so all you’ll see is a bunch of blanks on his ratings page.
But I got a screen grab of the ratings before Healthgrades erased them.

Why am I making such a big deal about Dr. Duntsch’s satisfactions ratings on Healthgrades.com? Simple. The discrepancy between Dr. Duntsch’s patient satisfaction and his quality of patient care clearly shows how patient satisfaction fails an a measure of health care quality.
Quite a few patients were extremely impressed with Dr. Duntsch … until they woke up from his surgeries paralyzed, in severe pain, or dead (yes, I really wrote “woke up dead” — how many of you remember that post?) Patients in the article told Saul Elbein that they didn’t know any better. They had no way to know how bad of a physician Dr. Duntsch may have been.

Healthgrades.com is not the way to make that determination.

In fact, Healthgrades.com has many complaints about the accuracy and validity of its ratings. It is rated at the lowest score by 88% of all people giving it a rating on ConsumerAffairs.com. I had one reader write me about how Healthgrades.com published that he was still seeing patients when he has been retired for 10 years, how Healthgrades published his home phone number, and how patients call his home phone number at all hours of the day and night, then yell at him because he is retired. According to the comments on the Consumer Affairs.com site, Healthgrades has repeatedly been accused of publishing inaccurate information about physician practices and of publishing a physician’s personal information (such as home addresses, private telephone numbers, and names of spouses). Before allowing the physicians to change the information, Healthgrades.com reportedly requires physicians to agree to legally inappropriate terms of service on its web site.

Of course when doctors complain about how patient satisfaction survey companies like Press Ganey have invalid statistics that don’t measure physician or hospital quality, those with a vested interest … like Press Ganey CEO Patrick Ryan … tell them to “suck it up.” We’re just a bunch of whiney professionals who can’t stand the fact that we’re being rated, right? Want to know the real kicker? Healthgrades.com CEO Roger Holstein has a lot of experience with healthcare information services. According to this article, he is a board member and director at … Press Ganey.

Healthgrades.com erased the ratings on Dr. Duntsch’s profile for a reason. That reason was that Healthgrades.com KNEW that Saul Elbein’s article exposed the disconnect between satisfaction and quality and if that disconnect is made public, it would adversely affect Healthgrades’ business model.

Healthgrades.com SloganIf you want to keep pretending that patient satisfaction is a good measure of health care quality, that’s your call. I’m sure that there are plenty of other physicians like Christopher Duntsch who will be rated highly at the Healthgrades.com web site. Healthgrades’ Twitter account states that more than 200 million people use its services to select physicians and hospitals and that it gives “comprehensive healthcare information to help you take action.” If you believe that what you read on Healthgrades.com or even on Press Ganey reports is an accurate reflection of health care quality, now you’ve got some transparency. You can now take full ownership of whatever bad outcomes may result from your decisions.

Oh, and if you want to talk to Healthgrades.com’s CEO Roger Holstein about this whole Dr. Duntsch issue, his number is 303-716-0041. If you need to speak to him, you better call him quickly, though … before Healthgrades.com changes that information, too.

Press Ganey’s Invalid Statistics

Thursday, May 30th, 2013

Remember that whole line about how Press Ganey won’t create reports or analyze statistics based on fewer than 7 surveys?

Yeah. That’s not true.

This report which was sent to me by a reader shows that the involved doctor was in Press Ganey’s 99th percentile! Oh. Too bad that the rankings were based on a single survey result.

Kind of like electing the mayor of a town based on one vote.

But don’t forget, everyone … Press Ganey CEO Patrick Ryan says that we need to just “suck it up” and apparently accept that most of their surveys have no rational basis.

 

Press Ganey Rating Single Survey

 

 

Unnecessary Care?

Saturday, January 12th, 2013

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.”
Nice threat.
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

Loading ... Loading ...

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.

Press Ganey Mantra: Suck It Up

Wednesday, January 2nd, 2013

“It’s a case of good intentions gone badly awry – and it’s only getting worse.”

Prophetic words in a Forbes Magazine article by Kai Falkenberg titled “Why Rating Your Doctor Is Bad For Your Health.”

According to the article,

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.”

Patrick Ryan - 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.”

Heck, he and his company are still making money.

Pressure to Admit

Monday, December 3rd, 2012

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.”

Patient satisfaction metrics are creating quite similar incentives with physicians. How long will it be before people wake up and see how much fraud that the satisfaction scores are causing?

Undertreatment

Monday, October 15th, 2012

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.

Silly me.

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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.

You Can Tie, You Can Lose, But You Can Never Win

Saturday, June 23rd, 2012

The article below was forwarded to me by a reader. It was originally published on the Student Doctor Network by an anonymous poster who goes by the handle “BirdStrike” and was made free to republish. For those of you who want further insight into how patient satisfaction rankings adversely affect medical care in the emergency department (aside from the fact that highly satisfied healthy patients are twice as likely to die from their medical care) – it will be interesting reading.

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.

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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:

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Press Ganey Flunks Own Rating Scale

Friday, May 18th, 2012

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?

Wow.

If Press Ganey were a doctor, it would be out on its ear.

I love irony.

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