The Physician-Patient Relationship, Patient Satisfaction and the Duty to Care

Most of the world would agree any physician’s primary duty is to the health of the patient. In the case of emergency physicians, we assume it would be particularly important the doctor control the practice and patients generally assume this is true. However, what if control of patient flow is not in the hands of the physician, or that even the priority of the care provided is set by policy rather than medical judgement. What happens when the pressure to see more patients faster and keep them happy during the process takes that control almost completely out of the physician’s hands? What if the outcome of treatment and health are not measures of satisfactory medical care, but the provision of quick service, medication, hospital admission, food, and entertainment are?

Turns out we now know that patients reporting the highest satisfaction in hospital surveys are more likely to be hospitalized, are charged more for medical care, spend more on prescription drugs and 25% more likely to die. Even worse, the healthier the patient reporting high satisfaction based on the surveys, the more likely they are to do poorly or die.

But how and why did we get into this mess? The short answer is that a patient paying for medical care is not the same as a customer buying, say, a car.  Yet, businessmen who took control of hospital and healthcare administration, applying a formula borrowed from sales and marketing of other “goods,” considered that immediate gratification equals excellent customer service. In fact, most healthcare organizations and the federal government continue to make the same error.  (More on how we got to a place where non-medically trained individuals became the most important decision-makers in healthcare organizations in a future.) Lets focus on the recent history for the time being.

Patient satisfaction really got its start when two researchers at Notre Dame, one an anthropologist (Irwin Press, PhD) and another, a statistician (Rod Ganey, PhD) developed a market survey for hospital administrators around the mid 1980’s. At first, only a few hospitals used this Press-Ganey tool, and mainly as a marketing device. The situation got out of control (even out of the control of Press & Ganey) once the federal government got involved in 2002.

In that year, two government agencies, the Centers for Medicare and Medicaid (CMS) and the Agency for Healthcare Research and Quality (AHRQ), got together to make their own survey. They called it the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. At first reporting these results was voluntary around 2005. Then as part of a plan to reduce the national deficit, hospitals were paid for publicly reporting patient satisfaction results which they did voluntarily. Once 95 % of them agreed to do so, by 2007, Medicare reimbursement was tied to those results under “pay for performance.” So you might well ask, “What’s the problem? The government started paying hospitals more based on patient customer service.” Sadly, these surveys are on not based on what patients need, from a medical standpoint, but what they want, so better health outcomes is not the result. Instead, patients are paying more and getting sicker or dying.

At least equally concerning is the issue of the system redirecting physicians and other caretakers from their primary duty to the health of the patient, to patients’ immediate gratification. Cynically one might surmise that hospitals are more concerned with their increasing their bottom line and the government with decreasing theirs. Alarmingly,  there is increasingly less concern with the opinion of patient caretakers who are charged with protecting the patient’s best interests and health.

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