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.

How We Got Here

I’ve been an emergency physician for almost two decades now and can honestly say I’ve learned to distrust our American Healthcare System. It’s not because I doubt the level of education of doctors but because less than a quarter of the cost we pay is for care provided by physicians. It is because it’s virtually impossible to not to have to pay the balance: ultimately, we pay to be made to feel happier over  healthier.  The system does not value the time physicians take to listen, but rather rewards ones that focus on efficiency of time. It discourages the ones that are transparent, empathetic and honest, while rewarding those that only pretend to be kind. Turns out you can easily force professionals to kowtow and appease if you treat them as expendable employees. Those are also some of the “whys” to the loss of respect in the medical profession:  our system no longer values the integrity to say “no” but rewards doctors for saying “yes,” even if it might cause harm. Finally, the system we have in place blames those same professionals for the ill effects of the behavior it engenders once the fall out predictably manifests itself.

I started this blog as a way to translate some of the jargon and bring understanding and transparency to people, so that anyone can understand how problems like the opioid epidemic is the result of misapplied national policies in the interest of profit and a culture of greed, rather than ignorance or the work of a few bad actors or uninformed pill pushers. I hope to warn patients that jargon such as “quality measures” and “meeting benchmarks” increase profits do not our health.

We, doctors, generally know this because we are often also patients, or their family members or surrogate decision makers. Over the years, many of us in medical education have bent the ears of students, residents, patients, colleagues, family members, hell just about anyone who will listen about how critical ethical medical practice is to our health system and ultimately our own health. In future posts, I hope to share with you how our system deteriorates and only keeps from collapsing because a lot of great people know this at least as well as I do and risk their jobs, happiness and reputations daily to make it work, and a lot more that no one seems to want to admit. Here we go….



Welcome! After 20 years of caring for an endless variety of patients, it is painfully clear to me what is most lacking in healthcare today is trust.  The deterioration of trust between all stakeholders involved in the complex equation of medical care in America, appears to me to originate in a lack of honest communication. My hope is to share what’s not being said so we can help each other truly heal.