All patients should be treated with professionalism and respect.  We all want our patients leaving our care happy, healthy and satisfied, if at all possible.  However, sometimes patients don’t leave an emergency department very happy or satisfied.  Sometimes the doctor could have prevented it, but many if not most times, such dissatisfaction has little if anything to do with what the treating physician did, or didn’t, do.

The reasons for a patient being dissatisfied with a particular health care encounter can be very complex.  It’s not so simple as to just include a line in a survey such as, “Were you satisfied with your doctor?”

Who should be held responsible for the results of these surveys, is where the crux of this debate lies.

So why are hospitals obsessed with patient satisfaction?

It’s the same reason Walmart puts greeters at the front door (the ED), not the back door (inpatient floors), and the same reason the government collects taxes and not sea shells: money.  The question we really need to be asking is: Why is the obsession with patient satisfaction in the ED so soul-crushing to those that work there?

1. Lack of control. A patient pulls into the ED parking lot.  The lot is full.  He doesn’t feel well, he’s in a hurry and having to search for a parking spot irritates him.  The wait to see a doctor is long, too long.  Once finally in his room, he sees a drop of blood on the floor from the previous patient.  He’s disgusted.  Despite great care by the doctor, it biases his overall view of the experience.  As much as he tries to remain objective, the patient satisfaction score suffers.  The patient gives a “1 star out of 5″ review after discharge but writes in the comments, “Doctor and nurse were great, though!”  The tabulated score remains 1/5, or “FAIL.”

The doctor gets pulled aside at her next group meeting and is told she’s on watch due to low scores.  She’s never been fired from a job in her life, but now her job is in jeopardy, over something that she has no control.

A patient leaves an ED satisfied.  He gets a patient satisfaction survey and throws it aside.  He has no need for it.  The visit went great.  It’s his preferred hospital for any time he gets in a bar fight and needs to be sewed up.  He got in, got his knuckles stitched, and got a free Sierra Mist and a meal tray.  On his way out the door, he tweets, “#CityGeneralERrocks!” on his smartphone to the world’s prospective ER “customers.”

Six weeks later, all has healed well, and there’s barely a scar.  Then, the bill comes.

“!&@!?#€!!!,” he thinks.  “$920?  Screw that place!”  He grabs the survey and nukes the hospital, doctor and nurse all with the lowest score possible.  He writes in the comments, “I would have rated you a ‘negative infinity’ if the scale went that low!”

You can save a life, walk out of the trauma bay drained but proud, and be pulled aside and told that on last month’s survey, you didn’t get a patient a coffee “like they do at the car dealership.”

You are told, “Get those scores up.  Administration is watching.”

It translates into, “You suck.”

It’s not that big of a deal, right?  Maybe you should brush it off, but you are human.  You haven’t “evolved” to the “new way” yet.  You’ve heard of ER doctors losing their group contracts and, therefore, their jobs over things like this.  It bothers you.

There’s a complete and utter lack of control, and this can be utterly demoralizing to some people, particularly those who thinks of themselves as doctors, not “providers.”  Some may not be bothered.  These are the new generation of ER doctors.  Thick skin. Carbon-fiber reinforced alligator hide. An unembittered new species of ER doctor evolved to thrive in his new and changing environment.  He goes in each room armed with an EMR tablet, a $5 Starbucks gift, and a devastating smile.

I imagine one would feel more in control owning and operating a hot dog stand in the chaos of Times Square.  An angry customer tells you your buns are flat (no pun intended).  His rant doesn’t frustrate you, in fact, you welcome it.  This informal “customer satisfaction survey” has given you a valuable nugget of information to make your hot dogs and buns tastier, and make your business grow.  You cut through his dissatisfaction with a smile and say, “Thank you for telling me, sir.  I’m sorry.  It’ll never happen again,” and you can actually mean it.  Fluff those buns up and 2014 will be a profitable year!

Sometimes a patient voices frustration in a survey despite your best efforts to be nice, helpful, professional and clinically astute.  This may be due to factors out of your control regarding ER wait times, a large hospital bill, dirt on the waiting room floor, or a rude staffer that wasn’t you.  If the results are used against you, it is very difficult to smile and say, “It’ll never happen again.  I’ll do better next time.”

You didn’t make it happen, and you have little if any ability to make it better next time.  You’re already nice to your patients, do your best to help them and treat them with respect.  There’s tremendous cognitive and emotional dissonance there.  Things like this can end careers and fuel burnout in a big way.  Such things are the undercurrents that cause doctors to go work for insurance companies, as non-clinical consultants, or just plain move on.

2. Fundamental unfairness. I think it was said best by commenter Doctor Amy, a hospitalist, in the comments section after a previous post I wrote on the subject,

Hospitalists feel much the same way as you do … The patients are essentially asked if the doctor ‘always’ did everything perfectly — the vagueness of the question should automatically invalidate the response … the hospitalist may well have spent a great deal of time doing just that — making sure all the home meds are correct, arranging rehab, taking care of the fall at 3am, controlling pain meds, actually addressing code status etc. The sat[isfaction] scores are not parceled out in a way to delineate any of that data. We are told we suck. Maybe we do … but this data sure as hell isn’t a valid way to show that.

While only being only one person and only one component of any given patient’s perception of their hospital encounter, Doctor Amy has obviously felt the weight of being held responsible for the dozens, if not hundreds of intangible factors that make up a patient’s overall satisfaction, or lack thereof.  Being held responsible for factors over which one has no control, is fundamentally unfair, and as such only depresses morale among those involved.  Poor physician and staff morale certainly can’t be good for patients, let alone hospital “business.”

3. Bad for patients (violation of our oath). This is definitely the biggest and least acceptable reason, and the one that bothers me the most.  This is the one that leaves us no excuse for looking the other way: our patients. You went to school for decades, indebted yourself $166,000, worked 100-hour weeks in residency (even though you only logged 79 so your program wouldn’t get sacked by ACGME) all because at age 16 you decided idealistically you wanted to be a doctor to “help people.”

Then you find out, that according to the Journal of the American Medical Association, the patient “satisfaction” obsession you’re coerced to participate in not only increases health care costs, but is associated with higher death rates with the purpose of increasing corporate profits, not for yourself as an emergency physician, but for “the men in suits.”  There is unwelcome pressure to treat viruses with antibiotics to keep patients happy, irradiate the brains of children with unnecessary CT scans to satisfy anxious parents and prescribe medications to people seeking to fuel dangerous addictions.

Evidence based medicine is good enough for Medicare, private insurers and malpractice lawyers to demand it, yet it’s not good enough to stop the harmful practice of satisfaction-survey obsessed medicine.  If you think this is just opinion without evidence, read: “Conclusion: In a nationally representative sample, higher patient satisfaction was associated with … increased mortality.”

The current system pressures doctors to violate their oath to “do no harm.”  It forces doctors to consciously and regularly make this decision, “Should I do what I think is best for my patient and possibly lose my job, or violate my oath and practice bad medicine to boost survey scores, to avoid being fired?”

Did we sign up for this?

4. Self-preservation. Patient satisfaction-obsessed medicine has been linked to higher mortality rates, and as currently modeled, should be banned.  There should be a moratorium on such policies until the methods can be reformed, with patient heath as their focus, not profits, so they can be applied safely, if at all.  The real questions is: why don’t more physicians have the courage to, as First Lady Nancy Reagan’s anti-drug slogan went,  “Just Say No?”

Emergency physicians and hospitalists are either employees, or de facto psuedo-employees of hospital corporations.  They are primarily there to serve their effective employers whose goals as non-physicians and MBAs are to increase patient volume to make as much money as possible.  Period.  You can throw out any idealistic nonsense you learned in medical school that says anything else.  If they don’t follow the rules, play the game and keep their bosses happy, the powers that be will find a way not to renew their contract.  “Do what I say or you are fired,” is the message, if not explicitly stated.

Doctors feel they are powerless to change a system larger than themselves and feel they have no choice in the matter.  To preserve their paycheck, they play “the game” to avoid being fired.  The whistle has been blown, but no one’s listening.  There is too much money being made.  The one’s who are being harmed, and who could change it are the patients, but they don’t seem to know they are being harmed.  After all, the system is designed to keep them “satisfied” first, and healthy, second.

But often, what makes a patient most “satisfied” isn’t what is best for their health.  Our current system doesn’t allow this to be reconciled, and doesn’t want to.  The loss of a “customer” isn’t tolerated, for any reason.

“Sick, but satisfied” comes back to the ED.  “Sick, but satisfied” is good for business.  “Healthy and dissatisfied” takes their business elsewhere, and is a lost customer.

Is this what we want our health care system to promote?

There is no debate as to the motivation behind the satisfaction-survey obsession.  Administrators and businessmen seeking profits drive it.  Period.  The sky is blue.  The sun sets in the West.  Again, we all want our patients leaving our care happy, healthy and satisfied, if at all possible.

But there is a tremendous sense of a lack of control among those held responsible for these patient satisfaction survey results.  The application of these surveys is fundamentally unfair, and not substantiated scientifically.  Also, those applying these surveys and their principles pressure physicians to violate their oath to “do no harm” and to help people.  As doctors, we place much greater value on our own sense of control, basic fairness, and helping our patients over making our bosses wealthier.

This can make some feel very demoralized, and even cause some to leave the specialty of emergency medicine or medicine in general.  Unfortunately, so far, the system which is linked to higher patient death rates has been perpetuated due to the great power imbalance between hospital-based physicians and their much more powerful corporate employers.  Hopefully for our patients’ sake, there will be much greater opportunity for positive change in the future.

“BirdStrike” is an emergency physician who blogs at Dr. Whitecoat.

Image credit: Shutterstock.com