Like many physicians, I’m a people pleaser.  On my medical school application, my personal statement was a literary cliché filled with my dreams of helping others, easing pain, soothing suffering — and I really meant it.  What I didn’t know then was how difficult it would be to negotiate making patients happy while doing the right thing medically.

Medical school and residency didn’t adequately prepare me for the emotional strain of saying “no” over and over to my patients.  How to harden my heart against the tears of a patient requesting an early refill for pain medication.  How to listen to all of the other modalities that have been tried and failed: “This is the only thing that works!”  How to guard against the emotional manipulation, charm, and charisma that many patients with addiction exude.  What to do when a patient reports coldly that they went to another doctor after you refused to prescribe an antibiotic for their cold, and got a Z-pack, which “worked like a charm.”

Doctors are stuck in a pinball game of guilt and blame.  We are blasted in the media for overprescribing antibiotics for viral infections, yet face angry and upset patients who criticize us on doctor-grading sites when we don’t prescribe them.  And while good communication helps ameliorate negative patient attitudes, the truth is that doctors get tired, and it gets harder and harder to “sell” the correct medical treatment as the work day progresses.

More recently, doctors are being criticized for overprescribing pain medication, with a recent CNN report from Dr. Sanjay Gupta titled, “Doctors are responsible for the opioid crisis.”  This, after years of medical societies lambasting doctors to consider pain as the “fifth vital sign,” and even threatening physicians with possible legal action for failure to control pain adequately.

No wonder doctors are burning out.

The trend towards rewarding (or punishing) physicians based on patient satisfaction makes the dilemma of providing the best care even more difficult. The reality is that patient satisfaction does not seem to correlate with quality of care.  In fact, more satisfied patients have worse outcomes and higher health care costs, partly due to doctors ordering tests just to satisfy patients.

But despite this data, hospitals continue to rate physicians based on patient satisfaction scores, and Medicare’s new merit-based payment system will likely include patient satisfaction (or “experience”) as a factor in payment.  This mixed signal hits physicians hard.  We have to choose:  are we going to be pushovers with great satisfaction scores?  Or will we refuse to be scapegoats, the cause of all of society’s ills?

I have spent the last fifteen years walking the fine line between quality medical care and patient satisfaction.  And I will admit it:  there have been times that I have taken the path of least resistance when it comes to yet another extended discussion about why the treatment that my patient wants is not the best choice, and just given in.  This usually happens when I’m mentally exhausted and dealing with a particularly demanding patient.

But now I see that this is no longer an option.  It’s time for me to stop being a pushover and take a harder line.  It will be emotionally draining, my patient satisfaction scores will probably drop, and some people will leave my practice.  But if I can stand firm, I know that eventually it will get easier.

I don’t want to be a scapegoat anymore.

Rebekah Bernard is a family physician and the author of How to Be a Rock Star Doctor:  The Complete Guide to Taking Back Control of Your Life and Your Profession.  She can be reached at How to Be a Rock Star Doctor.

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