An excerpt from Doc-Related: A Physician’s Guide to Fixing Our Ailing Health Care System.

Early in my career as a rural physician in Texas, I took care of a couple in their mid-70s named Vernon and Nellie. They drove in from another small town 50 miles away. Nellie usually did all the talking, while her husband, Vernon, sat quietly next to her.

Each visit, she would tell me how Vernon had endangered his health. “Dr. Valenzuela, Vernon ate ice cream for lunch, and I told him that was bad for his sugar diabetes. Dr. Valenzuela, Vernon ate popcorn last night, and I told him that was gonna make his blood pressure worse. Dr. Valenzuela, Vernon just won’t listen to me when I tell him he’s gonna end up deader than a doornail.” As she spoke, Vernon would just roll his eyes, tilt his head down and slump in his chair.

Each time I tried to engage Vernon about his health, he could only get a few words out before Nellie interrupted. I sympathized with the guy, but he refused to see me alone. Vernon was a Korean War veteran with PTSD, who hated clinics and hospitals.

One day, Nellie walked into the exam room in high spirits. I could tell she had some big news for me, so I obliged and said, “My goodness Nellie, I’ve never seen you glowing as much as you are today. What’s the occasion?” She smiled from ear-to-ear and said, “Dr. Valenzuela, Vernon and I just celebrated our 50-year wedding anniversary! Can you believe we’ve been married for 50 years?”

Vernon piped up and said, “Dr. Valenzuela, I know it’s been 50 years, but I swear it feels like five minutes.” Just as I was about to compliment Vernon for being so romantic, he leans forward in his chair and finishes with “… underwater. Five minutes underwater!” My first response was to just about to fall out of my chair laughing as I watched a rare grin on Vernon’s face. Nellie’s ear-to-ear smile twisted into a scowl. Nellie responded by saying, “He’s always trying to be funny, even when he ain’t.”

It was then that I learned Vernon had a sense of humor and loved to tell jokes, which I viewed as my connection with him. From that point on, I’d be sure to ask Vernon if he’d heard any good jokes during each visit. He always had a new one for me, although not all of them were for general consumption. Appealing to Vernon’s sense of humor actually made him more compliant with his medical conditions, although he still cheated on his diet from time to time.

Back then, my visits with Vernon and Nellie lasted an hour by the time we’d addressed his multitude of chronic conditions, saw new photos of the grandkids, and talked about social events at the Veterans of Foreign Wars (VFW) hall. I’d like to think they enjoyed having me as a physician, but those were the days before we measured patient satisfaction. Back when docs didn’t get feedback through the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) or Yelp. The only way we knew if our patients were happy with our services was when they verbalized it. From time to time — particularly during the holidays — we also received gifts from grateful patients. The gifts were commonly food or treats to share will all the staff. Today, we use surveys to better understand and improve our patients’ experiences with health care providers and staff.

Statistically, it’s likely that Vernon and Nellie would have scored me high on patient experience surveys, not because I was an exceptional doctor, but because older, sicker patients who generate higher health care costs rate their providers better⁠. On the downside, as a new physician still establishing my practice in a rural area, other patients would have likely scored me lower simply because expectations and demands are different for new physicians with whom they haven’t established a relationship.

Patient experience versus patient satisfaction

To complicate matters, clinicians are being rated and scored based on patient experience AND patient satisfaction. Although used interchangeably, they’re not the same thing. To measure patient experience, we have to ask patients whether something that should happen in a health care setting actually happened. They target what happened. The questions are standardized to be objective. For example, “Did you see the physician within 15 minutes of your scheduled appointment?” Patient satisfaction deals with whether a health encounter met a patient’s expectations. In other words, “How did we do?” It’s more subjective. An example of patient satisfaction could be whether the patient thought finding parking was a challenge.

CG-CAHPS targets patient experience. Here’s why it is so important: insurers track CG-CAHPs as a way of monitoring and rewarding health care organizations. As a result, organizations reward, or penalize, physicians based on survey results. Although patient experience surveys are standardized, they are not perfect. Survey findings can vary with how they are administered (phone vs. mail vs. email) and when they are completed (immediately after visit vs. weeks later). The surveys also need a minimum threshold of responses to be statistically significant. The average acceptable sample size is at least 40 responses.

Also, since most physicians score well overall, the clustering for percentile ranking nationally is very close. A CG-CAHPs raw percentage score of 85 percent (out of 100) for “How Well Providers Communicate with Patients” is only at the 50th percentile, where a raw score of 92—only 7 points higher—places clinicians at the 90th percentile in the nation.

Online physician reviews and ratings target patient satisfaction. As previously noted, this is a more subjective measure. Two people who receive the same care but who have different expectations for how that care should be delivered can give different satisfaction ratings because of their different expectations.

Studies show that those physicians with negative online reviews were more often scored poorly due to non-physician specific causes. In my career, I’ve read comments from patients that said they were not satisfied with their provider because they didn’t like the color of the walls in the exam room. Another mentioned that tea wasn’t offered in the waiting room, just coffee.

Surveys are not necessarily bad, but they have changed the way we interact with patients. Doctors are now feeling pressured to provide care patients don’t need because of fears of bad patient satisfaction scores or negative reviews online. This causes more stress on health care professionals. In a national study, 78 percent of clinicians said patient satisfaction scores moderately or severely affected their job satisfaction negatively, and 28 percent said the scores made them consider quitting.

Dealing with the Yelp effect

Measuring and reporting on patient satisfaction within health care has become a major industry. In fact, a recent Google search for “patient satisfaction” revealed 164 MILLION results!

To educate the public on how online ratings like Yelp affect physicians and impact patient care, Dr. Zubin Damania, aka ZDoggMD, created a funny, yet sobering musical parody called “Blank Script” based on Taylor Swift’s “Blank Space” song about a patient who doctor shops for narcotic medications and threatens to “screw them on Yelp” if they don’t abide by their wishes. Uploaded in January 2015, the video has been viewed close to one million times on YouTube.

Besides overprescribing, spending too much time focusing on what patients want may mean they get less of what they really need. Researchers at UC Davis found that the most satisfied patients spent the most on health care. They were 12 percent more likely to be admitted to the hospital and accounted for 9 percent more in total health care costs. Even more alarming, they were also the ones more likely to die.

The results could reflect those doctors reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request or to raise concerns about smoking, substance abuse, or mental health issues. What makes Yelp and other physician review sites so frustrating is that health care professionals can be disappointed to do an online search of themselves and find random negative reviews or some other misinformation about an experience. In most of these circumstances, physicians are not able to explain themselves or push back on the inaccuracies.

In fact, the Health Insurance Portability and Accountability Act (HIPAA) forbids health care providers from responding specifically to a negative review without patient permission. HIPPA is a federal law passed in 2016 requiring the development of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. Responding to negative reviews is even more challenging in employed models, where organizations have marketing and social media administrators responsible for responding to them. The response is usually generic and only a few sentences.

Ways to fix how we use surveys

The goal of customer surveys is to improve the customer experience. Like any industry, health care should value input from those who pay for and use their services. It should also do its best to make all stakeholders happy with the care they provide. Ideally, this should be based on objective feedback within the control of those providing the care.

Because services provided in the health care industry can lead to bodily harm, the focus of patient surveys in health care should not be to satisfy every patient’s expectation of care, but to find ways to improve care. This means treating patients as a partner in producing healthy outcomes.

To curtail the subjectivity of online reviews, vendors should ask standard questions that align with CG-CAHPS surveys. Online patient review sites should also be required to have a minimal sample size of 40-50 responses before posting ratings on any clinician. Given the sensitive nature of the health care industry, they should also establish a review and appeal process prior to posting feedback.

To truly improve care, we should rely on more information than just feedback from patients. Other sources of feedback should include focus groups and patient family advisors. We can also incorporate workplace data like staff surveys. Service data like phone answering rates and turnaround times for patient messages are also vital to care. Administrators should also be involved in helping to improve services through rounding and noting observations at the care centers.

Once we have enough useful information from various sources, we can use the results to improve services in a focused way. William Deming, the father of total quality management, once said, “Eighty-five percent of the reasons for failure are deficiencies in the systems and process rather than the employee. The role of management is to change the process rather than badgering individuals to do better.” It’s no different in health care.

With this in mind, we should not be rewarding, or penalizing physicians based solely on individual scores. Clinicians should be engaged in making improvements in their care centers, but they should not be solely responsible for patient satisfaction results. Instead, we need to look at entire care teams to enhance care. In the end, by improving the way we provide care, we will positively impact the way patients experience the care they receive.

Peter Valenzuela is a family physician and author of Doc-Related: A Physician’s Guide to Fixing Our Ailing Health Care System. He can be reached at Doc-Related.

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