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“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.”
Peter Valenzuela is a family physician and author of Doc-Related: A Physician’s Guide to Fixing Our Ailing Health Care System.
He shares his story and discusses his KevinMD article, “Patient surveys: the quest for positive reviews.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Peter Valenzuela. He is a family physician, and he’s the author of the book Doc-Related: A Physician’s Guide to Fixing Our Ailing Health Care System. There’s an excerpt from that book on KevinMD titled “Patient surveys: the quest for positive reviews.” Peter, welcome to the show.
Peter Valenzuela: Hey, thanks so much for having me on the show, Kevin. I’d love to hear your podcast. I appreciate you making time for me.
Kevin Pho: Well, thank you so much for joining me. We’ll talk about your excerpt and book in a little bit, but first off, can you share your story and journey to where you are today?
Peter Valenzuela: Yeah, sure. I’m originally from Texas. I’m a family physician by training. I practiced rural medicine in Texas for about five years. During that time I kind of realized I didn’t know the business side of health care, so I went back to school and got an MBA while I was practicing, and it kind of gave me different perspectives on how we practice and what we can do better.
After five years of rural medicine, I went into academics, and I was the chair of a family medicine residency program in Texas. From that point on, I started going into large medical groups and integrated delivery systems. My journey took me to Bellingham, Washington, where I was a VP of the network out there for PeaceHealth, and then recently I was at Sutter Health in Sonoma County, California. Now I’m with Mercy Medical Group as the chief medical officer. Our group here in California, I’m in Sacramento now, is about 500 physicians and multispecialty providers, and I just celebrated my one-year anniversary with the medical group here this week.
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Kevin Pho: So one of the things that you mentioned that struck me was that you didn’t really know the business side of medicine until you started getting your MBA, and I’m sure that sentiment is fairly common among physicians. So what about the business side of medicine did you learn that you didn’t know while you were practicing medicine?
Peter Valenzuela: Yeah, that’s a great question. I was literally one of those small-town docs that did a little bit of everything, and I was an independent physician that worked in a shared clinic practice with a few other docs. My wife actually did my billing. It was literally a mom-and-pop shop.
The first time I decided to go back to school, I was waiting for my patients to be roomed, and I had one patient say, “Dr. Brown, I’ve been waiting 45 minutes to see you.” And I had been in my office waiting for the patient to be roomed. So in my mind I thought, “There’s some problem with our throughput that I’m not understanding.” So the first thought towards getting some type of business degree really was around process improvement and not letting my patients wait.
But the second part was around how do we code, what gets denied, what do you have to pre-authorize, what’s the process for referrals. A lot of the things that, when you’re in clinical practice, when you’re in residency training, you’re just trying to take care of the patient, but you don’t realize what goes around taking care of the patient and getting credited for it and being paid for it and being successful.
Kevin Pho: Now, does it require an MBA for physicians to learn this business side of medicine?
Peter Valenzuela: No, I don’t think so. I’ve met a lot of people along the way that actually started developing passions for different things. I have doctors that are certified coders, and I have doctors that work with insurance plans now because they were kind of on the one end when they were trying to deal with pre-op. So I don’t think that it requires it, but you definitely need to have some type of practice management education or insights.
I’m glad that residency programs are now starting to try to incorporate that. I think the challenge with that at times is that the people teaching it may not have ever been in private practice, so they kind of teach you the academic aspects of practice management, but maybe not the real-life scenarios of practice management.
Kevin Pho: So one of the things that we talk about is having physicians take more of a leadership position, because one of the reasons why so many doctors are burned out is because they don’t feel like they’re in control of the profession. Now, you’ve done it. You’re a physician who’s in a leadership position. What kind of advice do you have for those doctors who want to climb up the ladder and attain more leadership positions within an organization?
Peter Valenzuela: Yeah, I think for sure the first step you should take, if you’re in an organization that’s large or semi-large, is get involved. Join committees. Understand how the back end of a medical group or an integrated delivery system works, whichever. Start being involved in different committees. I think the more valuable ones, if you want to go up in leadership, revolve around quality, value-based organizations, finance, and compensation. Those tend to be kind of the key ones that people should have some grasp of as they move up the ladder. That’s not to say that the other committees are not as important, but I think that if you have some committees that you join that have business aspects, it really provides a little bit more insight.
The other thing that’s becoming more popular is really shadowing. I think that it’s been great to see administrators come and round with the docs to see what it feels like. The docs can do the same thing in their own way, which is shadow the administration: What are some of the things that they’re working on, and what are some of the issues being addressed? So I think those are a couple of things you could try to do. Obviously, an MBA or higher-level education would be great, but not a lot of people have time for it. So it is a commitment, and if you’re serious about that, there are executive programs where you can continue to practice but do this on weekends, or at nighttime, or online.
Kevin Pho: All right, let’s talk about your book now, as well as the excerpt. Your book is titled Doc-Related: A Physician’s Guide to Fixing Our Ailing Health Care System. The excerpt is “Patient surveys: the quest for positive reviews.” So for those who didn’t get a chance to read the excerpt, can you just walk my audience through it and share the story of why you decided to share that particular one?
Peter Valenzuela: Yeah, sure. I think that a lot of physicians and clinicians today are really struggling with trying to do what’s best for the patient while also trying to make the patient happy. In my excerpt of that chapter from my book, I talk about the distinction between patient experience and patient satisfaction. Patient experience is doing the things that are expected during an encounter with a patient. Patient satisfaction is feeling like the patient got what they needed and they left there happy. Patient experience, they try to make more objective, like, did the physician see you within 15 minutes of your appointment? Did the physician review your medications? Patient satisfaction tends to be like, did you enjoy your interaction with your physician?
I think that somehow along the line that’s really become clouded together, where patient satisfaction has really taken over, and understandably, because of consumer-driven health care. But there’s a lot of research that shows that making the patient happy all the time doesn’t necessarily improve their clinical outcomes. In fact, it can be just the opposite. If a physician is hesitant to not prescribe something or not order a test because they don’t want to upset the patient, it may result in higher cost or damage to the patient.
Kevin Pho: Now, you’re involved with a lot of administrators. Do they see that difference between patient experience and patient satisfaction?
Peter Valenzuela: Surprisingly, no, and that’s the shame of it. I think that for them it’s really, what can we do to make sure that we have patients return, to have return customers? And the dialogue hasn’t really been aligned where physicians can say, “I want the patient to come back, but I want to take care of the patient the right way,” versus, “Well, we really want the patients to be happy, so we’re going to add more coffee machines in the waiting room, and we’re going to make the aesthetics look greater, and we’re going to have the valet parking.” Those are all nice-to-haves, but we also have to make sure that we take care of the patient.
Kevin Pho: So I hear a lot about physician compensation being influenced by their patient satisfaction scores. Can you give examples of that type of influence? You certainly don’t have to talk about your own health care system, but in general, how do patient satisfaction scores influence physician compensation?
Peter Valenzuela: Yeah, no, that’s a great question. I think that health care is trying to drive more towards value and making sure that we’re doing the right thing, and one of the things that they are looking at is the patient, and making sure the patient’s happy. A lot of organizations will base 5, 10, even more percent of the physician’s total salary on their patient satisfaction scores. I think that’s a mistake, not because we don’t want patients to be happy, but because a lot goes into making a patient experience go well: the phones being answered on time, being able to be scheduled appropriately, making sure that you’ve got a referral process, being able to respond to the lab results, and understanding other aspects of that that don’t directly involve the physician or clinician themselves. When you make an incentive that’s so individual-centric, you lose sight of the team mentality of what it takes to care for a patient, and I think that’s something that we have to consider.
Kevin Pho: So you mentioned a tension there. Good care doesn’t always lead to satisfied patients. There’s an incentive for physicians to give patients what they want, precisely because of the influence you mentioned, with their satisfaction scores influencing compensation. What kind of advice do you have for physicians to navigate this tension?
Peter Valenzuela: Yeah, I think that’s a tough one, and you led to it earlier. Physicians have to be involved in how decisions are made at the big table, at the leadership table. And I think when you have the right leaders in place, they understand this. When you look at health care organizations and you look at quality and performance, the best, the highest-rated health care organizations are physician-led. It’s not to slam non-physicians or non-clinicians, but I think there’s an understanding of those people as to what we’re trying to achieve.
I think that, just as an aside, what makes it even more difficult is that now we’re doing patient satisfaction online, like Yelp and others, and it’s tough to deal with those too, because organizations aren’t allowed to respond in a meaningful way to those reviews, because HIPAA doesn’t allow us to say, “This is really the deal that happened in this case,” right? And so helping doctors understand that it’s not fruitful for you to try to explain yourself online, because it actually could harm you to do it, is something that we have to educate people on.
Kevin Pho: So you mentioned in your article that one way to address this is to fix how we use surveys. Can you talk more about some of the ways and solutions to address this problem?
Peter Valenzuela: Sure, yeah. I think that surveys should be used to see how we can be better at what we do. When I say that, I mean kind of what I alluded to earlier: Are we able to get the patient in in a timely fashion? Are we following up with the important things that the patient needs from a referral standpoint? Is the patient receiving information that’s vital to being successful? Those are process improvements.
I think that having one survey to an individual is helpful to an extent, but conducting a broader survey where you ask about the caregivers that are taking care of the patient, or you ask the staff what some of the hiccups are that are going on behind the scenes, where you look at other ways to enhance the experience, I think that’s more meaningful. We should not make this an individual score for a physician. We should make it a team effort for those people involved, and I think that’s really vital to what we’re trying to achieve.
Kevin Pho: We’re talking to Peter Valenzuela. He is a family physician, and he’s the author of the book Doc-Related: A Physician’s Guide to Fixing Our Ailing Health Care System. There’s an excerpt from that book on KevinMD titled “Patient surveys: the quest for positive reviews.” Peter, let’s talk about your book, Doc-Related. What are some key points that you want readers to come away with?
Peter Valenzuela: Sure. Well, I think, first, the book is interesting because it’s kind of a medley of anecdotes and stories and data, as well as comics. For people that don’t know, I’ve been making comics for about five years, and the comics are satirical comics about the challenges of practicing medicine today, as seen through the eyes of physicians and clinicians.
So with each chapter I cover topics like patient satisfaction, coding, pre-authorization, the EMR system, leadership, and communication. I start each chapter with an experience that I’ve had, or someone that I know, then I provide some data around that topic, and then I end the chapter with solutions on how we can make it better. And just as a plus, there are comics at the end of each chapter that talk about the topic. So it’s supposed to be educational, but it should also be entertaining, and hopefully bring a few laughs along the way.
Kevin Pho: So give us a little appetizer. What’s a sample topic that you have in your book, through the eyes of a physician, and what are some of your proposed solutions to that problem?
Peter Valenzuela: Sure. I have a chapter dedicated to quality metrics. I think metrics are important, but we don’t necessarily measure the right things. When you think about the number of metrics in health care today, I think CMS has about 1,700 metrics, and a lot of them are really, are you checking the boxes, right? There’s not a lot of evidence to show that every single one of them improves outcomes, right? They’re process metrics, and understandably, because they are measurable. It’s tough to measure the most important things.
Remember, as physicians and clinicians, about 10 to 20 percent of the patient’s overall health care is affected by what we do. The other 80 to 90 is based on their decisions, whether they’re smokers, or alcohol, or living in underserved communities, or have jobs, or proper housing. I think that what we need to reassess is how we truly improve our patients’ overall health and outcomes. If we cut back on the amount we spend on quality metrics, we would save so much money that we could actually use it to help the things that matter to patients, like proper schooling, like vaccinations, like good water supply, like job training, like good housing. These social determinants of health might weigh more on a patient than what we as physicians can provide, and that’s kind of what the chapter alludes to.
I also talk about how metrics can be gamed, and how there are misaligned incentives with that, because we get paid for how we do things, and I have examples of how we can meet a quality metric but not necessarily do what’s right for the patient.
Kevin Pho: So to that point, is it a binary choice? Is the money that goes to metrics preventing us from addressing social determinants of health? Is it an either-or proposition, or can’t we have both?
Peter Valenzuela: I think we can have both. It’s always a “yes, and.” The key is some people in some health care organizations are doing it better than others, and my hope is that we can learn from those organizations and spread the word, so that we can focus on the right things.
The challenge that we have right now, which you alluded to, is that health care organizations get so big it becomes a very financially driven decision, and so sometimes doing the right thing doesn’t pay you, right? I can get into behavioral health, right? We know behavioral health is a big factor in the U.S. system, but reimbursements are low and they’re hard to find, and so a lot of organizations just don’t deal with behavioral health. They contract it out. If we really could focus on doing the right thing, it would offset costs down the road, and that’s something we should think about.
Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?
Peter Valenzuela: Yeah, number one, I would say, first, I’ll make a pitch for you: You should watch KevinMD and read KevinMD pages, because they’re really informative. Second, I would say that it’s like the old adage: If you’re not at the table, you’re probably on the menu. I think we as physicians and clinicians need to find ways to get to those tables where decisions are being made, because we can definitely influence and impact how we provide health care. We just have to have the right people that are motivated to do it. And you don’t have to be a physician. If you’re a health care person in any way and have clinical skills, that’s something to think about.
Kevin Pho: Peter, thank you so much for sharing your time and insight, and thanks again for being on the show.
Peter Valenzuela: Hey, thanks so much for having me, Kevin. I appreciate it.
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