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Measuring Patient Satisfaction: A Bridge Between Patient And Physician Perceptions Of Care

May 9th, 2014

Patient satisfaction is at the core of patient centered medicine.  Improved patient satisfaction not only leads to an enhanced patient experience—something every sick or injured patient deserves—it is also associated with improved treatment outcomes.  In 2008, researchers demonstrated that improved patient satisfaction was correlated with higher quality hospital care “for all…conditions measured.”  More recent work has begun to identify exactly how this correlation works.  For example, higher patient satisfaction has been associated with reduced readmission rates.  Furthermore, improved patient satisfaction has even been correlated with reduced inpatient mortality, “suggesting that patients are good discriminators of the type of care they receive.”

Despite the correlation between higher patient satisfaction rates and improved outcomes, measurement of patient satisfaction remains controversial among many health care providers.  Physicians, in particular, often chafe when organizations, such as The Commonwealth Fund through their site WhyNotTheBest, or the Centers for Medicare and Medicaid Services though their Physician Compare website, begin to publicly report doctors’ patient satisfaction data.  Additionally, employed physicians often fret when patient satisfaction is included in their reimbursement metrics.

Certainly there are instances in which sound medicine may lead to a lower rate of patient satisfaction; infrequently, satisfaction can correlate, not with high quality care, but with the fulfillment of patients’ a priori wishes for their treatment.  A good example of this problem is the difficulty in refusing to fill narcotics prescriptions and steering a patient toward alternative pain relief modalities when the physician has good evidence that a patient has a problem with narcotics abuse.  While the doctor in this example is practicing good medicine, it is highly unlikely that the patient will leave the office anything other than deeply disappointed.

Despite these relatively rare cases, many studies show a deep chasm between how patients and doctors view medical care, and thus demonstrate the need to measure patient satisfaction rates.  Patients and their doctors can view the same episodes of care quite differently so, without patient satisfaction measures, we are left with an incomplete or even misleading picture of patient care.

The Case Of Spinal Fusion Surgery

As an example of this phenomenon, we can compare patient and surgeon reported results of spine surgery.  Spinal fusion surgery rates have exploded over the last 15 years from 98,000 in 1996 to 465,000 in 2011.  However, are patients satisfied with their results?  The answer, in large part, depends on who is asked the question.

It has long been understood that patients report complications at rates many times higher than those reported by their surgeons.  However, the full extent of the gulf between patient and surgeon perceptions is apparent in a 2008 study on over 1,000 spine surgery patients.  While surgeons reported a 2.6 percent rate of spinal complications and a 2.9 percent rate of general complications, patients reported an overall complication rate of 29 percent.  Furthermore, patient reported complications correlated directly with their satisfaction with the results of surgery; the authors state “a “good” global outcome (operation helped or helped a lot) was found in 79.8 percent of patients who had no such complications but only 62.4 percent of those with complications”.

This difference in perception between surgeons and patients has profound ramifications for patient care.  One can easily imagine a patient and surgeon opting for surgery when discussing a procedure with a 2-3 percent complication rate, but declining that same surgery if discussing a procedure with a complication rate of 30 percent, and — if a complication develops — a 40 percent chance that the patient’s symptoms will not improve or may even be worse.

Importantly, it isn’t that surgeons are necessarily downplaying risks; a follow-up study shows that surgeons and their patients simply live in different worlds.  In 2013, researchers examined over 2000 spine surgeries to compare patient and surgeon perspectives on surgical complications, and they found something quite striking and unsettling.  In this study, both surgeons and their patients individually reported surgical complications and their severity.  When patients reported complications, their surgeons also reported one only 29 percent of the time. Furthermore, 61 percent of the patients for whom surgeons reported a complication did not report a complication themselves.  In other words, patients and their surgeons had very poor agreement on the fundamental question of whether the same surgery had resulted in a complication.

Additionally, we are not discussing minor problems from the patients’ point of view; just over half of the patient-reported complications, including many that the surgeon did not recognize as a problem, were ranked by patients as very or extremely bothersome.  The authors note, “These [patient reported] complications are neither infrequent nor inconsequential as far as the patient is concerned.”

Reaction to this study has varied, but at least some authors suggest that patients are too subjective to report “genuine ‘operative complications’”.  However, it is widely held that patients are the best judge of success of elective medical treatments, especially an elective surgery done for pain relief. Therefore, a much different picture of surgical results emerges when patient feedback is obtained than is obtained by surgeon reporting alone, and it is just this dichotomy between patient and provider evaluation of results that make measuring patient satisfaction so critical.

We Can’t Know What Patients Are Thinking Unless We Ask Them

We, as providers, often believe that we know everything about our patients and their care, but we are simply incapable of accurately assessing our patients’ perceptions of their care–what is important to them, how well we are delivering the care they need, what factors in our care improve outcomes–without asking our patients directly for their feedback.  Without gathering such data, we often do not really know if our treatments have been successful; it is not sufficient to assume success based solely on the results generated by physicians.  There is, in fact, a foundational and ineluctable difference in outlook between those of us yielding the scalpel or stethoscope and those of us subject to their effects.  As these results show, a provider cannot understand the experience of surgery, chemotherapy, daily glucose monitoring, or psychiatric care in the same way that treating patients actually live these treatments.

It is clearly important to understand patient satisfaction results both for patients contemplating treatment options and for payers contemplating coverage decisions.  It is important for doctors as well.  As the practice of medicine changes, physician burnout has become an issue.  Of note, there is a high correlation between patient satisfaction with care and provider satisfaction with their work.  This likely represents a symbiotic relationship between happier, more satisfied patients and happier, more satisfied practitioners.  Thus, a focus on patient satisfaction will lead to an improvement in the professional lives of physicians as well as delivering better treatment results.

Patients and their doctors inevitably view the same episodes of care through different lenses.  Therefore, knowledge of patient satisfaction is critical in understanding the patient experience and the effectiveness of treatment.  This knowledge helps patients make more fully informed decisions, and it helps physicians practice medicine more effectively.  In order to improve the quality of care in America, we need to vigorously pursue strategies to gain patient satisfaction data for all treatments and all providers and make this information as accessible as possible.

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2 Responses to “Measuring Patient Satisfaction: A Bridge Between Patient And Physician Perceptions Of Care”

  1. Sue Larsen Says:

    I have really enjoyed this post.

    An additional aspect to consider is the $145 Bullion dollars worth of directs healthcare costs associated with nonadherence and misdiagnosis, some of which could have been avoided through better patient communication. Patients who agree with and understand their treatment strategy are far more likely to be adherent. Likewise, patients who are engaged in an open dialogue with their physician from the outset are more likely to reveal critical information that may influence an earlier diagnosis.

    It seems that so often patient experience is mistaken for giving patients what they want, and unfortunately, this misses the point entirely. Patient experience is all about how you do the things you do, not what you do. It’s about patient collaboration- demonstrating an understanding and respect for each others perspective and rationale, and working together to deliver the best possible outcomes, as early as possible.

    It’s sobering to realize how much of the national healthcare spend is linked to the cognitive aspect of the consultation rather than the diagnostic or treatment aspect.

    Thank you for your post- it clearly highlights the importance of patient experience not only for patients, but for physicians’ satisfaction as well.

  2. Eric Reines Says:

    Thank you, Jim, for explaining this to us in further detail. The term “patient satisfaction” seems so much less than what is really important, but this is what regulators and payers want to measure. I have had plenty of dissatisfied customers to whom I have denied requested treatments. Many of them ultimately thank me a few years later. In primary care, this can work. But when my and my group’s pay depended on Press-Ganey scores when I was a hospitalist, I felt challenges to my integrity. I surmise that the surgeons referred to in the study had no idea of their patients’ dissatisfaction, whereas I was well aware right up front. My difference of opinion regarding treatment of my patients provided an opportunity for patient education, which itself sometimes produced satisfaction. In my current practice, I have been surprised to see so many patients with high expectations of questionable procedures, with poor results, who continue to request the same or similar procedures. I can only conclude that it is the attention that is important to these patients, and not the results of the attention. Noting physician burn-out and its correlation with patient satisfaction brings to mind the work of Bernard Lown and Rachel Remen, who open up a world view that is often not considered by procedure-oriented physicians. –Eric

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