Current healthcare reform efforts promote the related ideas that patients ought to be involved in their own care, and that patient satisfaction is a key measure of healthcare quality. U.S. primary care practices have clearly gotten the message: A recent survey by the New Medical Group Management Association found that 85% of practices conduct patient satisfaction surveys.
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Today, primary care providers are increasingly taking what’s been called a “negotiated approach” to practice where patient and doctor work cooperatively, discussing the patient’s expectations during an office visit.
Andrew Duda, MD, reports patients arriving with specific expectations for their care at least once daily, if not more often. He says that many patients search the internet for advice from “Dr. Google” before seeing him and that their discoveries make such requests inevitable. Duda practices with Henry Ford Allegiance Family Medicine in Leslie, Michigan.
As of now, though, the connection between high levels of patient satisfaction and the highest levels of quality care has not been proven. Patients may explicitly request tests, referrals, and medication that they do not need and that will not help them or be cost effective, and be disappointed if they don’t get them.
Yet sometimes physicians are tempted to oblige, and systems that rate providers using satisfaction metrics may encourage this. In some studies, the most satisfied patients have actually had higher mortality rates than less satisfied ones. Meanwhile, another strong emphasis in healthcare reform efforts is for physicians to use resources wisely, in alignment with evidence-based guidelines.
Using verbal judo
Duda negotiates with patients whose preconceptions about their care may not jibe with his clinical opinion. He takes an approach he calls “verbal judo” that he learned in medical school. “You try to get the patient to understand your point by making it their point…and by getting them to answer their own questions.” This way, he says, he and the patient usually reach a happy medium. They may settle on a test or treatment that costs somewhat less than what the patient had requested, and that will still provide real benefit.
He finds this approach useful when discussing options for the testing and treatment of prostate cancer, among other issues. They may have “lots of discussion about whether or not screening is necessary, based on the physiology of prostate cancer and the pretty nasty outcomes” that can occur with treatment of the disease, he says. Duda strives to help his patients stay focused upon concrete outcomes. He guides patients to consider key issues about whether or not a certain approach will lengthen their life or increase its quality, and about how it might be problematic. Usually, he says, once he has built rapport with a patient, that person will defer to his judgment, but patients are not always predictable.
Countering the magic pill mindset
Roxana Lascu, MD, ran a solo primary care practice in Lake Mary, Florida, for three years until recently, when she closed it and became a hospitalist with Orlando Health. In her practice, she found problematic patient requests falling into two main categories: request for unneeded antibiotics and for unnecessary tests.
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She attributes the patients’ frequent requests for antibiotics, even for viral conditions, to their wanting an easy fix. Often, patients, she says, are simply intolerant of being sick, and will press strongly to obtain prescriptions.
“With so many medicines today to counteract this or that or the other, there is a tremendous feeling that a pill is going to fix it,” she says.
She reports that about 70% of the time, she makes her point that antibiotics are unneeded, but that the rest of the time, patients dig in. They may tell her that they plan to go to a walk-in center for the drugs. In those cases, she will agree to call in a prescription but asks that they wait 24 or 48 hours before picking it up to see if they improve without it, as they often will.
Requests for tests were also a problem during her years in private practice, she says. She mentions women wanting Pap smears and mammograms yearly despite current recommendations for less frequent screening. In such instances, Lascu would strive to help them understand the disadvantages of too much testing.
Sticking with Hippocrates
Although Duda has occasionally lost patients who insisted on a course of action he could not sanction, he reminds himself that ultimately, “the point is for us to do no harm.” Both he and Lascu say that helping patients understand the facts underlying a sound decision usually leads to patients agreeing with such a decision and leaving satisfied, but not always.
Their observation falls in line with a growing body of research. Studies show that nonmedical services such as education and counseling may more strongly affect patient satisfaction than the actual medical services rendered, no matter what the patient came in wanting.