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Healthcare organizations have been using patient satisfaction scores since the late 1980s to improve care delivery and calculate physician and staff bonuses, among other purposes. Now, in the shift toward value-based care, such scoring is playing an even greater role in determining physician reimbursement and helping patients choose a physician.
But is it also changing the way physicians practice medicine?
Physicians, frustrated with feelings of powerlessness over how the scores are determined, fear that they give patients too much influence. Experts say the scores are here to stay, and offer suggestions for ways to approach them in the future.
“Physician reviews threaten the core values of medicine,” says Dana Corriel, MD, an internist based in Pearl River, N.Y. “Medicine is inherently built on the beauty of a patient-physician relationship. To add a review system into it almost makes it dirty.”
Patient satisfaction scores may make patients feel better by providing an outlet for their frustrations, but a 2014 study in Patient Preference and Adherence shows they may promote job dissatisfaction, attrition and even inappropriate clinical care among some physicians. Not only are scores not necessarily accurate at identifying negligent or incompetent physicians, according to the American Journal of Medicine, they do not correlate with better patient outcomes.
However, since patient evaluations aren’t going away, there are steps physicians can take to adapt to this reality.
Pleasing vs. caring
Corriel fears that these scores cause physicians to prioritize pleasing patients over doing what they feel is medically correct. “We run into a problem, because healthcare isn’t always about pleasing. It’s about making decisions that are evidence-based,” she says.
She feels that patient scoring can, essentially, be weaponized to manipulate doctors. She points out that, as many patients turn to the internet to research their medical issues, they also come in with preconceived notions of their problems, a particular prescription they think they should receive, or how they want to be treated.
“If you’re a physician and you deviate from that, the worry is that it’s not going to be acceptable and then the patient has the [score] to fall back on if the physician doesn’t do what the patient wants,” she says.
In a group practice where she formerly worked, a patient left a terrible review of the entire office and medical staff. “It turned out he hadn’t even seen me, nor had he seen any of my partners. He had seen a primary care provider from the floor above,” she recalls.
In her experience, patients also expect physicians to know everything, then react negatively when they don’t. “I know a little bit about a lot of things-that’s what an internist does,” Corriel says. “If someone asks me a question that’s very deep into the specifics about an organ system, I may not know it. That doesn’t make me a bad doctor. Patients don’t realize that we’re not superhuman.”
Scoring is biased against women and minorities
Another problem, research finds, is that patients are more likely to give negative reviews to women and minorities, particularly African-American physicians.
Natasha Sriraman, MD, MPH, FAAP, associate professor of pediatrics at Eastern Virginia Medical School, in Norfolk, Va., says she has experienced such discrimination as an Indian woman, and has seen it among colleagues who are also minorities.
“I’m a woman and a minority. I’m basically [zero] for two,” she says. “When I bring up [bias against minorities] in meetings, even with doctors and administrators, everyone is shocked.”
She cites another example of a fellow woman doctor who is also Indian. “She saved a man’s life and he told the male nurse, ‘I don’t want that woman taking care of me.’” Sriraman adds, “[Patient satisfaction scores] put a lot of power in patients’ hands who may not deserve the power to trash somebody who’s working really hard.”
Give physicians a voice
Sriraman grew weary of feeling that she and other physicians had no say in how patient scoring decisions are made, especially when they’re tied to bonuses and salaries. So she joined the board of her hospital and spoke to the CEO about what she sees as the unfairness of tying bonus and salary to reviews, over which physicians have little control.
“We doctors have to use our voices,” Sriraman says. “We need to make waves.” She feels that the responsibility for patient satisfaction should fall more on the practice managers or the hospital CEOs.
She adds that physician autonomy is being stripped away, and having a voice is one way to get it back, by sitting on a local hospital, regional, or a health insurance company board.
“We need to groom physicians to become leaders. Because you have people who have never been to medical school, never seen a patient di e, have never had to tell a parent their child has cancer, making these decisions,” Sriraman says.
Empower front desk and service staff
Perhaps the most frustrating part of patient evaluations is that, “Patient complaints are rarely about physicians,” says Guillaume de Zwirek, CEO and Founder of Well Health, a healthcare software company in Santa Barbara, Calif. “About 96 percent of complaints are related to bad customer service. Insurance didn’t cover it and no one communicated it to the patient, or the wait time was long, for example,” he says.
He points out that most of a patient’s healthcare interactions are not even with the physician, but with the front office, the billing team, the care coordinator, the pharmacy and so on.
“Communication is the problem in the vast majority of complaints, and it’s hard for patients to be heard,” de Zwirek says.
He says the best way to handle these common complaints is to empower all non-physician staff members to handle patient concerns in the moment. He believes that giving the administrative and front desk staff the training and tools to do so will give them greater autonomy, which can improve patient satisfaction, as well.
He suggests a variety of ways to do this including through improved technology, compensation bonuses and small thank-yous, or even appreciation days. “These people are super important, and what makes the engine run. When they feel valued, they deliver better results.”
Sriraman also believes that patients often leave negative scores out of frustration and because they don’t know where else to take their complaints. She says that a lot of patient frustrations can be resolved at the practice management level. “Practice managers have to be our advocate and our ally. They should be the ones addressing negative reviews or scores with the patients,” she says.
Use scores to improve communication
Regardless of these frustrations, patient scores, in some form or another, are likely here to stay.
“We should all be nice to our patients, listen to them, and treat them with respect,” Corriel says. “I think [patient satisfaction scoring] sets out to achieve that, and in that sense I do think there’s pros to it,” Corriel says.
Moreover, there is value in having satisfied patients, says Josh Johnson, Ed.D, PA-C, a physician assistant at Ali’i Health Center in Kailua Kona, Hawaii. “Based on journal studies, patients who are satisfied are more likely to follow through with their treatment plans and to recommend their provider. They’re more likely to go back to that provider to seek medical care in the future.”
Johnson says that taking the time to communicate to patients that physicians are open to resolving problems along the way may also help improve scores later. “It’s about being proactive and educating patients.”
He says physicians can also get in front of scoring by talking to a patient before a survey is sent home. For example, as a patient is discharged from the hospital, or at the end of a clinical encounter, ask, “Is there anything that we could have done better that would’ve improved your experience here?’”
Johnson accepts that scoring isn’t going away. Instead, he tries to use it as a motivation to improve. “If I know my scores in one quarter, I ask myself: ‘How am I going to implement change?’ That’s what medicine is, right? It’s looking at something wrong and asking what I can do to improve it.”