Patient Satisfaction: A Danger to be Avoided

Doctors intuitively know that the Yelpification of medicine is bad. But it’s not just toxic to the physician-patient relationship and bad for burnout, it’s actually dangerous.

The outsized and misplaced importance of patient satisfaction scores is a perfect embodiment of Goodhart’s law, well-paraphrased as “when a measure becomes a target, it ceases to be a good measure.”

If you make patient satisfaction scores a critical target—and they are—you will see consequent mismanagement. This is so blatantly apparent when it comes to urgent care and pain management that, if anything, high satisfaction scores are likely a more meaningful signal of poor care.

If a patient comes to an urgent care for a URI and wants antibiotics, they will be most “satisfied” when they receive the prescription they didn’t need. And all that over-treatment is not without risk.

Even outside of quality metrics, profit-centered health care businesses need patients to make money, and the “customer” is always right.

A study published in JAMA is a great example of the obvious negative externalities of prioritizing patient satisfaction scores. It analyzed a large number of telemedicine visits for URI:

72 percent of patients gave 5-star ratings after visits with no resulting prescriptions, 86 percent gave 5 stars when they got a prescription for something other than an antibiotic, and 90 percent gave 5 stars when they received an antibiotic prescription.

In fact, no other factor was as strongly associated with patient satisfaction as to whether they received a prescription for an antibiotic.

Another study out of UC Davis study analyzed a >50,000 person national Medical Expenditure Panel Survey and found that patients who were most satisfied had greater chances of being admitted to the hospital, had ~9% higher total health-care costs, and 9% higher prescription drug expenditures. Of course, if you’re a for-profit entity (and most “non-profit” hospitals certainly are), higher costs and more prescriptions often just mean more profit. A win-win-win.

But even worse, death rates also were higher: For every 100 people who died over an average period of nearly four years in the least satisfied group, about 126 people died in the most satisfied group.

Moreover, the more satisfied patients had better average physical and mental health status at baseline than the less satisfied patients, and the association between patient satisfaction and death was strongest among the healthiest patients. Perhaps the “worried well” should be worried.

The push to satisfy patients at all costs is no secret. But some doctors are fighting back, like Dr. Eryn Alpert, who sued Kaiser Permanente in 2019:

A doctor who refused to prescribe patients unnecessary opioids has sued Kaiser Permanente, alleging the way the company used patient satisfaction scores hurt her career and incentivized doctors to over-prescribe painkillers.

…

By requiring its employee physicians to achieve certain patient satisfaction scores in departments where those scores are closely related to a physician’s willingness to prescribe opioids, other addictive medications, and to order unnecessary medical testing (e.g. labs, radiology) in response to patient demand, Kaiser’s intent was to increase its profits so that … its executives and physicians would receive higher bonus compensation.”

These sorts of individual fights happen quietly all over the country, but the opiate crises may have created an opportunity for doctors to put the focus back on patient outcomes.

Do no harm in many cases means doing less, but the combination of short visits and Press Ganey pressures makes it harder for doctors to do the right thing. Healthcare may be a business, but patient care isn’t.

This article was originally published in Physician Sense in October 2019.