There is a summary write-up of a discussion between doctors on MedScape. This is not an article (or video since it contains the video of three doctors’ discussion in addition to the transcript) for public viewing; one must be a published scientific article author to be able to view the original. In case you do have an article in the NIH database and have access, the link is provided. I do have access so I summarize here what the discussion is about for those who do not have access and, as before, I need to ask you to sit down before you read it. Some parts of the article are shocking.
The debate title is “The Pros and Cons of Patient Satisfaction Measures” and it is a Primary Care debate between three doctors: Bradley P. Fox, M.D., William R. Sonnenberg, M.D., and Charles P Vega M.D. The discussion is dated July 8, 2014.
Apparently Dr. Sonnenberg made the suggestion that “patient satisfaction” should be used “as guide for physician evaluations and payment.” He presented a paper in the Keynote Physician, which is a paper of small circulation so he thought nothing of the ensuing consequence. Then later he gave a lecture in San Diego on Brochiolitis (children’s lung infection) and suggested that doctors “need to pin downs diagnosis” in patients because otherwise “parents will be taking their children to emergency wards or urgent care centers, where they will be given the obligatory prescription for azithromycin (common antibiotic), which seems to make everyone happy.”
This created what you may call chaos in the conference as ER doctors ran after Dr. Sonnenberg after his talk telling him that “Look, we know that what we are doing is wrong, that this is bad medicine. But our performance is judged largely by 2 parameters. First, do we get the patient door to door in 45 minutes? Second, do we keep the patient satisfied?”
Wow! WOW! and WOW!
They know that they are practicing bad medicine! They know and admit it! Plus they also admit that medicine is all about money because they need to get the patient out the door–in case you don’t know, there is a time limit set by each emergency room for what it considers to be acceptable to pass before they must admit the patient to the hospital. Thus getting patients to not be admitted is goal number one over and above patient health! Goal number two is to make sure patients leave with a smile, even if they were given the wrong treatment.
What happened to ethics? To the Hippocratic Oath that states “Do No Harm!”?
The discussion continues about how administrators are leading what doctors do. There is really nothing new about this since we all know and have always known that doctors can only do what the administrators, who are not doctors, let them do. This not only leads to bad medicine but also can have dangerous consequences, as our recent discovery of superbugs suggests. Superbugs do not respond to any known antibiotics. The reason for these superbugs is precisely the over-prescription of antibiotics for cases where it is not only not needed but may actually cause harm. If doctors are judged by patient satisfaction and they are not happy, according to what these three doctors are talking about, the patients did not receive antibiotic treatment!
Thus we have a multitude of problems here, not the least of which is patient education–or lack thereof.
The three doctors go on discussing how increased patient satisfaction is actually associated with higher patient mortality rates–which would be understandable based on the antibiotics argument but not on any other measure. They also discuss the importance of patient satisfaction for “patient adherence” meaning that we stick with our doctors.
It nearly seems to me that three used-car sales reps are talking here! Is this real?
They continue: “Right now, the effect of patient satisfaction on income is about 3% of a primary care physician’s salary and 2% of a specialist’s salary. This is not a major chunk of a physician’s salary, or anywhere close.”
This is a very interesting discussion. Pretty soon I will feel like a bag of peanuts for sale. How much of my health really maters to doctors?
The discussion continues: “Physicians are generally a very competitive lot, and if you look at a survey and see that you are in the lower 10% or 20% of a given metric, you will try to do things to increase it.” The discussion does not detail how far doctors are willing to go to achieve to be in higher than the lower 20% of a given metric and it is not clear what the “metric” in this sentence refers to but whatever I try to refer to in terms of what physicians are for, it sounds bad, except in one case, in which patient health is a metric.
Unfortunately the questions of metric with respect to patient health has not come up anywhere in this discussion.
But there is another angle to being watched and judged by administrators. Dr. Sonnenberg said
Once I was dinged for something I believe is distinctly unfair. Years ago, a patient had an x-ray in the emergency ward; I received the result 3 days later. I called the patient promptly when the x-ray showed up on my desk. The patient yelled and screamed and gave me a bad report, and I ended up getting certified for 1 year instead of 2 years. It did not matter that what I did was logical, proper, and the best anyone could have done. They did not care; they saw the and dinged me for it anyway.
Thus even when a doctor does the right thing, the administrators’ rules are above and beyond what a doctor may seem to be the right action–even if that is the right action for the patient.
Dr. Fox was the only one who suggested the kind of measurement that included the terms “real-time or medically sensitive approach” for being included in a metric of deciding the quality of a physician. A “medically sensitive approach” is still not “did we get the person healthy” approach but better than “was the patient out the door in 45 minutes?” for sure.
But then here is a not-so-funny statement for you:
One humorous anecdote I heard was that to get rid of the outliers, make sure you put down an abuse diagnosis in the coding. If you put down an abuse diagnosis — alcohol or drug abuse — those statistics are automatically excluded by Press Ganey. I have heard that this is a way to game the system…. (Dr. Sonnenberg.)
So the system is being gamed in medicine. Again, nothing new, only a confirmation of what we all already knew only it is odd to hear it from the mouth of a doctor. Isn’t it?
I am ashamed that I read this discussion but glad that I did as well for it proves what we all know: medicine today is in shambles because of incompetent administrators who look only at profits. There is nothing wrong with looking for profits if appropriate care is provided. But getting profits based on how fast the patient is kicked out of the office is not a profit center for a physician!
I am looking forward to your thoughts!