Patient Satisfaction

Every once in a while, the topic of patient and physician satisfaction shows up in the press, usually following publication of research or polls. I'm interested in what contributes to satisfaction in the patient-doctor relationship, though I'm not convinced that we need to be satisfied to have our needs met. Or, put another way, offering the best and safest medical care may not always satisfy my patients--or me. There is a lot of research about satisfaction, but no clear evidence that satisfaction matters. It is assumed to be its own valid outcome, though it is hard to measure reliably. There are a couple of fun satisfaction items that have landed in my Google Reader recently.

Yesterday I ran into this Annals of Internal Medicine study on management of patient expectations. The investigators audiotaped 200 medical visits and documented what patients wanted, then asked them later how they felt about the visit. It turns out that 97.3% of pre-visit expectations were at least discussed during the visit. How did these expectations come up? Forty percent of the time patients brought up directly ("I would like _______." Good, solid communication). Thirty percent of expectations came out by having patients mention symptoms. Also good communication; it's my job as a doctor to help people make sense of their symptoms. More than a quarter of expectations came out through "physician-initiated discusson." I'm not sure exactly what that means. Would patients never have mentioned these things if the doctor hadn't chased after it? Or did the doc just get there first? Thinking about this would get me way off track, so I'll drop it.

Regardless of how things came up, expectations were met around 67% of the time, and where doctors weren't comfortable, they did the right thing and suggested alternatives only around 22% of the time. I guess the rest of the time they just said: "Uh, no."

And what about satisfaction? "Patient satisfaction and trust remained high, regardless of whether expectations were met." So what can I learn from this study? Should I worry about what patients expect? If expectations aren't related to satisfaction, well then what is? And does satisfaction matter? I know plenty of people who aren't satisfied with their doctors, but they keep going.

Item number two showed up in Family Practice Management's March News & Trends, reporting on a Consumer Reports survey. I've pasted the clip in green below with my comments along the way.

The good news for physicians: The overwhelming majority of patients said they were "highly satisfied" with their doctor and that their health improved under their doctors' care. In addition, 77 percent said their doctors treated them with respect and 67 percent said they were patiently listened to and understood.

Already this seems more useful than the Annals piece, as they ask whether patient health actually improved. I'm also happy CR asked about respect, but shocked that so few doctors listen to and respect their patients. CR presents this under the good news header!

The bad news for physicians: The majority of patients said their doctors never talked to them about the cost of treatments and tests.

I hate talking money with patients, and frankly feel ill-equipped to do it. I know tons about tests and treatments, but very little about what they cost. My ePocrates handheld reference gives me some info, but I can't predict what insurance will cover and at what rate. I saw a patient in clinic one day with chest pain. It wasn't his heart, but when I shared with him some chest pain (i.e. heart attack) warning signs that should prompt him to call 911, he began to quiz me on on the costs of ambulance transport and emergency care. I had no idea what to tell him, and felt bad about it. I know money matters, but I just don't have the answers.

In addition, patients had these complaints:

• 74 percent said their physicians had not asked about emotional stress.

• 24 percent said their physicians made them wait 30 minutes or more.

• 19 percent said they couldn't get an appointment within less than a week.

I cannot believe that there are still non-surgeon physicians who don't ask about stress. The second two complaints above are systems issues, and inexcusable. I think making patients wait around to see a doctor demonstrates a real lack of respect for the value of their time. Patients don't have all day to hang out in clinics, waiting to be seen. Also, having to wait a week when you're sick or when your kid is sick and you're worried is just plain wrong. Who wouldn't go to the ER under those circumstances? Same day or next day access isn't that hard to provide; we should be doing it.

Patients weren't spared from the criticism, however. The most common complaint, shared by 59 percent of the physicians surveyed, was that patients don't follow prescribed treatments.

Sure. But I haven't done my back exercises in months, so I get that it's not always easy to do what you're told, even when you know it will help.

Other physician gripes included the following:

• 41 percent said that patients wait too long before making an appointment.

Or are they just waiting for their appointment?

• 32 percent said patients are too reluctant to talk about their symptoms.

Except emotional stress, which we don't want to talk about.

• 31 percent said patients request unnecessary tests.

Bloody internet.

• 28 percent said patients request unnecessary prescriptions.

Bloody advertising. In this case, I refer back to the Annals paper, which reminds us that it is important to negotiate with patients. We shouldn't offer wasteful or harmful interventions to patients, even if they want them. We should offer alternatives that address patient concerns and hopes.

Two more publications on satisfaction, and I still have no good idea about it's value, or even what it really is. I do know there is value in listening and respecting patients, getting them in when they need me and seeing them on time. And I'd like them to feel healthier.

But satisfied?