Issue: September/October 2019
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
"Your Customers will never be any happier than your employees."
―John Dijulius, The Customer Service Revolution: Overthrow Conventional Business, Inspire Employees, and Change the World
Your practice, I am sure, is being graded and evaluated based on some sort of patient satisfaction score. You and your department probably receive quarterly to even daily reports of your ability to “wow” your patients. These reviews can seem to be generated in arbitrary ways with questionable statistical significance. This process can often seem to be unfair to some people who feel downtrodden when seeing their results on these metrics. The goal of these patient satisfaction scores, which seems laudable on the surface is to improve the patient experience, improve customer satisfaction, and to improve patient care.
As a medical director, I am expected to review the scores and comments from patients for every provider. Some of the comments and results are infuriatingly funny, but certainly can be a cause of provider dissatisfaction. In our system only a nine or ten matters. An eight is the same as a zero. Comments from everything that the doctor was great, but I did not get a pillow, or I had to walk too far in the parking lot can torpedo your score even if the patient specifically comments on how great the doctor or nurse was as only that total score matters. Providers on the bottom end of these metrics see these results and their stomach can twist with rage and fear when they feel that no matter what they do or try, that their scores do not improve. They can feel that their livelihood is threatened and can feel hopeless when trying to change the outcome. Should they go park the patient’s car or bring extra pillows from home if that is what it seems that they need to improve?
The goal of making patients satisfied sounds like an appropriate proposal. We all can learn and practice new techniques to improve our individual ability to make patients feel that they are being cared for in an empathic way. No one wants a cold or rushed doctor who makes them feel that their issue is not important or that their perceived need is not met. Each of us has a different skill set and the idea of using a practiced list of things to do or even a script to help us remember how to improve our patient’s experience is not necessarily a bad idea. Emergency physicians should have the ability to accept constructive ideas in relation to improvement.
Speed can play a big issue in this regard. All of you know the doctor who is the dragon slayer in your department. These providers can see ten more patients a shift than the next fastest provider on a consistent basis. This skill is great on the busy days, but can come at a price if these same providers are the ones who generate the most patient and staff complaints while also producing the lowest patient satisfaction scores. Being fast does not necessarily mean less empathy. One of the greatest skills in medicine, in my opinion, is the ability to make a patient feel special and cared for in a short period of time. I have a friend who is a cardiologist who can see fifty patients in the office in a day and each one of them feels like the doctor took time with them and made them feel that their concerns and issues were addressed, while in actuality he was only in the exam room for five to ten minutes. I also know doctors who spend twenty minutes explaining things in endless detail to a patient who leaves feeling the doctor is cold and does not really care for them. Where is the difference?
Certainly, there are skills which can be learned and many of us would benefit from examining our own habits when treating patients. Our shop has recently started shadow rounding and suggesting different “techniques” for improving individual provider’s scores. These discussions bring the expected eye rolling, but may be of great benefit to the provider if they can actually accept the fact that there are things which they do or do not do which has room for significant improvement. This quest from improved scores though can lead to significant discomfort and anxiety for the provider making their already stressful job just that much harder. The goal of any exercise or initiative in this regard must take this fact into consideration or it can just be another step towards burnout.
Some might argue that focusing on improving these measures can lead to the worsening of patient outcomes and increased costs when it can seem that our new goal is to make the patient happy even if what they want is not what they need. This leads to my contention that hospitals and health care systems need to focus more on provider satisfaction if they want to improve patient satisfaction. The quote at the top of this article relates to this fact. Patients can sense when the provider is not interested or involved for whatever reason. Each of us, even the most compassionate and empathetic amongst our specialty have bad days when something in our life is causing us to not be at the top of our game. This does not mean that we are bad, but these are the days when a practiced script might even be more useful. However, I often note that these days of not being at our best performance may be more related to our personal level of job satisfaction or burnout rather than our actual abilities. I sometimes see a sense of doom and gloom over the provider who is at the bottom of any metric whether it be patient satisfaction, RVU production, patients per hour seen, or whichever metric is being evaluated by the administrators that week.
You also may have noted that I keep referring to people as “providers” and not doctors. I did this purposefully as this is now a contributing factor to burnout and leads to uncertainty about our future. The trend of using midlevels as independent practitioners or as replacements for double coverage slots for emergency physicians is rapidly developing, and in many ways more distressing component of many of our practice environments. Many of us feel threatened and fear replacement by someone although less qualified are certainly cheaper than ourselves. I have heard directors of large emergency departments stating that there is no department no matter how large which cannot be properly staffed with two emergency physicians with an ever expanding stable of mid-levels. Other directors will claim that they have hired their last doctor and will only need to add midlevels. How does that make you feel? Will this lead to increased satisfaction scores for yourself?
Are you satisfied? Would you give your job a 9 or a 10 on a satisfaction survey? I think we need to turn the satisfaction industry upside down and look at it from the other end to consider a different approach to improving satisfaction for everyone in the emergency department. I do not just mean patients, I really mean the staff. How do you satisfy a patient? Simply giving them what they want whether it be a CT scan, a blood test, an antibiotic prescription, a dilaudid injection, or whatever is not what we should do ethically. Many of us are fearful and worry that “our scores” are low and we need to improve them. I do believe that there can be real validity in the overall scoring related to an individual physician’s interpersonal skills but we should and really must use this information in the proper way. We all know excellent physicians who deliver exceptional care but have terrible patient satisfaction scores. These same physicians can feel pressured into bending their practice habits to “improve” their scores. They will bend and give the antibiotic prescription to treat the virus or order the X-ray that is not really indicated because they can tell that the patient will not be satisfied without these things being done. What does this do to the physician’s satisfaction? Does doing the wrong thing make him or her feel better about healthcare or their career? What is the implication for the doctor’s wellness to spend ten minutes explaining to a mother why a CT scan should not be performed on a child with a bump on their head all the while knowing that she is not buying it? The doctor knows in their heart that the mother will shortly be posting on social media or filling out a “satisfaction” survey slamming the doctor for doing what is medically correct, protecting the child from needless radiation, improving length-of-stay numbers, and decreasing costs.
The answer to this quandary is not straightforward, but we as a profession cannot shy away from it. Maybe simply acknowledging it will help, but we need to develop strategies to improve our satisfaction. I do believe in the opening quote. Our patients will never be satisfied if we are burned out and can no longer act like the doctors which we trained to be. Remember we are not providers, we are DOCTORS!