Patient Satisfaction: the New Measure of Medicine

It used to be, before people were forced into health insurance networks, that patients would vote with their feet if they weren't satisfied with the medical care they received. Physicians were motivated by the immediate feedback from the front desk when patients brought up the charge slip after being seen. If they didn't like the service or the charge for that service, they would tell the desk and all in the waiting room within earshot. Physicians knew that one negative comment would require 10 positive comments to neutralize and break even. Thus, they were committed

to give the best care and communication to their patients. Physicians got their business by word of mouth from satisfied customers. No satisfaction, no positive word of mouth, no business. Simple, immediate, accurate.

Now we have surveys, seemingly exhaustive lists of questions that administrators can collect and manipulate to see what's going on from a distant office with never any direct observation of those patients and their satisfaction. With the internet physician profiles there's an added element in which disgruntled patients or even non-patients can give their feedback or vent their spleen. By such methods, a physician can be smeared for giving good care, but not what the patient wanted or expected.

In such an environment, especially with the added pressure of computer controlled communication and 15-minute visits, physicians are more likely to give the patients what they want to save time and reduce the dissatisfaction risks. In that scenario, any confrontation of unhealthy lifestyles is inhibitted. Killing the messenger bearing bad news didn't stop with the fall of ancient kingdoms.

The health care industry has distorted the physician-patient relationship. Now strangers care for strangers, neither knowing the other inside the white coat or outside the white sheet. There is little or no social interaction or context. Abuses can happen in that environment. Administrators needed to come up with a system of oversight. The patient satisfaction survey was born.

The old physician-patient relationship with its long-standing, often generational history of care, never required patient satisfaction surveys. In my 2-physician clinic, we had a 90-95% satisfaction rating. Once we joined a large clinic, that satisfaction dropped to about 60% within months. For intimate and personal health care, bigger clinics are not better.

Now there is the push to establish "medical homes"--trying to reinvent the family practice "wheel " that was the victim of an intentional blow-out two decades ago. If those same administrators are in charge of the process you can bet there will be more exhaustive surveys to follow. But not necessarily better care.

Good cost-effective medical care requires the marriage of medical science with the art of communication. No computer program is capable performing the art of communication. No patient satisfaction survey measures the performance of good medical science. Patients would have to be educated to the level beyond medical school to achieve that.

So what in deed does the survey of patient satisfaction measure? It measures the physician's efforts to neutralize the political climate and the financial and social stresses brought on us all by the health care industry. The patient satisfaction score is no more a measure of good medical care than the number of Olympic gold medals is a measure of the health of this nations population.

Health Care Crisis = Disrespect for Family Medicine

The origin of the crisis in health care can be directly correlated with the decline in the respect for and support of general practice physicians now called family medicine specialists. As this society has moved farther and farther away from medical care given by someone who knows you and you know them [which I call "relational medicine"], costs have escalated due to excessive testing, inappropriate referrals to specialists, defensive practices [testing to avoid or to "cover your tail" against malpractice] and medical errors.

***If the doctor doesn't know the patient, more tests are done to try to make the diagnosis since there is no knowledge of the patient's life story--apart from the very sketchy profile we call the past medical history. That history is the bones but not the flesh and breath of the person.

***If the patient doesn't know the doctor, more tests are expected or demanded. "What does he/she know about me?" is the thought. "How can I trust this person to know what's wrong?" The patient trusts impartial tests much more than a rushed and exhausted physician--especially when her/his nose is buried in a computer, asking often obscure questions to comply with the demands of the computer's software program.

***If the doctor and the patient don't know the specialist, watch out! That person may or may not be good at communicating and may not be very good at whatever specialty for which they claim competence. Family physicians used to know and trust every specialist to whom they would refer their patient-friends--yes, patients used to be friends of and with their physicians--but now it's totally up to whatever "health plan" the patient has. That's why the first question anyone is asked now before being seen in any clinic, ER, hospital, surgical center, etc. is "What is the name of your insurance carrier?"

***If the doctor and patient don't know each other, the doctor-patient relationship is that of "strangers in the night". What is there to keep the physician from doing additional tests "just to be sure"? The specter of the malpractice courtroom where the attacking attorney is scoffing in hindsight at the physician's decisions, "You mean you didn't even do that simple test?" is on both the mind of the physician and patient. If the doctor knows their patient, many tests and even ER visits can be avoided. For example: When a patient of mine, the mother of a 2 y/o daughter with an acutely painful arm, called me after hours, I knew that she could follow my instructions on how to treat her child's condition because: 1. I had delivered her with that child, 2. I knew how she cared for her daughter since she had brought her in for well baby checks and on time, 3. I knew the mother was a physical therapist, 4. I knew she could give me an accurate history of what happened, 5. I knew she was capable of following my instructions and 6. I knew if it didn't work that she would come in and not go somewhere else and then sue me. So I proceeded to instruct her, explaining what I thought had happened and what the diagnosis was. She did what I said to do. The child was instantly better. We all went to sleep. Everybody was happy and not a dime was spent. Then I saw her the next morning to confirm that everything was OK.

***Errors happen when care is handed over to strangers. If the surgeon has never met the patient before and doesn't have any recall of the patient's problem other than what's on the chart, there is nothing to refute a typographical error. Whether something is wrong on the left or right side means little to the doctor but means everything to the patient. It's just as easy to type "L" as "R". For example, when a patient is asleep, there's no way to know which side the hernia is on. X-rays can be turned around so "left" looks "right" and "right" looks "left".

Family physicians become a family's doctor because that's what interests them--medical care in the setting of family dynamics, personal perspectives, life stories. People. And the human condition, the struggles coming into life and in leaving it. This is just how they are. These are the things that "turn their crank". Living in the community they serve--for good and for ill.

Surgeons become surgeons, because they like to cut bad things out or fix things and then be done with "it". They don't necessilarily know or care to know the strengths and weaknesses or life story of the patient. They don't want to struggle with the untreatable--things that can't be "fixed". That's their personality. It's not wrong; it's not good or bad. That's what they are and that's what they do. But you would be frustrated to go to one for some problem that cannot be "fixed" or cured. Surgeons are lousy when it comes to diabetes.

Next time I'll write about what's behind that decline in respect and support for family practice.

Family Physician in the Forest

In the forests of the upper Midwest, the rural hospital ERs are in the crack of the rock and the hard places. The family doctors that care there are in the cleft of that crack and getting shoved farther down with eaching passing day. Not that the city family docs have it any better--in my estimation, it's gotten even worse for them in the past decade. Now the rural MDs have urban shoulders to stand on. What the urban MDs have to stand on is giving them the squeeze.

Every study of cost-effective health care over the past 30 years has shown that family physicians are the best--even better than internists, given that family doctors take on "all comers"--caring for and treating everyone in the family without costing the family its life's savings. They were and are trained to care for 90-95% of every disease, every ailment that we Americans are prone to get. Often, when they saw one, they saw all in the family at once--dispensing penicillin, for example, for everyone in the family with a sore throat when the first one in that family had a positive strep test. That's preemptive sickness care: true preventive health care.

Each member of that family weren't charged a separate office visit either. That's not good business but it is good medicine.

To think that the "fix" for the high cost of health care 25 years ago was aimed at those family physicians is understandable given the greed that this culture has supported.

It's better "business" to make a charge for everyone--especially when business administrators took over medicine. That way the administrators have many more "encounters" from which to extract their 30% administrative service charge. That way the administrators at the top of the business can make over $100 million a year while the family doctors are struggling to stay in practice.

I recently learned that my 2-3 hours of after-midnight emergency care for a person who subsequently became a nurse [I just worked with her last weekend] was charged to her @ $10,000. I received a little over $200 for that care which included sewing up over 8 inches of facial lacerations and the reattachment of her right ear and of a portion of her forehead [scalp] left on the windshield when the paramedics first brought her in. I knew enough to tell the deputy sheriff to go back to the scene and find that scalp so I could reattach it. I did not feed the plastic surgeon's children that night, but I'm sure the administrator's conscience slept well.

It now doesn't surprise me that just looking at a wound, without any treatment, costs $600.

If family physicians could charge half that amount, there'd be family practice clinics on every block of every city. Everybody could have their own personal physician again.

Right now, half of all the primary care physicians are contemplating retiring or just quitting. Those that have medical school and residency training debts yet to pay, don't have that option. Without outside monetary support, a new physician has medical education loans of between $100,000 to $200,000 to pay back on top of the cost of setting up a practice. That's not counting the 11-12 years of delay of life's gratifications that the training also extracted. It's no wonder that fewer and fewer new physicians are going into family practice. The hours are less and the pay is much higher to go into a medical sub-specialty.

The current system allows for an agency that employs nurse practitioners to charge $500 for a home visit for a new mother and her child. For a self-employed family physician to make that house call and charge for it wouldn't get a fraction of that amount.

Let's hope that President Obama will get advice from the caring health professionals that have kept on fighting to care and not just feed the present system by throwing money at it. If he has the wrong advisors, that's what we'll get.

And we'll all be in that crack, heading for the big squeeze.

Hello There

If you like what's happening in medicine you shouldn't read this. If you think that a computer is able to diagnose your ailments and give you the best medical care you deserve what you get. If you think that communication is simple, good luck. But if you think that you need to have a physician that knows you and that cares to communicate with you then read on.