One thing that’s different about medicine as a business compared to most other businesses is the role of customer satisfaction, or, in the case of medicine, patient satisfaction. In most businesses, the overall goal is to keep the customer satisfied, so that he or she is more likely to think well of your product or service, purchase more of it, and provide good word-of-mouth to friends and family. Of course, price, quality, functionality, options, and many other factors go into producing customer satisfaction, which is why inexpensive crap can sometimes be very popular. Here’s where the difference with medicine comes in. In medicine there are definite standards and evidence to tell us as physicians, advance practice nurses, physician’s assistance, nurses, and any other provider what is and is not quality care. The problem is that those standards often conflict with what it takes to maintain high patient satisfaction scores.
Unfortunately, the more like a business medicine has become, the more patient satisfaction has come to the fore as a metric by which doctors and health care facilities are judged. These days, we live and die by our Press-Ganey scores, the result of the most commonly used patient satisfaction survey used by health care facilities. Indeed, Press-Ganey itself sells its services as “driving performance excellence” in health care. The inherent assumption behind patient satisfaction surveys like Press-Ganey is that if patients are satisfied then the doctors and facilities producing high satisfaction scores must be doing a good job. But it’s subtler than that. The underlying assumption is actually that patient satisfaction equals quality, and the further assumption is that Press-Ganey scores reflect patient satisfaction. Never mind that Press-Ganey scores include questions about a whole host of things that have little or nothing to do with the quality of care being delivered, such as parking and food. That’s why, as I’ve said before many times, patient satisfaction does not equal quality. Sometimes it can, but often it does not, and sometimes it even equals the opposite of quality.
So it was with interest that I saw a story on NPR, Patients Give Doctors High Marks For Prescribing Antibiotics For Common Sniffles:
When they’re sick, Americans seem to know what they want: antibiotics. And if they don’t get them, their doctors’ reputations may suffer.
A study published Monday finds that patients rated themselves happiest with their doctor’s visit when they got an antibiotic after seeking care for a respiratory tract infection, such as a common cold, whether they needed the drug or not.
I’m not a primary care doctor; so I seldom have to deal with this particular request from a patient, antibiotics for what is almost certainly a viral illness, but I know a fair number of internists and primary care doctors who almost certainly groaned in recognition when they saw that headline.
Here’s the study, which was published in JAMA Internal Medicine, Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine. Interestingly, the study came from the Cleveland Clinic, an institution that I’ve been lambasting regularly over the last five years or so for its tight embrace of the quackery of traditional Chinese medicine and functional medicine, an embrace that contributed to the director of its Wellness Institute publishing an antivaccine rant and later going full quack. It’s good to see the useful side of the Cleveland Clinic, which used to be a fierce rival up up the street from University Hospitals of Cleveland, where I did my surgery residency, and one that I used to think of as scientifically rigorous and thus a worthy rival.
The authors point out at the beginning of their brief study:
Outpatient respiratory tract infections (RTIs) are mostly viral in nature and rarely warrant treatment with antibiotics, yet physicians frequently prescribe antibiotics for such infections.1 This decision to prescribe antibiotics for RTIs may be owing to physician assumptions that patient satisfaction will be lower if antibiotics are not prescribed.2 However, evidence supporting these assumptions is mixed.3-6
Direct-to-consumer telemedicine is an ideal setting in which to evaluate the association between antibiotic prescribing for RTIs and satisfaction ratings among patients. Respiratory tract infections are the most common reason that individuals seek medical care in this setting and every encounter concludes with a prompt for patients to rate their satisfaction. We assessed the association between antibiotic prescribing for RTIs and patient satisfaction ratings in the Online Care Group direct-to-consumer telemedicine platform.
So here’s what they did. They studied patient encounters completed between January 1, 2013, and August 31, 2016 through American Well’s Online Care Group, a national provider of telemedicine services to consumers, which ended up being a total of 8,437 appointments for evaluation of upper respiratory symptoms. Patients with respiratory tract infections (RTIs) were defined as those with International Classification of Diseases, Ninth Revision (ICD-9), or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10, which I discussed yesterday in the context of discussing the forthcoming ICD-11), codes for sinusitis, pharyngitis, bronchitis, or other RTI. The authors then categorized prescription outcome as no prescription, prescription of an antibiotic, or prescription of a nonantibiotic medication. Patients rated satisfaction with their physician on scales of 0 to 5 stars (where 5 is most satisfied and 0 is not satisfied at all), dichotomized as 5 stars vs fewer than 5 stars. Individual physicians’ adjusted mean rates of antibiotic prescribing were assessed for correlation with their adjusted mean satisfaction scores, all adjusted for patient, physician, and encounter characteristics. Amixed-effects logistic regression model was then used to evaluate whether satisfaction varied by prescription outcome, accounting for clustering by physician.
Here are the results:
Among 8437 encounters for RTIs with 85 physicians, 5580 (66.1%) resulted in prescription of an antibiotic, 1309 (15.5%) resulted in prescription of a nonantibiotic medication, and 1548 (18.3%) resulted in no prescription (Table). Most encounters (87%) garnered a 5 star satisfaction rating.
A total of 1123 of 1548 patients who received no prescription (72.5%) rated their satisfaction as 5 stars, compared with 5075 of 5580 (90.9%) of those who received a prescription for an antibiotic and 1126 of 1309 (86.0%) of those who received a prescription for a nonantibiotic medication. Compared with receiving no prescription, receipt of a prescription for an antibiotic was strongly associated with rating care 5 stars (adjusted odds ratio, 3.23; 95% CI, 2.67-3.91), as was receiving a prescription for a nonantibiotic medication (adjusted odds ratio, 2.21; 95% CI, 1.80-2.71.) Physicians’ mean adjusted rates of antibiotic prescribing ranged from 19% to 90% (interquartile range, 56%-77%) and adjusted satisfaction ratings correlated with adjusted antibiotic prescribing rates (Pearson correlation, 0.41; P < .001) (Figure).
So, basically, for a study like this, there was a pretty decent correlation between the physicians writing a prescription for antibiotics for a viral upper respiratory infection and the odds that they would receive a five-star rating for the encounter. True, satisfaction levels were still pretty high, even for physicians who didn’t write antibiotics prescriptions, but writing those prescriptions pushed them significantly higher. The authors noted that the absolute difference in patient satisfaction rates wasn’t that high but pointed out that physicians are usually judged by the quartile they land in, not by absolute scores and that patients do often distinguish between physicians with patient satisfaction scores of, say, 4.7 stars versus 4.9 stars.
Indeed the authors note:
For individual physicians, frequent prescription of antibiotics was associated with better satisfaction ratings. Few physicians achieved even the 50th percentile of satisfaction while maintaining low rates of antibiotic prescribing. To reach the top quartile, a physician had to prescribe antibiotics at least half the time; almost all physicians above the 90th percentile had a rate of antibiotic prescribing greater than 75%.
The authors also pointed out that, based on their results, no “other patient or physician factor was as strongly associated with patient satisfaction as receipt of a prescription for an antibiotic.” By way of comparison, actually nothing the patients received was associated with patient satisfaction besides an antibiotic prescription was associated with a five star rating other than a non-antibiotic prescription (adjusted odds ratio 2.21) or using a coupon for a free or reduced-cost visit (adjusted odds ratio 1.58). For doctors, giving these patients a prescription for antibiotics far and away was the best means to increase the odds of receiving a five star rating for any particular patient encounter for an RTI.
Another striking finding of this study is just how wide the variation in prescribing practices is, with the mean adjusted rates of antibiotic prescribing ranging from 19% to 90% for RTIs. This variation is far beyond what can be explained based on evidence and suggests that there are widely differing interpretations of the role of antibiotics in treating RTIs. Either that, or some physicians are better at placating patients without writing for an antibiotic than others.
There are limitations in this study, as with all studies. For one thing, it’s observational. For another, it’s a specific type of practice, meaning that its results might not be generalizable to typical primary care practices. Also, no judgment was made on the appropriateness of the antibiotic prescriptions. Rates were adjusted for diagnosis, though, and the authors note that the “high rate of antibiotic prescriptions we observed is likely inappropriate for the diagnoses.”
I like to point out that there is one particular specialty in medicine that emphasizes patient satisfaction above all. Indeed, at the Cleveland Clinic itself (sorry, authors, I couldn’t resist, but this is the best example), Dr. Mark Hyman’s functional medicine clinic is touted for its popularity and for how satisfied the patients are with the care there, even though functional medicine is rank quackery that combines the worst of both worlds, namely the massive overtesting and overtreatment to which conventional medicine can be prone, with quackery like acupuncture, traditional Chinese medicine, naturopathy, and even homeopathy. Indeed, “integrative medicine” often produces very high patient satisfaction, even though it is an illegitimate specialty that exists to “integrate” quackery with conventional medicine.
It’s not just integrative and alternative medicine, though. There are lots of examples to echo this example of how treating RTIs with antibiotics (and risking causing antibiotic-associated complications for no benefit) is associated with high patient satisfaction. For instance, surgery and invasive procedures are, understandably, often associated with lower satisfaction because of the pain and discomfort, but overly aggressive preventive medicine is associated with high scores. As I discussed, overaggressive screening can lead to overdiagnosis and overtreatment whose harm outweighs the benefit in terms of lives saved by early detection and intervention, but patients (and doctors) love it, because it feels as though they’re “doing something.” There is even evidence that in some situations, increased patient satisfaction is associated with worse, not better, outcomes. One study that I discussed a few years back found that patients in the study who demonstrated the highest level of satisfaction were more likely to have an inpatient admission (adjusted odds ratio 1.12) than those with the lowest levels of satisfaction and also accounted for 8.8% more health care expenditures, including greater prescription drug expenditures. Worst of all, they demonstrated a higher mortality, with an odds ratio of 1.26, which means they had a 26% higher chance of dying. Also, higher patient satisfaction appears to be correlated with higher resource utilization. In addition, denying patient requests (such as for referral, pain medication, and laboratory tests) have been shown to be associated with poorer patient satisfaction scores.
In fairness, though, it must be noted that the relationship between patient satisfaction is complex. For some surgical measures, for instance, high patient satisfaction is correlated with measures of surgical quality. In other words, I’m not saying that patient satisfaction is never associated with higher quality medicine. I’m merely pointing out that the assumption that it’s always (or even frequently) associated with quality is clearly incorrect. Worse, in the case of common conditions like RTIs, the emphasis on patient satisfaction über alles can actually result in harm, as increasingly hospitals and health systems incentivize physician behavior based on patient satisfaction scores. Medicine is about making the patient better, and, unfortunately, that sometimes means not doing what the patient wants.
Source of cartoon used for this post: https://www.doc-related.com/single-post/2014/01/21/patient-satisfaction.
98 replies on “Patient satisfaction ≠ quality, round ∞”
Doesn’t surprise me — I’ve had MDs spend a LOT of time apologizing for not prescribing antibiotics and explaining why not. My protestations “I don’t want antibiotics!” fell on defensive ears.
Math even I can understand. 😉
Patient ignorance + Doctor pandering = drug resistant bacteria.
I’m sorry Orac, but y’all really need to sort out your medical industry. I know that we are probably as guilty of that up here, but a lack of available family physicians mitigates the issue to an extent. My doctor is booking 6-8 weeks in advance, and the other four in his clinic are about the same. If it takes over a month to get an appointment (two weeks for very priority but non-emergency room issues), there is little chance of getting antibiotics for a viral infection. That or the viral infection is a little more serious then the common cold. Single payor has a lot of issues, but it is definitely better then what you folk are stuck with now.
Waiting times can be artificial. How long did it take for waiting times to balloon out to 6-8 weeks? Was it 6-8 weeks last year? Was it 6-8 weeks five years ago? If so, the waiting time is artificial. If it was real it would be increasing progressively over time. If it is real, it will be maybe 8-10 weeks next year and maybe 16-18 weeks in five years time. Do you think that is likely?
Sheesh, my MCO is two days’ max to see an APN.
My highest rating goes to primary care docs who readily prescribe what I want. In the immortal words of William S. Burroughs (in “Junkie”), the ideal is “a croaker who writes scrip”.
“Mexican croakers are not like Stateside croakers. They never pull that professional man act on you. A croaker who will write at all will write without hearing a story.”
This is one reason I never complete the surveys I receive every time I see a different provider or use a different facility within the regional medical center that I use. The business-ification of medicine is enough to make me ask for a pain med prescription.
I never get handed a survey; they’re just in a box at the checkout desk of whatever clinic I’m seeing (university outpatient, generally, and my MCO home). I just want to get in, deal with the issue, and get out. They’ll hear from me if I have a complaint, but that’s yet to happen. Hell, if by some miracle I got a job with the university again, I’d still see my PCP at the long-wait, low-income clinic, as I like continuity of care and, well, I’m thoroughly satisfied, given that she explains her decision-making process. OK, once she failed to diagnose a diastasis recti and referred me for a surgical evaluation for a possible hernia (the surgeons thought it was for a cholecystectomy, leading to some confusion), but whatever.
I get the surverys in the mail a few days after seeing any new provider–and that’s a lot for old people. The only thing my PCP seems to do is take my BP and refer me to others! The surveys have been coming for about ten years now, even though I’ve told them I won’t do them and that I do not approve of this method of evaluation. Most of the questions are absolutely inane and are about the facilities. The ones about the medical staff and actual care are of the “did the [provider] explain everything so that you could understand?”
What is wrong with people? If I don’t understand something my doctor says, I will ask about it right then and there. Often I find the opposite and keep telling them that I know about such-and-such.
On another survey note, I got a political one the other day. The droning young woman could not pronounce Kavanaugh! When I said that this name has been all over the media for weeks, she said she never heard of him. I hung up. I think she writes survey questions at her other job.
My doctor’s office (a huge, 9-story everything-but-inpatient clinic) called me and just started up the automated survey. I really, really didn’t want to do it, but I was afraid if I didn’t it would negatively impact my doctor. So I sat through a poorly worded series of questions (they changed the scale at least once, maybe twice) and when offered the opportunity for feedback said “I don’t appreciate you calling me with surveys, this survey is poorly written, and I was my doctor judged on her skill, not my willingness to take your stupid survey.” (I may have been grumpy before they called.)
I can understand having a complaint line (I’ve used it), but if everything is fine then why can’t everything just be fine?
(I will say that my doc has never offered me antibiotics, not that I’ve ever asked, and my SO’s doctor actually said “You haven’t been sick long enough to need antibiotics, it’s just a bad cold. Drink water, take Nyquil and get some sleep. You can come back if you’re not better in 5 days.”)
And people wonder why there are so many recurring problems with Dr. Feelgood types.
The authors of the study explicitly note that their results do not necessarily generalize to other diagnoses and types of practice, but I can easily see something like treatment of chronic pain being vulnerable to the same phenomenon. Often, the person suffering the problem will want the physician to Do Something about the problem. Often that will result in opioids or other prescription painkillers being prescribed. Those things will work in some cases, but they have risks and limitations. So some people who aren’t helped by those medications will resort to homeopathy, or acupuncture, or some other alternative treatment. And because of the placebo effect, some of them will find that one of those alternative treatments appears to work. The importance placed on patient satisfaction ensures that clinics will be all the more eager to provide alternative treatments, or even conventional medications in situations where the medications are not appropriate.
And seriously, parking is one of the factors here? If you are on prescription painkillers, you should not be driving, full stop. Unfortunately, land use practices in this country have created far too many places where there is no practical alternative to driving, and I will grant that someone who is in so much pain as to seek a prescription for painkillers (or alternative treatment) will want to minimize the amount of walking needed. Those considerations should not, however, apply to your taxi driver or the friend/relative who is giving you a ride.
You seem to have made a leap in logic here. Not everybody who needs to park is on painkillers. Without a garage, the University of Chicago Medical Center would be utterly screwed.
Same age, Alain, at least where I live. I just had to keep repeating the “she’s a professional” mantra to not feel guilty.
^ I seem to have misplaced that comment. Long couple of days of travel.
That remind me of some past experiences: how do you get tested for an inguinal hernia (doc was a woman), and also, a mass located near the hole where the sun don’t shine and ALL the interns were of the female gent. No comments…
Alain
@Alain:
Can you ask for a male doctor if you want one? Even if you have to visit a different office? My PCP is a guy, but I really like him, and to be honest I don’t get “full” checkups. I remember when I had to get a physical before I went to Russia the first time – luckily I had a nice lady doc for it – I had a hard time even figuring out how to fill out the part of the form regarding sex and “intercourse.”
When we got to the part where a pelvic exam was the recommended thing, we went over the form and talked about my experiences and feelings and she was like “you absolutely don’t have to do this if you don’t want to.” So I didn’t.
Oh, cripes, I’ve mentioned the suspicion of Gardner syndrome already, but when you’re having such a cyst excised and people are wandering in and out making lunch plans (and leaving the door open), it’s just mortifying.
JP,
Trust me, I don’t want any mens, Drs or not, around these area of the body for several reasons which I won’t go into here but suffice it to say that the obvious reason, hedonism, rank at the 6794th position in the reason list.
Alain
@Alain:
Ah, I see, a sucky situation in general, then. You have my sympathy. FWIW, I am also extreme not a fan of any procedures or examinations in the general area covered by boxer briefs.
If you’re leaving after some sort of sedating procedure they will not let you go home in a taxi. In any case friends frequently want to wait or sit with the patient. It can be a very long and stressful day, and you might find reasons to go back to your car for a while.
I agree that it’s hardly a priority, but everything about being at the doctor’s/hospital sucks, and most of it is so obscure that the patient has no idea what is happening to them, let alone whether it’s standard of care. Parking can be comprehended, and it can’t be that expensive to build structures as you can get into them for $5/hour, and sometimes much less. Actual health care is obviously insanely more costly.
Meals are similar. You’re in the hospital, you’re miserable, and the food is going to make it worse. You know (or at least hope) that your medical misery will be for the best in the long run, but the icky meal feels like a pointless attempt to save a few bucks.
Unaccompanied, you mean.
Actually, the friend that I accompanied back after a ‘scope (hi, I’m 50!) loves the hospital food, especially the milkshakes. You can order whenever you want.
Actually the last time I had hospital food was when I was spending the night with a relative. The food was great, and it was cheap. Insurance didn’t cover my meal but it covered the patient’s. And the meal was really cheap.
It was a little bland, not high in salt or fat, but it had plenty of flavor. And once patient got the go ahead, they ate a huge breakfast.
Speaking’bout that, at which age does prostate cancer screening (rectal…not the psa test) should start according to the evidence?
Alain (42y/o).
Same age, Alain (50), at least where I live. I just had to keep repeating the “she’s a professional” mantra to not feel guilty for putting my PCP through it. The procedure itself is no big deal. I recall is as being in the “left lateral decubitus position,” that is, lying on your side. Somehow, television had led me to think I would be standing up and leaning over.
TMI?
My FIL’s primary care doctor for a while was a quack of the pill-pushing variety. My FIL saw him after throwing out his back right before a vacation. The doc prescribed a bunch of pretty strong pain killers and muscle relaxers and said to “mix and match til you find what works”, and didn’t take any of his other medications (for his heart) into account.
So my FIL turned into a drugged-out lump until the leg swelling scared him enough to stop taking most of the pills and just go get in the hot tub. And did this doc ever suggest PT or anything else to prevent more back problems in the future? Nope, just more medications with all kinds of interactions. But I’m sure he got great reviews from his patients.
I once had a Freudian shrink who was kind of on a mission (which cost him his controlled-substances license). There was one time, though, when I mentioned ketamine vis-à-vis depression, and he offered to write a script. This was an awkward moment of explaining, but his heart was in the right place.
The clinic here will not do a colonoscopy unless the patient is accompanied with someone who will watch after them. I have been the one to be with a friend, plus buy her lunch afterwards. Plus dear hubby has been with me for all of mine.
G-d save me from GI residents. Not only am I on the five-year plan, I had to have two in the space of two months because derm finally referred me to rule out Gardner syndrome. The second was much more uncomfortable. (“Give him the rest!”) I mean, taking the first turn around the transverse colon is going to be noticeable, but it shouldn’t be like some sort of space-alien probe otherwise, if you ask me.
I am also on the five year plan, only I had to get the third sooner than expected. I feel your pain. Though for the last one I was awake enough to watch the live feed from the tiny camera. But obviously not awake enough to drive. Though the hunger would also not help my anger management in traffic.
Sadly it make sense to me: I’m a college professor, and it seems like a lot of us feel that there’s a disconnect between how our students feel about the class and what they learn. (I wouldn’t say they are anti-correlated, but there are certainly things that will change one without doing a whit for the other.) Sometimes I wonder if it’s worth surveying students about the class they took after they take another class in the subject, just to see how they think Physics 211 prepared them for Physics 212 or what have you. Of course, that doesn’t work for students who are taking their one science class OR patients who have something like a cold which will go away regardless of what their doctor does.
That’s not how my first-year physics undergraduate curriculum worked. Mechanics, E&M, optics. Given the basically random choice of texts, there was no continuity whatever. I am grateful for Isaac Abella’s calling to find out why the hell I wasn’t at the E&M final, though. If only I had known that all the trig could have been dispensed with via Fourier and realizing that e was a stand-in for a function, everything would have been smoother.
I went to undergrad at a place with a reputation for being intense, and sometimes I felt bad for liking a class or professor because I didn’t think the class was hard enough. (Maybe ecology just isn’t as mind-boggling as relativity or quantum physics or E&M.) Looking back, I learned more from that “easy” ecology class than I did from E&M, which resulted in tears of frustration every homework.
I should clarify that: Easy classes weren’t always bad, and hard classes weren’t always good. Easy and good, hard and good, easy and bad, hard and bad.
But it was also a small school so if Physics 211 didn’t prepare you for Physics 212, the prof from 212 would immediately have words with the prof of 211(if they weren’t the same person).
I never actually got to Hegel because I didn’t realize that I was reading Kojève’s introduction rather than the primary material. Think I dropped that one.
Have to agree about student “satisfaction” scores. They are correlated to random things like the weather (the scores go up if it’s sunny), and some studies have indeed found negative correlation between how much the class learned and their satisfaction. Suggesting that having to do the hard work of learning did lower their satisfaction.
They’re also correlated to the professor’s gender and race, in predictable ways.
But it was also a small school so if Physics 211 didn’t prepare you for Physics 212, the prof from 212 would immediately have words with the prof of 211(if they weren’t the same person).
Now that I’d like to see! LOL
My sister, a pediatrician, got the worst example ever of the businessifcation of her profession. She had a newborn who wasn’t gaining, was in fact losing weight, and she’d recommended supplemental bottles, but the parents were whingeing because they wanted to only breast-feed. They started to skip appointments.
Finally the child’s life was in danger: my sister told the parents that if the child wasn’t in her office the next day, and hadn’t gained weight, she’d call CPS, who would immediately admit the child to the hospital and feed her. That did the trick, the parents grudgingly backed down and fed the baby.
However, they gave my sister a low satisfaction score, which her bosses got on her case about it! She asked if they thought the parents would have been more satisfied if their child had starved to death, but unfortunately, her bosses didn’t seem to get the point.
I have had a lot of PT from the hand clinic following some surgeries and I heard some horrible tales from these lovely and caring women (yes, they are all women–and it’s a large clinic). Several said that they can’t wait to retire to stop hearing about survey issues that have negatively impacted their evaluations–and pay. They all said they try very hard to do the best for each person but that some people simply cannot be pleased/satisfied. I think we all know people like this, so why don’t clinic administrators get it? None of those women seemed to me to have a mean (or even unkind) bone in their bodies and it’s idiotic that they have to put up with this survey nonsense just to keep their jobs.
It’s even worse outside of health care. Everywhere you shop, the sales people beg you to give them a “ten” lest they lose their jobs (or so they say). I noticed recently that AT&T switched to a 1 – 5 rather than 1 – 10–easier for people to give a top score I was told. So, what’s the point of asking if everyone gives a 5 or a 10?
It really does seem to be, in medicine and in your example, that it doesn’t matter how well you do your job, it’s just what the “customer” thinks. Bad enough in education, and even sales, but disastrous in medical fields!
That this would happen at a PT clinic seems especially dense. Why would I want a PT who goes easy on me, doesn’t push me, doesn’t give me hard exercises? How do I get better without trying? Heck, if you made me rate a PT I might well say 5 out of 5, was really hard on me, would recommend.
Yup. My mother was a physiotherapist and I can recall that one group of her patients (miners with knee injuries – this was north east England in the ’60s, when we still had some coal mines) swore that she was trained by the Gestapo (their word), as her attitude towards them was “When I say jump, all I want to hear is ‘How high and how often?’ ” and that they could thank her later when they could walk properly again. Being soft with them was not in the repertoire. Her success rate was very good.
It’s just a conference abstract, but I suppose this is timely. CIDRAP item here.
Ah, the Great Disconnect, one type practitioner too quick to give antibiotics, another type perhaps too slow to recommend them…
Uneven distributions of people with a higher illness burden or un-, misdiagnosed chronic disease, can greatly distort the situation and assumptions of various metric schemes. In some systems, a biologically useful dr will be penalized for actual success with extra sick patients; whereas “greet ’em and street ’em” types were rewarded.
Eric Lund
Those things will work in some cases, but they have risks and limitations. So some people who aren’t helped by those medications will resort to homeopathy, or acupuncture, or some other alternative treatment. And because of the placebo effect, some of them will find that one of those alternative treatments appears to work.
…or they may find alternative treatments that do work, for valid biological and biochemical reasons, after lengthy indifference and gross suffering in the MSM system.
I have never been asked by my GP’s practice to rate my satisfaction with my visit. Conversely the public hospital sector here has instituted a lot of measures over the last few years in order to improve patients’ satisfaction and involvement in their health care. These measures tend to revolve around patient centred care, open disclosure of adverse incidents and patient/family education on how to get their voice heard. There has, also, been an increase in people pulling out their smart phones and recording the clinical staff at work, sometimes while threatening to sue if they don’t get what they want.
Speaking of cellphone records – wonder what the patient satisfaction rating was for this physician:
https://www.washingtonpost.com/news/to-your-health/wp/2017/10/12/a-doctor-shouted-at-a-sick-mother-to-get-the-hell-out-now-hes-under-criminal-investigation/?utm_term=.d5494e841209
Orac’s post is great in that he shows patient satisfaction may be driving alternative medicine, and conventional medicine needs to adapt.
@ Orac,
The underlying assumption at Respectful Insolence is READER satisfaction equals quality, nice post my RI friend!
@ MJD:
Do you ever think before you write? Do you ever imagine how your audience here might react to what you say? What do your statements have to do with anything other than attempting to get Orac to allow you to write a guest post-
WHICH IS NOT GOING TO HAPPEN – at least not in this world.
You came to this palpably false string of words how, exactly?
Ugh. This is why I hate Press Ganey and all satisfaction surveys.
I remember a PA in the ER I used to work in, who tried to hold the line on opioid prescriptions. He wouldn’t write them for the “pain train” as we called the daily visits for our drug seekers, and he was very careful with everyone else. Most of our doctors prescribed the same way (we had one who was just tired of fight and wrote the scripts to get them out of the ER, which is what encouraged them to keep coming back).
The administrators raked this PA over the coals, and so the PA gave up and started writing the scripts. The administrators justification was these patients were Medicaid (Medi Cal), and the hospital got paid for the ER visit, which seldom used much in the way of resources. So it was easy money for the hospital to essentially be a pill mill. He couldn’t pressure the doctors, who had more clout. But the PAs he could bully, and he did.
The old “Nurse K” blog used to address ED drug-seekers on a regular basis. She’s still around on Twatter, but I miss the blog. (Amusingly to me at least, my neuro resident was like, “Oh, yeah, I love Dr. Grumpy” when I asked her what kind of reflex hammer she had.)
Oh, yes. With you on that one as well. I’m a nursing professor. My student satisfaction scores are horrible; they think they can dictate how I present material in the classroom and complain about having to teach themselves (a feature not a bug of the flipped classroom that produces deeper learning).
All they want are the answers to the test questions, and that’s true whether I read the textbook to them or employ active learning strategies.
Patient satisfaction surveys is like an incubator full of stool samples. You never know what you’r gonna get, but its all crap no matter what.
So from the tone of this blog post, am I to assume that the only people who should be assessing the service provided by doctors are the doctors themselves? Maybe doctors should fill in their own customer satisfaction surveys giving themselves a rating and review, and leave the clueless customer out of it altogether.
Or one could get rid of the stupid surveys in the first place. Like I said, if you have a complaint, complain.
We go to the doctor because we want their expertise, and that expertise will sometimes conflict with our desires. If the doctor gives me a treatment that makes me happy, but will actually make me sicker in the long run, how is that a good outcome?
The first thing I want from medical treatment is for it to be efficacious. After that, I would like to be treated with respect. A very nice nurse who takes my blood pressure incorrectly may be a “satisfying customer service interaction”, but they’re not practicing good medicine.
Basically, patient satisfaction shouldn’t and can’t be the only metric.
But that’s just silly. We go to the doctor to get help with illness. Obviously, if the doctor compliments you on your attire, gives you a lollipop, and pats you on the head, that isn’t going to result in a mitigation of the illness, no matter how good it makes you feel at the moment. Patients know this, we aren’t complete idiots as apparently many here believe.
If I go to a doctor, and they misdiagnose me, they are going to get a poor review and rightly so. If they correctly diagnose me and provide a treatment that cures or mitigates the illness, explaining the risk/benefit ratio, they will get a good review. It seems to me more like this blogger is acting as an apologist for bad doctors, and trying to claim that low patient satisfaction results can be disregarded, since it doesn’t always equate with medical competence. The problem is, it often does. If MDs are losing patients to NDs as they certainly seem to be these days, then perhaps its time to honestly examine why, and not simply discount the patient’s opinion as misguided and not worthy of consideration, justified by saying they don’t have a medical degree, so what can they possibly know about it.
Chordylias: But the study discussed in the post clearly said that patients gave the highest rating if they got antibiotics. Like, that was the number 1 driver of a good rating: did the patient get antibiotics, not “was the patient correctly diagnosed and treated”.
So maybe the patients who didn’t get antibiotics thought they were misdiagnosed, but what if the doctor was right, it was a virus and antibiotics won’t help. The patient will still give a bad rating because they think they are misdiagnosed.
The other issue is that the smart patients, the ones who know not to ask for antibiotics for a cold, won’t bother going into the doctor and so won’t be asked to take the survey, so the results are going to skew just based on who chooses to go into the doctor.
I think that the biggest problem most clinicians have with patient satisfaction surveys is that they are not applied well by hospital or clinic administrators. They need to be one of many tools used to evaluate care, not the only tool.
How do you even know that you’ve been misdiagnosed in the time frame that applies to patient satisfaction surveys?
As a nurse, i once got a complaint becauase i had to take a few minutes to finish serving meds to another patient, and instead of quietly dispensing pain meds as requested, i asked the patient his pain score.
Patient satisfaction surveys are like an incubator full of stool cultures: You never know what you’re going to get, but it’s mostly crap anyhow.
I do think that there are other situations where doctors really need to allow patients to drive care far more than they do.
With respect to the particular medical situation they’re talking about here, there’s a really clear medical answer: the drive to give more antibiotics is very harmful to overall patient health. Two counter-examples I’m aware of are transgender healthcare and chronic pain. In both examples, the patient is likely to have far more experience than the doctor when it comes to that care. For trans women, for instance, nearly all of the research regarding the safety and efficacy of hormone therapy is for post-menopausal cisgender women. As it’s an entirely different population, and the goals of the therapy are very different, extrapolating those results to trans women is questionable.
Most doctors don’t seem to be aware, for example, that the studies which show a link between breast cancer and progesterone supplementation were for medroxyprogesterone acetate. There have recently been a few studies which compared medroxyprogesterone acetate to micronized progesterone, and showed no relationship between micronized progesterone and breast cancer risk for up to five years of therapy. And my understanding of the research so far is that breast cancer risk in trans women on modern hormone therapy is lower than cis women, so even if MPA increases the risk a little, it might be worth it (older equine estrogens had much higher risk).
Furthermore, most of the medical field seems convinced that progesterone supplementation doesn’t improve breast growth, but the general understanding within the trans woman community is that progesterone increases the “fullness” of breast tissue (as in, makes them rounder: estradiol-only breast growth results in pointy breasts). To my knowledge, there have been no studies performed which would be sensitive to breasts growing to become rounder. And nobody knows whether or not cycling hormones makes a difference (the default is usually to not cycle hormones).
And then with estradiol, many trans women claim that injectable estradiol is the only effective treatment for them, but there’s again a dearth of medical evidence regarding that.
I have friends with chronic pain that run into similar situations: they have had years of experience with how their body responds to a variety of pain medications, and yet they continually encounter doctors who want them to do something that has failed to work for them in the past.
This sounds like a place where a lot of continuing education could be really helpful to both the patients and the clinicians. And I personally think that in cases of on-going care and treatment there is way more opportunity for partnership between the patient and the doctor, compared to popping in for antibiotics.
Thanks for the info on progesterone, I had no idea.
Your counter-examples also have much less impact on people other than the patient.
“But the study discussed in the post clearly said that patients gave the highest rating if they got antibiotics.”
That may be so, but it might be because the patient received anything at all, and antibiotics just happened to be the most common prescription handed out. In many cases, its the doctors who prescribe antibiotics, not prompted by the patient, to ensure a viral infection doesn’t turn into a bacterial infection, so its not always an erroneous thing to do.
The whole idea that patients being prescribed antibiotics is somehow the source of “superbugs” (a misnomer btw) needs reexamining anyway. Most “superbug” infections occur in hospital settings, so out patients getting a script is not the problem, thus won’t be the solution. But that’s much more difficult and might cost hospitals some money, so its much easier and convenient to blame these mythical patients who demand antibiotics at every doctor appointment. In fact, if are going to erroneously blame patients, why not blame pimply teenagers who take antibiotics for years? Because that would impact dermatologists ability to make a living, so it won’t even be examined.
You don’t say.
You have a grain of truth here, but I sense that you’re mostly talking out of your ass. Here. Go crazy. And try not to cherry-pick, as opposed to actually reading.
Or here, if you’d like something more targeted.
If doctors write a prescription for antibiotics for a cold, it’s because the patient demanded it and was obnoxious about it. Clinicians know antibiotics won’t help a cold, and even most cases of bronchitis don’t require antibiotics. You are assuming facts without evidence. And these patients aren’t “mythical.” I’ve been seeing them and dealing with them for 30 years plus.
Not every kid with acne goes on antibiotics. The ones who do are monitored closely; the dermatologists understand the issue of antibiotic resistance. And since there are plenty of other treatments to treat acne, your insinuation dermatologists are just in it for the money (again, asserting facts without evidence) is disingenuous.
This isn’t even about blame. You claim we’re blaming the patients. We’re not. We’re explaining that patient satisfaction surveys aren’t accurate, aren’t a measure of effective care, and don’t add anything to discussions about healthcare.
Well the real problem with antibiotic resistance is the astounding quantities of human-use antibiotics that are given to livestock to make them fatten up faster.
But that does not mean that there isn’t plenty of risk from inappropriate use in humans as well. And there are plenty of non-hospital-based outbreaks of resistant bacteria in places like prisons, so it’s not just a hospital problem. Most hospital-based infections are in very sick people as a consequence of care for other conditions, and there is literally a whole branch of care directed at preventing these infections: they’re called infection preventionists (or less kindly, the hand-washing-narcs).
Again, sometimes the very best care is not nice. Wearing a mask sucks. Getting pneumonia because you didn’t wear the mask sucks more.
Right. And just because many cases of antibiotic infections start in the hospital, this doesn’t mean that the antibiotic resistant bacteria evolved that resistance there. It could easily be the case that there was a relatively healthy patient given antibiotics unnecessarily whose body had some resistant bacteria as a result, and they didn’t have any infection because their immune system wasn’t compromised. Then they bring that resistant bacteria to the hospital, it gets deposited somewhere, and an immune-compromised patient picks it up. This could happen, for example, with staphylococcus epidermidis, which is a bacteria normally found on human skin and is also the source of some nasty staph infections in immune-compromised patients.
Just because the hospital is the transmission mechanism doesn’t mean it’s the source. The real world is far too complicated for such simple conclusions.
@Chordylias: The post also notes that the surveys ask about the quality of the hospital food and what the patient thinks of the parking. Those might be relevant if the hospital is being rated; they’re not relevant to the question “is Dr. So-and-so a good physician?” Worse, asking about that may cause people to take that into account in rating the doctor–not just in deciding “do I want to go out of my way to see this doctor?” but to things like whether to recommend the doctor to other people, who might be in waking distance or planning to take the bus. My doctor didn’t improve when I moved from Arlington to Somerville, but my visits to see her became easier: that’s a variable that is entirely outside her control.
If you ask me (now, sitting at home surfing the web) what I want from a doctor’s visit, it would include “she listens to my symptoms and is able to diagnose and treat the problem” along with “willing to renew my long-term medications and run any necessary tests” and “treats me with respect, answers my questions, and doesn’t try to sell me snake oil.” That set of goals/criteria means that they might get a higher rating for “you have pneumonia, here’s a Z-Pack, cancel that trip for this weekend” than they would have for “it’s a virus, get lots of rest, maybe you should stay home.” (The antibiotic did help, after I’d been sick for a week or so.) Does that mean that she’s a better doctor because I had a bacterial rather than a viral infection, or a worse one if someone comes in with a condition that can be managed but not cured?
MSM MDs have failed to adequately defend market share, if not help their viral patients. Given a choice between an at least premature antibiotic scrip, and the need for things that actually address viral infections and their effects, one would think MSM somewhere would investigate the antiviral supplements that might satisfy their patients demand for heap big medicine with perceptible results. This might solve the empty handed patient syndrome.
e.g 7-10-maybe more days of 50,000 – 60,000 iu vitamin D3 pills, lab, etc
one of the major vitamin C strategies
some combination of antiviral, perhaps class dependent, extracts,minerals and amino acids
When you can provide the evidence based studies that show your favored supplement have antiviral effects, then come back.
Until then, it’s your usual noise and fury, signifying nothing.
Panacea of no real counter evidence, closer to absolute zero, n=0:
Zzzzzzz. Mostly I try to help you all understand what’s going on.
Yah, in your head. “Zzzzzzz,” indeed, Mr. Delusions of Grandeur.
But what if I, the patient, do not want vitamin C any more than I want antibiotics? If I’m going to the doctor because I am sick it is because my existing attempts to treat the illness myself haven’t worked. Your vitamins won’t shorten the course of my illness (or it’s one day, big deal), and more to the point, they won’t treat my symptoms.
I go to the doctor because I want stronger or more effective symptom management than I can get OTC.
“Here’s some vitamin D.” “Will it help me breathe? Will it reduce my coughing? Will it help me get the rest that will actually end this cold?” “No, but it might reduce the duration by a day.” “Well this has been a waste of a copay.”
Sadly, evidence suggests that many patients are, indeed, made happier when given false remedies. If they weren’t, then alternative medicine wouldn’t exist.
Heck, this post itself is proof: antibiotics given for respiratory tract infections are almost never of any use. That practice might as well be the same as giving patients Vitamin C. Except that Vitamin C is way, way safer.
Either way, it’s lying to patients, and we shouldn’t be rewarding doctors for lying to patients.
Patients want to feel like they didn’t waste their time coming to see the doctor. If they walk out the door with a prescription it justifies the time they took to go in. Most patients don’t want to hear their illness is self limiting or that they’re really just fine. Heath care is too expensive: if we access it, people want to feel they got their money’s worth.
I heard a lot of comments to that effect from patients when doctors wouldn’t give them what they wanted.
JT: “Your vitamins won’t shorten the course of my illness (or it’s one day, big deal),”
You’re greatly missing or misunderstanding the details in your example. A spurious monotherapy, with probably less than 1% of the real world required vitamin C loads, IV or oral, that showed that “one day” benefit. No vitamin D3 repletion loading or more either, much less other modulators.
One IV vitamin C really does reduce symptoms quickly but temporarily and knock down the viral load or lesions, but cure would typically longer with more IVs, say over 24 – 72 hrs. CAM practitioners are likely to compromise and switch to oral supplement formulations asap. Ditto with a bacterial infection, but succeeds with a lesser antibiotic (e.g. amoxicillin) when served with the CAM course.
Oh, FFS. The next time I get an infected cat bite, I’m sticking with Augmentin, not running out for fucking IV vitamin C.
Prove it, prn. You keep claiming people “misunderstand” Vit C, but you never cite a reliable peer reviewed source.
Extraordinary claims require extraordinary evidence. You have none.
Panacea:
You keep claiming people “misunderstand” Vit C, but you never cite a reliable peer reviewed source.
You fail to understand things that are understood by any observer with days of actual experience or background, and are often credibly documented, if not blessed by MSM “authorities”. Things that if you cited such a lack of observation or power in high school chemistry, you would fail to pass/proceed there. You vaguely remind me of the kid at our bench who was getting ready to light a tablespoon of phosphorus (vs a match’s qty) in our inadequately ventilated hs lab on the first day; I couldn’t cite a specific source either.
Prove it, prn. … Extraordinary claims require extraordinary evidence. You have none.
The refuge of know nothings and vested interests. What I’ve cited are mechanisms, long known in science, some reconfirmed and elaborated by Levine, simple examples, and lower levels of trial evidence. It is various MSM institutions that have shirked their duty to customers, patients and citizens to carry the expense of properly formulated trials and communication, for generations.
Jesus, we used to burn that stuff in the dorm bathroom. Big deal. Have you ever lit a bowling ball on fire? Put a stick of purple chalk in 6 M hydrochloric acid? The very fact that you’re wandering around with this anecdote hanging out of your fly suggests that you never got much further, although an exegesis from you on band theory might provide some levity.
You know who you remind me of? A Walmart knockoff of the vinucube.
prn: Ah, the “generally known” gambit. Except it’s not generally know.
It’s what you generally claim to understand but you’re a crank. That statement was a wonderful example of Dunning Kruger at work.
Prove it. Provide me with a reliable peer reviewed source that supports your claims. No mouse studies or in vitro studies. PubMed indexed.
As with the exchange I’ve had recently (and not that infrequently) with Chris, it’s Medline or bust. Pubmed indexes all sorts of predatory OA trash.
Panacea: “…generally known”
I don’t claim that CAM or vitamin C details are generally known by the public, although they may be more familiar on average than fine MSM examples like you. Rather you make mistakes that you would not if you knew anything real about the subject, or had actually observed them.
Narad on P: ventilation and quantity count. also look at the mg/m3 hazard
I certainly couldn’t make this shit up.
Panacea,
No doubt you’ve noticed but what kind of personnality is in display when one particular person blame everyone else ’round him / her (You fail to understand…The refuge of know nothings and vested interests) but himself when asked to cough up the evidence but if you hadn’t, look again.
I never ever saw that person take up his responsibilities, ever, of presenting at least a modicum of evidence (#sarcasm) and if the philosophers didn’t consider his approach when devising the philosophy of science, that is their faults, not his / her.
Alain
Alain: I never ever saw that person take up his responsibilities, ever, of presenting at least a modicum of evidence…
Alain, a lot of what I discuss has been referenced, with some technical discussions and links during 2010-2012. And largely ignored. Some references with old studies are not so accepted here, even though that may still be the best evidence that exists. So I repeat these less often. Also MSM medicine seems to suffer from a newness bias including more $$$,$$$.
In many cases, others here misstate or misconceptualize what’s going on, or needs to happen, to work. Based on prior experience, accepted MSM references seem less likely to give answers that are complete, coherent and correct on adversarial subjects, although they are improving.
The stercoraceous irony burns.
@prn: Oh, no! No you don’t. You said, “*You fail to understand things that are understood by any observer with days of actual experience or background, and are often credibly documented, if not blessed by MSM “authorities”. *
You don’t get to say, “well lay people often don’t understand this” after making this claim that I just quoted in your own direct words.
I assume you mean by MSM as Main Stream Medicine rather that main stream media (which is how MSM is more commonly used) since many of us here are actually in health care (unlike you) and have expertise of some sort.
So quit playing word games. It’s tiresome and only proves you don’t know what you are talking about. I’ve taken courses in nutrition; I’m well aware of what Vitamin C does for us, why it’s important, and I also know that what you claim about it is not supported by any evidence I’m aware of. If you have some, show it to me. Otherwise, go away.
@Alain: SPOT ON.
Aside @Alain:
Instead of using the clumsy he/she or him/her constructs, you can simply use the third-person singular they/them. It flows better, has been in consistent use in English since the 1300s, and has the added bonus of being a bit more inclusive (some people prefer gender-neutral pronouns).
The singular they/them may feel a bit uncomfortable at first, but it really is common to use it for an unknown person. It’s less common in the context of a known person with unknown gender, but it still makes the sentences flow a lot better.
prn: You want to hook me up to an IV for THREE DAYS?
I’m going to ask this again, because this is what I care about:
1) Does your 3 day IV reduce the duration of my illness by more than three days?
2) Does it reduce the severity of my symptoms?
3) Does it help me rest?
Because if it doesn’t do any of those things then, frankly, it’s not helping.
prn,
“MSM MDs have failed to adequately defend market share”
But isn’t that exactly what you’re trying to do right now? Defend your share of the market? Aren’t you trying to persuade us that vitamins C and D are useful for fighting infections?
“one would think MSM somewhere would investigate . . . ”
Go for it: write a grant to investigate your chosen therapy.
Then get back to us.
Box oSalt:…But isn’t that exactly what you’re trying to do right now? Defend your share of the market?
Not exactly. “My share of the market” is likely a constant. “Defending my share of the market” is more akin to fending off corrupt cops in a 3rd world country aggressively looking for lunch or mistress money…
Aren’t you trying to persuade us that vitamins C and D are useful for fighting infections?
Not exactly. For those that are all pharma scientifical, I know they are waiting for divine revelation from BJM etc or higher authority. But I do remind them of “possibilities”, point out aspects, differences, or unfounded speculations on their part, and help them be aware of things they are totally ignorant of. There is also a truth in advertising aspect for passers-by, that are unaware of such disagreements and chasms between MSM, medical science, and reality.
“one would think MSM somewhere would investigate . . . ”
In a slightly free enough market, C and D are already slowly taking old medicine (medical errors really) out with the tide. So far, MSM’s only successful defense is more centralization (even of my / our money, and trampling our rights in various ways) vs actually selling a more desirable, useful product to compete for our voluntary spending, which MSM sellers are petulant about.
Go for it: write a grant to investigate your chosen therapy.
Waste of time and money for my personal purposes for something that probably won’t resolve in my lifetime. It’s actually long overdue MSM homework, that smacks of corruption at different levels across the decades.
Or he could work with his friendly doctor who prescribes whatever he asks to document one of these remarkable cures as a case report. Then the rest of the world could benefit.
But it’s much easier to pay yourself on the back and claim superior knowledge to all the thousands of people who have spent decades trying to figure out how this stuff really works.
Oh, no, it’s the Prn Anti-Massacree Movement.
I think totally OT, but I get back from a visit with my dad and an overnight with a professional chef, and ultimately the friend I’m staying with has a dry cough. So, the usual, some guaifenisin, stay hydrated, turn on the shower and sit in some steam. But then I go poking around for papers about antitussives, and lo and behold, PMC emits a something that <a href=”https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921574/>takes late Arthur Koestler seriously.
^ Hell, I might as well fix the link, if not the grammar.
Same thing happened when I was working the support line for PCs, we transitioned from “Try to get it right first time” to “We want CS skills, we can teach the technical stuff”. That’s how you end up with people who are unskilled at anything, reading from a script and following the flowchart.
Oh, and my Doctor rarely starts with a firm diagnosis. I normally get the “It’s likely to be this, here’s what we’re going to do to check that.”