Since the advent of patient ratings of physicians being used for reimbursement, there has been a lot of spurred interest in not only whether this type of pay for performance is fair for physicians but also on whether it impacts clinical patient outcomes.

Our concern is whether this focus on improving patient satisfaction scores will ultimately be to the detriment of patients themselves.

Take, for instance, a recent patient encounter:

“I used to just stop eating and my weight would go under 120 easy, but nowadays I can’t get below 127 pounds. The doctors at home didn’t see the problem,” the young woman answered in response to our asking what brought her to the integrative medicine clinic more than 100 miles away from her home.

Over the next hour, the attending brought up various diet and nutrition plans, alternative treatments and supplements, and exercise regimens. The patient replied eagerly, taking attentive notes, saying though she had tried some of these already, she felt she had a good connection with the attending and was willing to try them again. 

Afterward, when the attending asked for my thoughts on the encounter, I remarked, “I liked how you established rapport and gave her many options. But her BMI is normal, and she doesn’t have any other medical conditions. Why is she trying so hard to lose weight in the first place?”

The attending paused for a moment, “Oh. Right ... I’m not sure,” and then moved on to the next patient.

Body-image issues are known to be prevalent in young women, and I thought it was odd that instead of trying to understand why this otherwise healthy young woman was so adamant on starving herself to meet a certain number, we were glossing over that to tell her what she wanted to hear.

And in another instance at a different clinic: A young patient with sickle cell anemia asked to get a new port placed. He previously had it removed after it became infected and led to sepsis. The attending explained his concerns: “I understand it’s easier to have a port in place but, and please correct me if I’m wrong, you’re using it for monthly blood draws at the moment and haven’t had a need for transfusions or infusions for a long time. Your previous port was placed a long time ago and led to sepsis, a profoundly serious, potentially life-threatening disease. I’m concerned that right now the risks of a port would far exceed the benefits. If in the future you start needing transfusions or infusions, we can reassess if a port would meaningfully improve your quality of life. But at the moment, I wouldn’t recommend a port.”

The patient, unfortunately, was unhappy by this response and left abruptly. The attending later remarked that this encounter would likely end in a critical review and that would negatively affect his reimbursement. How have we gotten to the point where life-saving choices, and indeed even discussions, are actively discouraged?

It is unsurprising that clinician denial of patient requests leads to lower patient satisfaction scores. But we spend several years in training to develop our clinical judgment for evidence-based practice and create a mutual plan of care based on our patients’ preferences, not merely to boost rankings. 

For example, despite years of data on the importance of antibiotic stewardship, up to half of antibiotic prescriptions in the U.S. are inappropriate or not associated with a diagnosis, fueled by factors like perceived patient demand and desire to maintain patient satisfaction. Will the rising importance of patient satisfaction ratings drive more problems like this and the opioid crisis? While medicine should not return to days of strict physician paternalism, we must ask: Has the pendulum swung too far? Is the allure of patient ratings driving more problems?

Moreover, what can be done to help mitigate these issues before they become full-blown crises? One way can be to increase visit lengths to at least 20 minutes of patient interaction, which increased patient satisfaction scores compared to shorter visits. Not only would this help patients feel more valued, it would also help physicians feel less rushed when trying to address all relevant concerns. While it may not always be possible to increase patient visit lengths due to logistical concerns, another promising solution could be to better demonstrate empathy to patients, and indeed this may be improved by communication skills training to also lower burnout in physicians. Thus, while patient satisfaction ratings for reimbursement may be here to stay, there are ways to help improve these ratings by making patients feel more valued and by letting physicians re-connect with the humanistic element that drew many to medicine in the first place.

What are your suggestions to combatting patient satisfaction surveys?

Noor Shaik is in her preliminary intern year as part of the neurology residency program at the Hospital of the University of Pennsylvania, Philadelphia, PA.

Pravin Patel is a third-year medical student at Drexel University College of Medicine in Philadelphia, PA and has a PhD in Biochemistry and Molecular Pharmacology.

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