My patient only had 20 minutes to wait for the van headed to detox. The people who had worked to get him into a detox program already numbered in the double digits. Sam (not his real name) was the classic public inebriate — he woke on sidewalks with the shakes, vomited blood on a regular basis, had lost most of his teeth, and was such a frequent victim of head trauma that depressions and scars ridged his balding skull.
Over the last week, our substance abuse counselor had daisy-chained together an impressive series of phone calls, blood tests, and clearance forms to line him up for one of our rarely-available detox beds.
Only 20 minutes to go.
But it was 20 minutes too long for him.
Sam wanted pills to help his shakes, and he wanted them now. When I told Sam the nurses would bring them as soon as they could and that I needed to examine him before the van arrived, his head turned away, and his arm-crossed rocking picked up speed.
With a sideways look at me, he pulled from his jacket pocket his trump card — a crumpled prescription. He showed me how, just that morning, an emergency room doctor had already given him a prescription for Librium (a long-acting withdrawal drug,with highstreet re-sale value).
He was telling me that he didn’t need all this hassle.
Librium is, by any measure, a dangerous drug, with a narrow gap between helpful and lethal. If you shake out one or two extra pills to try to quell the violence of your withdrawal symptoms, or you take a dose, feel better, and then succumb to the lure of a readily available bottle, you can die. (Or, perhaps worse, go into a coma and endure prolonged, intensive, and expensive suffering.)
Librium is extremely dangerous to a serious inebriate and is a big cause of the markedly short lifespan of people like Sam. But Librium is also a really quick and easy way to get someone to leave your ER happily.
Despite Sam’s shakes, coughing, and symptoms that indicated he might be vomiting blood again, he had spent less than an hour from check-in to discharge in his Librium-producing ER visit.
Sam saw me looking at his ER client satisfaction survey and discharge instructions, and he said, “I want my prescription back. I’m not waiting any more.”
Sam was angry and realized that he already had an easy out — the prescription in my hands. His forehead shone with sweat, and his hands shook as he snatched the Librium prescription from me and limped away — right as the detox van pulled to the curb.
No one can force a person to make better decisions about his health. But you can set him up to fail, or set him up to succeed.
I hoped Sam would survive his — and the ER doctor’s — easy way out.
If Sam did survive his Librium, odds were he wouldn’t be able to quit his extreme alcohol addiction without a lot more than a prescription. He’d need support, a house, and a program.
But now his bed was gone.
How much is a missed opportunity worth — to Sam, to our community? It would take another 10 people working another week or more to get the opportunity back. And he’d have to be willing to take it.
The pressures we are building into our system are causing more and more experiences like this. Starting in October 2012, Medicare will pay 3,000 acute care hospitals more based on higher client satisfaction survey results. Doctors in busy urban ERs are extremely aware of the role these surveys play in their institution’s survival.
But for an individual doctor or nurse practitioner, it gets even more personal than that. Client satisfaction surveys also affect many insurance company’s reimbursement rates for individual providers, are an accepted factor in many board-recertification processes, and are a planned future factor in doctor pay under Medicare, with implementation expected by 2015.
Whom do you think will get a higher patient satisfaction score and hence get paid more, the doctor who dashes off a Librium prescription after spending five minutes with Sam, or the doctor who takes the time to try to explain the pitfalls, problems, and contraindications to him?
It’s hard to fathom how we got to the point where we actually pay popular people more for our healthcare.
No such system exists in any other professional or non-professional field. Not for lawyers, not architects, not nurses, not teachers. You can’t even pay your plumber less if she has a lower customer satisfaction score.
In client satisfaction surveys, 70 percent of practicing lawyers have very low satisfaction ratings. But we don’t pay less for our justice system, and I, for one, would argue strongly that we shouldn’t — at least not based on popularity.
There’s an even nastier, and more insidious, result from basing compensation on patient satisfaction. As Kevin Pho, writing as KevinMD, states, “Already, more than 80 percent of doctors, according to a survey from HealthLeaders Media earlier this year, said patient pressure influenced their medical decisions. And in primary care, linking bonus pay to patient satisfaction could cause physicians to be more selective in who they see, subtly keeping patients who they know will score them well, and referring disagreeable ones to other providers.”
A natural result of hearing a patient described as “disagreeable” is to think, “sure, but that’s not me.” The brutal truth is, my patients are disagreeable, and they’re not popular with many physicians. Trying to deal effectively with their problems will never make a doctor popular with them.
The Sams of this world may have worse outcomes when popularity drives pay. Maybe there will be more Librium floating on the streets and making its way to suburban teens’ parties.
Perhaps you’re still thinking, yes, but this won’t affect me.
But is that true? Who else are we systematically marginalizing when we base pay on popularity? Stay tuned for the second part of the series, Is It Racist To Pay Popular People More?
Disclaimer: Identifiable patients mentioned in this post were not served by R. Jan Gurley in her capacity as a physician at the San Francisco Department of Public Health, nor were they encountered through her position there. The views and opinions expressed by R. Jan Gurley are her own and do not necessarily reflect the official policies of the City and County of San Francisco; nor does mention of the San Francisco Department of Public Health imply its endorsement.
Jan Gurley is an internist physician who practices in a homeless clinic for the San Francisco Department of Public Health. She blogs at Doc Gurley: Posts from an Insane Healthcare System where this post originally appeared.
Dr Gurley’s made certainly the most impassioned case against inclusion of patient satisfaction in compensation calculations I’ve yet read, but to what degree do individual satisfaction ratings really impact individual instances of compensation? The scenario painted here suggests the ‘dissatisfied’ patient’s rating impact’s a) the individual clinician’s pay, and b) their pay for the specific instance of care.
As I understand the planned inclusion of satisfaction ratings in compensation, such is not at all the case.
“It’s hard to fathom how we got to the point where we actually pay popular people more for our healthcare.”
Well, it appears quite logical at first glance, as physicians provide a service heavily dependent on human interaction (probably much more so than the average plumber or repair shop that you might want to read and write reviews about).
But the problem is even more extensive than Dr. Gurley suggests – I will mention in passing only doctors’ efforts to remain popular in the context of requests with shaky or nonexistent indication/reasonning: requests for off work notes, disability requests, narcotics, antibiotics and other drugs, unreasonable imaging studies … probably the most widespread consequence is that fewer and fewer physicians dare to suggest to the patient that medically unexplained symptoms might be nonorganic or – gasp – related to anxiety or other psychiatric conditions.