In Medicine, More May Not Be Better

The dull whir of the computer running in the background seemed to have gotten louder as the patient fell quiet. She was a young woman, a primary-care patient of mine, seeking a referral to yet another gastroenterologist. Her abdominal pain had already been checked out by two of the city’s most renowned gastroenterologists with invasive testing, CAT scans and endoscopic procedures.

But she wasn’t satisfied with her diagnosis — irritable bowel syndrome — or the recommended treatment and wanted a third opinion. I tried to reason with her but failed to convince her otherwise. Even when I acquiesced and gave her the referral, she walked out visibly unhappy. I sat there listening to the whirring, feeling disappointed.

Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?

Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.

But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.

In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.

Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).

On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.

Consumer satisfaction is a metric that has been used extensively in other industries, and its increasing integration in healthcare may represent a desire to model medicine on industries that lead in efficiency, such as the technology, automobile or airline industries. But healthcare remains fundamentally different.

Consider Medicare’s initiative to have hospitals publicly report their patient outcomes and satisfaction data and have consumers compare them a la computers or SUVs. Of the 13 teaching hospitals within five miles of my apartment, the relationship between the quality of care and patient satisfaction was unclear. Within these hospitals, hospital mortality outcomes did not correlate with satisfaction ratings.

I’m a physician and I had difficulty making sense of the data, so how can we expect everyday people to use them in a meaningful way? Would they prefer a place where they or their relatives are likely to live longer, have a lower risk of readmission and have fewer infections, or a place where their pain would be better managed, their nurses more responsive and their bathrooms cleaner? Although ideally hospitals would score highly in both sets of measures, data suggest that is not necessarily always the case.

Patient visits can sometimes be like family dinners. They are probably not the best occasions to talk about Dad’s smoking habit or Mom’s Xanax addiction. But to maintain shared decision-making, clear and honest communication is vital. And in critical situations, most data suggests that patients want their physicians to be upfront about bleak issues such as life expectancy.

Yet a 2012 study by investigators in the Dana-Farber Cancer Institute found that patients who were better informed about the grim nature of their cancer and the goals of their treatment were less satisfied with their physicians. Such findings put a physician in a quandary: a more informed patient or a more satisfied one?

Emphasizing patient satisfaction and offering incentives to hospitals and physicians to keep their patients satisfied are laudable. But trying to transform patient satisfaction into a catch-all quality metric may not be the right approach. What is really needed is for physicians to take the time to help patients identify the things they need, not just what they want.

My patient with belly pain saw the third gastroenterologist, who thought she would benefit from a stent to her pancreatic duct. Just the fact that someone appeared to be taking her symptoms more seriously gave her hope, and she went ahead with the procedure. But the procedure gave her little relief, and soon after, she developed inflammation in her pancreas, a common complication of this procedure.

Today, medical schools, residency training programs and professional societies are beginning to teach physicians not just how to be better doctors but also to value the outcomes of their care, rather than the volume of their services. Although retraining all physicians to think this way is hard, fundamentally changing how patients view value in healthcare may be even more difficult.

Haider Javed Warraich, MD is a resident in internal medicine at the Beth Israel Deaconess Medical Center, Harvard Medical School. This post originally appeared in the Los Angeles Times on October 10, 2013.

4 replies »

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  3. I was very surprised to hear that people associate more care with better care. First off, those with no medical training don’t necessarily know what good care is. Preventative measures and quick surgeries seem much better to me than sitting in a hospital for a month. Wow.

  4. “Today, medical schools, residency training programs and professional societies are beginning to teach physicians not just how to be better doctors but also to value the outcomes of their care, rather than the volume of their services.” Haider Javed Warraich, MD – resident in internal medicine

    In my personal experience in the medical field – that probably dates back to before you were born – physicians have always been taught to value the outcomes of their care.

    I am a Radiologist and when I compare patterns of test ordering between younger physicians and older physicians, the test ordering of the older physicians appears to be more judicious than that of the younger ones. And yes, I see a lot of questionably indicated tests.

    As for MRI for back pain, there is more than patient expectations driving that train. We have things called: auto accidents, work injuries, lawyers and disability that have a lot to do with it. Oh and narcotics too – as you pointed out.