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Patients Rating Doctors: Let's Pay Popular People More!

Patients Rating Doctors: Let's Pay Popular People More!

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Doc Gurley's Urban Health Beat, Reporting on Health, patient satisfaction, doctor reimbursement

Doctor-blogger Jan Gurley writes for , a USC Annenberg School of Journalism online community for journalists and thinkers. Her blog explores the practice of medicine on the margins of society and what we can learn from it. You can see more of her posts .

Part One of Three: Let's Pay Popular People More!

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, 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 .

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, 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 , "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."

(Obligatory conflict-of-interest announcement: I am paid an hourly salary by a local government. My patients may fill out satisfaction surveys for other physicians in other settings, but they don't for me.)

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?

Keep up with the  or read .

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.

Doctor-blogger Jan Gurley writes for , a USC Annenberg School for Communication & Journalism online community for journalists and thinkers. Her blog explores the practice of medicine on the margins of society and what we can learn from it. You can see more of her posts .

Part 1 of 3:

Part 2 of 3: Is It Racist to Pay Doctors Based on Patient Satisfaction?

Part 3 of 3: Patients Satisfaction Surveys: Valid Test, Or Make-Work for Money?

Comments

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Unnecessary antibiotic prescriptions will go up, from patients with colds or flu who think they need them, and docs who don't want to make them mad. And then we'll have more nasty bugs that are resistant to everything, like MRSA or VRE, and more patients dying from them.

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I'm inclined to give patients a bit more credit. I think many, if not most, people would rate doctors based on whether they are treated with respect and courtesy, listened to, have information and options explained in everyday language, and feel they received the best available appropriate treatment. 

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Hope no one is fooled by this naked propoganda.

Things that have happened to me or loved ones:

- hours-long waits in "emergency rooms" while nurses openly chit chat, stand around

- regular,  45 minute wait past appointment time in a non-emergency room doctors office.  sometimes with coughing, unmasked patients in the same small room

- doctors refusing to prescribe basic allergy medicine e.g. claritin

- doctors demanding forms be filled out again because previous copy of form was on the wrong color paper (pink vs blue etc)

- doctor misreading x-ray,  told patient she needed ankle surgery and would never run again.   wrong ankle.

- pharmacist presribing wrong medicine due to paperwork mix up, with near deadly side effects

- doctor delaying surgery for life threatening condition till after he gets back from vacation.

- most of all,  paying WAY more than reasonable for nearly any treatment.

the list goes on.   has nothing to do with popularity and near everyone knows it.   

 

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Whine, whine. Most every professional is subject to reviews from the customers he/she serves nowadays. Physicians are no exception. Get over it. You're in the business to provide a service. Like it or not, clients will gravitate towards those who best meet their needs, and those that do will be recognized accordingly. Better get hip to this trend instead of whining about it.

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Annonymous should be renamed "oblivious" as it is quite clear from both common sense and the article that many people are not well served by what "best meets their needs". If this is where things are headed, Annonymous should not whine when taxes go ever higher to cover the extra unnecessary cost of substandard medical care driven by "patient satisfaction" rather than by sound medical practice

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Am I right to assume all these other "anonymous"s are not in the healthcare field?

The great majority of patients are reasonable, but disgruntled people are the ones who usually speak up.

We, as physicians, are not here to coddle people. I have had patients who get angry if they are told that they have to lose weight, or stop smoking, or needs medications, or that they won't get antibiotics for a cold. If I have to choose between "customer service" and appropriate medical care, I will choose appropriate medical care.

There's a reason we refer to people as patients, not customers.

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Experience has taught me to not even pay much attention to the local entertainment weekly's annual "Best Of" issue to find a candy store. I doubt Joe the plumber is going to evaluate healthcare with the degree of competence I would prefer. On the other hand, I would absolutely ask him for advice choosing a faucet, and ignore what my doctor might say.

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