Patient satisfaction with physicians in old-fashion terms was pretty easy to comprehend. Generally patients would develop and maintain a relationship with a physician on the basis of mutual respect. If a patient were not satisfied with the doctor, he or she would simply switch. Patients learned to use physicians with whom they were satisfied. No polls, no nonsense, just "voting with your feet." With the advent of "patient brokers"—such as HMOs, insurance companies, and IPAs—patients often are restricted in their choice of doctors and are herded to physicians listed in a book. Thus develops the need by these brokers to ensure patient satisfaction because the patient has relinquished free choice. However, it is not so easy for consumers to make choices about hospitals; thus Medicare’s claim that it is helping to protect consumers is suspect.

The notion that it is important to ensure patient satisfaction in the modern environment seems simple and easy to understand. Measuring it, however, is far from simple and easy to understand. The theoretical value of measuring patient satisfaction as a tool for delivering better quality care is also an easy to understand concept. Once again, the theory is very far from the reality. The reality is that patient satisfaction has become a competitive tool, which health care institutions and polling companies have used as potent financial forces. Patient satisfaction is no longer just a concept that relates to how satisfied a patient is, but rather it has become a concept that has been corrupted into a way to make money, attract patients, or to be used as a way to withhold money from providers. It has morphed from a well-meaning goal into something that may have serious negative impact on quality of care. Measurement of patient satisfaction is a self-perpetuating industry with its own set of business imperatives. Let me explain. First let’s talk about the way we report patient satisfaction measurements.

The polling companies advertise that they can work with poor performers (low percentile) to improve scores for hefty fees. They know that they can teach small changes that will move scores just a bit higher, but that small amount will appear to be a huge improvement in percentiles. The income of polling companies is guaranteed by our competitive system and our need to be "number one." We are being graded on a bell curve to stimulate competition and polling, not to measure satisfaction. We should be getting graded A through E if measuring real performance were the only goal. It is not.

Let’s move on to whose satisfaction we are measuring. Just to give you one example of irrational thinking, let me describe the Emergency Department situation. When we measure patient satisfaction in the Emergency Department, polling companies eliminate the scores of admitted patients. The purpose is to measure outpatients, and the people admitted are considered inpatients when their scores are tabulated. Thus scores are tabulated on the response of patients discharged from the Emergency Department. Most people would consider that the Emergency Department’s mission is to treat the truly ill. So when we publish patient satisfaction scores of our department and use those scores to develop our practices, we are using the input of the people who are not very ill (they were discharged). The people who least need the Emergency Department are the ones who have the greatest influence on the quantification of performance. Seems irrational.

Finally, I raised the possibility that patient satisfaction may be a harmful force. Few people are willing to study this because of the politics involved, but some are trying. Although we would like to believe that today’s consumers are sophisticated and can comprehend the difference between what they need and what they want, most of us know that it is often difficult. We have led people to believe that they should "get what they want" from vendors of consumer goods. Unfortunately people have generalized this concept and now believe that the same is true of health care. Patients often want procedures, imaging, tests, drugs, specific brands of implantable medical devices, etc., that they do not need. If we give those things to patients, we can expect somewhat higher patient satisfaction scores than if we do not. Remember, small numbers can dramatically affect percentile scores. If the value of our scores becomes more important than the value of our professional knowledge, it is likely that patients will get imaging, pain medications, antibiotics, etc., when they do not need them. Patient satisfaction gurus will tell you that there is always a way to keep your scores up and still do the right thing by giving adequate explanations to patients. Those gurus do not understand the pressures involved in treating a patient every 15 minutes or in competing with a patient’s "Internet training" or treating people from a multitude of cultures and backgrounds, etc. Pressure to keep scores up definitely affects many practitioners’ actions. We need to systematically study the effect of those pressures on utilization of drugs, testing, and imaging before Medicare initiates this new proposed policy. We already are blessed with a legal system that encourages waste and over-testing. It seems that we are now coming under even more pressure to waste with little attention being given to rewards for efficiency and exercising real professionalism.