Emergency Medicine Docs Bemoan Patient Satisfaction Surveys

SAN FRANCISCO -- Unfair, invalid, and biased patient satisfaction surveys are a menace to medicine, a trio of emergency medicine physicians claimed at the American College of Emergency Physicians (ACEP) annual meeting.

"The time is now to say this is one more administrative burden that we don't need," said Tracy Sanson, MD, an emergency medicine consultant, in an ACEP presentation. She noted that surveys have become crucial to hospital ratings and physician incomes, but "there is a real risk associated with this. We are in a very delicate balance for our own sanity, our own well-being, and the care of our patients."

The most influential patient satisfaction data are gathered by the Centers for Medicare & Medicaid Services through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Results from the 29-question survey of participating hospitals are publicly reported four times a year on the Care Compare website.

But there can be big gaps between patient ratings and overall hospital ratings, which are based on multiple quality factors. For example, in the Los Angeles region, two of the 10 hospitals with the lowest possible patient rating (1 of 5 stars) have overall ratings of 5 stars. While none of the 130 hospitals has a patient rating of 5 stars, 12 hospitals have overall ratings of 5 stars.

Meanwhile, "healthcare reimbursement is increasingly value-based, so your money bottom line is tied to patient experience," said Robert Strauss Jr., MD, of Christ Hospital in Cincinnati.

Sanson said research has suggested that "if your physicians are well cared for, then the patients are well cared for," and she questioned how physicians can be expected to give the best care right now. She pointed out that medical professionals face many stressors, and that the pandemic made things worse.

But per survey results, making patients happy is very difficult. For example, female physicians may seem outright invisible, Sanson explained. Surveys will ask patients "'Did your doctor show your courtesy? Did your doctor give you the information that you need?,'" she said. "When I have 'Dr. Tracy Sanson' emblazoned across my chest, and I've been in every orifice they own -- and sometimes I've created new ones -- they will say to the nurse that 'I never saw a doctor.'"

And any frazzled physician is not likely to earn high marks from patients: "I don't need a [survey] score to tell me that what I need is the time to go to the bathroom; to have the time to sit down making eye contact [with a patient]," she said.

Aimee Moulin, MD, of the University of California Davis, focused on inequities within the patient satisfaction survey population, which often excludes people with psychiatric illness, "because they might give us bad scores. But guess what? Maybe that's the patient population where we can do a better job," she said.

Other "vulnerable patients" who get left out of survey participation are those who are unhoused or those with inadequate internet access. She noted that the majority of people who complete HCAHPS surveys are a very specific demographic: 82% white and 94% with English as a primary language. Meanwhile, a little over half of emergency department visitors are white, while 23% are Black and 17% are Hispanic, she said. "We're asking questions of middle-aged white women about what they think about their care, so we get the answers as to what is important to middle-aged white women," Moulin said.

Press Ganey Associates, a provider of patient satisfaction surveys, states on its website that it is developing "new survey questions for patients and the workforce to enable assessment of diversity, equity, and inclusion topics." The company also says it's working to "help clients better understand the themes and subthemes and uncover actionable gaps for segments of patient populations and the workforce," although does not offer any more clarification.

Strauss expressed that patient satisfaction surveys aren't all bad. He explained that critics will say some hospitals are "teaching to the test" -- adopting sometimes-goofy scripts and multiple other strategies to make patients happy -- yet there's value in those approaches. For instance, patients hate to be kept waiting, so it's a good idea to express sympathy and validate their feelings. Also, patients like privacy, so shut the curtain or door during an examination, he added.

An ACEP attendee told Strauss, "When you say 'Oh, I shut the curtain,' I'm ... like, 'I don't have any curtains.'"

Sanson suggested that emergency medicine providers opt out of patient satisfaction surveys. "It's up to us," she said. "It's time for us to say we don't want to participate in this, a system that inherently is structurally racist, sexist, and unfair to us and our patients."

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