Patient Satisfaction: Benefit and Harm
Does patient satisfaction equate to high-quality care and better outcomes?
Leaving aside what the Stones originally intended in their lyrics, the above refrains from two of their songs can apply to many situations in life . We think we know what we need and get frustrated when we don't get what we want. But actually, we just conflate what we want with what we need. When we can acknowledge that wants are distinct from needs, then we can be open to having our needs met, instead of insisting our wants be fulfilled. We've probably all experienced settling for less than our initial expectations but nevertheless ending up satisfied.
Do these concepts apply to health care? What are reasonable patient expectations? What does satisfaction look like with respect to health care services? Is satisfaction the right goal for health care providers and institutions to target? Think about those questions, and then listen to the latest episode of the Radiology Firing Line series. Join host C. Matthew Hawkins, MD, his collaborator Saurabh "Harry" Jha, MBBS, and returning guests patient advocate Andy DeLaO, a.k.a. Cancer Geek, and health care informaticist Adam Powell, PhD. They tackle the subject of patient satisfaction in their usual thought-provoking style:
Who could argue against the health care consumer getting what they want? Putting aside legitimate universal customer service concerns — such as access (e.g., need to schedule six months in advance for a dermatology appointment), wait times (e.g., finally being seen an hour after the scheduled 15-minute appointment time), and too-numerous-to-list frustrations surrounding insurance coverage and denial — consumerism models don't always fit well in health care. When there is more at stake than whether your steak is cooked medium-rare or medium-well, the customer may not always be right. Unlike a Ben and Jerry's ice cream menu where every choice is a good choice (for your tastebuds but not for your waistline), there are sometimes no more than one or two medically sound alternatives to diagnose or remedy certain health care problems.
Informed discussions between patients and providers about health care choices are typically framed in terms of actual or potential harms and benefits. What are the harms and benefits of getting what you want? What if what you want is not based on solid medical evidence? Two examples of getting what you want resulting in harm are vaccination refusals that result in measles outbreaks and fulfilled demands for unindicated antibiotic prescriptions that result in resistant bacteria. Sometimes patient needs and wants align: You need that gangrenous bowel removed or you will die. You do not want to die, so you get the surgery. Other times, there is a need–want mismatch: You want sedation for an MRI because you got sedation the last time, even though you have no demonstrable claustrophobia. You don't actually need the sedation. If you receive the sedation without question, happy-face emojis get drawn on the satisfaction survey. If a doctor takes five minutes to explain why you don't need sedation, you have a better understanding about the risk-to-benefit profile of sedatives, but you may still leave unsatisfied.
Unfortunately, taking action, even unnecessary or inappropriate action, is often perceived as more satisfactory than explaining that less is sometimes more . Prescribing a pill for what ails you is viewed more favorably than counselling about lifestyle behavior modification. Like pills, expediency is easier to swallow than a long-term commitment requiring ongoing effort.
Backed up by research study results, Dr. Powell points out in the podcast that, paradoxically, more satisfied patients have poorer outcomes. Satisfaction in health care does not equate to quality, and vice versa. Andy DeLaO has it right: empowering patients is not really about satisfaction but about meaningful engagement between patients and providers, about building trust and relationships. Patients may not always be satisfied with what health care has to offer, but our goal is to guide them through a process of discovery, understanding, and acceptance, so that they get what they need. For this reason, informed decision making is certainly more empowering and I believe ultimately more satisfying than circling choices on satisfaction surveys.
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