Wednesday, June 24, 2009

The death of paternalism. At first I cheered, now I have regrets. (Or second choice title: How Press-Ganey is changing medicine)

I wrote this article on SDM (Shared Decision Making), that talked about involving the patient in their medical treatment decisions. It lowers costs overall and increases patient satisfaction. Even less educated patients really appreciate being told they have a choice in their care. I thought it was a win-win. But then reality set it.

I recently have been confronted with a new reality. The Press-Ganey. For those of you that don't know what this is, it is a survey that administrators of hospitals use as gospel for who is the best hospital. It is all about customer satisfaction. I've always practiced that educating your patients in the ER is the best medicine. Whether on nutrition or the nature of their disease process, my patients always appreciate it. Or so I thought. Now I'm being told that my patients don't want to hear that. They don't want to be told to quit smoking. They don't want to be told that it is best to have a primary care physician as opposed to the ER - even when I refer them to a free clinic for the uninsured. They want that prescription for a z-pack. They want their vicodin. They want that head CT or that MRI and especially that foot xray for that stubbed toe.

If you address their "real" needs and try to address their real issues, you get bad reviews (i.e. Telling patients that you are giving them imitrex for their headache as it is a much better migraine medicine than demerol, and neurologist recommend not giving opiods unless nothing else works, does not make you popular). If you ignore the necessary education and simply give them the prescription they want, you get good reviews. Is this the best way of practicing medicine? According to administrators, we should continue our good practice of medicine, and address our patients wants and needs. Unfortunately, these don't always line up.

I get that the patient has a say, and in that say, they determine that they don't want to hear your doctor advice. They are there for a purpose. Anything else is irrelevant. I don't subscribe to the paternalist view that everything the doctor says is the only way. But sometimes what helps you is not what you wanted to hear, but what you needed to hear. And if I am being told to stop trying to help my patients understand their disease, and improve their disease and even PREVENT their disease - then what good is SDM? What good is Press-Ganey? What good is customer satisfaction?

I was all over the neat idea of SDM a few weeks ago. Now I am thinking that paternalistic measures weren't such a bad thing after all. If patients have a right to dictate their care, even if it is not in their best interest, what then is my purpose?

I welcome discussion on this topic.


  1. Interestingly enough, I work in the advertising/interactive industry and I find that the same is true. What's best for our clients (maybe in cost, maybe in conversion, maybe in risk) is not always what they make their decisions on. Instead, they often make choices based on personal preference, the urge to wow their peers, or their fear of upsetting the higher-ups. So we look at the biggest and best work in the digital space with jealousy, "What a cool client to let them pull that off!"

    I dont have an answer, but I see a parellel. Our expertise (as physicians or creatives) gives us the ability to diagnose our clients needs... but sometimes they dont have the wisdom to see it.

  2. I am a neurologist and I strive to make the best decisions for my patient. However, often they don't like my plan or they tell me what do to. They've read something on the Internet or think they know something about medicine. But don't let them, you are the doctor. Their only option is to get a second opinion, not to negotiate with you on the medical plan. The doctor tells the patient what to do, not the other way around.

    This is not the hotel business.. we are not in the business in people as happy as possible - we are responsible for making the best medical decisions. And they are not happy to begin with. People see the doctor because they are sick, not because they are happy. And I deal with the drug addicts by compassionately sending them to drug counseling - they never come back.

  3. Perhaps the problem is that Press-Ganey is measuring the wrong things? It is not so different from asking college students to evaluate their professors on subjective measures such as how valuable the course was.

    My insurance company regularly sends out quality surveys on my doctors, but the surveys ask a lot of questions about how quickly I can get a routine or emergent appointment, waiting time at the appointment, etc. Maybe a few on perceived quality.

    There are a number of objective questions that could be used to evaluate the ER experience. Waiting time seems unfair alone, but pair it with related questions, such as whether the person's condition deteriorated while waiting in the ER, whether the patient was advised on alternatives to the ER (if it was a long wait), whether the patient came in knowing what treatment they "needed" and whether that specific treatment was provided. (If you know exactly what you need going in and you get it, why aren't you being managed on an outpatient basis? If you "know" exactly what you need and you don't get it, your responses to subjective questions may not be valid measures.)

  4. As a Press Ganey employee, I feel the need to chime in here. Satisfaction is rarely about your medical prognosis. It is how these people were treated. I am looking to my doctor and nursing staff for their expertise. When I walked through the door, my expectation was a team of knowledgeable, professional, and dedicate individuals. What grade do I give for this? A "C"! Think about going into a McDonald's. When you get to the counter you expect the person behind it to be able to take your order, process your payment, and give you your food in a prompt manner. Are you wowed by this? I doubt it. Does the fact that the garbage can behind you is overflowing or employees are acting like children detract from your experience? I would certainly say "yes". A care provider, remember, these people are all having what could be considered the worst day of their life. Remember that when you interact with them and their families. The way you deliver your opinion matters. Next time you speak with a patient, even if it is only for a few moments, sit on the end of their bed, make eye contact and connect with them. It makes a difference. Remember the old addage, "it's not what you say, but how you say it". That is the true basics here.

    Now to hit on a real area of concern, your survey sample population. In terms of evil, greedy corporation, Press Ganey is the poster child. For facilities that use them, they are being soaked. PG is committed to a 40%+ gross margin on all products. In fact, to maintain this, your facility's costs for their products increase by at least 4% every year. When was the last time CMS allowed you to increase your reimbursement? Their new capital partner, invested over $600MM in the company and is expecting significant returns. In fact, they are mandating that this company grow from $150MM to $500MM within 5 years. They cannot do this by looking out for the interests of healthcare. The average facility really cannot afford to be able to survey a large enough sample of it's ED population to truly have meaningful data that is insulated from outliers (high and low). The greater the number of visits, the harder this becomes.

    Here is the truth, these measures matter and the way we interact with patients matters. Want to effect wait times, try a liaison to update people on what is going on. Even if there is nothing to report to a patient, it has an effect that they are cared for and about. Give it a shot! As far as measurement tool, it DOES NOt matter. Data is commodity. Your facility will never use 80% of what their tool does so why pay for it? Save money, find a cheaper provider, raise your sample sizes, and invest in improvement efforts & initiatives. Satisfaction and interaction matters. You do not need a gold-plated ruler to do it effectively. The old wooden one will do just fine. In the end, you can cut costs and raise service levels. They only way this company will change and do the right thing is if you as customers make them do so. Vote with you wallet. Do that and you win. Press Ganey can only continue to hold hostage and pillage if you let them! Best of luck.

  5. to anonymous. yes. PG is nothing but about making money.

    all of what you described above works well for normal people. Drug addicts? Munchausen's? Munchausen's by proxy? Narcissists?

    No matter what you do these people are going to complain.

    Money for PG would largely be better spent on a liaison, I agree.