On Physician Culture and Patient Satisfaction

Patient satisfaction scores are increasingly used to help determine physician compensation, so it’s no surprise that physicians are becoming more concerned about those scores, and, understandably, questioning them. Reactions range from healthy skepticism to outright rejection. The reactions may be based on misunderstanding or ignorance, on a heavy-handed application of rules by administrators or as part of a larger distrust of institutions outside of medicine. Physicians should know how their scores were determined, the science behind the survey instruments used to “grade” them and exactly how their scores will be used. If they don’t, they should ask questions. On the other hand, physicians sometimes reject the entire process because it is easier to shoot the messenger than to take the message (“you need to do better”) seriously.

This post is aimed at helping those of us who work with physicians to understand the basis of their concerns, deal with them and help physicians accommodate to their new reality.

Press Ganey co-founder and Notre Dame professor-emeritus Irwin Press, PhD, taught medical anthropology for many years. Press applied the tools of cultural anthropology (interviews, participant observation, analysis of documents, etc.) to the contemporary practice of medicine and found that, like other “tribes,” it possessed a distinct culture, with its own language, customs and worldview. Known as “biomedicine,” important parts of this culture are passed along to new recruits as they proceed through medical education; newly minted physicians practice within biomedicine and, in turn, transmit it to others.

(Attempts to describe a culture run into dangers of oversimplifying and stereotyping. Nonetheless, and at the risk of not doing the subject proper justice, I will try to describe physician culture; I base my description on 21 years of experience teaching in a family practice residency program.)

Features of biomedical culture include faith in physical and biological science as bedrocks of knowledge and ultimate determinants of truth; “show me the data” expresses this faith. Training emphasizes the awesome responsibility involved in caring for patients and the autonomy required to shoulder it. “You’re the doctor” speaks of society’s expectation that physicians can and should make vital decisions that affect lives. While the patient’s own preferences (e.g., among treatment options) are becoming more important, it is still the physician who must sign the order sheet. Another feature is loyalty to the profession itself. At least since Hippocrates, physicians have come to regard one another as part of a fraternity, different from lay people. Modern medical education, with its long and rigorous induction into the profession, reinforces these ideas. As long as professional loyalty is balanced with moral obligations to patients (“first do no harm”), there is nothing wrong with it. Yet another feature is the realization that learning and striving to be better never stops; continuing education and periodic re-certification is a fact of life for doctors.

As well, medicine as practiced in the U.S. incorporates peculiarly American cultural biases: Action is better than inaction; sacrifices in the present are necessary for future benefits. Americans are individualists, and the interests of individual patients (rather than third parties or the larger community) are primary. This orientation warrants the pursuit of expensive, sometimes futile, treatments.

Some of the values of biomedicine are in conflict with contemporary reality. Although medical education still emphasizes individual responsibility, today much medicine is practiced by treatment teams (think surgery), or in group settings where other professionals have a legitimate say in what happens. The emphasis on individual patients, without regard to consequences that accrue to the community at large, is simply not sustainable. Autonomy is under attack from other health professionals (such as nurse practitioners) and governmental as well as business regulators. Each time a physician must justify a treatment choice to a payer represents a decrease in that physician’s independent decision-making. Every test a physician orders so as to defend him- or herself from a potential lawsuit, rather than to promote the patient’s welfare, is a mute reminder of the profession’s decreased autonomy.

In fact, cultural and financial riptides now affecting the medical profession have led some physicians to view their profession as under siege, especially from government and from business interests. In such a climate, it should not be surprising to think that some physicians see patient satisfaction as just another demand from “the suits” who don’t understand patient care from “the sharp end.” And they respond accordingly.

In my opinion, our job as a company, as well as our jobs as individuals, is to help physicians get past the shock, denial, anger, etc. that may accompany encounters with disappointing patient satisfaction scores. First, we should listen to and acknowledge their concerns, because to be concerned is to deem the data important enough to care about. Second, it will work better to frame our interactions with these physicians as teaching opportunities, rather than wrestling matches. This means that we understand how their data came about, that we can explain and transform data into information that can be acted upon to enhance clinical and business outcomes. Survey results are unique in that they can help physicians enhance their practice (and their patients’ treatment outcomes) by providing insights into patient experiences that are otherwise unavailable. Third, we need to stand firm. With value-based purchasing on its way, patient satisfaction is only going to have a bigger role in improving the quality of health care