In our view, the evidence supports a conceptualization of satisfaction as a quality metric unrelated to technical health care quality. Technical care quality is often invisible to patients. Consider the delivery of antibiotics within six hours in patients diagnosed with pneumonia in the emergency department. Patients will likely be oblivious to this care process but will be sensitive to wait times or any noise or odors near them. They will also care about how their physicians communicate with them, and for this reason, physicians shouldn’t be nihilistic about patient experience metrics.

Physicians have a responsibility to understand and address patient expectations during medical encounters, and unmet expectations are a key driver of patient satisfaction. Emergency physicians should strive to identify what patients want from their encounter and to address those expectations with empathy, tact, and respect—but there are crucial caveats. Physicians are obligated to steer patients away from tests or treatments that are either low-value or inappropriate, even if patients request them. Physicians are also obligated to deliver unwelcome news and to counsel patients about risky or self-destructive behaviors. We believe all physician duties can be carried out in a humanistic, patient-centered manner, but the primary goal of many emergency encounters is more nuanced than achieving an “excellent” patient satisfaction rating.

With the impending launch of the emergency department version of the Centers for Medicare & Medicaid Services’ Consumer Assessment of Healthcare Providers and Systems survey (ED-CAHPS), we argue for a cautious approach to incentives to boost satisfaction. These metrics may be helpful in identifying physicians with communication problems. However, incentives should not dissuade physicians from professional obligations to steward resources wisely and to engage in conversations that may challenge patients at the risk of making some dissatisfied.

Incentives also should not discourage physicians from caring for subgroups that may be more difficult to satisfy (eg, Medicaid patients, patients with mental illness or chronic pain). Lack of health care access may lead to fragmented care for these subgroups and an increased reliance on emergency departments. Questions remain regarding what drives these metrics and how they relate to personal and population health, calling for a measured approach to interpreting and rewarding patient satisfaction.

References

1. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1).
2. Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138(4):288-298.
3. Chang JT, Hays RD, Shekelle PG, et al. Patients’ global ratings of their health care are not associated with the technical quality of their care. Ann Intern Med. 2006;144(9):665-672.
4. Jerant A, Fenton JJ, Bertakis KD, et al. Satisfaction with health care providers and preventive care adherence: A national study. Med Care. 2014;52(1):78-85.
5. Fenton JJ, Jerant AF, Bertakis KD, et al. The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405-411.