Understanding the Patient Experience
There is little disagreement that the patient’s experience of care is important, and often more important than anything else. Yet there are problems with the most widely used measurement, the Press Ganey survey, as articulated by Dr. Bonnie Bermas in an editorial entitled “The Emperor Has No Ganey.” She recites the usual issues, known to all of us who have delved into the issue.
“The focus of these surveys is the patient’s perception of their overall clinical experience, not quality outcomes. Factors outside a physician’s control, such as ease of parking, wait times, discharge delays, and ancillary staff, contribute to scores. Providers’ race and gender can affect the results, with physicians of color and female physicians ranking lower…
Ideally, patient satisfaction would correlate well with patient-reported outcomes. In a study of 540 patients who had joint arthroplasty, this was not the case.”
Proponents of the surveys would argue that the patient’s perception is the total of their interaction with the system, and these issues don’t negate its utility. But she points out other data that do, in my opinion, raise important issues. First, overall response rates to the survey are low, and skewed toward older white women, meaning the sample is not representative of the patient population served. Second, when raw scores are converted into percentile rankings, trivial differences make enormous differences in outcomes.
“Not surprisingly, the authors found that a provider with a perfect raw score on patient satisfaction surveys fell into the 100th percentile. However, if this same provider was evaluated in the subsequent quarter, a 0.5 point decrease in the raw score, (new raw score 99.5,) corresponded to a new ranking in the 70.9th percentile, underscoring the sensitivity of these rankings to insignificant changes in raw score.”
Although the author did not make the point, this sensitivity of results to small changes in the raw score contributes to the common cause variability seen in aggregate results. An institution trying to make changes in its care processes is going to have a hard time discerning a trend, either improving or worsening, due to the noise in the signal. She does make the point that chasing the scores contributes to provider burnout. Perhaps a more graphic way to express the notion is many physicians have decided the system is rigged, so why bother.
When I was monitoring these scores regularly, it was easy to see scores tended to go down at times when volumes were high and tended to go up when volumes were lower. This seemed reasonable—delays in patient care, waiting for elevators, test results, etc.—increase as volume stretches capacity, which are perceived negatively by the patient. This might suggest the scores tell you something, but the observation is not actionable. There is no solution to problem of surges, as the pandemic experience has amply demonstrated.
I do think fatigue and burnout do contribute directly to the patient’s experience. After all, patients want, and deserve, empathetic care. Note this does not mean sympathetic or polite care. Rather, it is care delivered by providers and other staff who understand what the patient is going through and have a series of instinctual and learned responses that allow them to communicate that to the patient. However, it is not clear that these surveys, as currently constructed, measure any of that. Nor is it a simple problem or likely a simple metric.
In my consideration of the report in USA TODAY (13 March 2022), I pointed out that care-givers really are not fungible, and that the staff’s internal motivation is perhaps more important in health care than in other businesses. I want to conclude this report by quoting from what I wrote 13 January 2017 on empathy.
“Perhaps it is the ability to see an individual, not a group, that counts. As our medical organizations have grown larger and more complicated, those in charge of
setting the direction are increasingly removed from discrete individuals. Staff
become FTE’s and patients become “encounters” or “admissions.” Somehow, we must remain sensitive to the underlying reality that there is a real human being who is suffering, fearful, in pain, and/or dying and it is up to real, fallible clinicians to try and ameliorate that suffering, fear, and pain. The industrial model of health care has its utility, and in some areas is better than the “cottage industry” model of previous
medical practice. But the cottage industry approach has its value, too. When we discard that value, we find we don’t much like industrial health care either as patients or as providers.”
I would like to hope this editorial in the Annals of Internal Medicine is a sign that we are beginning to come to grips with this issue, but I fear it may be too little, too late. While it is clear the current state of affairs is untenable, there is, as yet, no consensus on a way forward. The fact this is true for a number of other issues in our shared public life does not offer much solace. So rather than trying to predict tectonic shifts, perhaps we all just need to remember there are real people behind the numbers. While it may not be possible to care for each according to his/her needs, we need to avoid retreat into “the numbers.” The fundamental paradox is that we have organized health care on a large scale, but at its heart, it remains one patient and one care-giver at a time. While we can predict, and perhaps even improve care at scale, there is always going to be fuzziness at the level of the individual. Perhaps this is the medical equivalent of the Heisenberg uncertainty principle.
28 March 2022
 Bermas BL. The Emperor Has No Ganey. Ann Intern Med, 15 February 2022. Publ. online at www.annals.org. doi:10.7326/M21-4075.
 Heisenberg articulated that “the position and velocity of an object cannot be measured exactly, at the same time, even in theory.” https://www.britannica.com/science/uncertainty-principle, 27 March 2022.
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