The assessment of surgical resident accomplishment is based on attending performance appraisals, standardized tests, and the evaluation mode in training modules.1 Residency remains an apprenticeship, where classroom teaching and on-the-job training on hospital wards and in operating room theaters optimizes clinical skills. Resident experiences with timely teaching concepts such as quality improvement, patient safety, high-value/cost-conscious care, and patient centeredness are limited, as these topics have not yet fully emerged in the core surgical residency curriculum.
Patient feedback surveys of hospitals and providers such as Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS) rarely play a role in the process of resident education and evaluation because a patient’s hospital “retail” experience is viewed as a low priority for a typical resident.2 In fact, the average resident time spent with a surgical patient on morning rounds is 2.7 minutes. This period includes entering the room, discussing overnight events, examining the wound, changing dressings, and delivering the care plan. Not surprisingly, teams solicit questions from patients only 7.7 percent of the time. When asked about their hospital experience, patients report lack of time with residents, fragmentation of care among teams, poor communication with patients/family members, lack of appropriate explanations of the care plan, and the need for better patient-centered care among hospital staff.3 As a result, newly minted surgeons will enter a world of patient-dominated feedback and public reporting but lack the skills to handle it.
Patient-centered care is not a novel concept. In physician and educator Lewis Thomas’ autobiography The Youngest Scientist: Notes of a Medicine-Watcher the author describes the physician’s focus on diagnosis, discovery, and identification of effective treatments. In 1937, Dr. Thomas observed, “If being in a hospital bed made a difference, it was mostly the difference produced by warmth, shelter, food, and attentive, friendly care, and the matchless skill of the nurses in providing these things. Whether you survived or not depended on the natural history of the disease itself. Medicine made little or no difference.”4
Dr. Thomas recognized that the most important focus remained with the patient experience, with successful health care delivery achieved through engagement, communication, and empathy. The struggle to balance the multiple aspects of patient care has existed for decades, and many patients have provided recommendations over the years on how to improve health care delivery. Most of this advice was useful, identifying actionable items and opportunities for improvement while also protecting surgeons from overexposure.
Today, patients have a voice through publicly reported surveys and unregulated social media (Facebook, Twitter, HealthGrades.com, and others), which allow users to compare and evaluate surgeons in a Web-based setting. In the near future, patient feedback may be used as a measure of health care quality, which will affect our reimbursement and quite possibly the sustainability and viability of our surgical practice.
In 2001, the Institute of Medicine (IOM) report Crossing the Quality Chasm provided six core aims for quality.5 In response to the IOM’s recommendations, surgeons now report on several of these measures such as surgical site infections, the Centers for Medicare & Medicaid Services’ Surgical Care Improvement Program measures, and Agency for Healthcare Research and Quality patient safety indicators.6,7 Many physicians have received patient feedback for decades and now receive reports on outcomes but have done little to change the way they deliver care.8 Instead, they continue to shy away from the aim of providing patient-centered care.
Now, in a health care environment in which transparency in performance is expected, financial incentives are associated with improved quality measures over public reporting alone.9 Therefore, internal and public reporting has proven to be an insufficient catalyst for change. Financial incentives are now driving the profession to shift its focus. We have seen successful industries achieve satisfaction, promotion, and loyalty from their customers. In doing so, Virgin Airlines, for example, has secured its financial stability, reduced marketing costs, and avoided lawsuits.10 By adopting similar strategies, the health care industry will undoubtedly see similar benefits. Patient feedback informs these strategies and leads to improvements in health care quality, justifying use of patient feedback to motivate better delivery of care and reimbursement.
However, scorn and resistance to patient feedback systems are strong and many physicians believe that the process is flawed for the following reasons:
- A single negative review may dramatically change a percentile ranking
- Response rates are low (~26 percent)
- At least 30 surveys in one period are necessary to draw meaningful conclusions
- Only angry people respond to surveys
- Surveys are delayed by 30 days from discharge
- Patients don’t accurately recall their experiences
These are just a few of the commonly held beliefs among health care providers regarding patient feedback systems.3 These views are mostly supported by anecdotal information, and research that validates these views is minimal.11 Studies that attempt to link patient satisfaction with cost, quality of care, and outcomes are also conflicting.12
Health care consumerism
Through standardized surveys that focus on waiting times, pain management, and communication skills, the “government has fully embraced the ‘patient is always right’ model, betting that increased customer satisfaction will improve the quality of care and reduce costs.”11 Due to the fact that supportive evidence is low, physicians have become resistant to the idea of bringing the patient experience into his or her practice. Perhaps this resistance is due in part to shortcomings in our understanding of how high-quality health care is related to the patient experience and health-related outcomes. Health care providers struggle with trying to please patients who may receive the best medical care but may not have retail-level satisfaction, and vice versa. Surgeons may resort to pleasing the patient for better scores by over-treating, performing extraneous tests, and even providing them with Vicodin “goodie bags” on their way out the door.11 This behavior is not the right solution.
Catherine Lee, vice-president of service excellence at McLeod Regional Medical Center, comments, “We are really good at caring about what you think about us. We are not good at caring about what you actually think,”13 resonating to the fact that the content behind rankings is most important, yet we repeatedly fail to use it to drive improvement. The focus on patient centeredness has been insufficient, but incredibly beneficial with serious contributions to safety in recognizing and responding to challenges such as literacy and management of disease.14
Patients are physician educators and serve as facilitators for change in health care delivery. We have demonstrated that with a powered sample and timely set of results, most hospitalized patients are pleased, offer constructive feedback in real time, provide us with opportunities to improve their experience, and fuel physician communication curricula; physician HCAHPS scores reflect this change.15 Patient feedback and reviews are not unreasonable, standardized surveys are not to blame, and financial incentives are essential to secure our practice.12
- Patel, MS, Davis MM, Lypson ML. The VALUE framework: Training residents to provide value-based care for their patients. J Gen Intern Med. 2012;27(9):1210-1214.
- HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems. Available at: www.hcahpsonline.org. Accessed July 20, 2013.
- Gupta M, Kunkel K. Patient rounds: Doctor-patient communication observations. Department of Clinical Effectiveness and Quality Improvement. University of Pennsylvania. Available at: https://extranet.uphs.upenn.edu/sites/CEQI/CEQI%20Staff%20Meeting/,DanaInfo=pennpoint.uphs.upenn.edu+default.aspx?InstanceID=20120925&Paged=Next&p_StartTimeUTC=20111025T143000Z&View=%7bA92A01D7-F4A1-491F-9C5F-D1F58A471B34%7d. (Secure access.) Presented September 25, 2013.
- Thomas L. The Youngest Scientist: Notes of a Medicine-Watcher. New York, NY: Viking Press; 1983.
- Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
- Surgical Care Improvement Project. Available at: http://www.jointcommission.org/surgical_care_improvement_project/. Accessed July 20, 2013.
- Agency for Healthcare Research and Quality. Available at: http://www.ahrq.gov/. Accessed July 20, 2013.
- Press Ganey. About us. Available at: http://www.pressganey.com/aboutUs.aspx. Accessed April 2, 2013.
- Lindenauer PK, Remus D, Roman S, Rothberg MB, Benjamin EM, Ma A, Bratzler DW. Public reporting and pay for performance in hospital quality improvement. N Engl J Med. 2007;356:486-496.
- Peiguss K. 7 Customer Loyalty Programs that Actually Add Value. Available at: http://blog.hubspot.com/blog/tabid/6307/bid/31990/7-Customer-Loyalty-Programs-That-Actually-Add-Value.aspx. Accessed April 4, 2013.
- Falkenberg K. Why rating your doctor is bad for your health.. Forbes Magazine. January 21,2013. Available at: Available at: http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health/. Accessed September 20, 2013.
- Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med. 2013;368(3):201-203.
- Institute for Healthcare Improvement Symposium. Respectful partnerships—The patient experience: Improving safety, efficiency, and HCAHPS. October 24, 2012. Available at: http://app.ihi.org/Events/Attachments/Event-2288/Document-1795/October_24_Respectful_Partnership.pdf. Accessed October 23, 2012.
- Institute for Family-Centered Care and Institute for Healthcare Improvement. Partnering with patients and families to design a patient and family-centered health care system: Recommendations and promising practices. December 2007. Available at: http://www.familycenteredcare.org/pdf/PartneringwithPatients.pdf. Accessed April 2, 2013.
- Gupta M, Fleisher L, Fishman N, Raper S, Myers JS, Kelz R. Patient Satisfaction In Real-Time: Inpatient Experience Informs Providers and Satisfaction Scores. 2013 Abstract, American Surgical Congress Submission.