Clinics in Dermatology (2014) 32, 444–447

DERMATOLOGIC DISQUISITIONS AND OTHER ESSAYS Edited by Philip R. Cohen, MD

Improving patients’ satisfaction with care Steven R. Feldman, MD, PhD ⁎ Department of Dermatology, Wake Forest University School of Medicine, 4618 Country Club Road, Winston-Salem, NC 27104

Introduction The socioeconomic current of our society continues to flow toward placing greater emphasis on “value,” measuring how much is being spent and what outcomes are being achieved. This is certainly true in medicine, where electronic data collection is allowing progressively more detailed assessment of patients’ outcomes (albeit with considerable limitations). Three of the most important outcomes that contribute to the value of medical care are objective improvement patients have in their disease, patients’ subjective satisfaction with the treatment outcome, and patients’ overall satisfaction with their care. Clinical trials measure objective and subjective improvements in disease, providing information about the value of treatment; patients’ satisfaction with care is at times an unappreciated outcome when medicine is viewed from a purely biophysiologic perspective. From the patient perspective, satisfaction with care is perhaps the most direct measure of benefit in the calculation of value. Although physicians can appreciate great joy when achieving objective success in clearing a disease and terrible frustration when being unable to achieve objective success, having very happy patients or very sad patients—the extremes of the patient satisfaction with care outcomes— may be equally or even more impactful on physicians’ perceptions of how the day is going, independent of patients’ objective treatment outcomes. We can expect that measure-

⁎ Corresponding author. Tel.: 336-716-7740; fax: 336-716-7732. E-mail address: [email protected]. (S.R. Feldman) 0738-081X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clindermatol.2013.10.004

ment of satisfaction will grow in importance as health care is systematized, providing a complementary countermeasure to cost reduction.

Patient satisfaction measurement My interest in patient satisfaction began when the medical center at which I work began doing patient satisfaction surveys. I prided myself in giving patients great care, specializing in psoriasis, giving patients the right diagnosis and the right treatment. The patient satisfaction surveys revealed that too many of my patients were (profoundly) unhappy with the care I provided them. This negative feedback was helpful to me, making me aware of problems that I did not know existed in my performance as a physician. Recognizing the importance of patient satisfaction feedback, I developed an online patient satisfaction survey website (that doubled as a physician rating website) that facilitated low-cost, detailed patient satisfaction data collection. What factors determine patients’ satisfaction with care? Let’s cut to the chase. Based on quantitative data from the online surveys that were collected, there is only one factor that matters much. It is not patient demographics, nor how long patients wait in the waiting room, nor how much time the physician spent with the patient. It is also not whether the treatment of the patient’s condition was effective. The one factor that determines patients’ satisfaction with care is whether patients perceive that their physicians care about them.1 Note that patients’ satisfaction is not determined by whether the physician cares; I cared deeply about my

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patients; yet, many were still unhappy. What determines patients’ satisfaction with care is patients’ perception of whether the physician cares. Systematic qualitative assessment of patient comments collected on the online patient satisfaction website found seven factors were associated with patient satisfaction, and many, if not all, of these tie into patients’ perceptions of how caring the physician is (Table 1).2

Improving patients’ satisfaction with care Although I have provided hard data on factors that affect patients’ satisfaction with care, my suggestions for improving patients’ satisfaction with care have not been rigorously tested in blinded, controlled trials. I believe, nevertheless, that it is critical to do those things that make patients perceive they are seeing a caring physician. I will categorize these approaches into three phases: before the patient sees the physician, seeing the physician, and after the visit. I would also refer you to a marvelous resource written by Dr. Victor Marks and colleagues from the Department of Dermatology and Dermatologic Surgery, Geisinger Health System, Danville, Pennsylvania.3 Presenting patient satisfaction from a “service excellence” point of view, they describe the importance of service excellence and provide a “how to” list with 27 specific standards for achieving service excellence. The caring (or uncaring) nature of a physician will be perceived to some extent before seeing the physician. The ease of contacting the physician’s office for an appointment, parking, the state of the waiting room, and the friendliness

Table 1 Qualitative analysis of patient satisfaction comments from an online patient satisfaction/physician rating website (www.DrScore.com) a Things patients liked • •





• • •

Access Communication -Listening, partnership, giving information Personality/demeanor (projecting empathy) -Humaneness, caring, support, trust, family/children Medical care -Technical competence, time diagnoses, treatment, thoroughness Follow-up, test results, referrals Facilities Office staff/coordination a

Adapted from Anderson et al.2

Things patients did not like Poor access Poor communications -Poor listening -Lack of partnership -Did not communicate information

• •

Poor follow-up Lack of interpersonal skills -“Took an apparent disinterest in my health”

• •

of check-in staff all reflect, in the patient’s mind, on how caring the physician is (regardless of whether those factors are under the physician’s control). It is frightful to me what the check-in window of our former office communicated to patients (Figure 1). How long patients wait in the waiting room is associated with patient satisfaction, but the effect appears to be mediated by perceptions of caring. If patients wait a long time in the waiting room but the physician is still able to communicate that he or she is a caring physician, then patients tend to be highly satisfied with their care; the problem is that it is difficult to make patients realize you are a caring physician if you have kept them waiting a long time. The human mind perceives things less in terms of absolute values and more in terms of context and contrast; how the physician is perceived may be largely determined by the context set before the patient sees his or her physician. The interaction with the physician is certainly critical as well. To begin with, I open the door to the examination room slowly, communicating to patients that I am not in a hurry (even though I ran to the room because I am in a hurry). Introducing oneself to all family and friends in the room communicates caring as well. Dermatologists are very efficient at assessment of skin disease and may be able to make the diagnosis of a skin disease and perhaps even choose appropriate treatment from the door of the room. Such efficiency may leave patients feeling as though the physician did not take time to do a thorough examination, did not take patients’ concerns into account, and did not care about the patient. To make sure patients feel they received a thorough examination, it is helpful to palpate lesions (touch also directly communicates caring) and to examine (or at least pretend to examine) lesions with a large, lighted magnifier (the very large one with impressive LED lights that I use was purchased for just a few dollars from eBay). I will query patients, “I bet the previous treatment you used was frustrating.” The purpose of this query is to communicate to patients that I understand their concerns and frustration, not to obtain information; I rarely get useful information from their response, because if a patient had a treatment that worked well and that he or she liked, the patient would not be in my office seeking treatment. In addition, involving patients in the choice of treatment—to the extent that they wish to be involved—helps patients feel that the physician includes them as a partner in treatment. Follow-up is a critical aspect of making patients feel cared for. Blood tests and biopsy results should be communicated to patients in a timely way assiduously (both for quality of care and medicolegal reasons). Giving patients easy access to return visits or other means to contact the office may be very valuable for building the perception of caring. As an academic physician-scientist, I do not see as many patients as a dermatologist in full-time clinical practice. I regularly give patients my cell phone number as a means to follow up, to answer any questions that come up, and most importantly, to make clear to patients how much I care about them. If I am

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Fig. 1 What a check-in window should NOT look like. This is the check-in window at our former office. The blinds and windows communicate that we may shut you out at any time because we do not care about you. The disheveled, cluttered desk communicates that we do not care much about the quality of what we do. All the posted signs are consistent in suggesting that we care more about your wallet than we care about you.

doing my job well, there should be few, if any, questions for which they need to call. Most patients are so respectful of physicians that they do not call, even if they have an issue that could be solved with the call. Giving a personal cell phone number to every patient may not be practical for a dermatologist seeing large numbers of patients, although it may be a very valuable approach to improving satisfaction in patients whom the dermatologist recognizes are at risk for poor patient satisfaction.

Conclusions Is there an argument to be made that patients’ satisfaction with care is not an important outcome to achieve? The idea that physicians should only have to worry about objective outcomes and not about patient satisfaction—that is, that unsatisfied patients can just go somewhere else—leaves me distressed in a couple of ways. First, this attitude, to whatever extent it occurs, would make physicians look bad. Second, perhaps I am projecting, but I find it hard to believe that physicians are not dedicated to making their patients happy. One of the arguments against the use of objective treatment outcomes as a measure of value is that it is difficult to account for the baseline severity of disease (renowned physicians who attract the sickest patients could have the worst treatment outcomes). This objection applies to patient satisfaction as a measure of quality as well: Some

patients are harder to please than others (I imagine my North Carolina population may be easier to please than folks in New York City). Physicians, nevertheless, have tremendous control over patient satisfaction and need not despair that patient satisfaction is something they will be rated on but cannot control. The impression that patients are not very happy with their physicians (which may be based on selected coverage in the media, for it is not likely for the front page of the newspaper to cover any of the millions of regular, happy patient visits that happen every day; the bias happens in the office, too, considering how unlikely it is for a dermatologist to see a patient thoroughly happy with the care they received from another physician [if they were happy, why would they go to another physician?]) is widely inaccurate. Our recent report on patient satisfaction with dermatologists revealed that dermatologists’ mean patient satisfaction score is a healthy 9.5 on a 0 to 10 scale.4 Folks like me, with a 9.1 out of 10, have plenty of room for improvement. I hope that nothing in this paper is interpreted as suggesting that physicians do not have to give patients accurate diagnoses or the best possible treatment. On the contrary, I take as a given that physicians are dedicated to giving patients great medical care, but great medical care involves more than just the right diagnosis and treatment. Great medical care includes providing a service that patients recognize as being great. Finally, if all we really did care about were objectively successful treatment outcomes, patients’ satisfaction with care would still be important to achieve in order to obtain good adherence to treatment needed for optimal objective treatment outcomes.

Patient satisfaction

References 1. Uhas AA, Camacho FT, Feldman SR, Balkrishnan R. The relationship between physician friendliness and caring, and patient satisfaction findings from a Internet-based survey. Patient. 2008;1:91-96. 2. Anderson R, Barbara A, Feldman S. What patients want: A content analysis of key qualities that influence patient satisfaction. J Med Pract Manage. 2007;22:255-261. 3. Marks VJ, Hutchison R, Todd M. Service excellence in dermatology. Semin Cutan Med Surg. 2004;23:207-212. 4. Camacho FT, Balkrishnan R, Khanna V, et al. How happy are dermatologists’ patients? A review of a study examining patients’ perceptions of dermatology practices. Dermatologist. 2013;21:38-42. Steven R. Feldman, MD, PhD, appointed in Dermatology, Pathology, and Public Health Sciences at Wake Forest University School of Medicine, directs the Center for Dermatology Research, a health services research center whose mission is to improve the care of patients with skin disease. His chief clinical interest is psoriasis, and he has served two terms as a member of the Medical Board of the National Psoriasis Foundation. Feldman’s research on indoor

447 tanning provided a firm foundation for the recognition and scientific study of tanning addiction. His studies on patients’ adherence are transforming how physicians understand and enhance patients’ use of treatment for chronic skin diseases. Feldman is chief science officer for Causa Research, a company that provides an adherence-improving solution to health care stakeholders. His general weakness in the area of interpersonal skills and resulting poor patient satisfaction led him to create the www.DrScore.com patient satisfaction survey/physician rating website. Feldman is a frequent speaker to lay groups, physicians, and industry professionals, and has published more than 600 papers in peer-reviewed journals. He is editor of five dermatology publications, has a regular column on patient adherence in PM360: The Essential Resource for Pharma Marketers, and is author of Practical Ways to Improve Patients’ Treatment Outcomes. Feldman is most passionate about biases contributing to misperceptions and conflicts in and beyond dermatology, and he wrote the book Compartments: How the Brightest, Best Trained, and Most Caring People Can Make Judgments That Are Completely and Utterly Wrong to help make the world a better place.

Please submit contributions to the section to Philip R. Cohen, MD, at [email protected]

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