My Doctor Won't Refer Me To Specialist. So I Fired Them.

There are a lot of great doctors who have trained at some of the finest institutions in this country who get a bad rap from patients because they won't do what the patient wants them to do.   What is a doctor to do?  In an age where The Medicare National Bank values patient satisfaction scores so much that they are willing to punish hospitals who don't score well, doctors are going to feel more and more pressure to provide care they feel may be unnecessary in order to meet patient satisfaction goals.

We already know that higher patient satisfaction scores are associated with higher mortality.  Heck, even the spelling of your doctor's name could influence your patient satisfaction scores.  Good patient satisfaction scores are so important that some hospitals are now doing the A.I.D.E.T. method on patients without a pulse.  Many variables play in to how patients perceive how satisfied they are with their care.  I think paying hospitals based on perception is a dangerous precedent filled with unintended consequences   My biggest concern for patients is that satisfaction will trump evidence.  I say this because I know that millions of dollars in hospital funding will be determined by a measly 300 random HCAHPS patient surveys.

When you look at big hospital systems discharging 25,000 patients or more per year, it's really hard to plan  hospital finance decisions based on the results of  1% of your discharge population's opinion on their care.  These are the one percenters  nobody is talking about.  As more and more physicians become employed through hospital systems, the importance of patient satisfaction surveys and their relevance to having a stable job will multiply.  I guarantee there will be hundreds of thousands of physicians out there that will provide medical care that makes patients happy, not care that makes them better.  

I discovered that first hand once when I was told by a patient that they "fired" their primary care physician because they would not provide a referral to a subspecialist for further testing of a very common medical condition.  This was a physician with whom I would have no problem having as my own physician.  The patient ultimately self referred themselves to the subspecialist, underwent exhaustive and expensive radiographic and quite frankly, dangerous procedural intervention, each of which carried their own risk of complications.  

At the end of the work up the subspecialist said they did not have an answer for the patient's symptoms and sent them back to their primary care doctor.  Not surprisingly,  the symptoms ultimately went away on their own without further testing.   What shocked me the most was the lack of insight months later for the patient's  anger at the primary care doctor for sticking to their training and telling the patient they did not need further workup for their condition.  But the patient, despite putting themselves through very expensive and unnecessary self referred testing, that we will all end up paying for, remains angry at their ex-PCP, to this day,  for not caving to their desires.

It's shocking to me how skewed some patients can be in their understanding of their symptoms and their distrust in their physician, to the point of bad mouthing them, even though they are so clearly on the losing end of the argument.  But Medicare doesn't care.  Some patients, no matter how much time you spend explaining until you're blue in the face why you don't need certain tests or procedures will walk out on you and give you a bad satisfaction score.  I don't know about you, but if 300 out of tens of thousands of patients  have the power to decide millions of dollars in hospital funding, and you are an employee of a hospital, you are never going to know which of those 300 pushy patients are going to assault your character out of their own frustration.

The path of least resistance defaults to giving patients what they want.  That makes them happier even if it isn't the right medical decision.  First thought that comes to mind?  Just fill grandma's Xanax and Percocet for her mild osteoarthritis and refer her, at her requrest, to the best rheumatologist in town.  We don't need her angry daughter filling out a bad survey because mom won't stop calling her every day at noon with the shakes and complaining about that hospital doctor that took away her happy juice.

The ABIM Foundation recently introduced the Choosing Wisely ® campaign to increase conversation about unnecessary testing.  What these campaigns fail to appreciate and what they find themselves up against are opposing end point pressures for doctors.  There is a very verbal subset of patients out there that simply won't be happy until they get all the just in case testing their FREE=MORE insurance can buy.  Choosing our tests wisely may lead to upset patients and interfere with our patient satisfaction scores.  This is in direct competition with cost conscientious care.  It's  not only possible, it's happening.  It happened right in front of my eyes.  Usually you hear about doctors releasing patients from their practice.  But in this case,  a patient fired their primary care doctor because they wouldn't do what they wanted, even though it wasn't medically necessary.

What a shame.  It is the new reality of health care in America.  Put on your seat belts and get ready for the ride.  Or, if you don't like wearing your seat belt.  Don't.  We want you to be happy.  And we'll take care of your head injury just the same. With a smile on our face and a jug of morphine the size of Texas just waiting to keep you happy.

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