You see a patient for the first time to establish care for Sjögren’s disease. She complains of dry eyes, dry mouth and diffuse arthralgias. You do not appreciate any synovitis on physical exam. Of note, you are the fourth rheumatologist she has seen during the past year. Toward the end of the clinic visit, she requests to be placed on prednisone 60 mg daily, stating it’s the only intervention that helps her pain. Although giving this patient high-dose steroids would make her happy, no clear medical indication exists to do so. After you explain to the patient your reasons for not giving high-dose steroids, the patient states that she is not getting adequate care and that she’s being neglected. After looking at her medical records from her other providers, you realize that this story was replicated with the previous three rheumatologists.
What do you do when a patient’s request interferes with your treatment recommendations?
The Patient–Physician Encounter
Before the 1980s, measurement of patient satisfaction was not included in routine quality assurance evaluations, and that was justified by certain patients’ lack of necessary scientific knowledge. In addition, methods to measure patient satisfaction were not available at that time.1
More than 20 years ago, a physician, Aaron Lazare, conceptualized the clinical encounter between physician and patient as a process of negotiation.2 Per Dr. Lazare, “Patients are conceived as appearing with one or more requests. … It’s the clinician’s task to elicit the request, collect the relevant clinical data, and enter into a negotiation that should foster a relationship of mutual influence between patient and clinician.”2
In those times, patients viewed physicians as a source of unlimited knowledge and wisdom. Over time, the perception of the clinical encounter as a two-way exchange became more accepted, mostly because of the hypothesis that encouraging patient involvement in healthcare decision making results in better health outcomes.2
In the late 1980s and early 90s, patient satisfaction gained widespread recognition and became an integral part of outcome measures for health services.
Patient Satisfaction Scores
When the concept of patient-centered care emerged, more emphasis was placed on individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions. It also includes improving health literacy through patient education, coordination and integration of care, all of which are factors in the concept of shared decision making.3,4
Hospitals invest a considerable amount of time, effort and money to improve patient satisfaction scores. The question then becomes, to what extent do patient satisfaction scores reflect the quality of care provided by physicians? The results of studies that investigate this question are conflicting. Some have shown that patient satisfaction scores correlate with the quality of care provided, while others have not.5,6