An astute reader might have surmised that I am Physician 1. An even more astute reader might have deduced that I am also Physician 2. How can one provider be scored so divergently?
Representatives from Press Ganey would probably argue that the relatively small number of surveys—eight for the rheumatology clinic and 11 for the ophthalmology clinic—mean the differences might not be statistically significant. The report, unfortunately, does not provide standard deviations to allow a statistical comparison. Further, studies based on Press Ganey have been published in peer-reviewed journals with response rates to the survey instrument as low as 7.5%.5 By relying on the responses from a minority of those contacted, the ratings are skewed unpredictably based on who is motivated to complete a survey. In addition, the U.S. government does not care about statistical significance. In distributing payment based on HCAHPS, what matters is whether the institution rates above or below the 50th percentile even if the difference between 50th percentile and 5th percentile is not statistically significant.
Unlike the citizens who are uniformly above average in Garrison Keillor’s fabled Lake Wobegon, all hospitals are not above average. For one three-month stretch, my rheumatology division received an overall Press Ganey rating of nearly 90% and was below the magical 50th percentile. Another quarter, our ratings minimally changed to 92%, a barely perceptible improvement, but the 2 or 3% change in absolute rank made a 44% change in percentile, placing us at the 92nd percentile.
Another possible explanation for the discrepant scores is the effect of residents and fellows in the clinic of Physician 2. A study from Duke, for example, found that residents receive slightly lower satisfaction ratings from patients compared with attending physicians.6 (Intriguingly another study found no correlation between the satisfaction of patients with a medical resident and the attending physician’s assessment of the resident’s skills).7 I am not aware of data to indicate that residents reduce the rating of a faculty member. However, based on recent HCAHPS data, teaching hospitals are less likely than nonteaching hospitals to receive an unqualified, positive recommendation from patients (http://www.hcahpsonline.org/Files/Chart_book_data_2013_1_April_V3._Merged.pdf).
Unpublished data from my university’s rheumatology clinic also show that the patient’s diagnosis influences satisfaction. Patients with fibromyalgia, for example, are significantly less satisfied with their care compared with the rating from all patients.
Although these observations might explain why my care is perceived differently in two separate clinics, the potential effects of trainees and underlying disease provide additional reasons to be dissatisfied with satisfaction as a measure of quality.
Practicing Medicine Should Not Be a Popularity Contest
What is the solution? Like virtually every physician, I want my patients to like and appreciate me. But practicing medicine should not be a popularity contest.
