50% of Doctors are Worse than Average

If you hired a lawyer who the world’s nicest office and excellent coffee in the lobby, but who lost the case for you every time, what would you think of that lawyer?  How about if you hired a hairdresser who was always on time and had some great gossip for you when you sat in their chair, but who made you look like a refugee from Flock of Seagulls every time you left the salon?  I am guessing that your general view on these people would be negative, despite their incidental charms.

However, when people are asked to rate their doctors, it is precisely the incidental charms that count the most.  The primary correlates to doctors receiving high patient satisfactions scores are: 1) whether they were made to wait for an excessive period of time in the waiting room; and 2) whether the doctor spent a long period of time with them in the exam room.  In other words, patients value comfort and attention and that, in their minds, tends to equate to high quality care.  Buyer beware.

In mid-December 2011, a research team from the University of Michigan School of Public Health analyzed data from around 15,000 patients who used a patient satisfaction survey tool called DrScore.com.  What they found is that, on average, patient satisfaction with their own physician ranks in the 90^th percentile.  The categories most highly correlated with satisfaction were, as previously noted, waiting time and amount of time spent with the patient.  I don’t know about you, but if I’m ranking my doctor, I’d be thinking about outcome and invasiveness of treatment as a big part of how I feel about them.  And yet, the question of whether their illness was effectively cured or whether they suffered unanticipated side effects is not nearly as big a factor in patient satisfaction as is the courtesy of the office staff and the timeliness of appointments and follow-up.

If you look at the questions asked in the DrScore survey, which you can find HERE, you see that only 2 of the 20 non-demographic questions in the survey get directly at clinical outcome.  The first is: On a scale of 1-10, how do you rank your treatment success?  This question is actually number 11 of the survey of 20 questions.  The second question is more indirect, asking “on a scale of 1-10, where 0 is the worst possible care and 10 is the best possible care, where do you rate your doctor?

So what? You might ask.  Patient satisfaction has been measured this way forever.  If people are happy with their doctors, then good for them.

True, but here’s the rub.  If you ask people if they are satisfied with the healthcare system and whether they think they get good value for dollars spent, they say “no.” As many as 80% of Americans say they are dissatisfied with the U.S. healthcare system in typical surveys.  If you ask people if they think money is wasted in excessive treatment they say “yes.”  If you ask 100 people if they have a friend or family member who got bad treatment and/or harmed by the medical care they received, you will get 100 yesses.  And yet those same people who hate the medical system love their doctors. It’s similar to how people separate their feelings about “Congress” from their feelings about their own Congressional representatives.  When you poll voters, they tend report 70%-80% dissatisfaction with how Congress is doing its job and 60-70% average satisfaction with the efforts of their own congressional representative.    No wonder you can never get rid of any of these people.

I have to believe this consumer schizophrenia is one of the reasons it is so hard to change the healthcare system for the better.  Payers have tried for years to effectively reduce the size of their provider networks to reward physicians who demonstrate better outcomes and to exclude those of less clear quality (the basic idea around pay-for-performance).  Yes, no doubt these things are hard to measure in the aggregate; everyone wants to bring in risk-adjustment and all that other stuff.  But for one individual patient, it is pretty easy to measure these things. I go to my doctor; he/she makes me feel better or not.  I feel more in control of my health or not.  Etc.  Yet whenever a payer tries to cut any provider out of its network, bedlam ensues as consumers fight the perceived reduction in choice.  And this is because every provider has his/her fans, not because every provider is effective.  I used to work for a doctor that used to always tell me, “by definition, 50% of doctors are worse than average.”  Hard to argue with that logic.

As health reform rolls along–and it will roll along in some form or another because the economic imperative is there regardless of the form the final law takes–it will become necessary to force more accountability into the system.  A big part of that accountability will and should fall in the lap of consumers, who are, in the end, responsible for what happens to them and how their own money is spent.  It will be interesting to see whether consumers will be willing to trade the provider of their choice (he has such great lollipops!) for the provider that costs less or delivers faster or better results when push comes to shove and their own cold hard cash is at stake.  Certainly those would be the primary determinants in any other significant consumer purchase.  No one buys a car because the dealer is highly attentive and has fresh minty breath or a piece of real estate because the realtor has such a nice car and is a good listener.     People are able to rapidly overlook these things if they think they are not getting a good value.

Over the last several years many new businesses have formed that are focused entirely on delivering quality and cost results to consumers so they can make better provider choices.  Virtually all of these are still pretty small enterprises with fairly light levels of consumer adoption.  Yet as consumers are put in the driver’s seat for the purchase of health insurance plans, as they will be through the health insurance exchanges that will likely soon be pervasive, will these businesses become as popular as Consumer Reports is for cars and appliances?  Today the average person spends far more time interviewing contractors and financial advisors than they do physicians; will this change when consumers have a greater sense that it is their own money being used to pay physicians? Taken to its logical extreme, maybe the next big reality show will be the one where physicians compete for consumers’ affections and get voted off the island by Paula Abdul when they fail to deliver in the charm department.

One of the questions on the DrScore.com is “to what extent does your doctor include you in decisions about your care and treatment?”  This reminded me of that Seinfeld episode where Elaine’s doctor decides she is “difficult” and writes secret notes in her file before blowing her off with a cursory treatment plan.  When she goes to the next doctor, he has already received her records (what are the odds of that happening in real life?) and treats her with the same disdain, driving she and Kramer (posing as Dr. Van Nostrum) to try to steal her medical records.  Thought I’d include the video clip of that scene, as it always cracks me up.  I’m guessing these guys wouldn’t have fared so well in the DrScore.com study.

httpv://www.youtube.com/watch?v=pyossoHFDJg&feature=related