Patient Satisfaction

I have for a while been annoyed by advocates of patient satisfaction. In the past my friends and I have approached this subject from the poles of objectivity and subjectivity. I dislike involving subjective ratings (feelings) in any objective outcome (promotion, success, hospital income). On the other hand, we can point to the WHO definition of health as
'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.'
This definitely includes feelings. So presumably a health service should aim to promote happiness as well as treat disease and physical infirmity. This is why the government blathers on endlessly about patient satisfaction, as though patients are customers shopping around for the best deal.
I've been into arguments about injustice before: about how a screaming person often gets seen before a quiet one (barring medical concerns about silence indicating inability), and how that punishes virtues such as patience, courtesy, consideration, self-control and the ability to wait one's turn. It's the same point I made in a recent post about achieving equality of outcome; it leads to unjust treatment of people. If you try to ensure that all children learn the same things at the same time you spend a lot of time and effort on the stupid ones and very little on the intelligent ones. Similarly with health-care, you can spend a lot of time on the needy. And in health-care that's appropriate because some things do need to be seen immediately. But the need must be objective, or else it leads to injustice.
This sort of inter-individual effect on justice seems a powerful enough argument to me, but some people would dismiss it as both insufficient to justify destroying a wonderful system of ratings, and a minor concern, since everyone does get medical care, even if the order is distorted slightly.
After all, if we weren't to use patient satisfaction, how else would we measure care? We'd have to rely on hospital inspections and outcomes, which we already do measure (and rely on to a fair extent). As we know, these are dangerous areas: hospital ratings and inspections do not reveal how a hospital really functions, with very highly rated hospitals suffering the two major health scandals of the last two years. Things can be hidden in a short inspection; inspectors don't see every aspect of day-to-day care, and outcomes depend on the severity of the cases and how the patients treat themselves.

If we aim for patient satisfaction, as now, or in a choice-driven NHS in which patients get easy choice of different providers, what will happen? The Conservatives say that care will improve, as those who provide poor care receive fewer patients and less money. They want more private companies, more choice and more market-like systems.
But the market won't be chasing good quality care. That's a little leap of faith. The leap is the logical deduction that patient satisfaction comes from better care, and better care alone. However, market systems require perfect knowledge. If every patient knew every range of possible treatments, their likely effect and could judge accurately surgeries and other procedures, then we'd be a nation of doctors and we could treat our own problems.
Just as companies distort the market by distorting what people know with advertising, publication bias (from pharmaceutical firms), false assurances and press releases, health-care providers can address patient satisfaction without improving care. This is more than a theoretical concern. Here is testimony from one doctor:
'When I first started practicing medicine, I had a lot of idealism about how I was going to improve care of patients in the ICU, and how some of my talent might even rub off on staff that were less talented. What I actually discovered was quite the opposite.

It turns out that healthcare in the US is set at a pretty low bar, and any attempts on my part to set it higher only caused widespread resentment. On the one hand, many resented the implication that a young physician like myself could offer anything of importance to older and more experienced physicians. After all, they've been doing it "this way" for years, and it's worked for them and for patients (so they believed). On the other hand, they also resented the implication that by making myself look smart, I made others look stupid. So, ironically, by trying to be the best physician I could be, I was actually putting myself in a vulnerable position. Since no one could support anything I did, I made enemies quickly.

There was a period in which I thought that even if I didn't have professional support, at least patients were better served by my care. All this changed with one experience that finally broke the camel's back. After rescuing a certain patient named M.S., I was dismissed from her care, by her family's request, because she was displeased that I did not treat her pain promptly enough. The fact that I had just saved her life didn't seem to concern her. This made me recognize that even patients don't necessarily want to get medical care. They only want certain petty concerns addressed -- usually issues of vanity. I decided that if neither the physicians nor the patients care about the quality of work that I do, why should I?

Since then, I have shifted my professional behavior markedly. Instead of trying to advance proper care, I have focused on image. Taking a cue from Machiavelli's statement that "people can see better than they can feel", I have made sure to portray the image that both patients and physicians expect, but avoiding making implications about others, even indirectly. I have found untold success in this method. In this world, it is better to look good, than be good. Since I have taken this route, my professional life has been much smoother. Because I portray the image expected of me, everyone thinks I'm their best friend. And because I don't act in a manner that appears to encroach on any other physician's territory, none of them see me as a threat. My personal life has also vastly improved. Since I don't have so much stress at work, I can remain relaxed at home. '

As the doctor notes, patient satisfaction wasn't about saving a life. Neither the patient nor her family knew that her life had been in danger, nor understood that it had been saved. What mattered was pain. Pain is quite subjective, and often treating pain is against best medical practice: there are endless people in hospital crying for better pain relief, calling the nurses torturers and so on, when any more will stop them breathing, get them addicted, interact badly with their other drugs or possibly a host of other medical concerns.
But even beyond the question of pain, the story demonstrates another truth: that satisfaction through ignorance is easier to achieve than satisfaction of the knowledgeable. If we introduce markets to health-care, then we will also introduce the typical market-failures and incentives, and one of the most damaging will be an even greater incentive to hide bad treatment, cover up failure, and generally rely on 'PR' over true ability.

My mother likes to tell the story of her inspection of two doctors in Liverpool. She was inspecting two gynaecology consultants, one of whom had some of the best post-natal survival figures in the country and one had a history of complications and problems (or something to that effect). One was friendly and liked by patients and staff, the other an aggressive man who told her that women couldn't be relied on to think clearly, especially when pregnant (and she was incubating me at the time), was disliked by staff and just about managed professional courtesy with patients. This second one had far fewer thank-you letters and gifts, but he was the one with the good survival rates.
Chasing patient satisfaction will not only get me seen much later than would be fair, but will give me poor care. I'll see a smart-looking doctor who is brisk and firm and projects an air of authority whilst explaining his decisions, and I'll feel comfortable that someone who knows his job is in charge. Actually, though, I'll be meeting someone who has more skill in acting than medicine, and who will skim over difficult decisions and problems because sounding uncertain will make me less confident and less satisfied. I'll meet someone who'll second-guess my responses as his main job, because my responses have suddenly become not just a secondary concern to his own actions, but more important than them, and the means by which his actions are judged.

If we return to what I've said in the past about leadership and democracy, we can see that this is the contrast between the popular and the sensible. In relationships it's the contrast between a reliable partner and a manipulative one. It's the clash between the subjective and objective; the hopes for absolute equality and the reality of equal rights. It's the same attitude that we decry as 'populism' but accept when it's coated with the sugary phrases of 'market forces' and 'economically sound'.
Economically sound means the same as well-evolved. People respond to incentives, just as creatures have responded to the environment. But evolved (in the biological sense) does not always mean improved, and a free market system in the NHS, or any pursuit of satisfaction over real care, will be the same.
If happiness is better, why don't we get everyone high on soma and let a ruling elite deal with unforseen problems?
Oh wait, things are going that way anyway... drugs, religion, apathy and plutocrats. Perhaps society is evolving after all.


We won't achieve benefits if people decide on the basis of satisfaction, not empirical statistics. And people do decide on that basis, which will affect my care too.
It's already affecting training: doctors are taught how to be nice. That's valuable time that could be spent on learning how to treat real conditions.
People are expecting to be made happy by many things, from the NHS to a shop assistant. Where that doesn't harm any other concern, that's fine with me. But aesthetics should contribute to good design, not detract from it. Where emotional appeal spoils something that otherwise functions well it's no longer something that the nation should invest in.

If the shop assistant takes longer to serve me because he's conversing with a customer then I've had my time wasted, even if it makes sound business sense. If a doctor does the same, then all the following patients will wait longer. That doctor might get good personal ratings, at the expense of the ward or hospital.
We could say that if the population as a whole wants this, then it doesn't matter that I don't want to waste my time waiting for other people to exchange life stories, or have my taxes pay them to do so.
But people are incapable of linking their individual decisions to mass effects. They will disagree with the mass effect and want to make the individual decision that causes it. They want everyone else to do what's right but to screw the system themselves. They can't cope with the Categorical Imperative that suggests that actions are judged by what would happen if everyone acted by such a principle.
That free markets, which are a version of mob rule, would lead to certain results doesn't mean that we actually want those results, nor that we should accept them. If we were to legalise drugs we'd get a lot of drug use, but that doesn't lead everyone to conclude that the population wants or ought to get a lot of drug use; the same applies to murder.

Do we want mob rule and the evolution of whatever panders to that best, or do we want a little bit of principle and insight? These are the things that supposedly distinguish democracy from anarchy (and mob rule). I can tolerate my local shop wasting my time, but I don't think that my government should do it. The government needs to be run by principles, not economics. The principle of 'give the people what they want' doesn't work when the people have conflicting wants. And when those wants are caused by a conflict of a principle with an immediate desire then the government should be governed by principle.

The conflict between immediate desire and long-term goals is well known:
http://www.ted.com/talks/lang/eng/dan_gilbert_researches_happiness.html
http://www.ted.com/talks/daniel_kahneman_the_riddle_of_experience_vs_memory.html
And just as well known is that giving in to immediate desire when it conflicts with long-term goals is bad for you:
http://www.ted.com/talks/lang/eng/joachim_de_posada_says_don_t_eat_the_marshmallow_yet.html

Sometimes we need government regulation to control short-term interests. We need the government to stop banks using the stock markets to take money from the economy and unbalance it. We need the government to take money from us to pay for upkeep of the infrastructure, because otherwise we'd not bother with repairs and we'd put it off indefinitely. Similarly, we need the government to prevent us from judging health care by patient satisfaction.