A recent post by Medscape, titled “The Opioid Crisis: Anatomy of a Doctor-Driven Epidemic,” suggests that doctors are at the root of the recent opioid epidemic. The solution, they argue, can be found in guidelines issued by medical associations. While the article discusses the role of patients, pharmaceutical companies, and doctors (who are, to be sure, keenly aware of the responsibility they bear in this crisis) the role that administrators play in this epidemic is notably absent.
SERMO recently asked 3960 doctors from 21 different countries for their thoughts on how a key administrative choice – issuing patient surveys – impacts prescription of opioids.
More than half of doctors felt that patient surveys issued by administrators influence them to prescribe more pain medication than they otherwise might.
Nowhere were the results more striking in the U.S., where the opioid epidemic has hit extremely hard. U.S. doctors reported that patient satisfaction surveys influence physicians to prescribe more pain medication than they otherwise would at a rate of 2 to 1.
What are patient satisfaction surveys?
The goal of patient satisfaction surveys is, if you’re an optimist, to improve the patient experience. Alternately, if you read the websites of major survey providers, the goal can be explained as to “Respond to Market Pressures with a Patient-Centered Strategy to Create Consumer Value” (from the Press-Ganey website).
How do they impact doctors?
Patient satisfaction surveys are just a metric and cannot, in and of themselves, drive any specific actions. The intended use and real-world effect, however, is that they enable administrators to assess and incentivize physician performance based on the experience (not just the health) of patients.
Surveys cannot account for responses from patients who came to the doctor specifically trying to get opioids. They cannot quantify the subjective experience of pain. They cannot accommodate the pressure to “do something” – anything – that patients expect and doctors have to handle (a 2015 poll of SERMO doctors found that 61% of physicians felt pressured by patients to “do something” at each appointment). And yet, despite the obvious limitations on the nuance these surveys can accommodate, they are now included as a metric for hiring, firing, raises, promotions, demotions, and other major decisions regarding physician’s careers.
A hot conversation accompanied this poll on the SERMO social network. Many doctors were adamant that their medical advice to patients could not be changed by such polls – the fault lies not with specific doctors, however, but with the system.
A Rheumatologist noted, “I can tell you that in my community, the hospital-employed ED, UC, and primary care clinic docs write for exponentially more opiates than every other doc in the community. Actually, could be 100-fold rather than 10-fold. The hospital uses Press-Ganey like a club in dealing with its employees. I have at times been astonished. These days, they’re back-pedaling furiously trying to extricate the ‘system’ from the firestorm.”
One Hematologist/Oncologist highlighted the specific challenge that opioid-seeking patients present to the otherwise arguably harmless surveys: “Surveys may be a good thing (food, quiet, room decor) but as currently administered, they are influenced too much by the drug abusing patient. Patient requesting narcotic pain medicines should be excluded from evaluating physicians.”
A Neurologist noted that surveys impact more than just prescription habits, commenting, “I don’t think it has greatly affected my prescribing but it has affected my ordering tests to “reassure” anxious patients when otherwise I may have tried harder to convince them it wasn’t necessary.”
A Psychiatrist dug into the way in which the surveys change the mental processes around prescription: “I think it’s a common sense…that doctors are conditioned to care about the judgment of their professional capabilities… I think the doctor’s anxiety to connect with patients greatly influences prescription. In my case I try to keep myself to a rational assessment of the case, but I admit that it’s really hard to be neutral to the expectations of the patients.”
An Emergency Medicine physician summed up the causation between patient satisfaction surveys and opioid prescription: “Surveys have a direct effect on prescribing habits. Especially in some emergency departments where salary and bonus is based on higher scores. You give the patient what they think they need – they are more satisfied with your care. Not rocket science. Wish it would change.”