Ira S. Nash, MD
Disclosures: The author has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1087.
Requests for Single Reprints: Ira S. Nash, MD, North Shore–LIJ Health System, 600 Community Drive, Suite 302, Manhasset, NY 11030; e-mail, firstname.lastname@example.org.
Author Contributions: Conception and design: I.S. Nash.
Drafting of the article: I.S. Nash.
Critical revision of the article for important intellectual content: I.S. Nash.
Final approval of the article: I.S. Nash.
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In this video, Ira S. Nash, MD, offers additional insight into his article, "Why Physicians Hate "Patient Satisfaction" but Shouldn't."
Federico Relimpio Astolfi
Endocrinology and Diabetes. Hospital Virgen del Rocío. Seville. Spain
September 8, 2015
A new paradigm for the clinical profession
The patient is the center and the focus of our attention. So, his/her satisfaction - or lack of it - should be carefully taken into account. But, we should also take into consideration that the clinical profession is a strained one. Scientific/Technical demands must be taken along with expense limitations to attain a difficult equilibrium called sustainabilty. If we are to put into action another focus of strain, and I do agree with the idea of a compelling need for that, the whole medical profession should clearly state a new labour paradigm in which every modern force can be assumed without making a stressful environment.
P Dileep Kumar MD FACP
East Michigan Hospitalists
December 13, 2015
Why we should refine "Satisfaction" scores
Dr Nash is right about one thing: Patient and family experiences are important in the business of caring. This point is usually ignored in the intense science of providing medical care. Relying on patient satisfaction scores from surveys is not the answer to this malady. The cure is worse than the disease as it stands now.The main objections against using patient satisfaction scores are not the themes mentioned in the article. Patient satisfaction has not been correlated with quality of care in any randomized controlled trials. If we insist on randomized trials and evidence based data for every intervention or procedure in medicine, this area should not be different. There is no reason to compromise on the gold standard when we deal with a vital topic. The quality of evidence is poor supporting adoption of patient satisfaction to a wide variety of purposes. A recent paper1 on patients undergoing elective cranial neurosurgery reported that overall patient satisfaction may merely reflect patient experience and subjective postoperative health status, and therefore it is a poor proxy for quality of care in elective cranial neurosurgery.The objections to adopting patient satisfaction scores to pay physicians is not related to the details of the process, time wasted in the process, diverting scarce resources or patients not being qualified judges of physician performance. The reason for practicing physicians’ objection is the way patient satisfaction scores are brought up and adopted without any scientific basis. Currently hospitals will not get credit for a satisfaction score of 4 out of 5. Adopting this methodology into physician payment formulas is unscientific. How did we determine that “good” is not good enough and only “very good” should count?Dr Nash has a 4 star rating2 out of possible 5 on a website currently. Even conceding that these online surveys may not be accurate because of several reasons, there are 5 other doctors listed on the same page practicing within a quarter mile range scoring 5/5 star rating. Does this mean that Dr Nash performs 20% below his peers and not eligible for a single value based point as it stands now? The patient satisfaction story is parallel to the board certification story. ABIM has gotten carried away by the board certification requirements and ever more unattainable standards were added to measure physician competence, prompted by experts who have nothing to do with practicing medicine and are unaware of the pressures and realities of current practice environs. In the end, physicians revolted en masse against it and ABIM had to backtrack its steps. Non-physician experts were devising complicated programs without any scientific merit to measure the competency of physicians.Patient satisfaction and value based purchasing are big business. No one can understand or follow the program details. Hospitals have to employ legions of personal to tease out the details of value based purchase to recoup some of the money subjected to penalties.We have to acknowledge patient experience, measure and improve it. Rather than blindly applying current patient satisfaction scores to payment methods we have to refine them before prime time. Maybe we have to include practitioner satisfaction to the measure. Are the doctors happy in practicing in the current settings? How satisfied are the doctors about the requirements of practice causing barriers affecting the quality of care they provide? How satisfied are they about the time they get to spend with the patient? How satisfied are they about the compliance of their patient population? Maybe we need a composite score including patient and physician satisfaction.Finally Dr Nash received Press Ganey’s inaugural Physician of the Year Award3 which is a clear conflict of interest which is not acknowledged in the paper.1. Reponen E, Tuominen H, Hernesniemi J, Korja M. Patient Satisfaction and Short-Term Outcome in Elective Cranial Neurosurgery. Neurosurgery 2015;77(5):769-76. 2. Healthgrades. Dr. Ira S. Nash, MD, Accessed on December 11, 2015 at http://www.healthgrades.com/physician/dr-ira-nash-2nhjs3. Nicole Briggs. Edgemont Resident Ira Nash Honored By Press Ganey. Scarsdale Daily Voice. 11/18/2015. Accessed on November 27, 2015 at http://scarsdale.dailyvoice.com/neighbors/edgemont-resident-ira-nash-honored-by-press-ganey/604793/
Philip Mendell, MD
Coral Gables, Florida
December 30, 2015
As a just retired internist, now voluntary medical school faculty member, my experience is at odds with Dr. Ira S. Nash’s article concerning surveys for patient satisfaction. (1)Any question asked a disgruntled patient will be answered in the negative, unrelated to the actual cause of the lack of satisfaction. Questions suggested by Dr. Nash such as “did the provider listen to you?”, “did the provider show respect?”, “did the provider explain things so that you could understand?” will be answered “no” … in order to get revenge.There are no patients more disgruntled than those who did not get the narcotics they wanted or a Z-Pack for a common cold which they “knew they should receive”. The list is long but it is often enough difficult to convince patients the contrary of preconceived notions.The article though does point up a major failing in American medicine today. All directions for actual “boots on the ground” medical practice are written by people like Dr. Nash who is primarily an administrator or perhaps a university faculty member, who have limited medical practices and do not see all comers. His thesis is abstract, very ivory tower and simply lacks understanding of day to day patient physician relations. It would be easy to please drug seekers but unlike clothing stores or Amazon.com the consequences can be quite negative.There used to be a town-gown balance but with the acquisition of the American Society of Internal Medicine by the American College of Physicians years ago administrators and university faculty became “king of the hill” and practicing physicians no longer have any voice.Please consider the content of this response in your future articles.1. Ann Intern Med. 2015; 168 :792-793Philip Mendell MD, MSc, FACP 1105 Palermo Ave. Coral Gables, Florida 33134
Ira S. Nash, MD
North Shore LIJ Health System
I am pleased that Dr Kumar agrees that the experience of patients and families is important. That was the central thesis of my essay. We also agree that there is no convincing evidence that patient satisfaction is a “proxy” for quality of care. I did not assert that it is. In fact, I believe that patient experience and quality must both be measured precisely because each is important and they are distinct from one another. Dr Kumar objected to using patient experience scores to modify payments to hospitals and physicians. I did not advocate that scores should be used this way. I did state -- accurately -- that CMS has adopted payment models that incorporate patient experience scores. I agree that there are methodological challenges in doing so. My piece is not an endorsement of the CMS or other “pay for performance” programs. Although space limitations precluded my including a discussion of it in the essay, I have advocated for, and led an institutional effort to implement, the public reporting of physician-specific scores, not tying them to compensation.Dr Kumar also took a couple of personal shots about my own patient experience scores and an alleged conflict of interest. He cited my patient satisfaction score of 4 out of 5 “stars” based on a handful of surveys on a website that invites comments from anyone (patients or not), and held that out as evidence of the absurdity of value based compensation models. Once again, I did not advocate for payment tied to ratings, and certainly not to ratings based on this kind of methodology . And, just for the record, based on our medical group’s public reporting initiative, my own patient experience score (derived from a validated survey tool and a sufficient sample size) averages 4.9/5 (https://www.northshorelij.com/find-care/find-a-doctor/cardiovascular-disease/dr-ira-s-nash-md-11360536#/patient-ratings).Finally, I am proud to say that he is correct in reporting that I received Press Ganey’s inaugural “Physician of the Year” award. I was recognized, in part, because of the transparency initiative of the North Shore-LIJ Medical Group (soon to be Northwell Health Physician Partners), which I lead, and in part because of my advocacy about patient experience, evident in my blog (www.nslijmdblog.com) and my opinion piece in the Annals, which was written, accepted and published well in advance of my receiving the award.
Nash IS. Why Physicians Hate “Patient Satisfaction” but Shouldn't. Ann Intern Med. 2015;163:792–793. doi: 10.7326/M15-1087
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Published: Ann Intern Med. 2015;163(10):792-793.
Published at www.annals.org on 8 September 2015
Healthcare Delivery and Policy, Hospital Medicine.
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