Satisfaction Guaranteed? The Surprising Downside of Happy Patients

[00:00:00] When you're really busy and you've got to get people through the system, a lot of times this lovely

[00:00:08] goal, lofty goal of transparent, engaging, and interactive conversation, there's just,

[00:00:15] there's not enough time for it to really happen. Right. And I know for a fact, because I would

[00:00:20] ask the doctors when I worked in a busy retail pharmacy, some of them I would ask, and if I

[00:00:25] felt like it, or if I thought I knew them enough, like why, why did you prescribe an

[00:00:30] antibiotic? If you knew it was a virus, he's like, listen, I just had to get him out the door. They

[00:00:34] wanted something. Right. The way they would tell me this is they wanted something. So in giving

[00:00:40] somebody what they want, they felt like that helped them, that made them feel better. It's kind

[00:00:46] of like the placebo response, is it not? Right. Yeah. So even though they don't maybe like

[00:00:51] the placebo response, they certainly were taking advantage of it. But long term, and then I think,

[00:00:55] well, the side effects for all of us for over prescribing antibiotics, bacteria being resistant

[00:01:01] for others, and also the killing off your good bacteria and all of that. But, and then I think,

[00:01:08] okay, well, then you could go into that. But that's a whole thing. Right. That's a whole

[00:01:12] thing to get into with somebody about why I understand you want to Z-Pack, but you have a virus.

[00:01:18] But that's a point too, is that it shows how in order to try to improve the system,

[00:01:25] they're missing the vote. Yes. Because patient education is really the key to better

[00:01:33] doctor-patient interactions and the whole system working better. But the system doesn't allow

[00:01:39] it. It doesn't allow it. So they're trying to figure out other ways in order to try to make

[00:01:44] that happen. They're trying to hack it. Exactly. And there's no hack for a good relationship. No.

[00:01:49] You are listening to Take On Health Care with Ted Suzellas,

[00:01:52] naturopathic doctor and pharmacist Mary Sheehan. Have you ever wondered what happens to the

[00:01:57] patient satisfaction surveys you filled out? You probably assume that your input is used to make

[00:02:02] the health care system better. But what if these surveys may actually make things worse

[00:02:06] for you and your doctor? On today's podcast, we take on patient satisfaction surveys.

[00:02:12] So we're taking on patient satisfaction surveys, which I don't know. And my career has been like

[00:02:18] the bane of my existence. A few months ago, I got the idea from LinkedIn. Dr. Corey Amon had posted

[00:02:26] this great post, which I think was referenced in some of the research that you did.

[00:02:30] Yeah. And one of the things, well, first of all, what does he call it?

[00:02:35] Killer patient satisfaction scores. And he says, it's Dr. Corey Amon.

[00:02:42] We all would love to get higher patient satisfaction scores. Many providers have their

[00:02:46] bonuses directly tied to these numbers, which is true. That happened to me too.

[00:02:51] But what if these higher numbers killed our patients? I'm like, what? And then he links

[00:02:57] some studies. Studies have shown a 26% increase in mortality in the most satisfied.

[00:03:06] Right.

[00:03:06] I mean, that's like crazy. And then he was talking about is this widely known to the

[00:03:11] executives, the ones that create it? Because the doctors, we on the front lines,

[00:03:15] we're not creating these satisfaction surveys. We really don't like them.

[00:03:19] You're just putting up with them.

[00:03:20] Exactly. And these things make us very sad. And then he also goes on to also

[00:03:25] quote from studies, higher patient satisfaction also means more hospital admissions,

[00:03:31] 12%, more hospital costs. They can't be happy about that 8.8% the C suite and more

[00:03:38] prescription drug expenditures 9.1%. So we're going to break that down. So that's what

[00:03:45] inspired the post. And what are your initial thoughts on the post? I know you've said,

[00:03:50] because you don't practice within the allopathic system, it doesn't really affect you as much.

[00:03:56] Yeah, as much. But what did you think about it when you first started talking about it?

[00:04:01] Yeah, I guess I was a little naive and not understanding the total significance of it.

[00:04:08] I do not realize until you've forwarded me that post that there was anything with bonuses tied to

[00:04:18] everything. So I was just, I really was shocked that it was something that was

[00:04:25] just so widely pervasive and so important to the medical systems.

[00:04:31] Yes. Yeah, it is shocking because can you imagine being a traditional doctor and all you want to

[00:04:39] do is take care of patients and you have this like you're like you get with your patients

[00:04:43] you're in the zone, you're trying to come up with the best solution you're trying to diagnose

[00:04:47] prescribed. But then in the back of your head, you have to have this whole other set of

[00:04:52] thoughts like is this patient going to be satisfied with this and what are they going to

[00:04:56] check on the box? That would make me sick in my soul. Well, it has made me sick in my soul.

[00:05:01] Like as a community pharmacist when it was a bigger deal back in the day, it's like wow,

[00:05:07] I just want to focus on my job. Why isn't my doing me doing a good job good enough?

[00:05:13] Why is this on top of it? And as we'll get into there are some

[00:05:18] there's some good things about it and we'll talk about that but it just seems to me like

[00:05:21] in our research, there's definitely more bad things about it. Well, and it's one of those things that

[00:05:28] there's you're going to see all different types pieces of it and some of the things the negative

[00:05:32] things we talk about is not things that are happening to the majority. Okay, that's good

[00:05:39] to keep in mind. Right. It's not everybody that's having these problems and working to try

[00:05:46] to do the best they can for the patient surveys. Yes, that is a really good point and what I like

[00:05:51] about it too like to talk about it for people is just what you said to know what is influencing

[00:05:57] your healthcare system. Right. So many things influence our healthcare system and this is just

[00:06:04] another layer. Right. And when you think about it, this is top down. So yes, which is part of

[00:06:11] the hospital systems because they're so big. This is their one metric to try to get understand

[00:06:18] what's going on. That's fair. And yeah, that's fair. So there's only so much they can do and then of

[00:06:24] course, as we're going to talk about later that Medicare and Medicaid got into this where

[00:06:31] then reimbursement is tied to these surveys because the government wants to focus on

[00:06:37] how healthcare is doing and trying to use their influence to try to make things better.

[00:06:43] Yep. And do that. That's the question. All right, so we're going to start with the ways in which

[00:06:50] patient satisfaction surveys make healthcare better for everyone. Well, let's talk about

[00:06:54] some of the comments. Oh, you want to? Oh yeah, let's talk about the comments. Yeah. The

[00:06:57] comments on the Lincoln Inpost. Right. Yes. Oh, yeah. Yeah. So one of my favorites was

[00:07:02] a comment. Something was responding to Dr. Mann's comment where he said, we prescribe zero narcotics

[00:07:09] and pretty strict on antibiotics as well. And this person in their astute comment made the

[00:07:20] association that in order to be pretty strict on antibiotics, you also need to have

[00:07:26] transparent, engaging, interactive and respectful conversations as to why the patient may not need

[00:07:33] those treatments. And that's a huge issue there as far as looking at over treating. Yes, which is a

[00:07:43] downside. Yeah. And yeah, and I guess too, when I know the comment you're referring to,

[00:07:49] when you're really busy and you've got to get people through the system, a lot of times this

[00:07:57] lovely goal, lofty goal of transparent, engaging and interactive conversation,

[00:08:04] there's just, there's not enough time for it to really happen. Right. And I know for a fact,

[00:08:09] because I would ask the doctors when I worked in a busy retail pharmacy, some of them I would

[00:08:15] ask and if I felt like it or if I thought I knew them enough, like why did you prescribe

[00:08:20] an antibiotic? If you knew it was a virus, he's like, listen, I just had to get him out the door.

[00:08:25] They wanted something. Right. And it wasn't, and the way they would tell me this is they wanted

[00:08:31] something. So in giving somebody what they want, they felt like that helped them, that made them

[00:08:38] feel better. It's kind of like the placebo response, is it not? Right. Yeah. So even

[00:08:42] though they don't maybe like the placebo response, they certainly were taking advantage of it.

[00:08:47] But long term, and then I think, well, the side effects for all of us for over prescribing antibiotics

[00:08:53] with bacteria being resistant for others and also the killing off your good bacteria and

[00:09:00] all of that. And then I think, okay, well then you could go into that, but that's a whole thing.

[00:09:06] Right. That's a whole thing to get into with somebody about why I understand you want

[00:09:09] to Z-Pak, but you have a virus. But that's a point too, is that it shows how

[00:09:17] in order to try to improve the system, they're missing the boat. Yes. Because patient education

[00:09:26] is really the key to better doctor-patient interactions and the whole system working

[00:09:33] better, but the system doesn't allow it. It doesn't allow it. So they're trying to

[00:09:37] figure out other ways in order to try to make that happen. They're trying to hack it.

[00:09:42] Exactly. And there's no hack for a good relationship. No.

[00:09:45] To really, there's no shortcut. There's no, yeah, that's so interesting. And then

[00:09:50] hearing you talk, I think, all right, so these guys that are running the money, the C-suite

[00:09:56] people are trying to find a way to measure so that they know that their organizations are

[00:10:00] doing a good job, which is totally understandable. So that's how they're doing it with these

[00:10:04] patient satisfaction surveys. And then I think, well, why can't they just like take a little field

[00:10:08] trip and hang out with some of their doctors? I used to have that thought all the time about

[00:10:14] maybe not meeting a metric at work. I didn't do enough shots or whatever I didn't do enough of.

[00:10:20] And I would say I would love for them to come down and spend a day with me. Wouldn't their

[00:10:24] eyes be opened? Yeah. And I mean, but they're too busy. They're too busy. Yes. They're very

[00:10:30] important. And they are crunching the numbers up there and coming up with more ways to make our

[00:10:34] lives hard with the best of intentions, I would assume the best of intentions. Yes, that's so great.

[00:10:40] Any other comments on that post that we really liked? It was a great, it was, he got a lot of

[00:10:44] comments on that. Yeah. And the people that make the surveys, some of them were commenting

[00:10:49] about how great they are and how necessary. Fantastic. I mean, it was a really kind of

[00:10:54] balanced discussion, I thought of people that did not like them and found some problems. And then

[00:11:00] the opioid discussion came up and of course it always comes up in Ohio and will touch on

[00:11:07] the influence the patient satisfaction surveys may or may not have had on the

[00:11:11] the opioid crisis. We'll touch on that. Yeah, good stuff. Okay. Now we will talk about

[00:11:20] some benefits. Right. Okay, feedback for quality improvement. Okay, yes. I mean,

[00:11:24] how else are you going to get feedback unless you've got, which would also be a great idea,

[00:11:28] have somebody with a microphone in the parking lot and having a conversation,

[00:11:32] then you could really get some feedback. But it would be hard. That would be cost prohibitive.

[00:11:36] But yes, you're going to get, you're going to see things from their perspective. And I liked

[00:11:42] that. Like I remember when they said, oh, we're doing these satisfaction surveys.

[00:11:47] And one of the things they asked was cleanliness of the waiting area. And I'm like,

[00:11:51] dang, when I'm coming into work, all I can think of is getting that gate open,

[00:11:54] figuring out what I have to do. And then it forced me to stop and look at the waiting area or maybe

[00:12:00] by the counter the cash register through their eyes. Right. And then you see that doesn't

[00:12:05] look so nice. So that's a good thing. Definitely. To look through someone else's eyes. And then

[00:12:10] people, I mean, that's a part of design of like apps. You're always thinking of the end

[00:12:16] user. Of course. Yeah. So I think it's good. I think it's good we think of the end user,

[00:12:20] how they may perceive it. And I had that thought too, the one time that I was taken into the

[00:12:26] emergency room via stretcher and I got to see nothing but the ceiling and they were so,

[00:12:30] the ceilings are so dirty. And I remember thinking they should paint some butterflies

[00:12:34] on that ceiling. Of course I was loopy on trauma, but just seeing something through

[00:12:39] other people's eyes. But I guess I like that. I guess, and I'm kind of afraid to speak

[00:12:44] this into existence, but the other side of getting away from the patient satisfaction surveys would be

[00:12:53] them directly monitoring patient visits with cameras inside the appointments.

[00:12:59] Yes. Then they could get real metrics. They could get real metrics and that is like kind of goes

[00:13:06] with what I say they should just hang out and visit, which is a different energy than being

[00:13:11] monitored. That's very stressful. Of course, I guess you could feel monitored if someone is there.

[00:13:16] Oh, wouldn't that be dreadful? And they would do it. Big brother. I know. Well,

[00:13:21] big brother's already here and they would do that. That is frightening.

[00:13:26] And then the other benefit, patient-centered care. That goes along with that. Like if you're

[00:13:30] looking through the eyes of the patient, then you're going to want the care that you give

[00:13:36] in whatever system office to kind of be centered around that person. And I think

[00:13:44] that's good. And the thing that comes to mind for me is birthing sweets, because I think the

[00:13:51] generation before I had my kids, it was pretty sterile and you were knocked out and strapped

[00:13:59] to a table. And I don't think that it was someone sitting in an office or even a doctor

[00:14:06] necessarily that said, we should change this up. I think it was the mothers, the people that gave

[00:14:11] birth that said, we want to do this a different way. So we're either going to do it somewhere

[00:14:15] else or you're going to change. That's what I think happened. And so that I think is a very

[00:14:21] good thing to have the patients drive the system and make it more about what makes them

[00:14:28] comfortable. That's not going to happen in every single situation, obviously.

[00:14:34] But yeah, I mean it is funny how that's such a novel concept in conventional medicine,

[00:14:42] patient-centered care. I know, not for you. That's your tired practice. But for them they need

[00:14:49] a word for it. You're just doing your thing. We have to reinvent, which again, it's so

[00:14:55] ironic to me. How could it be other than? Right, but it comes down to just listening to the patient.

[00:15:04] I know. That's what we talked about all the time. They don't have time, but you don't have time. But

[00:15:10] if you're able to ask questions and good questions to the patient, but then also

[00:15:15] leave time for them to ask questions so that and give them time to actually think about it,

[00:15:21] not as you're running out the door, do you have any questions? But actually give them a second to

[00:15:27] think about it so that they can reflect on the discussion, the diagnosis, the treatment and make

[00:15:33] sure that they have everything that they need. And you can't do that in six minutes or 12 minutes.

[00:15:42] So that, I guess if they really wanted to change things, if we really, I think dug into

[00:15:48] this data and looked at it, then if they were taking it to heart, they would change the system in

[00:15:55] that one way. You get to spend more time with your doctor. That's not happening though. Well, because

[00:16:00] it can't because there aren't enough doctors. Oh, that too. Yeah, there's a shortage. So they

[00:16:06] can't find the doctor. But there's a shortage because nobody wants to practice like this. Correct.

[00:16:09] It's so crushing. Yes. Yes. So yeah, it's one of those self-fulfilling prophecies where

[00:16:14] the more you try to restrict and try to utilize the doctors that you have,

[00:16:22] you end up making them hate medicine more. And so they leave more and you have less doctors. So

[00:16:29] they're more busy and they hate medicine more. So well, and the same thing is happening in

[00:16:34] community pharmacy. Yeah. That's why they're cutting the hours and saying there's a shortage.

[00:16:38] And I don't know so much there's a shortage, but it's just you can't practice like that

[00:16:43] and try to do a million things. And you're so terrified and burned out and it's just awful.

[00:16:50] Yeah. So we had looked at an article from the family practice management journal in 2022.

[00:16:58] Very recent. Yeah. Yes, not too far back. And their take on what patients really want,

[00:17:06] they want strong communication, tailored care, and an efficient workflow.

[00:17:12] So they want a naturopathic doctor. That is what they want. Right. But it's really an MD. Yeah, right.

[00:17:20] Even if it's that the MD actually pays attention and then prescribes their drugs.

[00:17:26] Right. Okay. So if the surveys are telling the higher ups that then we should see change

[00:17:32] rolling out at any time. But it's 2024 and this was 2022. Change takes time. The wheels of change

[00:17:38] turn slowly. Yeah. The ultimate goal is for patients to feel heard, respected and supported.

[00:17:45] Yeah. So simple. It is. But you already know that. Yeah. Well, that's where we're working on this

[00:17:54] topic for the podcast. It's kind of hard for me to relate because these surveys are like I said

[00:18:02] a top down. It's the management trying to understand what the doctors and the staff are doing,

[00:18:08] where when you have a small naturopathic clinic where I'm the management and the doctor,

[00:18:14] and I'm interacting with any other staff member, I know what's going on. Exactly. You as the

[00:18:20] management know what you as the doctor are doing. Right. It's that tight relationship of being

[00:18:25] the one and the same. Yes. Yes. Very good point. Very good point. And you did touch

[00:18:30] on this before. Another benefit is performance benchmarking. And I guess I would have to agree that

[00:18:36] I am not opposed to having no metrics. Things need to be measured. We're all in science. You

[00:18:43] measure things. You don't just hope and wish you measure what you're doing. So I'm not opposed

[00:18:49] to all of it. I just think we've gotten carried away and made too big of a deal. So I think

[00:18:55] that that's good to have some sort of basic benchmark. Right. And like

[00:19:03] then those benchmarks can go on the Google and everyone's looking to see how their doctor is

[00:19:08] rated and whatever, not that they necessarily understand who's maybe who's doing the rating.

[00:19:13] No. Or whatever. But I remember looking after my car accident a few years ago and I needed

[00:19:19] a plastic surgeon to fix my broken nose. So I went on the Google but I did the opposite.

[00:19:26] I was looking for the guy or girl that had reviews that said really bad bedside manner.

[00:19:33] Really? Yes. Because I don't not making friends. Yeah. I'm not hiring a PCP. No. Okay. So a guy

[00:19:39] that goes into surgery and who's really good at surgery probably isn't the hold your hand

[00:19:45] kind of guy or he wouldn't want to interact with people that are unconscious. Yeah. And

[00:19:51] I found the crankiest, oldest, most experienced guy I could. And when I met him, I just like

[00:20:00] I just brought myself to that not expecting him to be nice or polite or any of that and it was

[00:20:08] so liberating because I knew why I was hiring this guy and he wasn't any of those things.

[00:20:14] And I think the fact that I knew that and then like when he would like smile or do or say anything

[00:20:21] and I'm like, yeah, he's a human in there. But why would we why would we rate

[00:20:26] that guy the same as we would rate like, I don't know pediatric oncologist. Yeah.

[00:20:32] Right? Who has to talk to children and talk to their parents and be in these really horrible

[00:20:37] situations. This guy is doing something miraculous while someone's unconscious. It's

[00:20:43] different. But the other side of it and we'll go into when we talk more about the pitfalls

[00:20:49] of these surveys is that people typically only fill out the surveys if they're really,

[00:20:56] really happy or if they're really, really upset about the experience. And when you're talking

[00:21:02] about surgery, you have a much higher likelihood of having something bad happen because it's

[00:21:09] such an invasive procedure. It's very violent. Yeah. And yours was it was for plastic surgery for

[00:21:14] your nose. It was just to fix my nose, to fix it back to its original horrible thing,

[00:21:19] but at least it wasn't broken. Yes. Well, but that also comes down to the vanity part of it too

[00:21:26] where people if somebody people are paying for plastic surgery grant you were a different

[00:21:34] than maybe a lot of his other patients too where they're looking for perfection

[00:21:38] and that they can't actually, that he can't actually ever give them. And so when he does the

[00:21:44] best that could be done, it's still not good enough. Yeah. That's really interesting.

[00:21:49] And thinking back now, I'm wondering if I were to be given patient satisfaction survey on

[00:21:54] this particular surgeon, I wonder if they would ask what his bedside manner was like.

[00:21:59] Yeah. And then I mean, I'm in healthcare, I would say it's good to give him a good

[00:22:02] rating because I was overall satisfied. I don't know the people are really thinking about that.

[00:22:07] Right. I don't know. But yeah, it's a really good point. Really good point. And then of course to

[00:22:13] go along with that is the regulatory compliance and accreditation, right? Where Medicare and

[00:22:19] Medicaid want certain guidelines met and in order to enforce that then they can jack up your

[00:22:26] reimbursement. And with us in the pharmacy, they want a certain amount of the patients,

[00:22:33] well, they want the patients to have 90 day fills. Right. Okay. So then they need four fills a year,

[00:22:38] right? And then they want them to be picked up on time, which okay. So they have all the

[00:22:46] medications they need that doesn't guarantee that they're taking them, but at least it's

[00:22:49] something that they can measure. Right. Right. But what about the medications that

[00:22:55] need to be changed then if you're trying to push people to always doing 90 day fills and

[00:23:00] people have a backlog. Oh, I'm sure. Because they want it and then they want it filled early

[00:23:06] so patients will say, I'm a drawer full of pills and like, I don't know what to tell you.

[00:23:09] Like Lysinoprelatorvastatin and things like that. But at least it's measurable. So if you

[00:23:16] don't have that, then they can take the money away, change your reimbursement.

[00:23:20] So there's a lot of pressure to do something that may or may not reflect what's really happening

[00:23:27] with the patient. I mean, we do know that if people take their blood pressure medications

[00:23:32] regularly, then they have less problems with high blood pressure. Correct. So that I can get

[00:23:36] behind. Yeah. And if they have a three month supply, they're not going to run out of their

[00:23:42] medication as often. No way, no how. Right. And then also empathetic to people that can't

[00:23:46] get out as often and they might not know that you can get a 90 day supply and that might make them

[00:23:52] yeah, make them feel better and make everyone feel better that they have enough. So I guess

[00:23:57] I can get behind that. Yeah. But just linking reimbursement to those scores is just a scary

[00:24:06] thing. And just forces, that's where like we're talking about forcing people in the system

[00:24:13] to really focus on those scores so that they can get better payments. So the hospital, the doctors,

[00:24:20] everybody has to get better scores so that they can get paid more. Right. I don't hear patient in

[00:24:27] that any of that. No, no. Right. That's that's a problem. Yeah. And I mean, in my profession,

[00:24:33] of course, that's always a concern when we're taking cash and people are expecting sure I'm

[00:24:40] the doctor and I'm the pharmacy. Right. I'm recommending the supplements dispensing them.

[00:24:45] Right. So I mean, I know I guarantee there are natural medicine practitioners. I'm hopefully

[00:24:53] hopefully a lot less NDS than other natural medicine practitioners but a lot of people

[00:25:00] I'm sure are looking at well, oh, look at all these different diseases this person has. I can

[00:25:07] I can recommend this and this and this and this. It's almost like what I see with the

[00:25:14] I can't think of the name of it, the people through the Cleveland Clinic.

[00:25:18] Oh, yes. Functional medicine. Functional medicine. Yes. Yeah. I mean, the patients come away with

[00:25:24] so many pills from the functional medicine doctors but I just always focus on what the

[00:25:31] patient really needs and be mindful of their pocketbook too because for me, if I over prescribe

[00:25:40] then the patient can't keep up with the treatment so they can't keep seeing me and so it's a lose

[00:25:47] lose for me and the patient. So I feel like the way I approach it is that I try to,

[00:25:55] I mean, obviously honest. I'm an honest person. I'm trying to do what's most important for the

[00:26:00] patient and not try to rack up extra payments but also when I'm looking at these kind of things,

[00:26:06] I look at the worst case scenario and nobody on the outside can see what my morality is.

[00:26:13] And so when I look at, okay, what they can see is that if I recommend too much

[00:26:21] and they can't keep up with it, then they're going to leave and that's where they can see it.

[00:26:26] Yeah. And so you have a built-in feedback mechanism. Right. Right.

[00:26:31] And that's really interesting what you said about being the manager and the clinician. The

[00:26:38] manager wants to see a higher bottom line for the practice. Yeah. But the clinician is also

[00:26:44] very aware like we said looking through the other person's eyes, can they afford this?

[00:26:48] Does this make sense? Will they not be able to keep up? Right.

[00:26:53] That is so interesting. Yeah. And so I mean, if- Because your system's pretty simple,

[00:26:57] that you are wanting the same versus all of the layers in healthcare. Right. And if I were to

[00:27:01] get to the point where I started thinking about the money first, that's when I know I need to

[00:27:09] hang up, hang it up, retire, get out of it because- Boy, if the system was like that,

[00:27:13] would be gone now. Right. Absolutely. Right. If somebody said, well, as soon as we're sitting in

[00:27:17] those boardrooms and soon as we start thinking about money more than patient care, we should all

[00:27:21] just hang it up and they laugh and laugh. Yeah. But that's so great. So you have that like

[00:27:27] internal check on yourself. Right. And I would say that if anything, I end up

[00:27:35] sometimes doing too little because I don't want to over burden them with those extra pills.

[00:27:44] Yes. And instead of- And so I try to be as balanced as I can and look at what's most

[00:27:50] important, what's going to help this patient get the best, the quickest, better, the quickest.

[00:27:55] But also there's times where I know, okay, this patient cannot afford that. Right. So I want to

[00:28:02] look at something less that is at least going to give them benefits, but not move them forward as

[00:28:10] quickly. And I would say that would be my fault is that I don't always loop them in on that part too

[00:28:18] because I also don't want them to feel- A certain way. Right. Right. Yeah.

[00:28:23] Which goes with these satisfaction scores too. Right. But yeah, you don't want somebody-

[00:28:29] You don't want somebody to be down. Oh yeah, I'm poor. Yeah, doctor, I'm poor and I can't afford this.

[00:28:36] No one's going to say that. No. No one wants to be humiliated. It's funny though, the people

[00:28:40] the people that have the most money are the most likely to say I can't afford it.

[00:28:44] Yes, I've noticed that in pharmacy too. People that are on lower income, they don't want

[00:28:50] people to realize that or feel look at them differently because they don't have as much

[00:28:55] money. It's a status thing. Yeah. Yeah. Where the people are rich and they know they're rich,

[00:28:59] who cares? It's easy for them to say I can't afford this and I'm not going to pay for it.

[00:29:04] Right. So interesting. And now you're reminding me of times in the pharmacy

[00:29:09] where I've talked to people out of their medications like even in front of the managers.

[00:29:14] Look at me like what did you just do? But I knew that it was in the best interest

[00:29:20] of the patient. Of course I was always cognizant of meeting my metrics, whatever that took.

[00:29:26] Like even if I worked extra or whatever, but like you said sometimes you just know

[00:29:34] that you should say something that may dissuade someone from going down this path of a medication

[00:29:40] that's just not going to be the best for them and I always felt good about that because

[00:29:44] that's how I check myself too. Like who am I doing this for? Yes, I'm doing it for the man,

[00:29:50] but I'm also doing it for this person in front of me and my license and I'm sure you think about

[00:29:54] your license. You took an oath. Yeah. So did I. Yeah. And I wonder if the doctors feel that

[00:30:00] conflict too because they took this oath and then all these other things are really running

[00:30:04] contra to that. Right. And they feel that tension. Who wants to live with tension? No.

[00:30:10] And in the workplace, I think I'm going to skip that one because that was such a great

[00:30:14] point that you made a benefit market reputation and competition. So this is just where again

[00:30:19] these articles say that doctors have to be aware of their Google reviews and they have

[00:30:25] to be aware of how they're perceived. Yes, but I think you have to take that with a grain.

[00:30:30] Oh yeah. I can't imagine being a doctor who's really out there doing the best they can do

[00:30:37] and then somebody gives a bad review maybe for something that has nothing to do with them. And

[00:30:42] then that makes me think about you too because well, do you read your Google reviews first of all?

[00:30:49] Do you encourage people to write reviews? How does that, because to me like that's the equivalent

[00:30:54] of a satisfaction survey. Right. So every patient gets an email after appointments. Oh yes,

[00:31:01] I've gotten those emails. Yes. Okay. So that they can do a Google review and I definitely

[00:31:05] look at all of them. Okay. But I also... Do you take it with a grain? Or do you ever get like mad

[00:31:11] or upset? Well, only one time. Okay, why? But it wasn't even a Google review. It was on Yelp,

[00:31:19] which of course people don't look at healthcare providers with Yelp and this person did that

[00:31:25] review on Yelp because they only had one other review on Yelp where I have a five star rating

[00:31:31] on Google with a couple hundred reviews. So they went to Yelp and to air their grievances.

[00:31:38] Yes. Now mind you, they still later came back to me. And I was a good enough person who is

[00:31:47] confident in my abilities and doesn't get hurt by that. I never mentioned it. I didn't ask them,

[00:31:53] oh, could you... You came back. You must really want my services. Could you rewrite that review?

[00:31:59] But I think if you were that kind of person, see again, that just tells me that you care more

[00:32:04] about their wellbeing than your own ego. Right. Which I think is a really, really good thing.

[00:32:11] But and that's the thing. I mean, I mean, yeah, I'm sure a lot of people in the medical system

[00:32:16] have big egos and it hurts. But I would think so. Being adult. Yeah. I mean, who cares if

[00:32:24] you're not going to make everybody happy. And that was something very hard for me to learn.

[00:32:30] In my early in my practice, when I had patients that what I did wasn't good enough for them,

[00:32:38] that they felt like I didn't do the best for them and they left. I took that personally.

[00:32:43] Yeah. Because I want to do the best for everybody. But it took really looking at

[00:32:50] myself and realizing that there's a portion of the population that no matter what I do,

[00:32:57] I won't be able to help them. I won't be able to make them happy.

[00:33:00] It's true. And so all I can do is focus on... Those you can help. Well, focus on... But I don't

[00:33:07] know which one... That's true. You don't know initially. True. Good point. So it's about

[00:33:10] just doing the best I can and letting it all wash out. I love that. The patients that aren't

[00:33:16] right, they're not going to come back. Yeah. And that's okay. That's okay. Yeah. I remember too,

[00:33:21] they would kind of tell us repeatedly if you have a really good interaction with somebody,

[00:33:28] hand them this card and have them fill out a survey. I couldn't do it. Yeah. Because I was

[00:33:34] having such a moment a lot of times when even it was a 30, not even a moment, it was 45 seconds.

[00:33:40] I knew I was getting through. I knew I did something good. I knew I had a connection.

[00:33:44] And now I'm making it transactional. Right. I didn't want to do that because I didn't want them to

[00:33:48] then walk away with, oh, was that why she was so nice to me? Was that really true? Oh, yeah.

[00:33:53] It cheapens the whole experience. Yes. And I would never do it. Right. Never. Yeah. Yeah.

[00:34:00] I too had a bad review once and I knew it was coming. So I went to my boss and like, listen,

[00:34:05] if you're going to put me in front of all the difficult patients because he wanted to

[00:34:09] really stand back, I'm going to swing and miss sometimes. So up to you. If you'd like to

[00:34:16] get on my case about this, that's up to you. Right. Smart guy. You didn't. Because you are going to

[00:34:21] miss. You're going to swing and miss. If you're out there trying again and again and again

[00:34:25] and really putting yourself out there like you do when you care about people, you're

[00:34:30] going to miss. Yep. Oh, all right. So now pitfalls. But I think that's all we talked

[00:34:38] about already. Well, that's what I mean. I feel like so much of it isn't so great except for

[00:34:46] seeing things through the eyes of other people. Right. And then I guess if you were a patient

[00:34:51] and you're looking at the Google reviews or whatever, just take it with a grain of salt.

[00:34:55] Yeah. Or maybe do what I did. Like if you're looking for a surgeon, think about what kind

[00:34:58] of qualities you really want. You're not interviewing for a best friend. Right.

[00:35:03] And when you hear these really fluffy reviews and she was this and she was that,

[00:35:07] I'm like, well, I don't need that. I might need that in a friend or a confinup,

[00:35:11] but I don't need that in a doctor. Right. A kind of thing. So I guess that part is good,

[00:35:16] but I don't think much is good about them. But that's also actually brings up when you're

[00:35:24] talking about not needing the doctor to be your best friend. Right. I often have the

[00:35:31] conversation with patients who don't really care for their doctor that they want to,

[00:35:37] can I recommend somebody better? I always bring it down to, do you feel like they have

[00:35:43] your best interest at hand and they're trying to do the best that they can?

[00:35:46] Oh, I love that. Those are questions that should be on surveys. Right. Because if they're trying,

[00:35:52] even if the patient's coming to me for natural medicine, even if the doctor

[00:35:56] poops that, who cares? Right. Because they're going to them for a certain purpose with

[00:36:04] getting their diagnosis, their annual physicals. If they do have a disease, they need their meds and

[00:36:11] all that. But then they're coming to me for the other part of it. Yeah, I love that. And in so

[00:36:17] doing, then you also strengthen that relationship, I think with the physician, which is great.

[00:36:22] And I would do the same thing too if people would say, oh, the office didn't do this. What

[00:36:27] do you mean the office didn't give me my refill? It would never be, yeah, that office,

[00:36:30] they don't care, they're so busy. It's like, oh, you know what? I know they'll get to it.

[00:36:34] They care about you, always trying to reinforce how much. Because I think truly,

[00:36:42] most people that get into healthcare, whatever branch of healthcare,

[00:36:45] do care about people. It's this other stuff that's really getting in their way. And if we can

[00:36:50] just focus on what's important and you reinforcing that, I think is a beautiful thing.

[00:36:54] So one of the pitfalls that comes up when we search this topic is non-response bias. And I think

[00:37:01] that's important. So a low response rate can lead to biased outcomes, right? As the views of those who

[00:37:08] respond may not be representative of all patients. As you mentioned before, the really happy or the

[00:37:14] really upset. Yeah. And that's human nature. Of course, for all surveys, for anything,

[00:37:19] any kind of feedback. Yes. And that's where when we come down to these surveys,

[00:37:24] that's what makes them not that accurate is because you can't force people to give feedback.

[00:37:32] But the only people that are going to give it are going to be the really satisfied

[00:37:36] and the really dissatisfied. Yeah. So you're missing a lot. Right.

[00:37:39] So you're at the other, the two ends of the bell curve, really. Right. Right. There was a study

[00:37:44] that we looked at and we'll have all of this stuff in the description, a list of it all. But

[00:37:51] this study was barriers to participation in a patient satisfaction survey. Who are we missing?

[00:37:57] And it highlighted and looked at the people that are most likely to not fill out the survey

[00:38:05] or going to be people with language barriers. Makes sense. Substance abuse, cognitive

[00:38:10] limitations, psychiatric diagnoses and site deficiencies. Oh my goodness. Yeah,

[00:38:15] we didn't even think about that. Right. These people could be giving the system a wealth of

[00:38:20] knowledge. Yeah. And we're not even capturing them. Right. And for different reasons. Yes.

[00:38:26] All different reasons. With like the substance abuse is because they're already ashamed of

[00:38:31] what's going on in their life and possibly their interactions with the medical system. So

[00:38:37] of course they don't want to highlight that. Yes, that's a really good point. That's why

[00:38:42] that's in there. That makes sense. The rest were really evident. Why not? But you're right.

[00:38:48] Right. That is why they wouldn't want to. Yeah. It's really unfortunate that this happens,

[00:38:54] but also it just comes to the bigger issue of patients being able to give

[00:39:01] adequate feedback. And with the people that are going to be least likely or

[00:39:08] going to be some of these populations that need the most care and need the most help.

[00:39:14] And we should be then tailoring our services and our thinking about things through their eyes.

[00:39:20] Right. Great point. Yeah. So like for instance, when some of the people watching the podcast

[00:39:25] might know that I have two sons with autism and our oldest since December, it's late April right now,

[00:39:33] but since December, he's been going through some issues and it's come out as behavioral issues.

[00:39:40] Okay. And he's basically, he really isn't able to vocalize. His speech is very limited.

[00:39:50] His true experience. His internal experience. Right. You can only really guess.

[00:39:55] Exactly. So, and he can tell us some of his wants and needs if he's hungry or he's go to the bathroom

[00:40:00] and a lot of that he struggles with too. We can't ask him. It's hard to ask him what he did at school.

[00:40:08] We can sort of push and push and push and get a couple of, oh, I went to lunch. Well,

[00:40:13] it's actually not, I went to lunch. It's lunch, gym, leisure time. Yeah. But so he's been

[00:40:20] having these behavioral issues pop up at school, which then worked into home and having trouble at

[00:40:26] bedtime. And we're sort of grasping it, trying to figure out what's really going on. And of course,

[00:40:35] you start looking at it mostly as a behavioral issue. But because we can't get the feedback

[00:40:42] and nothing is changing in his life. So we couldn't, we can't say, oh, well, this is,

[00:40:48] this is a physical problem that is probably happening. But through working through all this

[00:40:54] a couple of months ago, I, he was, he had times where he would have really a lot of trouble at

[00:41:01] night going to bed and thrashing around his bed and sometimes even, you know, hitting his head on

[00:41:06] the headboard out of frustration. Oh my goodness. And so I would come into his bedroom

[00:41:10] and try to calm him down and everything. And the one night I finally noticed that he

[00:41:16] was doing a lot of burping as he's flopping around in bed. And then I finally put together that at

[00:41:23] least part of this problem is acid reflux. And so I was able to give him a licorice

[00:41:30] supplement that I put in with his nighttime cup and in his morning cup before school

[00:41:36] that has supplements and everything in it. And a lot of behavior went away almost instantly.

[00:41:42] Wow. It's like the next night he slept like a baby. He didn't have where it was,

[00:41:45] he was up for an hour prior and there was no problems then. And then the behavior at school has

[00:41:53] been getting better and better and better also. That's amazing. And you could have never found

[00:41:57] that on a survey. Right. Right. But that, but this is even above the surveys, it's just about

[00:42:04] talking to understanding the patients, especially these more vulnerable populations

[00:42:08] that are, that we're totally missing when we're trying to improve. Yeah.

[00:42:13] Saying that the, assuming that that's the point is trying to improve it because they

[00:42:18] just communicate so differently. Yeah. Yeah, that's, that's a great point. We are missing

[00:42:23] all of that really. Right. And I guess in one way I'm so grateful to have to be aware of that

[00:42:31] with my kids to help patients too. Because you're, you've kind of had this skill set

[00:42:38] this innate skill set of hearing what's not said and seeing what's not seen. Yeah. Like for instance,

[00:42:44] a good example is a patient that she's an adult and she has some special needs physical and

[00:42:55] mental emotional. And so she came to me for help. And at first I'm going by on the surface from

[00:43:05] what she's telling me and trying to treat with that. And then she comes back for her second visit

[00:43:13] and I start getting a whole different picture. Oh, so well, some of the problems she was having

[00:43:22] were just really basic that nobody cared to really help her with. Like she was having foot pain.

[00:43:31] Well, when I was trying to talk to her more because in general, when I'm seeing new patients,

[00:43:38] I will do a general more, a more general treatment with diet and some more general supplements to

[00:43:46] try to help because a lot of times that's enough for a lot of people. We don't get,

[00:43:50] need to get real specialized. But so she came back and so I'm asking more questions

[00:43:57] and about her foot pain. And well, it's, it works. She's a hostess at a restaurant. And

[00:44:06] it hurts so much walking or walking back and forth during her shift. That's where her foot

[00:44:11] pain is really coming from. And the more I question and try to understand this,

[00:44:18] one of her shoes doesn't fit. Really? Yeah. And so her feet aren't the same size.

[00:44:25] And she needed one shoe that was a little bit different size and that made all the difference

[00:44:30] in the foot pain. Oh my goodness. And all I can think of is she needs Gabapatt and Perkisette,

[00:44:34] right? Right. But then it didn't stop there. She was having incontinence issues and she's an

[00:44:42] adult and her forties and her mother takes care of her, but she's having incontinence

[00:44:48] issues and the mom was yelling at her for having accidents. Well, nobody ever talked about

[00:44:57] what about pelvic floor exercise to strengthen the black to help with bladder control because

[00:45:02] she doesn't want to do this. She's not doing it on purpose is that she can't help it. Yeah.

[00:45:08] And so it's about getting the physical therapy and a lot of other and just the more I started

[00:45:14] going through with this patient, a lot of things like it wasn't stuff that I could help with

[00:45:19] necessarily. Right. But trying to help troubleshoot because nobody else would to understand how can

[00:45:26] we make her life better and also help her to survive when her elderly mother can't take care

[00:45:32] of her name. She needs to be getting some occupational therapy, some independent living

[00:45:37] skill, occupational therapy to help her with her physical disabilities to be able to do

[00:45:44] things different so that she can do things by herself. Yes. And so that was really eye opening

[00:45:49] there because like I said, she talks well and at first I didn't really grasp what the real

[00:45:57] problems were and it just made me appreciate that. Well, for one, it made me sad that our

[00:46:04] primary care is never going to be able to do three even pay attention enough to be able to

[00:46:08] help her. Because of the system. Right. It's just basic things that people that have some of these

[00:46:17] deficits can't troubleshoot themselves and they need other people to help them.

[00:46:21] They really do need that. And like you said, the beginning if the system is rush, rush, rush,

[00:46:26] find the quickest thing, get her some Dietra pan for that, get her some Gabapentin

[00:46:31] pain gone, satisfied patient and you've missed so much. Right. You've missed all of it really.

[00:46:37] Yeah. Yeah. Well, that's sad. That makes me sad and no doctor wants to practice like that.

[00:46:44] No, no, but that's the thing too is a lot of people that have mental disabilities,

[00:46:53] people feel uncomfortable around that too. And I think that's a big part of it that

[00:46:58] people don't feel comfortable so that it's rush, rush, rush, push through. Which is the system anyway.

[00:47:05] Right. But even more so that people feel uncomfortable around people that have some of

[00:47:10] these special needs, which that might be a good use of resources to do some like training around that.

[00:47:19] Right. That's even deeper than that one, the next pitfall, which is patient understanding.

[00:47:25] Like that's a different level of not understanding. Right. And there are patients that don't have

[00:47:28] medical understanding, right? Like they don't understand that a Z-Pak or an antibacterial,

[00:47:34] antibiotic won't kill a virus. They just don't understand that. Right. But they've been

[00:47:40] receiving it their whole life. So anytime they get a cold or a flu or something,

[00:47:45] they go to the doctor to get their Z-Pak. Right. Exactly. Because that's what you're

[00:47:49] supposed to do. That's what you're supposed to do. Or that they just are focusing on something

[00:47:55] like wait times, even the people themselves are forgetting why they're there. Right. So that

[00:48:00] they can down the road be better, get well. Yeah. And then they might focus on being irritated

[00:48:07] about a wait time, which could ruin the survey. They just don't understand. Right. Yeah. Well,

[00:48:13] it's because that brings out frustration and brings out more of those feelings that

[00:48:19] the system doesn't really care about me. The system's not working for me.

[00:48:23] Of course. And that's understandable. Right. Because they should be understanding about

[00:48:29] my needs and that my time is money also. It's true. They're not wrong. Right. Yeah.

[00:48:37] Yeah. Right. Yeah. And so talking about the patient understanding, we found a Mayo Clinic

[00:48:45] online physician review talking about reflecting about these patient experiences.

[00:48:52] And a lot of them are going beyond the physician-patient interaction. Yes.

[00:48:57] And doing things, you know, issues with the staff, the environment or billing,

[00:49:02] not as much, I mean, not always about the actual doctor or the nurse.

[00:49:06] Which has got to be frustrating. Right. And I know there's a couple practices when I was

[00:49:11] in a busy retail setting where the patients that came to me for prescriptions had the same

[00:49:17] complaint about the same office staff member. Well, it's the person that answers the phone,

[00:49:22] they're so mean, they're cranky, they're this, they're that. What are we really going to do

[00:49:25] about that? Right. I mean, and that goes to kind of what you're saying is can we then

[00:49:32] should energy and time be spent with dealing with workplace conflicts and how to be compassionate

[00:49:38] and how to treat people as opposed to this other like maybe remodeling the waiting room because

[00:49:45] people didn't like the color on the survey. I don't know. Right. Put in a TV so that people

[00:49:49] can entertain themselves while they're sitting there. That's it. We have long wait times,

[00:49:53] but you can watch TV. Right. Wow, you're on your phone. We have a big screen and a little

[00:49:58] screen. Yeah, we'll give you free Wi-Fi too. Oh yes, that will solve everything.

[00:50:02] Which then again, that kind of goes into how it becomes resource and a lot of money is spent on

[00:50:09] these surveys. Right. Designing them probably third parties have to come in, right, administer

[00:50:13] them, analyze the data and that costs a lot of money. I would love to know how much that costs.

[00:50:18] Oh yeah. I would really love to know that. Yeah, it's just set up initially and it just

[00:50:23] the same surveys keep going out automatically. But someone's analyzing them and looking at the data.

[00:50:28] Yeah, that's true. That's true. So maybe it's- They all get sent back to press Gantley and they can

[00:50:35] what they want. Right. Or are they analyzing it? Right. They've done it. Well, they would

[00:50:39] have to analyze it so they could publish the results I guess or at least present it to the

[00:50:42] board. Right. I don't know. I feel like- But yeah, that does put extra on everybody.

[00:50:50] Yeah. Because I'm sure that the staff- And that's a thing. Like I said, I'm so out of the system that

[00:50:58] it's hard for me to know. So how do these surveys actually go out to patients?

[00:51:05] That's a really good question. I don't partake of the system myself.

[00:51:09] Right. And I'm trying to think like, okay, so at work when I work for corporate healthcare,

[00:51:14] pharmacy, we would give them a- Right. Or put it in their prescription bag.

[00:51:19] Yeah. I don't know if they get- They probably get text messages now to fill out surveys. I don't know.

[00:51:24] You can get something in the mail or something. Yeah. Because it has to be- It has to be

[00:51:29] automatic. It has to be. You can't have all that spending all that time. Right. Yes. Yes,

[00:51:34] I love the one about prioritizing amenities over essential services because I think you brought

[00:51:38] up some- Especially the one about the underserved population people with different kind of needs.

[00:51:43] That energy could be put there versus TVs. Yeah. But that's never- That data is never going to be

[00:51:51] uncovered in a survey for the aforementioned reasons. Yeah, I really like that. And then

[00:51:57] overemphasis on scores. See, this is where I- It just makes my heart hurt to realize how many

[00:52:02] years I practiced like that. You're just kind of striving for a number just to get the

[00:52:09] bosses off your back. It's not why we got into healthcare, but usually it's touched on that before

[00:52:13] why doctors are leaving. Yeah. Because it's not about why they got into it, which is really to

[00:52:18] help people. Well, exactly, yeah. And I don't want to overemphasize those scores, but I always laugh.

[00:52:24] I have nurse friends who- They're like, and now I got to ask the patient satisfaction

[00:52:30] questions. I have to ask them even if it's inappropriate. Right. Even if the five minute

[00:52:36] interaction, this beautiful interaction I had with this patient, when I ask these questions,

[00:52:41] it's going to ruin everything. Right. But you can't- So you bring that to your manager and they're like,

[00:52:47] the nurses would say, but you have to ask them questions. And then the managers might say,

[00:52:51] well, the nurses are saying, and then there are higher ups, but you have to ask

[00:52:53] them questions because that's what we're measuring. Right. And then the whole thing

[00:52:57] is lost. So the one nurse friend I have, if it comes down to it, they're like, so I make up a

[00:53:03] question. I pretend I asked. But what are you going to do? Yeah. Because you can't, if you really care

[00:53:10] about people and you know where this interaction is going to end on the best note for that patient,

[00:53:15] and you don't want to ask these foolish questions. Right. But if you don't ask the foolish

[00:53:19] questions, you may lose your job down the road, then you won't get to have that interaction.

[00:53:24] Exactly. Yeah. Check, check, check, check. I'm not saying that- You have to do it.

[00:53:28] Yeah. You got to do what you got to do. Right. Right. Which is unfortunate.

[00:53:32] It is, it is. But yeah, it just comes down to you have to look at all of the factors involved in

[00:53:39] being able to offer the best patient experience. Yeah. All factors. And do what's in your control?

[00:53:48] Yes. Because there is only so much. Right. When you're in the front lines of healthcare.

[00:53:52] Yeah. There's only so much that's in your control. Yep. Yep. Yes. The scripted nurse interactions.

[00:54:00] Yes. There is nothing worse to me than having to say something that just doesn't make sense

[00:54:07] in the moment or in any moment. Right. Some of the things that I would take, they want you to say,

[00:54:11] what? Yeah. This is what they want me to say to my patients. Oh my. That's moral. I mean,

[00:54:17] it sounds more like a Saturday night live skit than anything. Yes. Who's going through and

[00:54:23] doing this great patient interaction and right from one to five, how this experience was.

[00:54:30] Right. Or something that they've covered indirectly. Now remember to get your flu shot. Well, we just

[00:54:36] talked about this, this, this and whatever it is. Yeah. Just checking boxes to check boxes. Right.

[00:54:43] Versus it having some real purpose to it. Does your brother have to do these things?

[00:54:49] Yeah. This surveys and does he, does it bother him at all? It doesn't because he looks at the patient

[00:54:56] experience the way I do. Okay. So he doesn't care about corporate metrics. No. You go to

[00:55:02] university hospitals and go to his survey results and he has 250-300 surveys and his

[00:55:11] average is a five star review. That's great. But he does spend more time with patients.

[00:55:15] He spends more time. He makes less money because that's the deal that he has.

[00:55:19] And not everybody wants to do that or can do that, but he has found a way to make the system

[00:55:24] work for him and for his patients really. But yeah, he has definitely, as I was talking to him

[00:55:30] about this whole thing yesterday and I wish I would have written it down. The couple of,

[00:55:36] he had a couple of, he had just received his surveys from the last month that he had to

[00:55:42] look at and I can't remember, but the couple of patient interactions that where he got dinged on

[00:55:48] and he's like, that's the way it is. But he doesn't, like the higher ups don't come down on him and say

[00:55:55] you have to change your ways or? Well no because- Because there's enough good that's coming out.

[00:55:59] Right. Exactly. It's the minority and it's going to get buried in his really good scores.

[00:56:04] Yes. And yeah, and I think that's, that he keeps that in perspective. Right. Because some

[00:56:10] of my peers in pharmacy, if they got a bad like a patient called and complained about something,

[00:56:14] they really took it to heart. And then if it's on their performance review, then it's even a

[00:56:19] double whammy and they could be the best pharmacist ever. So those things need to be weighed out.

[00:56:24] So if I had being the manager of pharmacists that I knew was going to be so sensitive to that,

[00:56:30] I would, and I got a complaint, I would absolutely not tell them about that because

[00:56:36] that's going to hurt them. But I think in corporate you're so removed, you tell them everything.

[00:56:42] Well, but it's always how you do it too. I mean, you can tell them and say, yeah,

[00:56:47] we have this patient and this is the negative feedback we got. But it's how you handle it

[00:56:54] with that employee that makes all the difference. It can be. And sometimes you just can't.

[00:56:59] Right. Like I had one there was no way I could ever because no matter how I tried to, it would,

[00:57:04] yeah, but then again, that's a people problem. You have to know your people.

[00:57:08] Well, yeah, have to know your people. So if I got a bad review on one of my pharmacists,

[00:57:12] somebody called and complained, there was at least one time I can think of maybe two where I

[00:57:18] there was no way I could tell them this. But I knew, but I knew the situation and I knew

[00:57:22] the circumstance. I knew it wasn't a pattern. Right. I think that matters too. Like if it's

[00:57:26] going to be like, say I see something in a pharmacist that I'm like, yeah, this is

[00:57:31] one of these days someone's going to call and say, and because I'm seeing it, they're going to see it,

[00:57:35] then you would have to because then that's going to make everybody better. Right. Right.

[00:57:39] But these nuances that get lost when everything is so corporate. Yeah.

[00:57:45] But also, I mean, I guess I'm with my employees. I would talk to them about, so yeah, this person

[00:57:53] gave this feedback, but you minimize that it's an issue. Okay. Well,

[00:57:58] so that they get that feedback. But your people, right? You know your people. Yeah. Yeah.

[00:58:04] All right. But it is, I think it's very stressful. And I even the state board now,

[00:58:10] the Ohio State Board of Pharmacy has come in and said to retail pharmacies, you can't be pushing

[00:58:15] these metrics down the pharmacist's throats. And part of the metrics is that although they are

[00:58:21] also saying you can't make patients wait days and days for medications because that was

[00:58:26] happening because being so overwhelmed. So I think the overemphasis on all of this

[00:58:32] has created a real problem for patients and at least the Ohio State Board of Pharmacy is

[00:58:37] looking into this. And I guess what it comes down to also is if it wasn't tied to

[00:58:48] Medicare and Medicaid reimbursements, then that would change the whole feeling of it.

[00:58:54] Then it could be a lot more objective. But because we have this extra layer of the

[00:58:59] government getting involved. Oh boy. Yeah. The government always messes it up. It does.

[00:59:04] Yes, that's another layer. Talk about being removed from what's really going on in the

[00:59:09] front lines of healthcare. Wow. Yeah, that is very true. And there's really not much you can

[00:59:17] do about that. You kind of have to play that game, don't you, as a healthcare provider

[00:59:22] if you want to get reimbursed from the government and so many people have Medicare?

[00:59:26] Yeah. But it comes down to all you can do is your best. Right. And if you really have the patients

[00:59:35] best at hand and you do everything you can and you're limited amount of time,

[00:59:41] the patients will appreciate that. And you're a lot more, you're a lot less likely to get

[00:59:46] A bad review. A bad review. Yeah. And you had this one about the phones. I was thinking

[00:59:51] about the phones tied to the metrics. One of the big box stores would ask patients how many

[00:59:57] times the phone rang before someone answered. And then if it was five or three or more,

[01:00:02] then they would get the pharmacy staff will get yelled at. Meanwhile, they're doing a million

[01:00:07] things when there's no staff. Yeah. But nobody cared because that number of how many rings,

[01:00:12] how many people said it rang too many times affected their, that's ridiculous. Talk about

[01:00:18] not seeing the big picture. Yeah. But that happened. Yeah. That's mind blowing because

[01:00:24] that should be corporate saying, okay, we need to have more people on the phones.

[01:00:29] So the phone's not ringing as much and not saying, oh, these people are just goofing off.

[01:00:36] So that's a great point. What are we doing with the data? Oh, we have data.

[01:00:40] Okay. That's a great point. Then someone has to analyze that data. Yeah. And then

[01:00:44] they've come to the total wrong conclusion. Exactly. Yes. Yes. Yes. I mean, sometimes it could be people

[01:00:50] that are messing around. They're talking to their coworkers and ignoring the phones.

[01:00:57] But you also should be able to, you should also be able to see that well then those phone

[01:01:04] wait times vary by the shift and by who is in charge of the phones.

[01:01:11] Of course. It's a variable. It does change. Yes. Mm-hmm. Yep. Stress on healthcare workers. Yeah,

[01:01:19] that's where it really, really hits. But yeah. And also anything else about stress

[01:01:24] on healthcare workers that we wanted to say? No, I mean, it's a problem because it is

[01:01:30] affecting their pay. Right. And yeah, and creating all these extra layers of busy work

[01:01:38] that they have to do when they don't have enough time to see the patient.

[01:01:41] So that ultimately is affecting the patients? Right. That's what we all need to keep in mind.

[01:01:45] Exactly. Yeah. These metrics that your doctor is beholden to is affecting your care. Yes.

[01:01:52] Yeah. And then another pitfall, I thought this was a really interesting topic that you had

[01:01:57] uncovered with your research is gaming the system. Yeah. Yeah. That's where I think it

[01:02:03] kind of gets real. Avoiding difficult conversations, talk about that. That's such a good thing again.

[01:02:09] Right. Well, I mean, if you are totally focused on this metric and am I going to

[01:02:18] get the best reviews and I need to get better reviews so that I can make more

[01:02:22] so that I can pay off my boat or my kids' college or whatever it is,

[01:02:27] then maybe you don't want to talk about the patient's weight issues or smoking issues or alcohol

[01:02:34] or any of these factors that are really, yeah. Could make them out. Yep. That is avoiding difficult

[01:02:40] conversation. I would not have thought about that, but sure. You really need to tell them this

[01:02:45] and maybe you've told them 15 times already and this is the time, you know, they're going

[01:02:49] to get hit with a survey. Right. They're going to be mad at you. They had a really bad

[01:02:52] experience in your office. Yeah. The truth hurts and they didn't like it. Yeah. It also

[01:02:57] can be for other reasons too, like say I have patients that well, they don't want to take medications.

[01:03:04] And so they're, and maybe they're not seeing me yet, but they're going to their doctor,

[01:03:09] they have high cholesterol, but they don't want to do anything. They want to take the medication.

[01:03:13] So eventually the doctor is like, why should I have that conversation? And even more so if

[01:03:19] they're worried about their scores because they're worried that these are the patients that are

[01:03:23] going to get more irate about me constantly talking about their cholesterol and they'll give

[01:03:29] me a bad review. Yep. Yep. And then also with kind of the healthcare providers trying to kind of

[01:03:38] game the system or trick the patient satisfaction system is, and I think Dr. Aman was pointing

[01:03:44] to this too, they prescribe unnecessary antibiotics, which we've had on many times. They want it. So

[01:03:49] let's just give it to them. Is it going to help? No, but let's just give it to them. Pain medications

[01:03:56] when maybe they don't need it, which we can talk about that a little bit and then unnecessary

[01:04:02] tests. They really want this test. They really want it because they don't really understand

[01:04:06] why they don't need it. Right. And they're pushing so much you just like, all right,

[01:04:11] give them the test. What's it going to hurt? Right. What hurts the bottom line? Yeah. Right.

[01:04:15] The then they're spending too much money. Yeah. Yeah. So we get antibiotic resistance, opioid

[01:04:20] dependency, increased healthcare costs, which is the last thing as we need is an

[01:04:25] increased cost. I'm talking about from a corporate perspective, people that come up

[01:04:28] with these surveys and the opioid dependency. So prescribing unnecessary pain medications,

[01:04:34] which became a problem. And that was touched on several times in that LinkedIn post we

[01:04:39] referenced in the beginning. I think it's, I don't think that patient, I think it was a bigger

[01:04:46] problem than gaming the system because there was other issues that were pushing.

[01:04:52] Well, if there was no pain score, if we didn't change pain from a symptom to a disease,

[01:04:58] right, then we wouldn't have been measuring it differently to begin with. Right.

[01:05:02] And like when I was in my truck accident years ago and we had discussed pain and how I was

[01:05:09] going to manage it, ibuprofen you'll be fine. He writes me a prescription for Percocet. I'm like,

[01:05:14] I don't understand why you did that. I don't, I have to ask because I'm so interested in the

[01:05:18] opioid crisis and I'm a pharmacist. He said, because we have to. Right. Because if I don't,

[01:05:24] then I get a little ding because I didn't give you proper pain control. Yeah. But you did. You

[01:05:29] said I would be fine with ibuprofen. He's right. You understand. Yeah. And I didn't,

[01:05:34] I didn't know they had to do that. Yeah. I mean, I remember having a tooth extracted. Okay. And

[01:05:42] got prescribed Percocets for it and I didn't even want to fill the script. My wife was like, well,

[01:05:50] just in case you need it. Sure. We don't want you to be in tons of pain in the middle of the

[01:05:55] night and not be able to get to the pharmacy. So she filled the script, but there was no way

[01:05:59] I was taking it. How many did they give you? Because back in the day, it was like 30 or 40.

[01:06:05] Now they're a little more careful. Well, there's rules. They can only do three days. Right.

[01:06:10] It might have been three days. I explained this is, I don't know, five or six years ago. I can't

[01:06:15] remember what, how much, because I didn't need it. I didn't care. So it didn't matter to me

[01:06:20] how many prescribed. Exactly. Exactly. I framed my Percocet prescription. I'm like,

[01:06:24] this will be the last. Yeah. Yeah, I wasn't going to get mine filled either. Yes. But yeah, you can see

[01:06:30] how just to give them what they want, get them out the door. Again, not thinking, not asking a

[01:06:35] question. Do you have addiction in your family? Do you, you know, like just write the script?

[01:06:41] Yeah. Like, wow, this is a much bigger, more complicated issue. But if you're only focused

[01:06:45] on that one metric, that one piece of the survey, you do something you wouldn't do

[01:06:50] were it not for the survey. Right. Exactly. And that definitely, I'm sure, fueled a lot of the

[01:06:56] opiate crisis. It did. It wasn't the cause though. I just, but it did. Yes. But it did fuel it. Yeah.

[01:07:03] Yes. And then we were going to talk about overemphasizing on patient

[01:07:08] pleasing. Which goes along with a lot of those same things. Exactly. But it also goes into

[01:07:16] paying more attention to things like wait times and the luxurious amenities. Yeah. And things like

[01:07:24] that as opposed to good solid patient care and taking care of their problems so that they can get

[01:07:31] over it. That is, well, that's a lot of common sense right there. You just summarize the

[01:07:36] whole thing Ted, right there. Yes. And that goes into maybe resource misallocation. Exactly.

[01:07:42] And we touched on that. So we're going to buy a fancy new waiting room where people are waiting a

[01:07:46] long time, but at least they're comfortable. They have a massage chair and an ice TV versus

[01:07:50] like training for dealing with underserved population, which would be a much better

[01:07:55] allocation of resources. Right. And then hit on erosion of trust. I would not have thought

[01:08:00] about that. But that's huge. That's like thinking long term. But that's also just what

[01:08:05] we were already talking about when you didn't want to give that patient the survey after the

[01:08:12] interaction because that does erode that trust. Because then they wonder why they question my

[01:08:17] intent. Exactly. Your intent and your integrity. Oh, okay. Yes. This person's only being nice to

[01:08:24] me because they're trying to get good survey results. Maybe they'll get a bonus for that.

[01:08:29] And they didn't really care about me. That's awful. It is. That's really awful. Yeah.

[01:08:35] If you don't have trust, if you don't trust your doctor, that is to be integral. Right.

[01:08:43] To wellness and healthcare. But another one that I think is even more important than that

[01:08:50] is avoiding challenging patients. So maybe you don't accept the patients that are going to be

[01:08:59] more difficult because they are going to be a lot less satisfied. So I can pad my schedule with

[01:09:08] the easy patients but not worry about the ones that are having a lot more complex problems

[01:09:15] because of course they're not going to get better as easy no matter how good a doctor you are.

[01:09:21] You're right. And you're going to get more feedback that's negative.

[01:09:26] So again, you're missing a big chunk of the population that needs, that really needs you.

[01:09:32] Right. Oh, that's a problem. Yeah. Yes. I mean ways to, so manipulation is a big downside.

[01:09:41] So how do you mitigate that? How do you mitigate the effects of manipulation? I mean,

[01:09:48] again we're talking about really an overhaul of the system. Then you and I are not going to

[01:09:54] we have to overhaul the system and the only ones that can really do that are the people that are

[01:09:58] running the system which are not the doctors or the pharmacists or the nurses. Because they're also

[01:10:02] worried about the bottom line and that's it. The people that are running the system. Yeah.

[01:10:07] And so I guess yeah, that takes us down a whole other rabbit hole with this because

[01:10:12] yeah which I don't think we need to go down. Well, I think a little bit. A little bit.

[01:10:15] Yeah, because when you look at corporate behavior. Oh, let's. Can we look at corporate

[01:10:21] behavior? Let's. You look at any corporation, the CEO is only focused on the next couple of years,

[01:10:30] maybe the next five years. Pops. Yeah. They're in probably more so just the next year with making

[01:10:36] sure that our stock price is doing as best as we can for the dividends and everything.

[01:10:42] True because the answer is to the board. Right. Right. And so they're not looking at

[01:10:47] long-term benefits. They don't care about that because I'm going to be gone by then.

[01:10:52] Very true. That's a problem in the system. Yeah. And that's why the system won't ever get fixed.

[01:10:57] You're right. Because nobody, nobody's in it for the long haul. The people that are high up,

[01:11:04] it is just a short-term gig to be able to get to their next thing or to retire.

[01:11:10] Right. And if and by doing, if they put in too much work then

[01:11:17] they're spending too much money, their stock price starts going down and then they get fired.

[01:11:23] Yeah. Yeah. So it is again, it is a systems problem. Right. And who, I mean, again,

[01:11:30] who gets hurt is the patient. The patients and the doctors too. The whole, I mean, the staff.

[01:11:36] It's the corporate and the management that are insulated.

[01:11:41] That's true. And there is really a lot of pain in the system. I can do that.

[01:11:45] That's why I went out. Yeah. It's a very painful, painful place to be for those reasons and many that

[01:11:53] I think patient satisfaction surveys. What's to me is what's interesting in talking about this is we

[01:11:57] really did get to touch on what's really wrong with the system where it's so reflective in

[01:12:05] the problem of patient satisfaction surveys, which is beyond what I think most people think

[01:12:08] about when they think about patient satisfaction surveys. Right. It turned out to be such a good

[01:12:13] topic. Is there anything else that we wanted to say about medic, really need to say about

[01:12:17] mitigating manipulation? No, I mean, because again, it's not something that you or I are going to solve.

[01:12:24] Right. Right. Or anyone at our level. Yeah, patient satisfaction surveys the good we talked

[01:12:30] about so much that's bad. Anything else we want to really talk about? How would you rate this

[01:12:39] podcast? Let's rate the podcast. What do you think about this podcast on a scale of one to five?

[01:12:45] I'm always good at rating everything out of five. So I'm going to rate, of course,

[01:12:51] I'm going to rate our audio or video, our knowledge, our experience. Everything is going

[01:12:56] to be a five. Everything's a five. What do you think, Todd? How would you rate this podcast?

[01:13:02] Are you satisfied? Of all the podcasts I've ever seen, this is definitely one of them.

[01:13:07] That's right. You're not going to get the survey, Todd. No survey for you.

[01:13:15] I love it. Okay. Anything else we want to say about that? We're going to link

[01:13:19] all of the stuff that we talked about if anyone wants to do a little bit of a deeper dive.

[01:13:24] Yeah. So I just have a couple of... You have really good final thoughts here.

[01:13:27] I have some final thoughts here. I didn't see these slides that you're snuck in here.

[01:13:30] Please. So when it comes down to patient satisfaction surveys, and we touched on this,

[01:13:38] but not in a lot of detail, it comes down to they can't be accurate to begin with.

[01:13:45] I mean... Man, that's what we've come away with. You're right.

[01:13:49] Right. Because of... We talked about the non-compliance and not bias.

[01:13:55] Yeah. You're right. But also even more so, and just like I was

[01:13:59] alluding when you asked me about how I would rate this podcast, I think that most people,

[01:14:06] when they're doing a survey, there's a couple of factors that fall into that.

[01:14:12] There's one known as social conformity bias.

[01:14:16] Oh. Yes. So that's where people will answer based on what's the most socially acceptable

[01:14:22] answer. And they tend to downplay undesirable attitudes while inflating the more desirable

[01:14:29] opinions and attitudes. That's just human psychology.

[01:14:31] Right. Right. And then another one, acquiescence bias, which goes... It's very similar, but it's

[01:14:38] basically when you're asking somebody for a survey statement, they're always going to agree.

[01:14:45] Okay. And we have studied that. They've done social studies on that.

[01:14:48] Yeah. Okay.

[01:14:49] Yes. But looking at all that and the psychology of it, what do we expect? Because when you're

[01:14:59] answering a survey, there's a lot of different reasons why you're just going... If you're going

[01:15:06] to actually do it, you're just going to give all five-star ratings.

[01:15:11] Just to get it over with really.

[01:15:11] Because maybe you don't care about the questions. It doesn't really...

[01:15:16] You didn't read the questions.

[01:15:17] Right. Or it just doesn't impact you.

[01:15:19] Sure.

[01:15:19] I mean, I think about when I was in... Especially in medical school, not as much in undergrad,

[01:15:26] but at the end of the semester, you're always getting rating the professor.

[01:15:30] Oh, yeah.

[01:15:31] No matter whether I like them or not, I couldn't give them really bad ratings because

[01:15:40] they're another person and that could harm them.

[01:15:44] Right.

[01:15:45] And I think that's what a lot of people look at too is they don't want to harm their doctor

[01:15:50] or the doctor's staff because even if it's not the best care, they have a relationship with them.

[01:15:57] And they're going to downplay some things unless they feel really harmed.

[01:16:03] Yes.

[01:16:04] And in general, we don't like to be confrontational.

[01:16:08] Well, yeah. Why the doctors avoid hard conversations?

[01:16:10] Why we all avoid hard conversations?

[01:16:12] Exactly.

[01:16:13] And the last thing I want to say with the psychology of this is that by admitting that our doctor isn't

[01:16:22] doing an amazing job, people look at that.

[01:16:25] They don't want to admit that because, well then that says something about me.

[01:16:28] Oh, wow.

[01:16:29] About my intelligence and about my decision making.

[01:16:33] Why I don't have the best doctor out there.

[01:16:37] Yeah, that's very interesting, isn't it?

[01:16:39] Yeah.

[01:16:40] Yeah.

[01:16:40] And so then I want to have this video that we saw, at least this portion of it.

[01:16:49] I just find it fascinating because this doctor who I don't know who he is.

[01:16:54] He's on YouTube and he does a lot of stuff and I'm sure a lot of really good stuff too.

[01:16:59] In fact, I saw when I was looking at Coriomon's LinkedIn that he'd linked a different video

[01:17:08] of this guy's too.

[01:17:08] Oh, he did.

[01:17:09] Oh, I missed that.

[01:17:10] Yes.

[01:17:10] But anyhow, so this doctor on this big whiteboard is going through how the Prescanley scores are

[01:17:20] tallied and what they all mean and how it gets rated and when it comes down to it,

[01:17:27] doctors scores are the worst doctor scores are about 70% and the best are about 91%.

[01:17:36] So his total takeaway is that why are we complaining about this?

[01:17:43] People love their doctors and you should just shut up about it because

[01:17:47] it's not doing anything.

[01:17:48] You need to understand that these surveys are accurate and people love their doctors.

[01:17:53] Oh, wow.

[01:17:53] Maybe he should watch our podcast.

[01:17:56] Oh my goodness.

[01:17:57] Yes, we'll have that link as well.

[01:17:59] And thank you all for listening and watching our podcast and be sure and

[01:18:04] click whatever button you have to click to follow and so you don't miss an episode.

[01:18:10] Thank you for joining us for this podcast.

[01:18:12] Mary and Dr. Ted want to remind you to use the internet wisely and to always be sure

[01:18:16] to consult with your medical provider with any questions or concerns that you may

[01:18:19] have as you work towards your wellness goals.

[01:18:21] We look forward to sharing more content with you soon.

[01:18:24] Thanks for listening.