Dr. Wattana and Dr. Todd's case study illustrates how Press Ganey and other such surveys may influence physicians to “please” patients. Pleasing patients is rewarded with higher patient satisfaction ratings that reflect favorably upon the physician, the department, and the hospital. Ms. Cowan notes that the problem lies in the surveys themselves: the surveys promote an assumption that patient satisfaction is an index of physician competence. Competent doctors practicing good medicine may receive poor Press Ganey satisfaction ratings because they are practicing good pain medicine. In the ED and often in broader pain medicine, Press Ganey ratings are virtually meaningless because the metric is flawed and inappropriately applied in these settings. Not only is the content of many patient satisfaction measures of questionable relevance, but problems with interpretation abound . As an example, excellent pain care may well entail setting boundaries and disappointing patients who had expectations of receiving opioids. In the current political and health care climate aimed at reducing inappropriate opioid prescribing, physicians should be supported in adhering to best practices, and be rewarded for good and safe patient care.

Compassionate care must not be confused with indulging patient expectations. A physician's most compassionate act may be gently yet firmly telling a patient that he/she cares too much about his/her well-being and safety to fill the opioid prescription that he/she is requesting. Such a decision may result in the physician receiving a scathing Press Ganey satisfaction score from the patient; yet this decision may also have saved the patient's life or someone else's. At minimum, the physician would have compassionately refused to enable the patient in engaging a harmful behavior. In the case presented here, the physician is beholden by oath to do no harm and to practice in the patient's best interest. With these ethics in mind, the physician surely must disappoint the patient, and his/her satisfaction ratings will therefore suffer.

While the notion of patient satisfaction is important, it must be measured differently in pain medicine. It also should be noted that patient satisfaction has been empirically associated not only with higher prescription medication and overall health care costs, but with increased mortality as well . The field of pain medicine must challenge evaluators to evolve beyond a widely used standard metric that generates flawed data, and promotes gross misperceptions regarding professionalism, compassionate care, and competency. Appropriate and field-specific metrics are needed for pain medicine, particularly in the ED. This raises the question of whether the practice of assessing patient satisfaction in the ED in cases in which opioids are requested should be suspended, with quality performance measured by survival rates or other objective metrics. Ethical issues associated with the utilization of inappropriate measures of physician performance have been addressed in the literature . Until appropriate measures of performance are developed, routinely utilized, and interpreted in a manner appropriate to the context of the specific clinical situation, hospitals, health care organizations, and payers are challenged to understand that Press Ganey and other similar satisfaction surveys are limited and potentially harmful to patients and providers alike, particularly when they relate to patient requests for opioids.


et al
A national study of patient satisfaction, health care utilization, expenditures, and mortality
Ann Intern Med
Bad measures don't make good medicine: the ethical implications of unreliable and invalid physician performance measures
J Bus Ethics