When Physicians' Careers Suffer Because They Refuse to Prescribe Narcotics

In some new systems where doctors are reviewed by patients, physicians unwilling to supply addicts with pain pills receive poor patient-satisfaction feedback. That is judged as poor performance by hospital administrators.
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Tony is a 50 year old Midwestern emergency physician who quit practicing medicine last year, in large part because he was frustrated with his patient satisfaction scores. Tony is not an incompetent or uncaring physician. Quite the opposite—he was known by his colleagues and the majority of his patients to be a first-class doctor, though he did not want his real name used to avoid professional repercussions. How then could low patient satisfaction scores drive him from the practice of medicine?

To begin with, it is important to say that Tony’s decision to leave medicine can be traced to a number of factors—increasing stress associated with working swing shifts in the emergency department, frustration at the growth of healthcare paperwork and bureaucracy, and concern that his practice was being increasingly controlled by non-physicians. But the “straw that broke the camel’s back,” he says, was the pressure he felt to increase patient satisfaction scores. What are these scores?

When patients visit a doctor’s office, outpatient clinic, or hospital, they are often asked to complete a survey rating various aspects of their healthcare experience. Such surveys may cover many domains, including some outside the ambit of healthcare, like parking and food service. Where these surveys concern physicians, they usually ask questions about friendliness, responsiveness, and the degree to which the physician inspired confidence and trust.

Such patient satisfaction data are playing an increasing role in a number of important healthcare decisions. For one thing, physicians can be hired, fired, promoted, and compensated based in part on their patient satisfaction scores. Increasingly, these scores also determine how hospitals are ranked and paid. The Center of Medicare and Medicaid Services has been publishing this data and has begun distributing funds to hospitals based in part on patient satisfaction.

From one perspective, the effort to take patient satisfaction into account in allocating healthcare dollars is a welcome change. For many years, private and public health payers compensated physicians and hospitals based almost solely on the quantity of care they provided, essentially ignoring quality. The more patients they cared for and the more they did for each patient, the more revenue they generated. Now quality, defined in part by patient satisfaction, is playing a greater role.

Though attending more carefully to patients should strike any physician as a good idea, such perceptions are not always reliable. For one thing, a patient’s assessment of a physician visit or hospitalization can be colored by a variety of factors not under the control of either. For example, a patient frustrated by the difficulty or expense of parking may assign lower scores to every aspect of a hospitalization, including the quality of care provided by the physician.

In some cases, patient perceptions may prove downright misleading. Tony practiced medicine in a poor community. A high percentage of his patients complained of pain, and many were known to visit a variety of emergency rooms on a regular basis, seeking prescriptions for powerful pain relieving drugs, a pattern often referred to as “drug-seeking behavior.” We need to be careful about applying such a potentially derogatory term to any group of patients, but the problem is well known in the field.

In one study of drug-seeking behavior, 178 patients made a total of 2,486 emergency room visits in a single year, nearly 14 visits per patient. When asked why they were returning so frequently for more pain relievers, many replied that their medication had been lost or stolen, or that they have used up their supply. Nearly 30 percent rated the severity of their pain as 10 out of 10, and nearly 15 percent explicitly requested a particular medication by name. These include narcotics, benzodiazepines, and muscle relaxants.

This problem is widespread. A colleague recently cared for a suburban housewife from one of the nicest parts of town. She was both well-educated and well-off, and everything about her radiated health and success. When asked what medications she was taking, she mentioned a well-known narcotic pain reliever. When asked who had prescribed the medication, she replied, “No one.” When asked where she was obtaining it, she replied “Oh, just a person in the neighborhood.”

The problem of prescription drug abuse and drug-seeking behavior is abetted by a robust and growing black market for prescription medications. In some parts of the country, the pain relievers OxyContin and Vicodin can have a street value as high as $80 per pill, making a 60-pill bottle worth nearly $5,000. Just this week, the Food and Drug Adminstration proposed new restrictions on prescription pain relievers in an effort to stem the tide of abuse.

Regional variations in the rate of prescribing such powerful medications are well documented. For example, just a few years ago 49 of the top 50 U.S. prescribers of oxycodone were located in the state of Florida, and 25 of these practiced in Broward County alone. There is no evidence that residents of Florida in general or Broward County in particular suffer a disproportionate share of the nation’s pain. Instead such remarkable disparities point to a radically different prescribing culture.

So what is Tony’s objection to the patient satisfaction data collected in his emergency room? He believes strongly that all physicians have a professional responsibility to prescribe medications only to patients with legitimate medical needs. For this reason, he resolutely refused to prescribe powerful pain relievers to patients he judged to be engaged in drug-seeking behavior. It is not that Tony would not help patients he believed to be hurting, but he would not do so for those seeking more than they needed.

Other physicians and emergency rooms in his vicinity did not always take the same view of the matter. Specifically, they were less reluctant to prescribe pain medications to patients, even those who already had prescriptions from other providers for such medications. Why? In some cases, they were more trusting of their patients. In others, they did not take the trouble to consult the appropriate patient databases. And in still others, Tony speculates, they sought to avoid low satisfaction scores.

Not unexpectedly, Tony and other physicians who decline to prescribe such powerful pain relievers often receive lower satisfaction scores from patients they refuse. Tony attempted to argue with administrators that these scores should not count, or at least not count for as much, as those from patients he believed really needed them, but the hospital insisted on counting all scores equally, regardless why patients sought care. The result? The ratings of Tony and like-minded colleagues suffered.

In other words, physicians who more readily prescribe such drugs tend to receive higher patient satisfaction scores. And higher patient satisfaction scores often translate into higher overall quality of care scores. Tony and others behold this perverse situation with a mixture of dismay and disgust. How, he asks, could any hospital or medical practice even tolerate, let alone reward, such conduct, simply giving patients what they want and contributing to an illegal black market in prescription drugs?

Tony would be the first to admit that a satisfied patient is a good thing. In fact, he asserts, it is highly desirable that patients’ perspectives play an important role in assessing the quality of healthcare. But when patients ask physicians to do things that violate core professional responsibilities and may end up promoting drug abuse and illegal drug trafficking, patient satisfaction scores cease to serve as indicators of healthcare quality and become instead serious sources of corruption in healthcare.

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Richard Gunderman, MD, PhD, is a correspondent for The Atlantic. He is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. Gunderman's most recent book is X-Ray Vision.

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