Risk for Conflicts of Interest in Physician Satisfaction Scores | Timothy G. DeEulis, MD

In the October 2023 SGO Ethics Series blog, Risk for Conflicts of Interest in Physician Satisfaction Scores, Lois Ramondetta, MD, presented an incisive case study which outlines potential conflicts of interest between the physician patient satisfaction metric and the physician’s ethical responsibility to accurately and compassionately discuss all potential options for care with the patient.  

This article may prove particularly useful to fellows and new attendings, since the scenario described is as likely to present as a first case for the newest Gynecologic Oncologist in a community setting (make or break on referrals) as well as a weekly consult at a highly ranked specialty cancer institution.  Dr. Ramondetta’s handling of the visit and after visit, including her intuition about the potential results of the visit, her attempted prompt morning after follow up call,  her arranging for a call by her APP in her absence, and especially her courage and compassion in calling the patient to discuss the concerning survey response was exemplary, not only from a visit conduct and advance care planning perspective but also a risk management standpoint. Some may not realize that an institution may also utilize this data for risk assessment and that the comment has likely been reviewed not only by the patient experience officer but also the CMO and Risk Management before it arrives in your inbox. 

As CMS mandates patient satisfaction metrics both as a requirement for institutional based performance comparison under ACA and as a qualification to receive MC incentive payment distributions, patient reporting with open-ended comments about their physicians in these surveys is likely to continue.^[1-3] (As a recent physician-patient at Duke (I underwent a dome osteotomy ORIF and peroneal nerve transposition by Duke Orthopedic Trauma—my right leg is replete with titanium rod plates and screws currently—so far, so good)  I found that similar surveys may present to your electronic chart (mine is on my cell phone) as early as when you are in the midst of dressing post exam.   More commonly, the surveys arrive within 24 hours post encounter, with a reminder at 72 hours, and are available for completion for seven days.  The surveys invariably solicit an open-ended comment about my experience with my physician at each encounter, outpatient, or hospital.  I have had an extremely positive experience with my surgeon at Duke and his extended outpatient care team and inpatient hospital and rehabilitation care teams at Duke Regional Hospital (where I formerly practiced), and all of my survey comments were positive.  I admit that it helps to know how an organization works, even historically. However,  the surveys and reminders do arrive so rapidly that I could imagine that a rapid visceral response such as Dr. Ramondetta received during her vacation period is entirely possible (the patient experience system does not know and probably does not care if the physician is on vacation).  The surveys do generally follow the  Press Ganey 7/10 question format as well, some of which deliberately ferrets out any negative experience from the patient perspective.^[4-5]  

Studies of patient satisfaction surveys in non-cancer diagnoses that I consulted show provider-specific surveys are maximally responded to and contain the most provider positive comments if made available to answer within 48 hours after the OP visit/hospital discharge. Those lingering after seven days or no response in non-cancer patients are more commonly associated with negative comments or subsequent risk management issues. However, in advanced cancer patients who are already experiencing anticipatory grief (the referenced patient reported she was in denial), the early arrival of the same Press Ganey type one-fits-all survey solicitation coapts with the usual period of grief resolution transitioning from denial to anger in the traditional model^[6]). 

This overlap has the potential to elicit an angry response to a candid and cautious discussion as a bad news experience attributed to the messenger instead of the disease. Further, necessary and appropriate on-site assessment of new emerging diagnoses (such as the exclusion of bowel obstruction in the ER for this patient) and its unexpected situational/financial impacts on a long-distance outpatient visit originally anticipated as counseling about options for continuing treatment unavoidably complicate the patient’s grief processing and may amplify an emerging denial to anger response.^[7-11] The patient may also have unrealized expectations owing to institutional reputation, which further may accelerate a negative reaction regardless of ethical discussion of the case as it stands.  It seems conceivable that the referring medical oncologist, who it turns out may have made some effort to discuss goals of care with the patient prior to the second opinion visit, may have referenced Dr. Ramondetta owing to her national reputation as a certified sub-specialist in hospice and palliative care and ethics as well as  gynecologic oncology to conduct a consultation bearing these issues.  I do not know. 

Similarly, I would not anticipate health care delivery systems embracing pre-visit education on advance care planning or goals of care in the near future.  The current magnitude of pre-visit demographics and (again) CMS mandated PROMIS scoring in several domains already requires several hours of patient centered effort for a new patient visit, even from a physician-patient,  and sometimes requires customer service, social work or occasionally IDT support for others.^[12]   

By our own efforts, early identification of a complex situation and readiness is still possible.  A few ideas are as follows: 

• A personal phone call to the referring physician in advance of the visit.  Information shared in a several minutes conversation may provide invaluable information as to the patient’s goals and current status not available in a stack or disc of computer-based template encounters.

• A personal phone call to the patient introducing yourself and asking an open-ended question such as “how can we best prepare for your visit?” The risk is that you may be on the phone for 15 minutes of unreimbursed time; the benefit is that the patient is appreciative of your interest, begins a positive relationship and may be privy to information not included in the last visit note you received and will likely share what are her goals for the visit.  

This will provide time to prepare for a tailored discussion, to plan discussion over one or several encounters as discussed by Dr. Ramondetta, and to make sure that she will have her critical family or support system there or available during and after the visit, particularly if a goals of care discussion is anticipated. 

• Some version of a rapid preclinical tool such as the expanded ESAS with financial toxicity assessment which can be completed at the point of care in the waiting room over a few minutes’ timespan (even if the PROMIS scores have yet to be completed).^[13] The ESAS results may alert you to patient symptom burden pre F2F visit and allow modulation or use of subsequent follow up discussions to refine a recommendation and personalize goals of care.

• A day after phone contact from the physician is invaluable, often identifying unanticipated concerns and reinforcing to the patient that you personally care regardless of the gravity of the situation.

I personally have done so from vacation over the years and have not found this an inconvenience, as long as you can track down your coverage if some action is required in your absence. Dr. Ramondetta attempted the same in her case. 

Finally, the most difficult patients in my experience are normal patients with a difficult problem that they cannot process.  The referenced patient has already been buffeted by her disease, its symptom burden and attendant financial toxicity, and in this case encounters both a candid though compassionate discussion of her prognosis and a change in condition of a potential bowel obstruction on arrival requiring Dr. Ramondetta to send her to the ER for triage and supportive care.  All of this was immediately followed by the prompt  extremely untimely though “timely” arrival of the patient satisfaction survey and its demoralizing sequelae for the kind and honest physician who has done her job well. 

References

1. HCSHPS Survey (Medicare.gov) OMB #0938-0981 (expires September 30, 2004) 
2. CAHPS® Clinician and Group Survey (CG-CAHPS) Agency for Healthcare Research and Quality, Rockville, MD, page last revised October 2023 https://www.ahrq.gov/cahps/index.html 
3. CAHPS® for Merit Based Incentive Payment Survey.  Agency for Healthcare Research and Quality, Rockville, MD, page last revised October 2023 https://www.ahrq.gov/cahps/index.html 
4.  Frederick Forth MD and Sidna M Tulledge-Scheitel MD “Patient Satisfaction with Providers: Do Patient Surveys Give Enough Information to help Providers Improve Specific Behaviors?” Health Serv Res Manag Epidemiol 2019 Jan-Dec; 6:  2333392819885284. 
5.  Andrew R Stephens, Zachary L. McCormick, Aaron Cogar, Taylor Burnham.  “Evaluating Opportunities for Improved Outpatient Satisfaction in an Interventional Spine Clinic: An Analysis of Press Ganey® Outpatient Medical Practice Survey Responses”.  Interventional Pain Medicine Vol 1(4), December 2022, 100143 
6.  Patrick Tyrell, Seneca Harberger, Caroline Schoo, Waquar Siddiqui. “Kubler-Ross Stages of Dying and Subsequent Models of Grief”. STAT Pearls, National Library of Medicine, updated February 26, 2023. 
7. Hoppenot, C, Peters, PN, Couro, M, Diaz-Moore, E, Hurteau, J, Lee, NK and Yamaha, S. Diane. “Malignant Bowel Obstruction Due to Uterine or Ovarian Cancer: Are There Differences on Outcome?”  Gynecol Oncol 2019; 154(1): 177-182.
8. Peters, Pamela N, Julia M Moyett, Brittany A Davidson, Sarah Cantrell, Sara E Bliss and Laura J Havrilesky.  “Cost Effectiveness of Management Strategies for Patients with Recurrent Ovarian Cancer and Malignant Bowel Obstruction”.  Gynecol Oncol 167(3), December 2022; 523-531. 
9.  Julia M Moyett, Elizabeth P Howell, Gloria Broadwater, Angeles Alvarez-Secord, Catherine H Watson, and Brittany A. Davidson.  “Understanding the Spectrum of Malignant Bowel Obstruction in Gynecologic Cancers and the Application of the Henry Score”.  Gynecol Oncol 174, July 2023: 114-120. 
10. Peters, Pamela N, Laura J Havrilesky, and Brittany A Davidson. “Guidelines for Goals of Care Discussions in Patients with Gynecologic Cancer”. Gynecol Oncol 174, July 2023:. 247-252. 
11. Howell, Elizabeth, Julia M Moyett, Melissa Greene, Gloria Broadwater and Brittany A Davidson.  “EP 315/H 712 Palliative Care Utilization and Goals of Care Discussions During Admission for Malignant Bowel Obstruction in Gynecologic Malignancies” in E-Posters, BMJ Publishing Group Ltd., 2022. 
12.  Ron D Hays, Karen L Spritzer, Benjamin D Schalet and David Cella. PROMIS®-29 v 2.0Profile Physical and Mental Health Summary Scores.Qual Life Res. 2018 Jul; 27(7) 1885-1891.  Published online 2018 Mar 2022. doi: 10.1007/s11136-018-1842-3 PMID 29569016 
13. Intro to PROMIS @ healthmeasures.net (United States Department of Health and Human Services ) last updated 04/12/2023. 

Timothy G. DeEulis, MD, is a gynecologic oncologist and palliative care provider in Huntington, West Virginia.