While dissatisfied patients might not return to a practice where they've felt ignored or mistreated, too frequently physicians, practice managers and other staff members are just as happy to see troublesome patients seek treatment elsewhere.
However, medical professionals might not be aware of the potential adverse outcomes patient discontentment can lead to, from a decline in referrals to negative publicity or even malpractice lawsuits. Such ripple effects from improperly addressed patient grievances can hamper a practice's ability to thrive.
"Physicians are almost always the last leg in the sequence of events for the patient," says Tim Tobolic, M.D., one of five family practitioners at Byron Family Medicine in Byron Center, Mich. "So everyone has to be tuned into (patient expectations) from the first moment that patient calls in on the phone.
Sometimes, if they perceive an unpleasant voice or attitude, it's just downhill from there."
Contrary to popular opinion and news headlines, patient satisfaction with physicians, staff, service and care received from health plans has increased modestly in recent years.
According to the National Committee for Quality Assurance's 2000 State of Managed Care Quality Report, positive assessments of health plan performance in areas such as doctor communication, courteous and helpful office staff, customer service, and quick delivery of care stayed the same between 1998 and 1999. In both years, 78.2% of members surveyed said they always or usually got the care they needed when they wanted. Scores for attentive physicians also remained high, rising from 89.2% in 1998 to 89.4% in 1999.
NCQA spokesperson Brian Schilling says his agency has plans to start tracking similar measures for individual practices within a few years. In the meantime, physician practices that pay attention to the existing data, as well as the impact that poor customer satisfaction can have on their business, can draw from health plan experience to maintain and improve their patient relationships.
Thirty percent to 40% of patients who are unhappy never complain, says John Goodman, president of e-Satisfy, formerly the Technical Assistance Research Project, an Arlington, Va.-based customer service measurement company. But among noncomplainants, e-Satisfy's managed care data shows the retention rate is about 23% lower than among patients who complain and subsequently are satisfied.
When people complain but can't reach anyone who will help, Goodman says, there is usually a 40% loss of loyalty. He says word of mouth from satisfied patients telling acquaintances about good treatment travels to just one or two people.
Those who never complain about their problem to the practice told three people they were unsatisfied, whereas those who voiced their grievance and yet remained unsatisfied told as many as five or six people about their problem.
But small practices, and some large ones too, don't always have the resources to hire a patient advocate or other personnel whose job is to handle patient complaints. Enter the Golden Rule and the enlightened medical practice staff, one in which each person takes responsibility for better managing patient complaints and for treating patients as staff members themselves would like to be treated.
That type of ownership doesn't come easily. It requires carefully considered communication skills, which often require training that can take time, though not necessarily a lot of money. Fortunately, one of the more valuable assets most practices have is common sense. If all practice staff, from physicians and nurses to those in the front office, reflect on their own desires and experience as healthcare consumers when dealing with complaints, the workplace can actually benefit from attending to patients' fears and expectations as well as their medical conditions.
"I believe sincerely that difficult patients are teaching any organization how to do it better," says Susan Keane Baker, a former hospital administrator for 17 years in Connecticut and New York. Baker currently teaches and consults on patient satisfaction and risk management issues for group practices, insurance companies and managed care organizations.
"Patients who complain are actually more loyal than those who are dissatisfied but say nothing," Baker wrote in her 1998 book, Managing Patient Expectations.
"Difficult patients can be viewed as opportunities because there is no competition for them."
Physicians, managers and practice consultants agree that for the most common complaints, such as waiting, front office employees and medical assistants bear the burden because patients don't want to be perceived as difficult by their doctor. Only one of 50 patients who complain of relatively minor inconveniences will go to management, according to e-Satisfy. And front line staff members also are reluctant to bother the doctor with nonmedical issues.
Basic awareness and openness can keep less serious complaints from escalating, Baker says. A sincere staff member who wants to prevent frustrations is on the lookout for them and can be helpful rather than defensive. Subsequently, the staff can focus on the problem rather than the personality of the patient who has voiced a concern.
Even though we all know how we want to be treated when we have a complaint, Baker says, most people haven't had any education in handling complaints. One remedy a practice manager can use is to ask other staff members how they have dealt with a specific situation successfully. Establishing a protocol and a designated person or committee to handle more serious complaints assures both patients and the practice that no one slips through the cracks.
"There's a lot of skill-building that's fairly easy to do and has huge payoff," Baker says, suggesting that practices can use patient satisfaction surveys, build an affordable library of books and videos, or even attend a few classes on basic customer service. "It isn't always a matter of the practice having to spend a lot of money."
Nancy Elliott, M.D. a breast surgeon at the six-physician Montclair (N.J.)Breast Center, says she believes no matter where the complaint stems from, it's important for physicians to deal with it directly themselves whenever possible.
"The patient respects most that the physician decided to call," Elliott says. "If the patient is reasonable, very often she will be impressed and come back."
Elliott says she was impressed and inspired by her treatment at the Four Seasons hotel in Philadelphia, where she stayed to take her recertification exam. To improve patient relations, Elliott says practice staff can learn a lot from the hospitality industry.
"When a woman comes for a mammogram, we want her to leave with a similar, very positive experience," Elliott says, adding that regular visits are more likely if the appointment is a pleasant one.
While patients can have unrealistic expectations, Baker stresses that doctors should be open to the idea that patients can indeed be right when they are dissatisfied with their medical outcome. It is important for doctors, historically among the best and brightest, not to get defensive and not to be afraid to say I'm sorry, Baker says.
Even when the doctor doesn't have all the answers, Baker says a timely response is preferable to waiting on dealing with a patient, which can lead the patient to think the doctor is trying to hide something.
Physicians might want to bone up on their state's malpractice laws, Baker suggests. Some states, recognizing that a patient might sue as a means to find out what happened, have passed legislation that protects physicians by saying an apology cannot be presented at trial as an admission of guilt. Some states have similar protections for physicians and practices that decide not to pursue collection on a bill where a patient feels he has been hurt.
Of course, patients can be wrong too. Baker advises practices to adopt a strategy, such as the Walt Disney Corp.'s, to let the guest (or patient) be wrong with dignity. She cautions doctors not to wave a red flag at the patient, for example, by telling a patient that no one else has ever complained about a certain situation. That tells the patient he is wrong when what he wants is to feel that his input is valued.
A physician can assure the patient of his desire to maintain an ongoing relationship. Let the patient vent, and even if he is wrong, let him know the practice still wants to take care of him, Baker says. Problems tend to escalate when a patient feels ignored or abandoned.
"Some of these so-called problem patients actually have a problem physician," Tobolic says.
Frequently, a patient's complaint has nothing to do with something the practice has done, he adds, but stems from a negative hospital or HMO experience, or perhaps a problem with an insurance company or another doctor.
"Often what we're dealing with has to do with other administrative things and not direct medical care," Tobolic says. "You still have to be patient with the patients and also remember that they may indeed have medical problems. Most of these people feel that their problem is fairly urgent, so you have to take that into account, too."