Patient satisfaction scores are an ever more important metric as healthcare leaves the sterile walls of an exam room and transitions online. As clinicians – whether MD/DO/PA/NP – our reputations has healthcare providers have been somewhat tarnished by shady practices of large medical groups as well as a few, a very small few, bad apples.
One thing you can always stand behind is your patient satisfaction score or your customer review, as it’s referred to in the online space. The thought that patients are being referred to more and more as customers was at first quite foreign to me. It didn’t sit well on the tongue. But as the clinician is divorcing more and more from the medical practice – as the two entities are diverging, it’s natural for the patient to become a customer.
As the patient becomes the customer, the physician becomes the employee rather than the owner of the private medical practice. We, as a group, have chosen to trade the headaches of being a small business owner for the simplicity of being an employee.
I can see a time when many of us who have been employees for years will take everything we’ve learned from our medical groups and go back into private practice. A physician may have worked for a large medical group for 2.5 decades but then decides to spend their last few years owning a small private practice. One thing that won’t change is the customer service part of healthcare – the retail service.
Retail service
We’ve all had the patient who tell us how hard it is to be in retail. He or she might be a salesperson at a Nordstrom’s or a cashier at a grocery store. They tell us how exhausting it is to deal with so many different people, each demanding something else, some in a bad mood, others who just aren’t good people. “You don’t know how tough retail is, Doc!”.
Yes, we know this all too well. Physicians are in retail the same as the cashier at Jack in the Box, as the sales clerk at pet shop and the front desk person at the home cable company. When you are the person at the point of sale, you are in retail. Until healthcare becomes free, clinicians will remain in retail.
Retail service isn’t easy but there are tricks to the trade to satisfy the customer without sacrificing the care (the service).
Take waiters and waitresses – that’s a brutal job. You’re running around, fulfilling demands, remembering orders, at the mercy of the kitchen, and trying to satisfy subjective expectations from a hundred different individuals. One person wants to know if the chicken had a name before it was slaughtered and the other is wondering why there is butter on only one side of their toast.
And yet, every once in a while, we come across that one waitperson who is amazing. They are always in a good mood. They are always on point. And they always seem happy. We’ve ruled out manic disorder NOS. We’re fairly sure they aren’t on uppers. They don’t seem to have a benzo drip attached to their arm. We don’t see them popping LSD between tables. So what gives?
Dismissing that waitperson as “having a gift” or just being “naturally good at it” is simply dismissive. There are a set of skills in that person’s repertoire that if someone else replicated, they would succeed.
I haven’t gone to a Starbucks in a few years, but when I used to go, I was always impressed with how consistent the customer service was. No matter the sex or race or weight or height of the person taking my order, they were friendly without seeming like they were a pushover. They never seemed overworked or exhausted even though they seemed perpetually slammed. Someone must have trained these people – someone must have figured out the secret sauce.
Patient satisfaction
Satisfying a patient is only possible once you know what their expectation is. Bold statement, isn’t it? As clinicians we view ourselves as health experts. Meaning, if I offer you the right clinical expertise then you, as the customer, should be satisfied.
It doesn’t work that way, as most of us have unfortunately found out. It would play out that way if there was no other source for patients to get health related information. If I, Dr. Mo, am the only person who knows how 2 drugs interact, then the patient’s expectation becomes 90% obtaining that information – bam! Patient is satisfied.
Whether we like to believe it or not, these days patients can get 90% of what clinicians know from other sources. Some of my patients have googled a broader DDx than what I can come up with on the phone or in the exam room. “Right, amyloidosis, that was in my differential as well. Uh, I’ll be right back.”
For good or bad, whether we like it or not, and no matter how much we fight it, patients come into the clinic or connect with us online with specific expectation which have to be met. The magic sauce is figuring out what those expectations are. And you’d think that’d be the end of that. But no, it’s more fun than that.
Patient expectations
Lucky for you guys, I’ve had many failed relationships, which makes me an expert on relationships. When your partner has a particular expectation of you, they will rarely express that expectation to you verbatim. “Well, I wanted you to want it!”
WTF?!
Some patients don’t even know what their expectations are. These are the majority of patients I deal with. They know they need to be seen but they don’t know what they exactly want to get out of the visit. It’s unplanned. They’re winging it.
The other group has an agenda and they have very specific expectations which need to be met. And both groups need their expectation to be met or else they will not feel satisfied.
For added fun, the expectation satisfaction game is a moving target. Even if a person tells you what their initial expectations are and you meet those expectations, they might set that expectation a little further away – they make it a moving target. Or they might seem to be totally satisfied during the conversation but as you reveal more information, their expectations change, making you want to pull out whatever hair you have left on your thinning scalp.
This is actually okay. Even though I just gave you two different patient expectation scenarios, the process of figuring out the expectation isn’t too different. The goal is for you to be engaged, involved, and remain dynamic when interacting with the patient.
Engaging the patient
View the patient interaction as a conversation and not a patient doctor interaction. This is a big pitfall for medical professionals. We have scientific and linear minds. That’s why mechanics and handymen and contractors get frustrated working with us. “Look, is it A or B? And if so, what options are we looking at? Why can’t you just tell me how much it will cost?”
I’ve owned an auto mechanic shop before and even when it comes to cars, you can’t do the whole: if x then y. There are options and preferences, extraneous circumstances, unknowns, and… goddamn leaky vacuum lines.
You’ll never go wrong having a conversation with the patient. For now we don’t charge the patient by the minute. A little chit chat can break the ice and it’s so damn powerful. I like to start by saying something engaging, often humorous about how I had a problem with technology. “There you are, I thought I lost you there for a minute or thought you hung up on me! Geez, give me a chance at least!”
Or something about their name: “Okay, let me try this, is your name ********? No, that didn’t sounds right, did I totally butcher it or just partially?”
All you’re trying to do is to show the patient that you’re not a robot. That they can let their guard down and maybe ask you a question they’ve been afraid to ask. They won’t worry as much about coming across as stupid – a real phenomenon when patients speak to us seemingly more smarter clinicians.
When I do telemedicine I also like to do this one: “So Mr. *****, you’re over in Washington, right? Is your traffic as bad as our Portland traffic?” Do the same with weather or population or air pollution – whatever you can think of.
Ask questions. Find out what they are worried about. Find out what fears they have. Ask questions. Find out what solution they are looking for. Find out what made them make the appointment. Ask more questions.
This is as beneficial to you as it is to them. By having a chit-chat you are less likely to get irritated on the phone – after all, you are having a conversation. You are humanizing the voice on the line rather than treating them as a hurdle to overcome in order for you to collect a paycheck or finish a shift.
You know what makes for a great salesperson? Someone who sets aside their agenda and focuses on finding out what the client’s problems are. Next, if they have the right product to sell, they will tell you why and exactly how their product will solve the stated problems. You’re a clinician, so by definition you always have the right product to sell the patient.
Asking questions
When the 62 yo 275 lb dude hobbles into my exam room with a shoe on one foot and a loose sandal on the limping foot, placing only pressure on their heel, wearing their PJ’s, I know that they didn’t injure their toe playing doubles tennis. They have gout.
Not only do I know it’s gout, I would love nothing more than telling him it’s gout without saying hello and tell him that over the counter meds are more than sufficient to treat it and that there are diets he can research himself online to decrease his chance of recurrence. Done. 7.5 seconds. You’re welcome.
I’ve tied this. Much like my relationship, I’ve failed miserably. If you dare give a patient a diagnosis without asking enough questions, they will lose complete faith in you. And from that moment on they will ask you 1,001 unquenchable questions. You will spend the next 38 minutes explaining gout to them.
Fortunately, the opposite holds true as well. If you ask a ton of questions, just shy of the patient thinking to themselves “Geezus, lord, how many more questions is this guy gonna ask?!”, you will ensure that the patient is felt heard. You hopefully helped them get everything off their mind, off of their chest, and off their plate.
My friend M. is a great listener. Every time I talk to her she just asks questions and whatever I say she just has the perfect reaction to it. Me, I’m a terrible listener. Fortunately my friends know this and so they come to me with concrete problems and not for a shoulder to cry on. However, in the exam room or on the virtual visit, I’m a beast when it comes to listening:
- I will not interrupt
- I will not give an impression until the very last possible minute
- I will ask question after question
- I will tease shit out the patient didn’t even know they knew
- When they are ready to end the conversation, I throw in one last tidbit
- I summarize the visit and I ask if any other questions exist
The point of asking questions is to engage the patient. Your goal is to start broadly and hone in on the details. Inbetween, you’ll ask a few very high-yield questions like: “So, okay, let me ask you this, when you decided to schedule this telemedicine visit on your app, what sparked it, what was the one thing that went through your mind where you thought you better talk to a doc?”
Another iteration of this is: “I got some great info from you so far, but let me ask one more question, what’s the one thing you worry about the most regarding this issue? What are you most worried it might be or afraid of?”
Those of you who do this and have done it know that quite a few times we get something seemingly ridiculous and sheepishly stated, like: “Well, I just wanted to make sure it’s not cancer.” If you can tease out this factoid sooner rather than later, you’ll save yourself so much headache. And you’ll get a better customer satisfaction score. And the visit will be shorter. And you’ll be far less frustrated.
Listening and feeling heard
Again, back to my slew of failed relationships. I say: I’m listening, she says: yea but you didn’t hear me. What?!! Wait, wait, what?! Do we at least agree that the goddamn earth is round?! I know, shocking that I’m single!
When it comes to significant others I have zero desire to play the listening-hearing-heard game. Even though in the back of my mind I know I’m just being a stubborn ass, I don’t care – I’d rather have a plant or a pet snake.
But when it comes to my patients, I’m shockingly enlightened. I have amazing patient satisfaction scores, I always have. Because I treat the patient visit like a social experiment with a scientific approach. This isn’t to brag – my satisfaction scores are a fact. I have a recipe for them and I’ve busted my ass to get there.
When it comes to the patient visit, even if it’s only 7 minutes long, I have a begging, a middle, and an end. Sure, I have some unhappy people from time to time. But they felt heard. I listened and made them feel heard. No matter how much they disagree with me about the viral URI diagnosis and the lack of antibiotic prescribing, they can’t deny or unhear the fluffy stuff I told them.
I don’t kiss ass and recommend you avoid the same. Kissing ass leaves you feeling vulnerable and defeated and might make you resent your work or the patient.
The fluffy stuff is something like: “I know this isn’t what you expected to hear, but I genuinely care about your health and have witnessed the many side effects of antibiotics and the long-term negative effects they can have on a patient who doesn’t have a bacterial infection. I would never leave you without antibiotics if I thought that I would endanger you in any way. For that reason I won’t prescribe you antibiotics for the symptoms you have. I know they will get better with the methods I’ve shared with you.”
No doubt that the patient will want to punch me in the face. They are so frustrated that they can’t get the medication they think they need. And maybe they’ll have a few choice words for me like: “Well, my death is on you!” But, when they go to fill out my clinician survey, they can’t get those sweet fluffy words out of their head. Their mouse is hovering over the Extremely Unsatisfied but they can’t get their finger to click.
YES!!
VICTORY IS MINE!!! (head tilted back, arched back, knees bent, fists pumping – evil laugh).
The diagnosis
Have you ever heard a patient say: “Oh okay, so your diagnosis is a urolithiasis and not a nephrolithiasis. Interesting. I really liked your differential diagnosis and the 4,208 different things you consider before coming up with that diagnosis.”
No, fuck no! They don’t care about all the hard mental work we put in to make sure we don’t miss something. They don’t care about all the different things we’ve considering. They don’t appreciate that I can tell the difference between a voice affected by laryngeal edema versus peritonsillar swelling versus pharyngeal mucus.
Logic gets tossed out of a moving car when someone is sick. It also happens when someone is in love, when they have a new baby, and when they experience the death of a loved one. Reasoning with a sick person is a losing battle so don’t rationalize excessively. Be the health expert they turned to and sell them on your suggestion.
Your patients don’t know what they don’t know. Horner’s Syndrome because your left eyelid twitched? $#!^% please! The patient didn’t go to medical school, they aren’t aware of all the potential variables which need to be accounted for, and, fortunately for us, they’re not the ones who are gonna get paid $100+/hour.
I’m not talking ill about patients here – but they aren’t the experts. We can’t judge them for what they don’t know. And though it frustrates the daylights out of me when someone thinks they are an expert because they read a wiki on cauda equina, it changes nothing – I still have a patient visit to complete. Wiki might have the facts, but I have the sales tactics to reassure them.
My point is that as clinicians we place 98% emphasis on the diagnosis while the diagnosis is only an afterthought and maybe even a nuisance to the patient. They want their expectations met. They want their fears addressed. They want to feel heard and they want you to listen.
The curly B-line on the x-ray are a brilliant finding to give your colleague a hard-on but totally useless to the patient. They just want to make sure they aren’t going to die. That they don’t have cancer – the same lung cancer their mother unexpectedly died of at age 62 even though she never smoked. But we didn’t capture that and she left the visit wondering and not fully having faith in your diagnosis. Maybe she left giving you a bad review or made a follow-up appointment as a bounceback because she just wasn’t convinced.
Burden of info transmission
You would think that the majority of the burden of information sharing would be on the patient. After all, they came to us. They should be the ones to tell us everything we want and need to know. They should ask all the important questions. If that was the case we wouldn’t have a term like “poor historian” or “goddamn pain in the ass manipulative passive aggressive patient”.
But I’m joking, even though I want to be able to label that angry patient as just a bad person, there is more to it. What is it I said or didn’t say that unleashed their wrath on me. Don’t get me wrong, no human should verbally mistreat another human being, but in the heat of the moment, we’re not logical creatures. Hence, teen pregnancy.
Think back to the last time you hired a plumber or electrician. If you didn’t give them all the information and didn’t ask all the questions, it’s all on you. They don’t care. They have plenty of business. They aren’t there to sell you on shit. “Look man, do you want your garbage disposal replaced or not?” There is a zero fiduciary responsibility on the part of the plumber.
If you’re going to be a clinician, the burden is sadly on you to gather all the necessary information. And I’m here to tell you that, yes, it can be tedious and a pain in the ass. But if you do it, if you do it right, it’ll make your life so much easier. And eventually it will become a system you follow – a habit.
Not only is the burden of information gathering on us, but the burden of relaying our impression and assessment is on us. It’s not enough to listen to the patient, you also have to make them feel heard. Now you know why I’m single!
Do it for yourself
Getting happy telemedicine customers is a win-win situation. To elevate your customer satisfaction game all you have to do is engage in a conversation. A conversation is fun, all you’re doing is be naturally inquisitive. That shouldn’t feel like a drag to you. After all, the clinical shit is the easiest part of being a medical professional.
If you engage in a genuine conversation with your patient then you give yourself the space to be inquisitive. You can try to find out what they are worried about, why they want the antibiotic when the data shows that it’s bad for them, how they deduced pancreatic cancer from their seasonal sniffles.
It’s like the waitress who stays in a pleasant and positive mood even when you’re being an asshole and taking your shit out on them. You’re snapping at the waitress because your snotty toddler has you at your wit’s end, but she remains calm and remains attentive and offers solutions. By the end of the meal you apologize to her and leave her a great tip. That’s magic!
When you’re inquisitive, when you ask questions, and when you get to the bottom of why the patient decided to pay the money and hop on a telemedicine visit with you, you’ll satisfy that customer.
Giving them your diagnosis is 1.1% of the whole equation. So focus more on the process and less on the final diagnosis.
Are you in a bad mood?
Man, some days I am Count Grumpula – I’m annoyed by the sun, birds chirping, and even the rainbow unicorn frolicking in the meadow. I wanna break off its horn and beat it with it. …too much?
This is one reason I love being able to pick up a shift last minute or work however long I want. In such a situation I have zero reason to be in a pissy mood. I chose to pick up this shift when I felt like it. I can choose to stop at any moment.
And this is what I would recommend – ideally you can work for a company which allows you the flexibility in picking up a last-minute shift. Ideally when you didn’t just get off of a collect-call from your son who is in jail.
But when you’re scheduled for a shift, it’s not as easy. Imagine you wake up to the melodious sounds of your partner emptying their colon in the bathroom at 7:48 and you have a shift starting at 8:00. You didn’t sleep well and you have 361 things on your to-do list for the day which you want to get done between patients. Yea, bad idea.
Besides a rectal tube for your partner, what else could you do to make your scheduled shift easier?
Multitasking
Don’t plan anything during your shift. Look, if you have some downtime, great. But even then, doing 2 things at the same time is emotionally and mentally exhausting. You can’t hide this exhaustion and frustration from your patient. So don’t do it. Stare off into space between patients. Fantasize about the sexy barista, sip on your coffee, or pick your nose.
Morning routine
Have a morning routine. I swear it works, try it. I’m a single dude so I get the entire day to myself and get all the space I need. But those of you with fetuses running around, in-laws visiting, and partners sharing your space with you, you need a morning routine and maybe a shot of Versed.
This is the one time you can be totally selfish. Someone wants to talk to you during your morning routine? Give them the middle finger. Metaphorically – don’t flip off your toddler. But man, enjoy your morning coffee. Make that awesome avocado toast with cracked peppers before you get online to listen to your patient telling you about their green colored diarrhea.
Just like a high-level athlete visualizes their moves before every game, you will benefit from playing out your day in your mind. I don’t spare any details, from pulling out my laptop to asking questions to the patient, to possibly being interrupted by something unexpected and planning how I would deal with it.
It works. I’m tellin’ ya, this shit works.
Interruptions
When I’m doing a telemedicine shift, I don’t wanna be interrupted. Even when I’m in the urgy seeing patients back to back, I don’t want to be interrupted. I’m thinking about a ton of different things and don’t want to lose my train of thought.
Every time I’m interrupted, it takes effort on my part to get back to the task. This is draining. It exhausts me and makes me sounds agitated on the phone.
More money in your pockets
Angry patient sue. Unhappy patients sue. Satisfied patients rarely sue.
And if you follow my patient satisfaction recipe you’ll have an easier time doing telemedicine. Which means you can do more telemedicine. Which means more money in your pocket; of which I’ll take a tiny 10% commission.
If you have high patient satisfaction scores it’s really hard to discredit you in a malpractice suit.
If you have high patient satisfaction scores, it’s really hard for anyone to believe the one psycho patient who brings false allegations against you.
If you have high patient satisfaction scores you’ll be picked over the other clinician for the job.
If you have high patient satisfaction scores it’s hard for your boss to chew you out about you missing a shift or some other drama on your part.
If you have high patient satisfaction scores you are able to take on higher-paying administration jobs.
You can read this other post on 5 steps to being a superb clinician.
Here is a post on patient satisfaction scores and prescribing rates.
Learn how to say “no” strategically to telemedicine patients.