You Can Tie, You Can Lose, But You Can Never Win


The article below was forwarded to me by a reader. It was originally published on the Student Doctor Network by an anonymous poster who goes by the handle “BirdStrike” and was made free to republish. For those of you who want further insight into how patient satisfaction rankings adversely affect medical care in the emergency department (aside from the fact that highly satisfied healthy patients are twice as likely to die from their medical care) – it will be interesting reading.

By the way, the “Death Knell” article is now number two on the list when you do a search for the term “Press Ganey”. The “Flunking Own Rating Scale” article I wrote is number three on the list. Clicking on the link to this article a lot will make it climb in the “Press Ganey” search term rankings as well.


What you’re getting at, is the core of why patient satisfaction scores in the ED are so soul crushing to some of us and what is so fundamentally different psychologically and philosophical about being a physician in the ED, compared to any other setting.

Outpatient physicians have always had their own version of “Press-Ganey”. So does every business in a free market. In their case it’s “name”, “reputation”, and “practice building”. If their patients don’t like them and aren’t “satisfied”, they go elsewhere and the practice, and ultimately the docs pocketbook, suffers. If their patients are satisfied, the physician benefits with a more robust practice and fatter wallet. This is like any other “business”. The better a business is at providing a product or service, the better off the business is. This is how it should be. Doctor makes patient happy, happy patient makes doctor happy. It’s a positive feedback loop. (Although a physicians practice is more than “just a business”, it is a professional practice held to ethical standards, it has to pay the bills, with dollars and cents, according to the rules of business.)

However, the ED is like no other business in the world. In the ED, you’re swamped no matter what. You have no control over your workflow. There’s essentially no risk, ever, of not being busy enough to “put food on the table”. Being overwhelmed with patients is the rule. Whether or not there are too many patients to see, or twice as many patients than you can see, or three times as many patients as you can see, does not affect your pocketbook, and does not increase your job satisfaction. In fact, the busier it gets in the ED and the more”customers” there are, the worse the job satisfaction. It’s a negative feedback loop. Unlike the outpatient doc, where the more satisfied the patients are, the busier the practice is, the healthier the pocketbook is and the happier the doc is. In the ED it is the exact opposite. In fact, you are grinding the machine to increase the job satisfaction (and profits) of someone else such as an administrator that you might not have even met or barely know.

This is why outpatient physicians in private practice (and all good businessmen including hospital CEOs), especially ones in their earlier years building a practice (or business), just don’t see what all the complaining is about. To them, “patient satisfaction” is their lifeblood. Without it, they can’t pay their staff, their practice overhead or their own salary let alone have any profits left over. This is a crucial difference. Another crucial difference is that when they reach the point of saturation, there are several protective mechanisms not available to ED physicians, that keep the work load and stress load to a manageable level:

1. “Office closed”.

There is no law stating that the overwhelmed pediatrician, plastic surgeon, dermatologist or business owner has to keep the office open after 5pm, through 2am and until 7 am and around the clock because there is a line of patients with no ability to pay him or with government insurance that pays $0.08 on the dollar lining up around the corner. There is no contract with the hospital corporation stating he and his partners MUST find a way to provide coverage to all customers, no matter how rapid and unmatchable the increase in volume all the while meeting some arbitrary “door to doctor” time-, and patient satisfaction goal.

The legal burden, at the threat of $50,000 dollar fines, to ever expand your workload to non-urgent patients, regardless of the ability to do so, and regardless of the support staff provided, while being held to a “boutique standard” of satisfaction is an oppressive burden.

2. The ability to tell an abusive insurance provider, “Your payments aren’t worth my time” and go “non-par” (non-participating).

The fact that EMTALA makes this option almost impossible, even for non-emergency patients that abuse the ED, is further oppressive. The only thing providing any significant upward pressure on the payers in this country to pay physicians acceptable wages, is the ability of physicians to individually opt out or insurances that arbitrarily, and unfairly cut or eliminate payments for services to an unacceptable level. This dissatisfies the customers (patients), who switch insurances to companies that have more doctors in their network since they pay doctors more fairly.

It’s like walking into a convenience store paying for your groceries and being told even though you paid for a gallon of milk, you only get a quarter cup. Even though you paid for 10 rolls of toilet paper, being told, “From now on, you only get two for the price of ten, and we reserve the right to give you even less, for any reason, at any time” and being bound by a law that prevents you from taking your business to a company that treats you ethically.

Not having this ability, in relation to non-emergency care, and being bound to “satisfy” such “customers” who use EMTALA as a means to pillage your services to have to keep your job, is wrong.

3. “The schedule is booked”.

A human being should know that there’s some limit to his potential daily workload. What other profession expects you to show up at work and be told upon arrival, “Here, you have twice the work to do today,” then before you can get halfway through the first part of the days double workload, “Here you go, here’s four times the work. Get it done. Get it done as fast as you would get a single days work done. Don’t cut corners because that could be devastating and dangerous and keep a smile on your and the customers faces. Yeah, I know it’s tough but you can do it. If not, that’s okay too because we have a mega-group that wants your job for 20% cheaper anyways”?

Ever walk in for a shift and there’s 4 patients waiting? You go see those four as fast as you can and when you come out of the fourth room, there’s eight on the board. You and your wing man dig your heels in deeper, dive in and see those eight together and when you resurface, there are 12 patients on the board. As the shift goes on, the harder you work, the worse it gets and the sicker the patients get? Of course you have. Do administrators work under these conditions? Hell no. Only a fraction of a fraction of a fraction of people reach this level of education, knowledge, professionalism and ability to handle stress that would leave most people naked, in tears, shivering in a bathtub. Yet administration doesn’t even have the respect to evaluate physician performance with something other than a sloppy, unqualified patient satisfaction survey, that out of context and in numbers not up to scientific standards, means nothing.

Treating all patients with respect and dignity is part of being a physician and a professional. However, being expected to function within this model, while following the standards of medical care and ethical practice, while being expected to take care the multiples of the sickest and most critically injured patients in the medical world, yet be subjected to standards of “customer service” designed for luxury product salespeople standing around showrooms waiting for customers to arrive……is just plain wrong.

4. Abusive, non-compliant and insatiable patients can be turned away, permanently, and discharged from non-EMTALA bound practices like any other free business.

Plain and simple, it is basically humane to allow physicians this ability. Yes we all know ED physicians signed up to take care of such patients. It is well known that ER physicians cannot turn away people that are drunk, violent, abusive or rude. All other doctors can. All other businesses can. You can’t walk into the hospital CEO’s office drunk, violent, abusive and rude and have you’re a-s kissed. ER physicians cannot turn away patients who have threatened to kill their staff and coworkers. All other doctors can. Hospital CEOs can. ER physicians have to take care of the child run over by the drunk driver, and turn around and treat the drunk driver in the next room, and stay professional and keep their cool, then suffer the consequences of a negative patient satisfaction survey of a patient who is upset they waited “too long” while the physician ran the trauma codes.

As far as I’m concerned, the least society and hospital administrators could do, to thank us for routinely handling some of the worst situations in the medical world, under the worst conditions, with a huge portion of services provided for free, is to qualify patient satisfaction scores?

Is this asking too much? If a patient comes into a family practitioners office, is late, rude to staff, hasn’t taken his medication, and writes a complaint letter to his doctor complaining that his blood pressure is still high, that he’s upset and switching doctors, the physician has the ability to qualify this complaint and verify its validity. He rips it up and throws it in the garbage. He knows this patient likely can’t ever be satisfied and puts very little weight on it. He does not question his own performance as a physician and shouldn’t, nor does anyone else.

On the other hand, a complaint such as this: “Doc, your staff is rude. I always have to wait 2 hr to see you and when I finally do, you’re out of the room in 5 minutes. You don’t listen. I’m feeling sicker. I’m thinking of switching doctors” has great value. The physician may be offended at first, but after thinking about it, he realizes there is an element of truth to it and he actually thanks the patient for letting him know. It’s qualified. It’s given much greater weight than the complaint of a patient who has unrealistic expectation and makes inappropriate demands.
The outpatient private practitioner serves a master: the master is his patients and the master is himself. If his patients dislike him, he suffers. If they’re HAPPY, he GAINS. It’s a positive feedback loop.

In the ED, if patients dislike the ED doc, and his ED, it’s no loss. There’s a waiting room full of desperate people waiting to fill the void. There’s no loss. In fact, there’s often a subconscious (false) belief that if a few patients are steered away, it just might lighten the load.

This is wrong. The revolving door never stops bringing in work. There’s often also a false belief that, “If I just push it a little bit more past max velocity that I’ll get a break”. The faster you go, the harder you work, the more the billboard says, “one hour wait………45 minute wait……..15 minute wait…….13 minute wait” and sends more piling in. As more masses pile in, the ED physician won’t ever earn more, he’s working at or very close to maximum capacity all of the time. It’s a negative feedback loop: the faster you cut through the never ending workload, the more satisfied you keep the many times insatiable patients, the more pile in to generate money for the corporate suits bonuses. It is exceedingly unlikely that any “increase in customers” will increase the ED physicians “business, paycheck, job satisfaction or livelihood”, because as I stated before likely he has already settled in to his maximum sustainable pace and has an oversupply of patients to begin with.

Making matters worse is that there is NOT a linear correlation between “quality of medicine practiced and patient outcomes” and “patient satisfaction scores”. In fact, often times it is the opposite (see thread on topic). Telling someone they may have cancer is not “satisfying” to the patient, but it may be your job to do it. How do you send someone a satisfaction survey after that? Telling someone you have the ability to do their ingrown toenail repair, but don’t have the time, because it’s 3am, you’re working single coverage, have two critical care patients in your ED and have a ped vs motor vehicle coming in, and that a podiatrist can take his time and do it much better Monday morning is not likely to ever “satisfy” a patient, but it’s the right thing to do. How do you send that patient even a level 1 or 2 bill for your time spent evaluating them and their toe and ruling out infection/abscess/osteomyelitis and explaining the situation and treatment options, knowing that the patient going to say “he did nothing for me”, when in fact your decades of training allowed to rule out life and limb threatening causes of the toe pain within seconds of looking? (Yes, toe pain can be life and/or limb threatening.)

A lay persons view of what “feels most satisfying” often has no correlation with proper medical practice, and in fact, often is the opposite. This is what makes the application of the current model of corporate centered patient satisfaction to the ED setting immoral and unethical and incentivizes the physician to perform outside of the standard of care to support not better patient outcomes, but corporate revenue.

The current corporate model of “Patient satisfaction” in the ED goes like this:

You can tie, you can lose, but you can never win.

An A+ is the only grade accepted. A “5 out of 5” is expected. A “4 out 5” is not a “B” grade. It drops the “B grade” physician, not down a rung, but to the very bottom of the not bell-shaped, but steeple shaped curve. Also, it dis-incentivizes good medicine, it incentivizes catering to unhealthy demands by many patients, it is fueled by non-physician administrators desire to generate money for themselves with no regard to proper practice, and is powered by coercive threats to physicians that if they truly do the right thing, instead of “getting in line” for administration that they lose their contract and jobs.

The reason that the application of patient satisfaction surveys to yourself in the ED feels disturbing and wrong, is because it is. It’s unethical, bad for the patients and bad for the physicians involved.

For those of you that demand proposed solutions:

1. EM leadership (ACEP, ABEM, SAEM) should have the courage to support their own and make a statement that current patient satisfaction surveys are ill suited to ED setting and promote substandard care, and are fundamentally unfair to ED physicians as currently applied to the ED setting.

2. EM physicians should demand that their leadership be allowed to construct their own model of monitoring patient satisfaction that qualifies cases of inappropriate patient expectations (for example, unsatisfied because ED physician refused demand to violate standard of care, order inappropriate CT, prescribe inappropriate antibiotic/pain medication, etc). This could involve anything from reverting to “the old fashioned way” of dealing with complaints such as ED director addressing complaint with ED physician based on merit, to developing a new model of formal patient satisfaction surveillance as a joint project between EM leadership and polling companies.

Any solution should center on EM physicians being active partners in developing and applying any patient satisfaction monitoring systems that apply to ED settings. EM physicians need to take this specialty back. This could be one small step.


  1. Long Time E.D. doc on

    This may turn out to be the ultimate treatise on the topic.

    I’d suggest that it be forwarded to every hospital administrator, although I suspect most wouldn’t bother to read it. Then again, why would you read this article (or any article for that matter) if you believe you already know everything about how an Emergency Department works? After all, administrators walk through the E.D. for several minutes at a time a few times a year when VIP’s are present. What’s not to understand when making institutional decisions? (“We are clearly committed to the Press Ganey data…”) What we do in the E.D. is obviously so straight forward. Hence, this is why E.D. physicians/groups are considered easily replaceable.

    Thank you again for an article that will circulate for a long time to come!

    • Thanks, I’m glad you identified with it. My point was to present what is essentially a moral and ethical argument against this practice as it is currently applied that goes far beyond simple whining and complaining, that if people get behind it, could empower those affected, specifically EM doctors, hospitalists, and patients. The focus should be on moral and ethical fairness for those who are subjects of the surveys, and what is best for patients. We cannot lose sight of these things for the sake of profits alone.


    Since there are no pt satisfaction surveys with “excellent reliability and validity” or that are “adequately powered”, this position statement supports a ban on the currently available surveys. You forgot to mention the American Academy of Emergency Medicine in your list of EM leadership, despite the fact that ALL its members are board-certified specialists in emergency medicine or EM residents, and it has over 6000 members.

  3. Wow. Amazing read. As an ER Doc this makes me simultaneously proud of the work I do and disheartened by how frighteningly accurate this is. It’s a manifesto.

  4. Hmmmm,

    I might need to rethink how I score evaluations like the Press-ganey

    By my nature, I assume that 5/5 means that service was perfect, and there is nothing they could have done better. I don’t believe in perfection though, so I never/rarely score any business, service, or employee as a 5/5 or 10/10 or 4.0 whatever the scoring system.

    Specific topics, I might give a 5/5 to, but overall I almost never score anything as perfect.

    4/5 means I was satisfied and happy to me.

    Sorry if I ever visited your hospital and some administrator, who thinks everyone understands your scoring system the way he does, abused you for it.

  5. Nursing fun: Our ER (ED if you’re Whitecoat) is seeing approximately 30-50% more than we are budgeted for each shift. Yesterday alone, we saw the # of patients budgeted for in the entire day just during the evening shift. The least amount of patients that we’ve been seeing lately is the amount we’re budgeted (ie. staffed) for.

    We are expected to, and I kid you not, spend time calling all of our discharged patients to check on them, see how they’re doing after discharge and see if they have any questions and encourage them to fill out their survey when it arrives. This involves pulling up and reviewing everyone’s chart, making a call, getting no answer, and moving on to the next one. It doesn’t matter if you’re an elderly fall patient discharged home with home care or an 18-year-old who wanted a pregnancy test…you have to call them.

    So we’re 15 deep in the lobby and 10 deep in the back and we’re calling toothaches and chronic abdominal pains.

    So, the last time I got all my scheduled breaks was like last job, but I’m expected to do mandatory education, online renewal of my ACLS/BLS while on my shift, call a bunch of toothache patients who list the grocery store as their home address, and then see a couple more patients than is safe to take care of. But, please, “Look for a survey in the mail in the next month and please take the time to let us know how we did.”

    Only good thing about the surveys is that if the numbers start creeping down and the volumes start creeping up, SOMETIMES (although rarely) this can be used as muscle to get more staff.

  6. In your honor, when my husband unfortunately ended up in the Emergency Department twice recently I made a point of filling out the Press Ganey surveys and giving everyone the highest scores.

  7. Hospitalists feel much the same way as you do. I had to stop several times while reading this post and read parts out loud to any doctor within earshot.

    The patients are essentially asked if the doctor “always” did everything perfectly – the vagueness of the question should automatically invalidate the response. Not to harsh on surgeons – (but I’m an internist, it’s second nature) but if the orthopod rushes in and is abrupt and doesn’t take time to hold grandma’s hand and walk the family through the whole hospital stay then the patient won’t say the doctor ALWAYS explained everything and treated them with respect. When the hospitalist may well have spent a great deal of time doing just that – making sure all the home meds are correct, arranging rehab, taking care of the fall at 3am, controlling pain meds, actually addressing code status…etc. The sat scores are not parceled out in a way to delineate any of that data.

    We are told we suck. Maybe we do…but this data sure as hell isn’t a valid way to show that.

    • You’re right. Hospitalist deal with the other side of the identical coin and work very much “in the trenches” like EM physicians.

      I’m curious as to what parts you “had to read out loud?”

  8. This is one of the greatest things I have ever seen written about the current state of Emergency Medicine, Sad but true.
    Luckily, I work in a place where we don’t do satisfaction surveys. We don’t call toothaches back to check on them, and you know what? The job is still plenty hard enough!

  9. Any possibility of a good old union?

    Working in groups you guys are just underbidding each other and further undermining yourselves

    Australia which has a union culture, the EM docs have better pay,, lifestyle, and dignity

    The whole bill is nonsense, 2.5 billion annual health expenditures, 6% is physicians, 31% administrative cost,
    Not sure rest but: 6% other workers maybe, then what 30% corporate profits minimum Id say

    Just do a sit in strike and take care of emergent cases and FT screen. Let everything else pile up and you can get any lost wages back when you negotiate from a place of strength

    • I like your take on this. Unfortunately, I think you are right, that no one will really listen until the doomsday scenario you describe. I’m working on something right now, which will explain more where I think this is going, and how we can best empower ourselves. It’s good to here someone’s view of things from the other side of the world, literally.

  10. And although you guys dont realize it cause you take care of people at the worst moment of their lives or people living the effects of poverty

    You have more public support than any other physician group hands down

    Not a police department in the country that would break up a sit down strike of ED physicians and I think certain labor agreements can allow for nurses not interfering by somehow using them to pick up the clog you want to leave

    This article is great and I think Im still doing the EM match next year, but nothing else is going to fix these issues except straight up action as much as you can without anyone dying. All the billing and RVUs can be paid back in full if it was pulled off right

    Jon q public who already feels like shit reading his newspaper in his underwater mortgage is not going to feel any better reading of stories that if he should get in a car accident his life may be compromised from inhumane work conditions from a toothache or hangnail

    Its media and lobbying working against physicians every step of the way with this obamacares attempt to enslave healthcare workers

    Its just going to follow this downward trajectory, they are playing dirty and like I said 2.5 trillion a year in the biggest profit margin business in this country and the last thing they can strip from people to piss away on wall street

    Not enough people will see this article and it wont effect them as strongly as it does people in healthcare.

    I see a labor lawyer as the best investment to your careers

    Even the largest group should see how this will play out and that theyll be down as well soon enough

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