Patient Satisfaction? In a Jail?

I think everybody would agree that in the wide world of medicine outside of jails and prisons, patient satisfaction is critically important.  Partly this is because patients are not just patients, they are also business clients.  If they are not happy, they will go to some other doctor and some other hospital.  Many studies have shown that patient satisfaction scores have a strong correlation to revenue and market share.  That is why hospitals routinely track patient satisfaction scores.  Studies have also shown that roughly 80% of patient complaints are generated by less than 10% of practioners.  These complaint-prone physicians, PAs and NPs are often “shown the door” by hospitals and practice groups.  Their negative impact on revenue is just too great to ignore, even if they otherwise practice good medicine.  images-2

But, as I have often heard, correctional medicine is different.  Our patients are a captive group (literally!).  They cannot go to a different practitioner if they are unhappy.  We do not have to please our patients to stay in business.  Our “market share” does not rely on patient satisfaction.  Plus, because of safety and security issues, we have to say “No” to patient requests more than outside physicians; and, of course, inmate patients are not going to be happy about that.  So who cares if inmate patients are unsatisfied?

The answer is:  We all should care.  A very lot. 

There are two main reasons for this.

First is the time management issue.  Inmates unhappy with their medical care may not be able to leave, but they certainly can return time and again to the clinic, write grievances, complain to their families, or contact the ACLU.  Responding to these takes time.  In the end, it takes less time and effort to develop a trusting patient relationship than it does to respond to complaints and grievances.

Second, (and more importantly) it is hard to practice good medicine if your patient does not trust you.  In my last post, I discussed that the medical efficacy of everything we do is enhanced by the placebo effect if the patient trusts us and believes in us.  On the other hand, our medical efficacy is hindered if our patients question our competency or our sincerity. Even in corrections, we want and need our patients to be happy with their medical care.

However, this can be harder for us in corrections to accomplish than it is for outside practitioners.  Our patients come into the facility already mistrusting the “system,” which includes us.  Many inmates, maybe even most of them, start out not believing that we have their welfare at heart.  We truly do have to say “No” to inmate requests more than outside doctors.  So we often start out fighting an uphill battle in gaining their trust.  This makes it even more important for us to pay attention to those factors that engender trust with our patients.  But what are those factors?

Interestingly, there is a surprising amount of published literature addressing the question of what patients like and dislike in their interactions with practitioners.  My favorite CME site, Primary Care Medical Abstracts, recently published fifty-one such articles.  Fifty-one! Who knew that much research existed?  I will provide a few of the citations below, but I would like to summarize what these articles say.

Patients want their doctors to look like doctors.

This is not so surprising.  All of us, including you and me, tend to make initial judgments of competency by appearance.  What would you think if the pilot of your next airline flight sauntered on board looking like the lead singer of a rock-n-roll Hair Band?  Patients are no different.  In studies, people were shown pictures of doctors and asked which doctor they would prefer. Not so surprisingly, they want their doctor to look like a doctor.  They like white coats.  They like nice shirts, nice pants, nice shoes.  They like cleanliness.  They do NOT like sandals, t-shirts or jeans.  They do not like provocative clothing—no miniskirts, cleavage or muscle shirts.  They don’t like ear rings on men or gaudy jewelry on women.  Interestingly, they didn’t care one way or another about ties.  And they thought scrubs were OK.  The further that the doctor’s appearance deviated from the test subjects perception of what a doctor would look like, the more the subjects questioned their competence.

(Note:  Sometimes I will use the term “Doctors” and sometimes “Practitioners.”  I mean to include with both terms physicians, physician assistants and nurse practitioners.  This particular study asked test subjects about “doctors” but the answers would not have changed for any medical practitioner.  Actually, the principles I discuss here would equally apply to nurses in their encounters with patients, as well). 

Of course, you don’t have to dress professionally to do your job.  But if you don’t look like a professional, you will constantly have to overcome the instinctive perception that, well, you’re not a very good doctor.  And remember–we in corrections already are starting out being mistrusted.

Patients want their clinics to be clean.

19960508I’ve seen that this sometimes slips in correctional facilities.  But again, medical professionals are partly judged on our competency by how clean our clinic is.  I recently toured the Deberry Special Needs Facility in Nashville. The warden there, Bruce Westbrooks, talked about his belief that facility cleanliness is the basic key to every other part of the prison discipline.  If a prison facility is clean and well-maintained, he said, there are fewer fights, fewer rule violations etc.  Once cleanliness slips, this is perceived by both inmates and staff as a lax attitude toward self discipline in general and, as a result, everything else slips with time.

I agree with Warden Westbrooks and I believe that this is even more important in a health care setting.   Patients, including inmates, expect a health care clinic to look and smell clean.  If it does not, they will immediately suspect lack of caring and competence of the staff.

Patients want their doctors to be attentive and to listen.

Here is an interesting study:  Doctor one walks into an ER patient’s room and does a quick history and physical.  Doctor two does exactly the same thing.  The only difference is that doctor one stands up during the whole exchange and doctor two sits down.  Patients are then asked how long the doctor spent talking to them.

I find this amazing:  When the doctor sat down, patients perceived that he spent twice as much time with them, even though the two doctors spent exactly the same amount of time in the room.  The teaching point here is that we communicate with our patients in many non-verbal ways.  Standing gives the impression that “I am in a hurry to get out of here.”  Sitting gives the impression that “I am settling in so I can listen.”  Other non-verbal cues that patients like are when the doctor looks them in the eye, and nods to show that she is listening.  Such behaviors are habits that do not take extra time, but result in increased patient satisfaction.

Another good habit is to allow the patient to speak without interruption and then stating back to them what their complaint is.  Doctors are notorious for interrupting patients too quickly.  I myself have this bad habit, but I have found that if I can stifle myself (usually with a sock) and let the patient talk, the better and faster the clinic visit usually goes.  I’ve found that patient themselves will give me the signal that they are ready for me to chime by pausing and looking for a response.  The difference in time between when I (in my impatience) would have interrupted them and when they give the “pause” signal that they are ready is generally less than thirty seconds.

What is your experience?

Patients like their doctors to explain things.

This is a concept that practioners commonly misunderstand.  As an example, one study looked at patients who went to an urgent care center expecting to be prescribed an antibiotic.  After the clinic visit, the patients were asked to rate their satisfaction with the visit.  Who do you think tended to be happier with the visit, those who got the antibiotic they expected or those who did not?  The surprising answer is:  Those who did not!  Why?  Because the practitioners who did not prescribe the antibiotic had to explain why!  The ones who gave the antibiotic prescriptions just wrote out a prescription and handed it over without talking much.  The key satisfaction factor here was whether the practitioner talked to the patient and explained things!

Inmates are no different.  We correctional practitioners often have to say “No” to inmate requests.  If we explain why we are doing things differently than the inmate expects, this goes a long way to assuage their disappointment.  Many will actually leave the clinic satisfied.

I have found it also important to explain the natural course of the patient’s condition.  For example, people with a cough from a chest cold need to know that these coughs often persist for a long time, sometimes more than a month.  If you don’t explain this, they are going to be back in your clinic in a week complaining “I’m no better.”  Same thing with tendonitis and other musculoskeletal “tweaks.”  These do not get better quickly.  Other conditions, like a simple UTI in healthy women, should be all the way better in two days after you give antibiotics.  If they are not better by then, they need to know to come back.

Patients like to know how long they are going to wait.

These studies were done in hospital ER waiting rooms.  Surprisingly, satisfactions scores did not relate well to overall waiting time.  People know when they go to an ER that they are going to have to wait.  Rather, satisfactions scores were related to whether their expectations of how long the wait would be were met.  For example, if patients were told the wait would be one hour and they waited less than an hour, they were happy.  But if they waited more than an hour, they were unhappy.  The expectation was set when they were told how long the wait would be.  Patients also were unhappy if others in the waiting room “jumped ahead” and were called before them.

In corrections, one “wait” is the time from when an inmate submits a non-emergency medical request until they are seen in clinic. Another “wait” is the time from when we draw labs or do x-rays until we inform the inmate of the results. Here is the key concept:  We set the patients’ expectation when we tell them how long this wait will be.

Lets say, for example, that the average time it takes to get an x-ray report back from a radiologist and to re-schedule a follow up appointment is three days.  If we tell inmates that we will let them know x-ray results “in a couple of days,” but they wait 3 days, the inmates will be unhappy and complain.  This is just human nature. Instead, it is better to overestimate the wait time so you always meet the expectation!  Instead of saying “a couple of days,” tell them about a week.  Then, when the appointment happens in three days, the patient will be happy that you were so quick!

The take home message from these 51 articles is that by changing how we interact with our patients in simple ways, we can markedly improve their satisfaction with our care, reduce complaints and grievances and generally make life better for everyone around us.  Try this experiment:  pick one or two ways in which you can improve your interactions with patients–dressing better, cleaning the clinic, better eye contact.  I will bet that you notice an improvement in patient demeanor within a week.

Besides these, what other tips do you have for improving patient satisfaction in your correctional clinics?  Please comment!

The following is a short sampling of the fifty-one articles.  If you would like a longer list, contact me!

PHYSICIAN BEHAVIORS THAT PREDICT PATIENT TRUST

HOUSE STAFF NONVERBAL COMMUNICATION SKILLS AND STANDARDIZED PATIENT SATISFACTION

PATIENT EXPECTATIONS AND SATISFACTION WITH MEDICAL CARE FOR UPPER RESPIRATORY INFECTIONS

MEETING WALK-IN PATIENTS’ EXPECTATIONS FOR TESTING: EFFECTS ON SATISFACTION

ARE PATIENTS MORE SATISFIED WHEN THEY RECEIVE A PRESCRIPTION? THE EFFECT OF PATIENT EXPECTATIONS IN GENERAL PRACTICE

RELATING PATIENT SATISFACTION TO WAITING TIME PERCEPTIONS AND EXPECTATIONS: THE DISCONFIRMATION PARADIGM

EFFECTS OF ACTUAL W AITING TIME, PERCEIVED WAITING TIME, INFORMATION DELIVERY, AND EXPRESSIVE QUALITY ON PATIENT SATISFACTION IN THE EMERGENCY DEPARTMENT

11 thoughts on “Patient Satisfaction? In a Jail?

  1. Al Cichon

    Everything you said is exactly true. These all also apply to the rest of the health care staff.
    Sadly though, it does not matter to the dedicated problem inmate.
    That said, things tend to go in thirds – 1/3 will be ok no matter how you approach them so long as it is not totally off base.
    Another 1/3 will not be happy no matter what you do (said problem inmate).
    The remaining 1/3 is the ‘swing’ vote – goes with the vocal 1/3 – I’d rather have 66%.
    One additional consideration is the negative officer – always finds something to comploain about – or join in complaining. Even joining an inmate in complaining.

    Reply
    1. Jeffrey Keller MD Post author

      Very well put, Al! There are those inmates (and outside patients, as well, for that matter) who will not be happy no matter what you do. Most will not be happy even if you say “Yes” to their requests and they get their way. They then just come up with a new request or complaint, such as “It’s still not working.”

      It is impossible to please everybody! However, I can be respected by everybody.

      Reply
  2. than aw

    Inmates looks for Jesus or Santa Clause when they come to see us. It is important to att he baseline establish some ground rules. Some are already upset because they already know Jesus and Sant Clause are not with the clinics so they are ready to find it in the referrals. It takes some time for them to realize and because of the confinement, rest and better nutrition off all other garbage they put into their system, most of the time they turn around and began to work with you. Most of this crowd relate to us their pain and injuries relief. Additional provision of non-pharmaceeutical tecniques appears to improve satisfaction.

    Reply
  3. Brad Chandler

    Jeff, I would add one more point, inmate patient satisfaction contributes to Staff safety as well. As we know, agitated inmates are dangerous too all staff. Whether agitated about their healthcare, their food services or their mail call, inmate and staff safety is at risk.

    Warmest Regards,

    Reply
    1. Jeffrey Keller MD Post author

      Excellent comment, Brad! I have noticed this myself. Inmates irritated at one aspect of detention tend to transfer that irritation to other inmates and staff.

      Reply
  4. Jeff Dubin, LISW-S

    I often visit a locked psychiatric hospital to which people are committed due to Incompetent to Stand Trial or Not Guilty by Reason of Insanity status. Although the patients are called patients, they are treated IN EFFECT very much like inmates. I wish everyone working there would read this article, and particularly Brad’s comment about safety.

    Reply
  5. Elissa Hughes

    I would like to mention that it is not only physicians that are the providers in corrections but nurse practitioners and physician assistants. It would be nice if they were recognized.
    Sincerely,
    Elissa

    Reply
    1. Jeffrey Keller MD Post author

      Sorry about that, Elissa! I used the term doctors because most of these studies (but not all) were of doctors, rather than any kind of practitioner. But of course these principles apply just as well to PAs and NPs and I should have made that clear. In fact, I just did! I edited the article to make this clear.

      I didn’t mention another study that asked patients whether they preferred to see a physician rather than a PA/NP. The answer is that the patients didn’t care whether they saw a physician or a PA/NP per se, they preferred the one who explained things the best!

      Reply
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