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Winter 2008 - Vol.3, No.4
Christopher T. Addis, M.D.
Chairman Department of Medicine
Chief, Division of General Internal Medicine, Medical Associates of Lancaster


What makes a great physician? Being the brightest in the department? Being the most compulsive in the division? Although these are admirable traits, what makes physicians great is their effectiveness. This is a new and important word in the vocabulary of the medical staff.

Although physicians have always found it necessary to budget their time wisely, changes in the practice of medicine over the past two decades, particularly in how a physician’s time is valued and reimbursed, have lent new urgency to the importance of executing one’s duty to patients in a time-efficient manner. A medical staff member quickly learns that dissatisfied patients utilize a disproportionate share of resources. Their anxiety and frustration are transplanted to the nursing, ancillary, and attending staffs, as well as to all the attending physicians. No matter how great the diagnostic and therapeutic acumen possessed by physicians, their efforts will be continually bogged down in a quagmire of questions, explanations, and re-explanations necessitated by a dissatisfied patient. As we will see, communication is the key to being effective. This is most important between physicians and patients, but also among all members of the health care team.

Recently there has been an increasing emphasis on the “patient experience.” A direct link between pay and performance, not only for reimbursement of hospitals but for physicians as well, is becoming a hot issue. According to Joseph A. Miller, senior vice president for the Society of Hospital Medicine, about half of the hospitalist programs in the country have some of their compensation tied to quality measures. That proportion is not only likely to increase, but will include patient satisfaction scores. Epstein has discussed how HMOs linked reimbursement rates to patient satisfaction.1 We are seeing the pendulum swinging back again to pay-for-performance.


Recent data from Press-Ganey surveys of patient satisfaction at Lancaster General Hospital indicate there is considerable room for improvement in these scores. This crucial issue must be addressed. Press-Ganey scores have identified many long term problems, but there are three key patient complaints that can be addressed in the short-term:

  • “I never know who my doctor is.”
  • “My doctor never spends any time with me and is always in a rush.”
  • “I never know what happened to me or what’s going to happen next.”

These issues are especially apparent among patients cared for by the Department of Medicine. Surgical patients generally know who their surgeon is, what was done to them, and when they are likely to go home if recovery proceeds uneventfully. They have an expected course in mind which – in the absence of unusual complications – is often routine, is usually fulfilled, and can be quite satisfying. But the medical patient’s clinical course often varies day-by-day according to the patient’s response to treatment and the results of new incoming data. This understandably can be confusing and contradictory to a layman, especially when many consulting physicians are involved.


In formulating strategies that address these three key complaints, it is vital to understand that these complaints have a common cause – inadequate or unsatisfactory communication between physicians and patients. Fortunately, communication problems are remediable, and it is remarkable how much can be accomplished by seemingly simple measures. In the immediate future, a pilot study will be undertaken on 7 North to evaluate three strategies that should increase patient satisfaction noticeably.


Complaint #1: “I never know who my doctor is.”
Strategy: The name of the “active” attending will be listed on a white dry-erase board in the patient’s room above the names of the RN and CRNA. The attending may refer to this board when re-introducing himself or herself to the patient.

Complaint #2: “My Doctor never spends any time…”
Strategy: Bedside seating will be provided so the doctor may sit, rather than stand. A “half minute” of seated conversation has a greater impact on the patient than “thirty seconds” of standing.

Complaint #3: “I never know what happens…”
Strategy: Notebooks will be provided to patients so they can keep journals in which brief entries can be made by the doctors, PAs, NPs, nurses, and the patients themselves. A brief description of the diagnostic or therapeutic plan, a diagram, or merely the spelling of a diagnosis, will enable the patient to understand his or her clinical course and share the information with family members.


To assess these strategies, a baseline (pre-7North initiative) score will be compared with the scores of ongoing discharge surveys after these new physician behaviors are implemented. Hopefully, patient satisfaction will improve. Although data from surveys can be problematic, it is the best tool yet. Measures will be in keeping with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey recently released by CMS so we may compare “apples to apples” when looking outside our institution to similar hospitals.


It truly is ironic that in an age of text-messaging, e-mail, and pagers, we actually speak to each other less and less. As pointed out at a Johns Hopkins Summit Meeting on this topic, “The patient-physician relationship must mirror our daily lives by relying on methods of communication that are not limited to inflexible, one-on-one visits.”2 A satisfied patient will be less frustrated, less prone to over-utilize human resources, and less likely to prompt unnecessary tests.

These changes will not only improve the quality of the physician’s work life, but are likely to have a positive financial impact. They will enhance the loyalty of patients and the reputation of the hospital. In a recent article, Stern and Papadakis commented, “Patients’ perceptions of physician conduct can help identify the minority of physicians who have consistent problems with professionalism, and help to reward those whose performance is exemplary.”3 An article in JAMA in 2002 noted that patients’ complaints are associated with physicians’ risk management experiences.4 The better the relationship between the physicians and the patients, the less risk there is for litigation.

Communication is at the heart of any important relationship, whether within a marriage or between a doctor and patient. Strategies to help the physician be a better communicator and thereby a more effective one will have long-lasting effects that will nourish future relationships within the hospital system.

[1]Epstein, et al. Paying Physicians for High Quality Care. NEJM 2004; 350:406-410
[2]Ahmed J, Alford M, et al. Defining the Physician-Patient Relationship, 3rd Annual Disease Management Outcomes Summit. October 30 – November 2, 2003 Phoenix, Arizona;
[3]Stern DT, Papadakis M. The Developing Physician. NEJM 2006; 355:1794-99.
[4]Hickson G, Federspiel C, et al. Patient’s Complaints and Malpractice. JAMA 2002;287:2951-2957.

Neither Dr. Addis nor any member of his immediate family have any relevant financial relationships with any corporate organizations associated with the manufacture, license, sale, distribution or promotion of a drug or device to disclose.

Christopher T. Addis, M.D.
Medical Associates of Lancaster
2110 Harrisburg Pike, Suite 100
Lancaster, PA 17604