I recently changed my children’s dentist because his office was too nice. As with their doctor, it is impossible for a lay person to have any idea whether their dentist is clinically competent or good. Most of us choose our dentists the same way we choose physicians – by personal recommendations from people we know, by recommendations or referrals by our other doctors, and occasionally by looking online. When we moved to Salt Lake City a few years ago, we chose our doctor by the personal recommendation of a colleague, and I chose the dentist by asking the pediatric office staff where they usually send their patients.
The thing is, patient perception of quality does not necessarily correlate with good care. In medicine, it has been shown that improved patient satisfaction correlates with more antibiotic prescriptions, more pain medication prescriptions, and perhaps not surprisingly, increased mortality. For hospitals, patient satisfaction correlates far more with hospital food or cleanliness, than anything about the physicians or care providers, though increased staffing ratios were also correlated with better scores. The PPQ scores are part of the routine surveys that are regularly administered and publicly available. Increasingly, these patient satisfaction measures are the way that physicians, and hospitals, may get paid, and they are influenced by a variety of factors. Many consulting groups are in the business of helping hospitals improve these survey results, and if you’ve ever gone to a car dealership, you will recognize a few of the interventions that correlate with better “customer satisfaction” scores.
Having a clean customer area and snacks available have been shown to improve customer satisfaction scores. So have telling your customers that your goal is to provide excellent customer satisfaction and that they may get a survey regarding your service. At UCSF, I remember one of the endocrinology fellows proposed that the donuts that were available in the waiting room for his diabetes patients be discontinued. While that was likely a beneficial intervention in terms of their diabetes control and obesity, it most likely didn’t endear him to his patients. Some of the more cynical proposals on how to raise our PPQ scores in clinic included suggestions about more formal dress code, fresh-baked cookies and punch in the waiting room, and making some hi-tech equipment visible. These are all likely to boost PPQs without altering what I would consider to be excellent care in our clinic.
As a physician aware of these surrogate measures by which patients evaluate healthcare quality, I am no better qualified to judge the dentist’s clinical acumen and ability than the average person. But I do recognize that Dentistry, like Medicine, has become a business, and the way dentists and physicians still get paid is by doing procedures. From a customer satisfaction perspective my experience at the dentist couldn’t have been better. The dentist waiting room was wonderful – they had a separate play area for the kids, which included a tree house and other great distractions. We hardly waited at all and the staff were professional and friendly. The room where the hygienists cleaned the kids’ teeth had several examination beds with a huge aquarium full of spectacular fish. Each examination bed had a private TV screen on the ceiling with headphones so that the kids could watch a cartoon while the hygienist was doing his thing. The dentist then came and examined the kids one by one.
First up was a girl who looked to be about twelve. “She has some pre-cavities,” he told the mother after examining, “we could cap these off to prevent them from developing into full cavities.” The mother hesitated. “If you want, I can have my assistant do it right now, it’ll only take twenty minutes,” the dentist added.
I know nothing of dentistry. My only experience is that of a dental patient, and though I have no idea whether this treatment was indicated or not, everything seemed a bit too smooth. Was the procedure really indicated, or was it part of the calculus of paying for the nice office and the fancy ceiling TV screens? I shared this anecdote with my friend who lives in the UK and she said that even her “minimalist NHS dentist” capped her kid’s molars right away. The thing is, with the national health service dentist, there wasn’t a question in the back of her head whether her dentist was selling her on a procedure at least in part because of the profit margin needed to pay for the fancy office. I prefer my dentist to treat me as a patient, not as a customer to be satisfied in a profitable business. Doctors are notoriously bad at running businesses (or are they?), and that’s the way I like it. I want my doctor to look at me and think about what I need or don’t need, and not factor in how much he spent on the expensive equipment in the office and how many procedures need to be done to pay the front office staff and nurse or the aquarium maintenance.