Respectful Insolence

Patient satisfaction versus quality of care

If there’s one thing that purveyors of “complementary and alternative medicine” (CAM)–or, the preferred term these days, “integrative medicine” (IM)–and hospital administrators seem to agree on, it’s that “patient satisfaction” (whatever that means) is very, very important. Hospital administrators live and die by patient satisfaction surveys, in particular a common measurement derived from Press-Ganey surveys. In fact, Press-Ganey itself sells its services as “driving performance excellence” in health care. The inherent assumption is that if patients are satisfied then they are doing a good job. But it’s subtler than that. The underlying assumption is actually that patient satisfaction equals quality, and the further assumption is that Press-Ganey scores reflect patient satisfaction. Never mind that Press-Ganey scores include questions about a whole host of things that have nothing to do with the quality of care. For example, parking has been a problem at both cancer centers I’ve worked at, and Press-Ganey scores have always taken a hit because parking is a big issue in the surveys.

Similarly, promoters of CAM/IM seem to believe in patient satisfaction über alles. In fact, two large surveys of the state of “integrative medicine” in the U.S. have been published in the last six months or so, one by the Samueli Institute and one by the sugar daddy of quackademic medicine, the Bravewell Collaborative. Did either of them look at outcomes? Well, yes and no. If you’re talking about actual medical outcomes, as in outcomes research, the answer is a resounding no. If you’re talking about “outcomes” as in patient satisfaction outcomes, then the answer is yes. Both surveys focused like a laser beam on patient satisfaction. Lacking any concrete measures for the quality of care they provide, apparently CAM/IM promoters bragged about how happy their patients are with their services. Of course, this makes perfect sense, given that both surveys were nothing more than one huge exercise in argumentum ad populum. Trying to argue that people are very happy with your service is part and parcel of that. Certainly the CAMsters aren’t trying ot argue for the superiority of their woo based on science.

So, both promoters of “integrative” medicine and a large segment of conventional medicine view patient satisfaction as being a major indicator (but, in all fairness, not the only indicator) of quality care. But is this assumption valid? Does patient satisfaction correlate with high quality care? You might be surprised at the answer suggested by a recent study published a week ago in the Archives of Internal Medicine from a group out of UC-Davis entitled The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality.

This study was designed to look for correlations between patient satisfaction and outcomes, asking the question: Is there a correlation between health care outcomes and patient satisfaction. The answer is yes, but, if this study is to be believed, it’s a negative correlation, in which patient satisfaction is correlated with worse outcomes in some measures. Let’s take a look.

The authors frame the question thusly:

Satisfied patients are more adherent to physician recommendations and more loyal to physicians, but research suggests a tenuous link between patient satisfaction and health care quality and outcomes. Among a vulnerable older population, patient satisfaction had no association with the technical quality of geriatric care,8 and evidence suggests that satisfaction has little or no correlation with Health Plan Employer Data and Information Set quality metrics.

In addition, patients often request discretionary services that are of little or no medical benefit, and physicians frequently accede to these requests, which is associated with higher patient satisfaction. Physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services, such as advanced imaging for acute low back pain.

In order to investigate the relationship between patient satisfaction and outcomes, the investigators undertook a prospective cohort study. Basically, they looked at respondents to the MEPS from 2000 to 2007. The MEPS is described thusly:

The MEPS is an annual nationally representative survey of the US civilian noninstitutionalized population assessing access to, use of, and costs associated with medical services. The MEPS household component uses an overlapping panel design in which individuals are interviewed successively during 2 years. During each year, respondents complete self-administered questionnaires about health status and their experiences with health care. The MEPS sampling frame is drawn from respondents to the National Health Interview Survey, an annual in-person household survey conducted by the National Center for Health Statistics. The National Health Interview Survey data are linked with death certificate data from the National Death Index, enabling mortality ascertainment among MEPS participants.

Basically, tbe investigators followed over 50,000 adults and linked them to mortality outcomes. Let’s start with the good. One correlation that was noted was that patients with higher levels of satisfaction with their care used the emergency room less. It wasn’t a huge amount less. The adjusted odds ratio was only 0.92, which means that the patients who had the highest level of satisfaction (the highest 25%) were 8% less likely to use the emergency room during the study period than those with the lowest level of satisfaction (the lowest 25%). All in all, not that impressively different, but it definitely has to be acknowledged as a positive.

Now let’s look at the negatives.

Patients in the study who demonstrated the highest level of satisfaction were more likely to have an inpatient admission (adjusted odds ratio 1.12) than those with the lowest levels of satisfaction. They also accounted for 8.8% more health care expenditures, including greater prescription drug expenditures. Worst of all, they demonstrated a higher mortality, with an odds ratio of 1.26, which means they had a 26% higher chance of dying.

Data like this always have to make you wonder. Is there a confounding variable that accounts for the negative correlation between patient satisfaction and outcomes? And it’s certainly possible that there may be. However, even if there is, at the very least this study is strong evidence that there isn’t much, if any, correlation between patient satisfaction and the actual quality of care as measured by a few key concrete outcomes. Why might this be?

The authors provide some possible explanations in the discussion. One aspect of this relationship is that patient satisfaction does correlate with how much the physician fulfills the patient’s wishes and expectiations:

Patients typically bring expectations to medical encounters, often making specific requests of physicians, and satisfaction correlates with the extent to which physicians fulfill patient expectations. Patient requests have also been shown to have a powerful influence on physician prescribing behavior, and our findings suggest that patient satisfaction may be particularly strongly linked with prescription drug expenditures.

In other words, giving the patient what he or she wants isn’t always what’s best for the patient. As “paternalistic,” as this might sound, this is not a new observation. Physicians have known this for a very long time. Perhaps the most striking example of this phenomenon is antivaccine parents. Such parents don’t want their children to be vaccinated, but not vaccinating is rarely in the best interests of the child. Physicians who just go along with such parents, such as antivaccine apologist Dr. Jay Gordon, are very popular and likely generate high Press-Ganey scores because they basically give the people what they want. In contrast, pediatricians who try to do the right thing and persuade such parents to vaccinate their children (or even fire such patients whose parents won’t vaccinate) don’t and as a result generate a lot less patient satisfaction. This is an intentionally chosen extreme example, but the same sort of dynamic occurs in more subtle ways in every patient encounter. A less extreme example is very common in primary care, specifically the example of the patient who demands antibiotics for a viral infection. The doctor who acquiesces will have the more satisfied patient than the doctor who does not. But who provided the better care? Not the doctor who gave unnecessary antibiotics, which can select for resistant organisms and cause complications for no benefit.

The next time you see a hospital brag about its Press-Ganey scores, remember that at the very minimum it’s meaningless in terms of whether that hospital actually delivers quality care and at the worst Press-Ganey scores correlate negatively with some outcomes. Although we don’t know for sure yet whether patient satisfaction correlates with outcomes in CAM/IM, the medical literature suggests that it very likely will not.CAM/IM, of course, is nothing if not the philosophy of “keeping the customer satisfied” to a whole new level in medicine. Indeed, that is its only purpose. CAM proponents think this is a good thing. However, evidence from conventional, science-based medicine suggests that it very well isn’t. None of this is to say that we should revert back to a paternalistic, doctor knows best” approach. It is, however, an indication that it is not the job of doctors to “keep the customer satisfied.” Ideally, we should do that in partnership with patients, not dictating to them what they need the way we did in the old days. However, there are dangers in going too far in the other direction. Patients need a doctor, not someone whose primary consideration is to satisfy them.

Comments

  1. #1 dt
    February 20, 2012

    Over this side of the pond there is also a depressing trend for hospital Trusts and primary care practices to seek out the approval of their patients. This has arisen from the latent commercialisation of medical care which states that you must give the customer what they want, promoted here in the UK under the government diktat of “patient choice”. Since the money follows the patients, it is important that the patients are kept happy, and financial penalties get imposed if satisafaction targets and indicators are not met, hence the emphasis placed upon high scoring surveys.

    There is nothing wrong with providing a good quality service appreciated by the patients, but as you say often the criteria upon which the service is judged is one of trivial clinical significance and never outcome-related, and more to do with factors like how long patients waited to see the doctor.

    Another insidious effect of emphasis on providing a high quality patient experience is that paradoxically this can rebound spectacularly. Patients are encouraged to report on every aspect of their “patient journey” through the medical care pathway, and their expectations of supreme quality is raised, often above what can reasonably be expected. Hence numerous complaints are generated that I spend senseless time resoponding to. Examples include answering why the receptionists was rather rude in her manner, why it took 20 minutes before the discharge medication was ready to be dispensed and so on. Highly frustrating.

  2. #2 prn
    February 20, 2012

    Self indulgent “satisfied patients” who take inpatient for outpatient procedures or linger in the hospital “hotel suites” are a special form of Russian roulette. I’ll pay for nice, but outpatient or early and out is my goal.

    Biologically based “CAM” and nonstandard medicine is a flash point to techies. What should a doctor do when techie patients have taken care to research their choices, consult well credentialed doctors, and have relevant, peer reviewed journal articles in their hand that happen to violate everything the doctor or staff “knows”? e.g. elective major surgery on chemo with 5FU.

    Or IV vitamin C is used outside the burn units.

  3. #3 starskeptic
    February 20, 2012

    I want a health-care provider who has enough clinical detachment to see that my complaints might have nothing to do with what’s wrong. That may entail hearing things I might not like – but then I’m not paying Him/Her to be my friend…

  4. #4 Anj
    February 20, 2012

    I’m commenting on the Skeptical OB blog and this is one persistent selling point of lay midwives and home birth.

    Freedom Of Choice
    Client Satisfaction

    In fact, in some posts I have seen on home birth or midwife websites, no claim at all is made WRT safety or health outcomes. Sometimes, there are delicately worded statements about “risks”. Sometimes the “safe and gentle birth” phrase is used to implicitly deny risk.

    A lot of woo gets around measuring health outcomes by simply ignoring those outcomes and instead focusing on selling an experience, feeling “cared for”, and treating “the whole patient”.

    This leads to opposing sides arguing past each other, since they frame the argument in way that ignores each other’s framing. “Patients’ rights! Freedom of choice! Compassionate care!” versus “Needless deaths! Injured babies! Substandard care!”.

    In order to win an argument like that, you must first acknowledge the arguments of the opposition, however much you are loathe to do so. Otherwise, you are preaching mostly to those who already believe you.

  5. #5 BT
    February 20, 2012

    I was recently approached by a local hospital’s nursing administrators who wanted to measure patient satisfaction due to their new EHR system. I told them that would be hard as the patients have no direct knowledge of the of the documentation system in any hospital. They got very concerned that they would now be hard pressed to show the advantages of the EHR over the paper system. I suggested many variables to assess but they only were concerned about patient satisfaction.

    Worse, there is another hospital that now provides “healing touch” services. The medical director supports it, not due to scientific evidence, but because patients say they feel satisfied that the nice lady came in and waved her hands around. The best I can say for it is that is another faith-based intervention like the chaplain coming in to pray with the patients.

  6. #6 Kathryn
    February 20, 2012

    I know this is anecdotal, but it may illustrate a reason why patients who are less satisfied with their doctors may not have as many inpatient procedures.

    My mother hated doctors in general because she had a tendency for rare/paradoxical side effects of medications, and because something about her demeanor inspired medical personnel to be condescending. She would rather suffer through symptoms that would send most people to the ER, just to avoid contact with the medical system. For example, she probably should’ve had her hip joints replaced but she never mentioned her hip problems until it was too late (chronic conditions made anesthesia too risky).

    Perhaps a more generalizable example would be more convincing. When she was sick enough she had to be hospitalized, she hated the hospital and the doctors enough that she insisted on being released before they thought she was ready. To make matters worse, she hated dogs and was furious that they wanted to bring a therapy dog in her room. “Lack of patient satisfaction” definitely affected the frequency and length of hospital stay.

  7. #7 palindrom
    February 20, 2012

    Anj@4 — If one is careful to find the right provider and setting, it’s possible to arrange a perfectly fine birthing experience in a hospital, where the full armamentarium of modern medicine is available in case something should go wrong, as it frequently does.

    As a species, we’ve pretty much hit the limit of safety with our combination of huge heads and a pelvis designed for upright walking. I’ve read that this is the reason why human babies are so helpless — we’re all “premature” compared to other animals because if our heads got any bigger before birth, none of us would survive it.

    Having witnessed birth firsthand, I’m glad to be male. No way that’s gentle!

  8. #8 Elaine Schattner, MD
    February 20, 2012

    Hi Orac,
    The lack or negative correlation between patient satisfaction and QOC didn’t surprise me. It’s a plausible function of limited resources in any health care system – if we spend more on fancy entryways and snacks, there will be less money for nurses, for example.

    But I don’t think it’s reasonable to use this observation as a particular argument against “alternative” care or NCCAM.

  9. #9 ischemgeek
    February 20, 2012

    I’m no medical professional… but frankly, I’ll take rude-but-competent over nice-but-unable-to-tell-me-no-when-I’m-asking-about-something-ridiculous.

    That said, not all docs are competent, sadly… but that’s where it’s the patient’s job to have active bullshit detectors and seek a second opinion.

  10. #10 AllieP
    February 20, 2012

    Anj, as another regular commenter on that blog, I see what you’re saying about the different framing of the arguments, but at the same time, I think the homebirth advocates are discussing even what they are advocating for in a way that baffles many critics.

    They frame homebirth as a relaxing, comforting experience that occurs in the familiar setting of your own home, while critics wonder how 1) making sure you have dinner and snacks ready for your lay midwife 2) dragging inflatable pools in your living room which you subsequently fill with fecal matter and blood to get sloshed all over your carpet, 3) giving birth while your toddler throws a temper tantrum in the next room because no one is paying attention to him and why is mommy screaming so much, 4) then you are left to launder all your own towels, carpets, blankets, couches, etc. could POSSIBLY be preferable — even from a patient satisfaction angle, not to mention the safety/health standard.

    In other words, even if a planned homebirth went utterly perfectly, it sounds like my worst nightmare.

  11. #11 TBruce
    February 20, 2012

    I’m sure that Michael Jackson was very satisfied with the care provided by Dr. Conrad Murray.

  12. #12 Calli Arcale
    February 20, 2012

    Patient satisfaction is an important metric, but it has to be taken in context. All of the great quacks have had very high patient satisfaction ratings — even the ones with mountains of dead patients, such as the infamous John Brinkley, the “goat gland doctor”, who transplanted the testicles and ovaries of goats into his human patients to treat a whole host of vague complaints, mainly impotence. He had lots of satisfied customers, but he killed a lot of people too, and it’s pretty certain that his transplant procedures never did any good whatsoever. So patient satisfaction should obviously never be your overriding metric; it’s much more important to know whether your treatments *work* than whether or not people enjoy them.

  13. #13 Calli Arcale
    February 20, 2012

    In fact, as I think about it…..

    The right way to look at patient satisfaction is probably with endpoints not in the “did you enjoy your care” venue but in more concrete things. You want patients to be comfortable and not anxious, of course, but what you really want overall is a solid, trusting relationship between the patient and their care team (doctors, nurses, technicians, anesthesiologists, etc). So any patient satisfaction measures need to look more to that than anything else, I think.

  14. #14 Marry Me, Mindy
    February 20, 2012

    But I don’t think it’s reasonable to use this observation as a particular argument against “alternative” care or NCCAM.

    Of course, Elaine, that’s not what he’s doing. In fact, it is the other way around. It is the WOOsters who constantly harp about how satisfied their patients are. This post is showing that happy patients is not the same as good care. Don’t tell Orac, tell the whackaloons who always tell us about how their patients are so happy with it, so it must be great.

  15. #15 Lancelot Gobbo
    February 20, 2012

    “CAM/IM, of course, is nothing if not the philosophy of “keeping the customer satisfied” to a whole new level in medicine. Indeed, that is its only purpose.”

    I think you just described a placebo, Orac. How odd!

  16. #16 Andreas Johansson
    February 20, 2012

    One possible confounder that occured to me reading the piece: sicker patients are presumably both more likely to die and to develop a personal trusting relationship with their doctor because they’re seeing them frequently. (I, reasonably healthy individual, haven’t even met, let alone been treated by, “my” doctor, so the day I need medical attention I’ll be receiving it from a complete stranger.) Being treated by someone you know and trust surely has to be good for patient satisfaction.

  17. #17 palindrom
    February 20, 2012

    I’m (closely) related to a provider who gets very good patient-satisfaction scores by listening to her patients carefully, treating them sympathetically and respectfully, AND delivering very competent care together with meticulous followup. Given how medical care is delivered these days, this requires inordinate time and dedication, but she’s consitutionally unable to do a half-ass job at anything.

    In any case, bad patient-satisfaction scores shouldn’t be taken as a badge of honor. It’s still possible, barely, to do an objectively good job and keep the patients happy.

  18. #18 Old Rockin' Dave
    February 20, 2012

    There is another possible reason for the difference. I am generally satisfied with my health care, and I have used more resources than most people. I can’t help but be satisfied with my internist, who is also my pulmonologist. After all, he keeps me breathing. It was his partner that identified my valvular heart disease that resulted in timely valve replacement and saved my life. They did the routine PSA (no surprise, I advocate them) that led to my prostate cancer being found while it was still, just barely, potentially curable with surgery alone.
    I am satisfied because, for a number of medical reasons, I have a somewhat higher risk of premature death, and my doctors conspire to keep me alive. It means more inpatient procedures and hospital stays than most people have, but that’s just part of the price for living. Staying alive with the minimum possible impairment is very satisfying. Disability and death are not.

  19. #19 lilady
    February 20, 2012

    What a silly way to measure quality of care parameters in a hospital. All the tertiary care teaching hospitals in my area of New York State, have problems with parking. On the *plus side* the hospital where all of my family’s physicians have admitting privileges, do not have CAM/Alt or Integrative Medicine Departments.

    There is always the instantaneous patient satisfaction route, by speaking directly with a department head (during the day) and in the middle of the night asking to speak with the AOD (Administrator on Duty).

    Recently, my husband’s cardiac stress test showed some changes and he was scheduled to have a cardiac catheterization…with the possibility of placement of cardiac stents. My husband has had other minimally invasive PCIs (Percutaneous Cardiac Interventions)… including right and left atrial ablations done in this hospital, performed by an extraordinarily competent interventional electro-physiologist.

    I was able to find some statistics about the PCI physician who was scheduled to do the catheterization…numbers of each PCIs and the RAMR (Risk Associated Mortality Rate) in the two hospitals where the physician practiced, through the statistical database maintained by the New York State Department of Health:

    http://www.health.ny.gov/statistics/diseases/cardiovascular/docs/pci_2006-2008.pdf

    The database is not the be-all and end-all…my husband is not a statistic, but it provided us with a measure of assurance that the physician is a highly rated interventional cardiologist.

  20. #20 Roland
    February 20, 2012

    I’m certainly in agreement with Orac here on the substance of this post – the only thing I’d say is that easy affordable parking isn’t the totally obvious side issue it might appear. If someone is not able to get around easily because they’re ill then difficult parking might be a serious obstacle to their getting access to the treatment they need. So I don’t think parking is just a patient satisfaction issue – this point gets made by campaigners in the UK who point out that the work of the NHS can be badly hampered by the apparently easy money to be made out of parking charges.

  21. #21 mark streety
    February 20, 2012

    Several clarifications for the author and fellow posters, from a hospital pat sat veteran:
    1)a single overall patient sat score for a hopsital or a hospital dept is a rollup of numerous questions asked re call lite response, pain control, hotel functions such as meals and room comfort, etc etc. Certain questions matter more to patients depending on the dept/type of care. We ask the patient these types of questions because they are the true experts re these matters.We work on low scores and celebrate high scores to build the care environment that our patients expect. These pat sat results can be compared online against all other hospitals because we all use the same survey(HCAPHS) for all inpatients. Press Ganey is only one of several service providers of same.
    2) Pat sat is about the customer’s experience, not about Clinical Quality outcomes. For Clinical quality outcomes,we have hundreds of clinical outcome measures that we track for that, those are reviewed with physician leadership regularly and root cause analysis and other system improvement techniques used to improve actual Quality outcomes. These Clinical Quality results can also be compared online with all other hospitals. Physicians and other clinicians are the experts re Clinical Quality.
    3)In nearly 31 years as hosp exec, I have met only 1 doctor uninterested in improving his or her own performance re any patient complaint. Only 1, out of over 500 personal interactions.
    3) Hospitals that are focused on pat sat do so in order to improve the patient’s experience, to minimize any future govt financial penalties for performing worse than their peers, and to help ensure that the patient tells friends/family(i.e. future patients) that they are pleased/happy/loyal. This is especially true for the ambulatory/outpatient environment.
    Hopes this helps build greater understanding and perspective.

  22. #22 Orac
    February 20, 2012

    No one here is saying that it isn’t worthwhile to improve patient satisfaction, particularly when it is below average. However much you don’t think it to be the case, though, patient satisfaction scores are too frequently used by all too many entities as surrogates for quality of care. Perhaps it’s because they’re easier to measure, given all the companies like Press-Ganey that’ll do your surveys for you. Maybe it’s because medicine has become too much like any other business. Who knows?

    This study is just one more bit of evidence on top of many more suggesting that patient satisfaction should not be used as a surrogate measure of quality. As the authors pointed out, any correlation between patient satisfaction and quality of care is tenuous at best and negative at worst in some situations, and, as others have pointed out, quacks generally have very high levels of satisfaction among their marks.

  23. #23 hoary puccoon
    February 20, 2012

    My husband’s brother-in-law hasn’t walked in years because his nice, understanding doctor agreed to do a hip replacement, in spite of the fact the bro-in-law was grossly obese and at obvious risk for complications. Which promptly occurred. A less congenial doctor, who said, “I won’t operate until you get some exercise and get your weight under control,” would have been so much better for him.

    I wonder how many of the popular docs are the ones who *aren’t* telling their patients to stop smoking, lose weight, etc.

  24. #24 Anj
    February 20, 2012

    I think the most useful study would be to compare:

    Patient Satisfaction
    AND
    Patient Compliance

    not to see which HCPs or clinics have the best patient satisfaction, but to see if increased patient satisfaction is associated with increased patient compliance.

    If your goal is to improve outcomes, then you will want to have the best patient compliance. I would assume that there is probably a positive correlation. Cause and effect? Factors that contribute to both? No idea, design a study and find out.

  25. #25 Terrie
    February 20, 2012

    Patient satisfaction is fine, provided everything else is working correctly, but there are factors that mean that sometimes you don’t want to raise it. I’m sure every patient would be much more satisfied if, say, they weren’t charged a bill. But that’s hardly going to improve things.

  26. #26 Bronze Dog
    February 20, 2012

    I’ve certainly read enough about woo infiltration into hospitals to understand the abuse of patient satisfaction measures. Patient satisfaction is something worth pursuing if it builds trust and cooperation between doctors and patients, but far too many places seem to be taking on the view that “the customer is always right.” Customer preferences can’t make quackery work, so why should a hospital open its doors to charlatans?

  27. #27 Denice Walter
    February 20, 2012

    A know a fellow who would shop around until he found an empathetic doctor who would agree to his own self-treatment plan- not exactly based on medical consensus – he just didn’t like certain meds and wouldn’t comply unless he did- the poor doctor probably figured that at least he’d take *something* that would have a partial physiological effect and patient satisfaction- and compliance- was achieved. Not the best of all possible worlds but the patient was happy. I venture that alt med revolves around a similar principle: people reject standard care and seek out a woo that works within certain limits that they can tolerate: e.g. I won’t take psychiatric meds for my symptoms but ( herbs, supplements, Qi Gong, accupuncture- choose one or more) is alright.

  28. #28 Jay Gordon, MD, FAAP
    February 20, 2012

    “Physicians who just go along with such parents, such as antivaccine apologist Dr. Jay Gordon, are very popular and likely generate high Press-Ganey scores because they basically give the people what they want. In contrast, pediatricians who try to do the right thing and persuade such parents to vaccinate their children (or even fire such patients whose parents won’t vaccinate) don’t and as a result generate a lot less patient satisfaction. “

    I know how much you love my numbers: 33 years of private practice in July of this year.

    One does not stay “popular” (or out of trouble) if one just gives parents what they want. Patients would get sick, then sicker, die, leukemia goes undiagnosed, illnesses requiring antibiotics go untreated and so on. And “popularity” tends to wane when those things happen.

    As usual, when you comment about pediatrics, you’re just plain wrong. (I do not make comments about your surgical subspecialty because I might sound pretty uninformed.)

    By the way, who else here has never even heard of Press-Ganey scores??

    Best,

    Jay

  29. #29 Sara
    February 20, 2012

    When my 34 yo husband had a heart attack in December, I didn’t give a damn whether the cardiologists could provide the warm and fuzzies. What mattered was whether they could save his life with their skill and knowledge. They did! And I still have a husband who can provide me all the warm and fuzzies I need.

  30. #30 lilady
    February 20, 2012

    @ Dr. Jay Gordon: Yes…we are very much aware of your stance on vaccinations:

    http://drjaygordon.com/vaccinations/vaccination-schedule.html

    And, your constant tweets that poke fun at, and minimize the impact of recent measles outbreaks:

    Jay Gordon, MD, FAAP @JayGordonMDFAAP

    @tweek75 13 cases of measles in Indiana is more “random” than epidemic and could occur in a 100% vax’d population. “Declining rates” is BS
    In reply to Todd W

    “33 years of private practice in July of this year” (and not following the American Academy of Pediatrics-Standards of Practice regarding immunizations)

  31. #31 Marry Me, Mindy
    February 20, 2012

    Rumor is that Jay has a new mouthpiece. Another actor, Mayim Bailick (who plays Amy Farrah Fowler on The Big Bang Theory). She’s got a book on parenting, and like Jenny Mac, espouses dangerous practices.

    Unlike Jenny Mac, Bailick actually is not an idiot, and has a PhD. Although it is not clear how her PhD in neoroscience (studying obesity) has any relevance in making her an expert in parenting. But Jay has endorsed her any way.

  32. #32 Karl Withakay
    February 20, 2012

    @ Jay Gordon, MD, FAAP

    “(I do not make comments about your surgical subspecialty because I might sound pretty uninformed.)”

    Well, you’re neither an immunologist, nor an infectious disease specialist, nor an epidemiologist, but that hasn’t stopped you from devising your own vaccination schedule.

    On occasion, I have wondered if Dr Jay really has no problem with vaccines or the current vaccination schedule. I wonder if he is merely playing the role of accomodationist in the belief that he is performing a public service by getting parents who fear or question vaccines to follow his alternate schedule cunningly devised by him with the intention of convincing those parents that he has the solution to their vaccine concerns. The intended result would be those children eventually receiving many or most of the recommended vaccinations rather than none at all…

    And then Dr Jay makes another comment, and the thought passes.

  33. #33 Cynical Pediatrician
    February 20, 2012

    Oh, good grief.
    Parents want all kinds of different things.
    Some want antibiotics for every little URI. Some want to avoid vaccinations. Some want evidence-based medicine. And some just want convenient office hours.
    “Doctor” Jay is being intellectually dishonest, as usual. The art of pediatrics is applying science and empathy to the grey zones where evidence meets uncertainty. There are certain lines of incompetence which shouldn’t be crossed. Within those boundaries, pediatricians create their own practice choices. Some yield to parental pressure (real or perceived) at the slightest whim, telling people what they want to hear (e.g., Dr Jay, most CAM practitioners, and many pediatricians of dubious quality). Needless to say they are VERY popular as long as they don’t screw up too badly.
    Other pediatricians go the other way with a very rigid and blunt style, treating the child with the utmost in quality care–but not so much the parent. Lack of bedside manner is excused by great results in surgeons, though less so in pediatrics.
    Most of us travel in the middle, knowing how far to push parents, and when to give in. Tell us, “Doctor” Jay, how often does a parent leave your office dissatisfied because you didn’t do exactly what they wanted? If your answer is “never,” then you’re not being a very good pediatrician. A great people-pleaser, an even better businessman, but not a good doctor. Orac’s point, which absolutely applies to pediatrics, is that satisfaction doesn’t correlate with what’s best for the patient, and may often be inversely related.
    And: you haven’t heard of Press-Ganey scores? Do you not have privileges at a hospital? I know you don’t keep up with scientific literature, but apparently the business of healthcare escapes you too?

  34. #34 lilady
    February 20, 2012

    @ Marry Me, Mindy:

    “Unlike Jenny Mac, Bailick actually is not an idiot, and has a PhD. Although it is not clear how her PhD in neuroscience (studying obesity) has any relevance in making her an expert in parenting. But Jay has endorsed her any way.”

    She is also heavily wrapped up with the “Holistic Moms Network”:

    http://www.holisticmoms.org/2009/04/16/advisory-board/

    Might there be room for another anti-vax doctor (Dr. Jay) on their Advisory Board?

  35. #35 Orac
    February 20, 2012

    Another actor, Mayim Bailick (who plays Amy Farrah Fowler on The Big Bang Theory). She’s got a book on parenting, and like Jenny Mac, espouses dangerous practices.

    Oh, no! Not Mayim Bialik! Not Amy Farrah Fowler!

    Got any links?

  36. #36 Orac
    February 20, 2012

    How is Bialik wrapped up in the Holistic Moms Network? I don’t see her name on the web page to which you linked.

  37. #37 Orac
    February 20, 2012

    Oh, no. No wonder Dr. Jay likes her:

    http://www.justmommies.com/celebrity-baby-updates/mayim-bialiks-parenting-style?page=0,2

    Quote:

    JustMommies: Do you do no vaccinations, or do you select specific ones with your doctor?

    Mayim Bialik: We have not vaccinated, but some people do selective vaccination. There is a recommended modified schedule that Dr. Sears has been recommending.

  38. #38 Marry Me, Mindy
    February 20, 2012

    Sorry, no link. I saw it mentioned on Amy Tutuer’s blog the other day. Although I’ve heard her name mentioned among the whackaloons before.

  39. #39 Marry Me, Mindy
    February 20, 2012

    Hmmm, apparently she uses the “some people think…” Rhetoric occasionally. The other instance I heard about is where she was asked why she opposes OB intervention in Labor and Delivery (she is apparently a homebirth advocate). Her answer was that “some people think” that if a child isn’t strong enough to be born on their own, they don’t deserve to live. She doesn’t agree, although she never actually provided an answer of her own.

    It’s all “plausible deniability” speak

  40. #40 Fred
    February 20, 2012

    One does not stay “popular” (or out of trouble) if one just gives parents what they want. Patients would get sick, then sicker, die, leukemia goes undiagnosed, illnesses requiring antibiotics go untreated and so on. And “popularity” tends to wane when those things happen.

    I don’t necessarily agree with this statement.

    In the case of so-called chronic Lyme disease and perhaps the more dubious Morgellons, quack specialists are highly protected, in fact guarded, by their patient followers. Those doctors give patients what they want and tell them what they want to hear and that is precisely why they are indeed so popular.

    Contrary to your statement, most of their patients would likely not die without years of endless antibiotics and antimalarials. Oftentimes, the chronically ill gravitate towards woomeisters because they have not found relief in mainstream medicine. Those patients are happy, because they found a doctor that would acknowledge that they have a medical problem, and give it a label, any label, then treat it. Desperate patients incorrectly see that as “Well, at least the doctor is trying…”

    The LLMDs (Lyme literate medical doctors) are very popular for that reason, but it would be incorrect to say that their patients if untreated would die from their disease. Odds are in many cases, the patient didn’t really need years of unlimited antibiotics in the first place. Odds are most of the Morgellons patients don’t really have foreign fibers growing filling their bodies.

  41. #41 lilady
    February 20, 2012

    Mayim Bialik is the author of a parenting book “Beyond the Sling” and Dr. Jay wrote the book’s “Foreword”.

    Here in this interview with “People” magazine, she discusses her views on vaccination:

    http://celebritybabies.people.com/2009/06/04/mayim-bialik-talks-attachment-parenting-with-cbb/

    “Reader N.S. remembers reading about your contemplating whether or not to vaccinate the kids. What decision did you reach?

    We are a non-vaccinating family, but I make no claims about people’s individual decisions. We based ours on research and discussions with our pediatrician, and we’ve been happy with that decision, but obviously there’s a lot of controversy about it.”

  42. #42 Fred
    February 20, 2012

    I’m sure that Michael Jackson was very satisfied with the care provided by Dr. Conrad Murray.

    Absolutely, satisfied and protected him for his ‘quality’ of care all the way to the grave.

  43. #43 lilady
    February 20, 2012

    @ Orac: Sorry for not providing the link to Holistic Moms Network and Mayim Bialik…here it is:

    http://www.holisticmoms.org/category/aboutus/what-moms-are-saying/

  44. #44 Marry Me, Mindy
    February 20, 2012

    “We based ours on research and discussions with our pediatrician”

    And I wonder who that might be?

    I told you, she’s his new mouthpiece. You can just see his hand up her back. Don’t let your lips move, Jay

  45. #45 Lawrence
    February 20, 2012

    That’s very disappointing – I like that show…..

  46. #46 Chris
    February 20, 2012

    I keep wondering how Dr. Jay will react if a child of one his celebrity parents becomes permanently injured. With the rate of measles continuing to rise, there is a higher chance one of his patients will be a victim.

  47. #47 Marry Me, Mindy
    February 20, 2012

    I wonder if in the introduction of Mayom’s book Jay admonishes her to not opine on topics outside of her area of expertose lest she come off ignorant? Or does that only apply to Orac?

    (Don’t answer, that’s rhetorical)

  48. #48 lilady
    February 20, 2012

    I’m “thinking more and more” that Dr. Jay is the pediatrician that Mayim Bialik “consults” for her children:

    http://www.facebook.com/official.mayim.bialik/posts/10151135253310008

  49. #49 Jay Gordon
    February 20, 2012

    Did you see this one?

    http://www.ncbi.nlm.nih.gov/pubmed/22336803

    AUTHORS’ CONCLUSIONS:
    The design and reporting of safety outcomes in MMR vaccine studies, both pre- and post-marketing, are largely inadequate. The evidence of adverse events following immunisation with the MMR vaccine cannot be separated from its role in preventing the target diseases.

  50. #50 Orac
    February 20, 2012

    You missed part, Jay:

    Exposure to the MMR vaccine was unlikely to be associated with autism, asthma, leukaemia, hay fever, type 1 diabetes, gait disturbance, Crohn’s disease, demyelinating diseases, bacterial or viral infections.

    Funny that.

  51. #51 Jay Gordon, MD, FAAP
    February 20, 2012

    I’m sorry, David, but we must both be cherry-picking. You missed some key phrases so I’ll emphasize them:

    AUTHORS’ CONCLUSIONS:
    The design and reporting of safety outcomes in MMR vaccine studies, both pre- and post-marketing, are largely inadequate. The evidence of adverse events following immunisation with the MMR vaccine cannot be separated from its role in preventing the target diseases.

    Funny that!

  52. #52 Lawrence
    February 20, 2012

    Celebrity hangers-on tend to reinforce & amplify the echo-chamber effect, getting so caught up in the limelight – that it leads to a downward spiral of behavior.

    Many celebrity addicts are abetted by their groupies, and it seems that people like Dr. Jay have become addicted themselves to the spotlight….

  53. #53 lilady
    February 20, 2012

    Dr. Jay, do you remember this one?:

    “Lilady, I swear if we met in person we might actually share a half bottle of wine and laugh a little.

    I will not comment on nor link to recent vaccine fatalities in Asia because they are aberrations and detract from the real discussion of the real issues.

    I was in Qatar trying to track down the DDoS hooligans preventing me from posting my relatively worthless anecdotal evidence on RI and SBM!

    Jay

    Posted by: Jay Gordon, MD, FAAP | March 16, 2011 6:58 PM”

    (“More dubious reasoning from animal rights activists” Respectful Insolence-March 15, 2011)

    oh noes! Have I offended the charming Dr. Jay?

    Catch you later Jay…I’m having dinner with the guy that I share a half bottle of wine with and have many laughs with.

  54. #54 MI Dawn
    February 20, 2012

    @Dr. Jay: yes. Many of us have heard of Press Ganey reports. I loathe them. The questions are stupid and are focused on the basis of a 2 year old’s whining: was your call lifpght answered promptly? Did the nurse come right away? Give the names of your nurses. Well, I’m lousy with names. No points there; ALL my nurses introduced themselves; should they suffer because I don’t remember names?

    I’m in a small/medium/large hospital. Staff numbers vary. Emergencies occur. I accept apologies for delays but many don’t. (I once had a patient complain her Advil was delayed 30 minutes. Yes, it was – we had a woman suffer an amniotic fluid embolism in the delivery room and all available hands were there. And yes, we did explain the emergency -not specifically due to patient confidentiality- but she downgraded EVERY score and gave that as her reason. She acknowledged the emergency but couldn’t understand why “someone” couldn’t give her the Advil! Oh and by the way…she was discharged. She just wanted the “free” Advil before she left the hospital)

    Another patient I’ll never forget….especially since we lost the term mother. We managed to section the baby who survived and went home after some NICU days with a grieving father who’d lost his healthy wife with their first baby. As far as I know, no one figured out why the AFE occurred-she had just arrived – ambulatory – for a labor check when she collapsed in L&D.

  55. #55 LW
    February 20, 2012

    I keep wondering how Dr. Jay will react if a child of one his celebrity parents becomes permanently injured. With the rate of measles continuing to rise, there is a higher chance one of his patients will be a victim.

    A good friend of my sister is a retired pediatrician. Unlike the good Dr. Gordon, she tried hard to get her patients vaccinated, but she wasn’t always successful. One year there was a measles outbreak and one of the children whose parents wouldn’t allow her to vaccinate developed measles encephalitis and suffered profound brain damage. She practiced in one of the anti-vax strongholds in Colorado, so her patients’ parents were likely in the same socioeconomic group as Dr. Gordon’s. There is no reason the same kind of tragedy could not happen in Dr. Gordon’s practice.

  56. #56 Orac
    February 20, 2012

    Good job sowing fear, uncertainty, and doubt, Dr. Jay. Tobacco companies would be proud, as would anthropogenic global warming denialists. There are plenty of studies showing no link between MMR and autism, and they’re high quality studies.

  57. #57 Denice Walter
    February 20, 2012

    @ lilady:

    Perhaps the gentlemen I know are slightly more… um ..exuberant *but*
    seriously, _share a half bottle of wine_!

    Now *that* is a classic!

  58. #58 Chris
    February 20, 2012

    LW, that is so sad. Too bad that child had to pay the price for his/her parents’ ignorance.

  59. #59 Fred
    February 20, 2012

    I am acquainted with a 40 year old woman who has polio. She was born in NC, but now living in NY. That is a very sad sight. She is wheelchair bound and like a child.

    I can not imagine how people would choose not to vaccinate against polio. Her parents have abandoned her as she requires too much care.

  60. #60 Sauceress
    February 20, 2012

    I notice Jay Gorgon is still endorsing the idol of the antivaxx cult, and discredited fraud Andrew Wakefield on his website

    Seems the words of a manufactured personality cult hero still trump evidence in Jay’s professional world.

    Remember Jay Gordon has previously informed us here on a number of occasions that his standard of evidence is his own experience, and that his experience overrides any scientific evidence.
    ~~~~~~
    #51 Lawrence

    Celebrity hangers-on tend to reinforce & amplify the echo-chamber effect, getting so caught up in the limelight – that it leads to a downward spiral of behavior.

    It fits!

  61. #61 Orac
    February 20, 2012

    I wonder if in the introduction of Mayim’s book Jay admonishes her to not opine on topics outside of her area of expertise lest she come off ignorant? Or does that only apply to Orac?

    How could he do that when he’s so great at opining on topics outside of his area of expertise and coming across as ignorant himself?

  62. #62 Sauceress
    February 20, 2012

    “I notice Jay Gorgon…”
    Proof reading fail!

    Should read “Jay Gordon”.

  63. #63 lilady
    February 21, 2012

    It seems that Dr. Jay runs a “concierge medical practice.”

    http://www.yelp.com/biz/jay-n-gordon-md-faap-santa-monica

    “It is a concierge medical practice, so you will have to bill your own insurance and pay out of pocket for most care….”

    “They do not deal with insurance. There(sic) prices are not cheap. I guess you get what you pay for. It is not easy to make the payments….”

    So, while all the other pediatricians are grousing about medical insurance reimbursements…especially the costs associated with immunizations…Jay is running a boutique/concierge pediatric practice. Nice going, Jay.

  64. #64 Prometheus
    February 21, 2012

    Apparently, “Dr. Jay” has only read the abstract of Demicheli et al (2012). In the full text version, the authors conclude:

    [p 20]: “Existing evidence on the safety and effectiveness of MMR vaccine supports current policies of mass immunisation aimed at global measles eradication and in order to reduce morbidity and mormality associated with mumps and rubella.”

    [p 21]:”The design and reporting of safety outcomes in MMR vaccine studies, both pre and post-marketing, need to be improved and standardised definitions of adverse events should be adopted. More evidence assessing whether the protective effect of MMR could
    wane with the time since immunisation should be addressed.”

    Strangely, those two paragraphs (which constitute the entire “Conclusions” section) don’t sound nearly as damning as the excerpt cited by “Dr. Jay”.

    Clearly, “Dr. Jay” has a fixed bias against vaccines and reflexively jumps on anything that even sounds like it supports his minority opinion (often without reading or understanding it fully. His claims to be “pro-safe-vaccine” notwithstanding, I cannot recall a single instance when “Dr. Jay” has supported vaccination, not even in the face of endemic pertussis in his home state.

    So far, the data show that the MMR is safer than not vaccinating and is not associated with – among other things – autism, asthma or diabetes. In addition, the MMR is safer than wishing for a “safer” vaccine while praying that “herd immunity” will keep you (or your children) safe.

    The fact that “Dr. Jay” has been in practise for 33 years without being censured by the state medical board speaks volumes about the inadequacy of that body’s oversight of physician competency.

    Prometheus

  65. #65 Todd W.
    February 21, 2012

    Totally missed that Jay Gordon, MD, FAAP (gotta include those all important letters to show how important he is!) showed up here.

    @lilady (#30), that tweet from Jay was in response to me asking what he would do to prevent future outbreaks like the one currently growing in Indiana (as well as last year’s outbreak of 21 cases in Minnesota). I’ve yet to get an answer to that question, so I guess I’ll try in this thread, too.

    Jay, what would you recommend to prevent measles outbreaks in the future? (Not holding my breath for an actual answer.)

  66. #66 Beamup
    February 21, 2012

    This sort of thing isn’t limited to medicine, either. For example, I work in software, including data processing. And I often see things like:

    “I’m getting this error message, how do I fix it?”
    “That error message is saying that your application was not designed to deal with the data coming into it. You should do X, Y, and Z so that it can properly handle this data.”
    “That sounds hard. Can’t I just ignore that data?”
    “Well, yes, but then you’re throwing away your business-critical data. You really don’t want to do that.”
    “I’m just being paid to resolve the error message. I’m going to discard the data.”

    And of course, guess who then has to deal with it when they ask where all their data disappeared to…

    The point, of course, is that what will satisfy the person on the spot at the time is NOT the right solution to the problem.

  67. #67 lilady
    February 21, 2012

    @ Todd W: I knew it was you…and was awaiting your post here.

    Just as an observation; I am well beyond my child rearing years, but in this pseudoscience climate with boutique/concierge pediatric practices…I would make certain to question a pediatrician about his/her “philosophy” about immunizations. I wouldn’t want to expose my babies in a pediatrician’s office to unimmunized kids.

    @ Dr. Jay: I waiting for you to explain why you deviate from the AAP Standards of Care regarding Immunizations. I do know exactly what those Standards are, having audited thousands of charts in private pediatric practices and hospital-based/public health clinics.

  68. #68 Matt Carey
    February 21, 2012

    Dr. Jay,

    have you read the full report? If so, would you care to comment on this section:

    “The study ofWakefield (Wakefield
    1998), linking MMR vaccination with autism, has been recently fully retracted (The Editors of The Lancet 2010) as Dr.Wakefield has been found guilty of ethical,medical and scientificmisconduct in the publication of the paper; many other authors have moreover demonstrated that his data were fraudulent (Flaherty 2011).”

    The authors of the Cochrane report accept the idea that “many other authors have demonstrated that his [Wakefield's] data were fraudulent”

    They also accept the idea that the 1998 Lancet article linked MMR to autism (a claim Mr. Wakefield’s supporters try to deny, claiming he only called for more research).

    Also,

    At that time (1998) an excessive and unjustified media coverage of this small study had disastrous consequences (Flaherty 2011; Hilton 2007; Offit 2003; Smith 2008), such as distrust of public health vaccination programmes, suspicion about vaccine safety, with a consequential significant decrease in MMR-vaccine coverage and re-emergence of measles in the UK.

    Interesting how it is the Wakefield study and the press coverage that followed it that is considered the cause of the decrease in MMR coverage and the re-emergence of measles in the UK.

    I say “interesting” rather than “obvious” because Mr. Wakefield and his supporters consistently try to shift blame onto the UK government for their action to stop importation of the single measles vaccine.

  69. #69 Beamup
    February 22, 2012

    @ lilady:

    Dr. Gordon has previously answered that question. In short, he believes that his personal experience trumps the entire AAP.

  70. #70 Lance Turtle
    February 22, 2012

    Sorry if I’ve missed this in the comments but…..

    Isn’t this a resounding argument for socalised medicine? There is less choice in socialised healthcare systems and less impetus for physicians to do what the patient wants. I would also hypothesize that if you did the same study in a socialised healthcare system you might get quite a different result.

  71. #71 hoary puccoon
    February 22, 2012

    Lance Turtle @ 70—

    How much less choice is there, really, in socialized health care systems?

    My husband and I have a summer home in France. We have had the same family physician there– not a “society” doctor, but an ordinary GP– for the last fifteen years. How many Americans do you know who can say the same?

  72. #72 Harbo
    February 23, 2012

    Remember that the Fat Man said;
    “the worse the private(doctor) the better the bedside manner”

    Not quite a “rule” but a good thought.
    But then I am nasty enough to always be suspicious of the “Nice”.

  73. #73 TheOtherAnonymous
    March 1, 2012

    My hospital loves Press-Gainey. In fact we have department meetings where 20+ minutes are spent with someone from administration upset that only 90% of our responses are “excellent”. They then spend quite a bit of time telling us how to buff up our scores, including how to choose which patients to encourage to answer the PG questionnaires.

    So what is Press-Gainey really measuring? Our skills at convincing patients (er…”clients”) to rate us “excellent”…and really nothing else. All at a cost of hundreds of thousands of dollars of course.

    -An NC FP

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