Can I Take Your Order? Patient Satisfaction in Emergency Medicine

A man named Tim goes out to eat at a restaurant. He asks Joe, the server, for his recommendation. Joe insists the salmon is by far the best choice, based on his experience and extensive culinary expertise. Tim inquires about the steak, as he has read online that it is a much better choice. Just as Tim says “I think I'll go for the steak...” Joe cuts him off politely, saying, “Sir, please trust that the salmon is the best choice for you at this time.” Tim is served the salmon, and even though it is an excellent dish, he leaves the restaurant flustered and dissatisfied. Sound familiar?

Customer satisfaction is achieved when the goods or services rendered by a company meet or exceed the customer's expectations. Similarly, patient satisfaction is achieved when a patient's own expectations for treatment are met or exceeded.1 Notice that the terms “customer” and “patient” as well as “goods” and “treatment” are being used interchangeably. The problem with substituting these terms is that unlike most other industries, health care providers do not allow their customers (patients) to readily choose the goods and services (treatment) provided, thus making it exceedingly challenging to meet patient expectations and provide appropriate clinical care.

Emergency physician compensation is becoming more dependent on patient satisfaction scores. In 2012, the value-based purchasing program was introduced as part of the Affordable Care Act, with the intent of compensating delivery of health care based not only on the quantity of care provided, but also on the quality. Various patient surveys (HCAHPS, Press Ganey, etc.) have been created to evaluate the patient's perception on an array of factors that influence the hospital visit experience. Hospital systems, however, are beginning to focus on individual practitioner scores with arguments such as “the most robust predictor of global satisfaction is the quality of interpersonal interactions with the emergency department provider.”2 While there is clearly substantial benefit in developing positive relationships with patients, there is a concern that involving patient satisfaction survey results in the emergency physician compensation model will change the way we make clinical decisions.

Emergency physicians may be more likely to bend to patients' requests for antibiotics, advanced imaging, laboratory testing, or narcotics, particularly in patients presenting with low or mid acuity complaints.2,3 In an age where medical information and clinical opinion are available at a patient's fingertips, the number of patients presenting with requests for certain medications and tests will only increase. In a survey performed in 2012 to assess the impact of patient satisfaction ratings on physicians and clinical care, physician responses were overwhelmingly negative. The sentiment was that such ratings are a defective tool for measuring quality of care, that they encourage improper medical practices, and that they can create a conflict of interest when tied to a physician's salary.4

We are entering a climate in which patient experience will continue to have direct financial implications for physicians. So what are we to do? We want to continue giving patients the best evidence-based care possible, but we also have a responsibility to understand and address their expectations during medical encounters. It has been shown that a patient's perception of their experience is in part related to the amount of information relayed and the total time spent with the physician.1,5 In the setting of emergency department overcrowding and significant administrative pressure to reduce length of stay, it is difficult to imagine being able to spend the time that every patient desires and deserves.

Frustration caused by unmet expectations is inherently human. For now, the best we can do is continue caring for our patients to the best of our ability while treating them with the respect they all deserve. This means the following:

  • Always introduce yourself.
  • Maintain good eye contact.
  • Give estimate on how long the visit will take.
  • Use simple terminology.
  • Review test results.
  • Provide an opportunity for questions.
  • Utilize shared decision-making in appropriate clinical scenarios.

Focus on communication and collaboration with each patient, so that even though many will not get the steak they thought they wanted, they will leave with a good understanding of why they ended up with the salmon instead.


  1. Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: What does the literature say? Acad Emerg Med. 2000;7(6):695-709.
  2. Boudreaux ED, O'Hea EL. Patient satisfaction in the emergency department: A review of the literature and implications for practice. J Emerg Med. 2004;26(1):13-26.
  3. Mack JL, File KM, Horowitz JE, Prince RA. The effect of urgency on patient satisfaction and future emergency department choice. Health Care Manage Rev. 1995;20(2):7-15.
  4. Zgierska A, Rabago D, Miller MM. Impact of patient satisfaction ratings on physicians and clinical care. Patient Prefer Adherence. 2014;8:437-446.
  5. Gross DA, Zyzanski SJ, Borawski EA, et al. Patient satisfaction with time spent with their physician. J Fam Pract. 1998;47(2):133-137.