ZDoggMD on Patient Satisfaction Scores: Why Press Ganey Is Hurting Patients

This article discusses ideas from ZDoggMD — Dr. Zubin Damania, MD , Stanford/UCSF-trained internist, founder of the Health 3.0 movement. Full archive: zdoggmd.com | YouTube @zdoggmd

Patient satisfaction scores — Press Ganey surveys, HCAHPS, and their equivalents — are now tied to physician compensation, hospital reimbursement, and professional reputation. ZDoggMD has made the case that this is one of the most perverse incentive structures in modern healthcare: it rewards giving patients what they want, not what they need, and punishes the honest medicine that produces good outcomes.

What Patient Satisfaction Scores Actually Measure

Patient satisfaction surveys primarily measure the patient experience of care — whether they felt heard, whether their pain was treated, whether they received the information they wanted, whether wait times were acceptable. These are real things that matter. They are not, however, the same as care quality, and conflating them produces harmful clinical consequences.

A landmark study in JAMA Internal Medicine found that patients with higher satisfaction scores had higher prescription drug costs, higher hospitalization rates, and — importantly — higher mortality. The highest-satisfaction quartile had 26% higher mortality than the lowest-satisfaction quartile. Giving patients what they want in a clinical encounter is correlated with worse health outcomes at a population level.

The Opioid Connection

ZDoggMD has connected patient satisfaction scores directly to the opioid epidemic: emergency physicians who were measured on pain satisfaction scores prescribed more opioids. Patients who received opioids for acute pain — appropriately or not — gave higher satisfaction scores than patients whose pain was managed without opioids. Institutions that pressured physicians to improve satisfaction scores created incentives to prescribe.

A physician who appropriately declines to prescribe opioids to a patient seeking them gets a poor satisfaction rating. A physician who prescribes them inappropriately gets a better score. The survey cannot distinguish between these two outcomes. Neither can the hospital when it uses the scores to evaluate physician performance.

ZDoggMD's Alternative Framework

Patient experience matters — but it should be measured through qualitative feedback, direct relationship assessment, and outcomes-linked metrics, not through survey instruments that create incentives misaligned with clinical care. A patient who was well cared for and given an honest, evidence-based conversation about their condition may not rate that conversation as highly as one where they were told what they wanted to hear.

Presence Improves Real Satisfaction

A physician who isn't typing notes during the visit — who makes eye contact, listens, explains — produces the kind of experience patients actually value. The documentation is handled. The relationship gets the time.