I Can't Get No (Patient) Satisfaction.

March 2019 • Volume 128 • Number 3 www.anesthesia-analgesia.org 393 DOI: 10.1213/ANE.0000000000003973 Increasingly, patient satisfaction constitutes a measured outcome in published medical trials.1,2 In this issue of the Journal, Siu et al3 prospectively investigated determinants of patient satisfaction with postoperative pain management after video-assisted thoracoscopic surgery. The authors surveyed 300 patients using a modified questionnaire that assessed multidimensional factors including pain scores, psychological factors (ie, anxiety and depression), activities (ie, ambulation and sleep), medication-related side effects, patient information, and involvement in decision-making. The ability to participate in analgesic decisions was found to be the most reliable predictor of patient satisfaction. Other positive predictors included the provision of information regarding treatment options, while pain intensity and interference with sleep constituted negative determinants. Despite its apparent simplicity, the term “patient satisfaction” can be riddled with ambiguity, as medical care represents a multidimensional experience, with each individual facet giving rise to varying levels of satisfaction (or dissatisfaction) among patients. Siu et al3 minimized the potential semantic trap by focusing their study on satisfaction pertaining to acute pain management, focusing on postoperative days 1 and 2. They did not assess patient satisfaction with chronic postsurgical pain, which may be related to a higher degree of dissatisfaction, influenced by different factors, and subject to different treatments. Patient satisfaction with acute pain management encompasses 2 distinct elements: satisfaction with the outcome (ie, the success of the pain regimen) and with the process itself (ie, the collective effort to achieve analgesia). Although overlap exists, the 2 components should be viewed as separate entities. For example, a patient could receive inadequate pain control but be thankful for all the attempts/information provided to ensure optimal analgesia.1 Conversely, a patient with minimal postoperative pain could be unsatisfied due to his or her paternalistic exclusion from the decision-making process.1 Although Siu et al3 did not explicitly differentiate between the 2 components, their questionnaire contained elements related to both outcome (eg, questions 1–6 and 12) and process (eg, questions 7, 8, 10, and 11). The results by Siu et al3 echo those of Caljouw et al,4 who previously noted that satisfaction was dependent not only on anesthetic outcome but also on how patients were approached and the information that they received. Together, these 2 studies highlight the fact that processrelated factors (eg, participation in decisional process) may be as, or even more, important than outcome-based parameters (ie, pain intensity) in ensuring patient satisfaction. These findings mirror conclusions previously published in the surgical literature. For instance, after hand surgery, improvement in strength, range of motion, and activities of daily living emerged as major predictors of satisfaction.2 However, in addition to these outcome-related factors, process-based parameters appear critical to surgical patients, because patient information, shared decision making, length of follow-up, duration of waiting time, state of facility, and food can significantly impact patient satisfaction.2 Moreover, a surgeon’s perceived empathy has been intimately linked to his or her patients’ contentment. Outcomeand process-related determinants both fall under the control of health care providers. Thus, it may be tempting to believe that physicians can become the sole architects of patient satisfaction. Unfortunately, evidence shows that satisfaction also depends on patient-related factors that can escape medical control (Table).5 For example, in a recent observational study, patient-related sociodemographic variables such as male gender, older age, and higher education level were associated with increased satisfaction scores after anesthesia.6 Similar results were reported in a cross-sectional analysis of 16,222 patients undergoing nonobstetric surgery in the United Kingdom.7 Younger age, female gender, and obesity, as well as histories of stroke, neuropathic pain, and long-term opioid use, constituted nonmodifiable parameters associated with severe discomfort after surgery. Other patient-specific factors may be modifiable. For example, psychological traits (eg, anxiety, depression, and catastrophizing) can be alleviated by relaxation techniques, cognitive behavioral therapy, and an improvement in postoperative pain and recovery.7 In addition, independent of pain control, attention to patient comfort through simple measures, such as carbohydrate loading/early feeding, early mobilization, and limiting sleep interference, may also increase patient satisfaction. Therefore, as noted by Siu et al,3 patient education and preparation for surgery can play a role in promoting satisfaction. I Can’t Get No (Patient) Satisfaction