Patients give the same doctors different ratings depending on where their visit took place, according to a small U.S. study.

Although doctors might act differently in an emergency room compared to a calmer office setting, researchers say the results also suggest that ratings are not a completely reliable measure of the quality of care physicians give.

As healthcare payers put more focus on improving patient experiences, said senior author Dr. Christopher Jones, of Cooper Medical School at Rowan University in Camden, New Jersey, "these scores are being used more and more to reward physicians and hospitals which do well, and to punish those who don't perform so well."

For the study in Annals of Emergency Medicine, the researchers compared patient satisfaction surveys collected from three different locations staffed by the same set of doctors. One setting was the emergency department at Cooper University Hospital - a more culturally diverse and urban environment, the researchers say. The other two settings were urgent care sites in more suburban areas nearby.

The study team used quality ratings of 17 doctors from both emergency room and urgent care patients. Surveys were collected between June 2013 and August 2014 by Press Ganey, an independent quality assessment company.

The surveys asked patients to rate on a scale of 1 (very poor) to 5 (very good) how courteous the doctors were, how much doctors took time to listen, whether they kept patients informed about their treatment and their concern for patients' comfort.

The study team hoped that looking just at the doctors' ratings on courtesy would rule out the influence of outside factors, such as interactions with other healthcare staff, on patient perceptions of the doctor.

Nevertheless, patients who saw doctors in the hospital emergency room gave them consistently lower scores on all of the survey questions compared to patients who saw the same doctors in urgent care settings.

Based on 17 emergency department surveys and 79 from the urgent care settings, all of the doctors' average scores for each courtesy question were between one third and one half point lower in the emergency department setting.

"As physicians it is also important to us that we are creating strong patient-physician relationships, that our patients feel respected, and that they are happy with the service they receive," Jones said by email.

More on this...

However, it is hard to measure this relationship without the influence of factors like wait times, other staff members and even how the treatment center looks, he added.

Doctors may also be influenced by the conditions of treatment centers, said Gayle Prybutok, a nurse and professor who studies emergency department conditions, who was not involved in the study.

Working conditions in hospital emergency rooms can be harsh, she said by email. "Physicians who are exhausted from working 24 hour shifts with frequent sleep interruptions often have difficulty being cordial during patient interactions."

Urgent care centers tend to have more limited hours and may have shorter wait times, she said. "Interactions with all providers are likely to be more cordial because stress in the environment is limited."

Prybutok suggested it might be better to use these scores to compare quality ratings between similar types of settings and try to improve the way services are delivered to patients.

"Comparing apples to apples is more useful than comparing apples to oranges and trying to draw conclusions that lead to the design and implementation of process improvements," Prybutok said.

Interactions between patients and doctors should not feel rushed, patients should be encouraged to ask questions and doctors should make sure they understand and give written instructions in the patient's language, she said.

"Our study shows that satisfaction scores patients give their physicians are influenced by factors other than just the patient-physician relationship. Until we determine how to control for these other factors, we should be very cautious about using satisfaction scores to make comparisons between different physicians," Jones said.