Gender and racial biases in Press Ganey patient satisfaction surveys
Are we collecting the best data, and enough of it, to evaluate physician performance based on patient satisfaction?
Other issues with surveys
In addition to the limitations associated with percentile groupings, survey data are always subject to nonresponse bias, and small sample size can lead to nonsignificant results. Skewed responses also can make it difficult to identify true outlying providers who may need remediation or may be offering a superior patient experience. Satisfaction surveys also lack an assessment of objective data and instead assess how patients perceive and feel, which introduces subjectivity to the results.
Additionally, focusing on improving patient experience ratings can incentivize unnecessary or inappropriate care (ie, overprescribing of narcotics, prescribing antibiotics when not indicated, or ordering testing that may not change management). Some physicians even state that they are not getting the type of feedback that they are asking for and that the survey is not asking the right questions to elicit patient input that is meaningful to their practice. Lastly, the incorporation of trainees and advanced practice providers in the patient care experience leads to the assessment of an alternative provider being included in the ultimate score and may not be representative of that physician.
Patients’ perception and survey results. In some circumstances, the patient’s understanding of their medical situation may affect their responses. Some may argue that patients may mistake a physician’s confidence for competence, when in reality these two entities are mutually exclusive. In a randomized controlled trial, researchers from Mount Sinai School of Medicine and Columbia University Medical Center surveyed inner-city women with newly diagnosed and surgically treated early-stage breast cancer for their perceived quality of care and the process of getting care, including referrals, test results, and treatments. They compared the responses with patient records to determine the actual quality of care. Of the 374 women who received treatment for early-stage breast cancer, 55% said they received “excellent care,” but most—88%—actually got care that was in line with the best current treatment guidelines. Interestingly, the study found African American women were less likely to report excellent care than White or Hispanic women, less likely to trust their doctor, and more likely to say they experienced bias during the process. However, there was no difference in actual quality of care received in any group.22
You can’t improve what you can’t control. Ultimately, while many providers think patient satisfaction survey results may help inform some aspects of their practice, they cannot improve what they cannot control. For example, the multicenter study by Rogo-Gupta et al found that older patients (≥63 years) have more than a 3-fold increase in odds of giving a top satisfaction score than younger patients (≤33 years), independent of other aspects of the care experience.15 Additionally, they found that older physicians (≥56 years) had a significant increase in odds of receiving a top satisfaction score when compared with physicians who were younger than 55 years old.15 Given that physicians clearly cannot control their own age or the age of their patients, the negative impacts of these biases need to be addressed and remedied at a systems level.
Why might these biases exist?
While we cannot completely understand all of the possible explanations for these biases, it is important to emphasize the long-standing prejudice and discrimination against women and people of color in our society and how this has impacted our behavior. While strides have been made, there clearly still seems to be a difference between what we say and how our biases impact our behavior. Women are still tougher on women in professional evaluations in other fields as well23; it is not unique to medicine. While workplace improvements are slowly changing, women still face inequities. The more research we publish to describe it, the more we hope the conversation continues, allowing us to reduce the impact of bias on our sense of self-worth and identity related to our careers, narrow the pay gap, and see women advance at the same rate as male counterparts. Considerable transformation is crucial to prevent further workforce attrition.
With regard to the lower scores provided by Asian patients, studies suggest that cultural response bias, rather than true differences in quality of care, may account for these discrepancies. Previous literature has found that Asian patients are more likely to select midpoints, rather than extremes, when completing Likert-type studies24 and are not more likely to change medical providers than other race/ethnicities, indicating that lower ratings may not necessarily imply greater dissatisfaction with care.25
Far-reaching effects on finances, income, well-being, job satisfaction, etc.
Depending on how the results are distributed and used, the effects of patient satisfaction surveys can extend well beyond the original intentions. At some institutions, income for physicians is directly tied to their Press Ganey satisfaction scores, which could have profound implications for female and Asian physicians,13,15 who would be paid less—resulting in a wider pay gap than already exists.18
When negative and not constructive, patient evaluations can contribute to physician burnout and a loss of productive members of the workforce.26 This is especially important in obstetrics and gynecology, where physicians are most likely to experience burnout due to multiple factors such as high-risk medical conditions, pressures of the electronic medical record (EMR), the medicolegal environment, and difficulty balancing patient expectations for autonomy with professional judgement.27 Burnout also disproportionately affects women and younger physicians, which is especially concerning given that, in 2017, approximately one-third of practicing obstetrician/gynecologists were women, while that same year more than 80% of trainees matching into the field were women.28 In one survey sent to members of a prominent medical society, 20% of the medical professionals who responded said they have had their employment threatened by low patient satisfaction scores, 78% reported that patient satisfaction surveys moderately or severely affected their job satisfaction, and 28% stated they had considered quitting their job or leaving the medical profession.29Another related effect is the association between malpractice proceedings and a lack of satisfaction with perceived quality of physician-patient communication.30 This may be an important determinant of malpractice lawsuits, and ensuring high patient satisfaction may be a form of defensive medicine.
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