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Research Article

Provider Personal and Demographic Characteristics and Patient Satisfaction in Orthopaedic Surgery

Lu, Laura Y. MD; Sharabianlou Korth, Mortiz J. MD; Cheng, Robin Z. BS; Finlay, Andrea K. PhD; Kamal, Robin N. MD; Goodman, Stuart B. MD, PhD; Maloney, William J. MD; Huddleston, James I. III MD; Amanatullah, Derek F. MD, PhD

Author Information
JAAOS: Global Research and Reviews: April 2021 - Volume 5 - Issue 4 - e20.00198
doi: 10.5435/JAAOSGlobal-D-20-00198

Abstract

With increased emphasis on cost-effective value-based care, patient satisfaction has risen as a new “vital sign” to capture the quality of clinical care. Although there is evidence that patient satisfaction is associated with patient-reported health outcomes and communication-related measures, there is debate over the importance of patient satisfaction in patient care and reimbursement policy. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is widely used to capture the patient hospital experience.1-5 HCAHPS results are publicly reported, and many hospitals are required to report HCAHPS results to receive up to 2% of their annual Medicare hospital reimbursements, a value of nearly a billion dollars.6,7 In this regard, hospitals and ultimately physicians are incentivized to view patients as both individuals to be cared for and as customers of the healthcare system. Such motivations undoubtedly alter the patient-physician relationship and provide impetus to understand the factors that affect patient satisfaction.

Patient satisfaction is a complex entity that involves modifiable and nonmodifiable factors and both conscious and unconscious input. It is inherently tied to expectation and is negatively affected when expectations are not met.4 In some settings, patient satisfaction is correlated with resolution of symptoms and pain, especially in the long term, but more consistently it is associated with interpersonal connection, communication, empathy, support, warmth, and perceived competence.1-5 A patient-centered communication style is at the heart of what patients perceive as a satisfying experience with their healthcare provider. As such, it is clear that cultivating better physician communication skills, a modifiable skill, is beneficial for patient satisfaction and, more importantly, for improved patient health outcomes.8

However, this satisfaction benefit is not always realized with better communication because nonmodifiable factors can negatively influence patient satisfaction. For example, studies show that female physicians excel over their male peers in communication style and patient-centered style. This difference occurs for positivity in verbal and nonverbal communication, empathy, accurate interpersonal perception, focus on feelings, good listening, expression of respect or praise, and a focus on prevention.9-11 However, female physicians do not attain higher scores in satisfaction questionnaires, reflecting a gender bias embodied in the concept of patient-centeredness.12

Furthermore, patient-physician race concordance is associated with patient satisfaction. African American patients with Caucasian physicians rate their clinical visits as less participatory than Caucasian patients. However, in race-concordant relationships, patients feel that they participate more in decision-making and have higher satisfaction with their clinic experience.13,14 It has been reported that race concordance is associated with an 85% increased likelihood of receiving a top score when compared with discordant patient-physician pairs.15 These trends reveal that patients and physicians, such as all human beings, hold implicit biases that may influence their attitudes, perceptions, and satisfaction, and therefore, might affect the results of patient satisfaction questionnaires.

Although there are multiple studies that have evaluated patient characteristics and communication-related elements that affect patient satisfaction, there is a paucity of information regarding physician-specific characteristics that may influence patient satisfaction. In this study, we sought to explore the relationship between nonmodifiable physician characteristics, such as sex and race, and patient satisfaction with outpatient orthopaedic surgery care as expressed in the Press Ganey Satisfaction Scores. The results of this study have implications for both reimbursement policy and diversity in orthopaedic surgery.

Methods

Press Ganey Satisfaction Scores from all patients who rated physicians from a single institution's orthopaedic surgery outpatient clinic (n = 11,059) were analyzed. Twenty-five physicians completed a survey with general demographic data and other provider-specific characteristics (Table 1). Provider demographic information that was collected included sex (female, male), age (continuous variable), ethnicity (African American, Asian, or Caucasian), body mass index (continuous variable), cultural background (USA or other), married at the time of the survey (yes or no), and previous divorce (yes or no). Physicians who were African American were excluded from the study because of the small sample size and concerns for provider anonymity, leaving 24 for final analysis. No other ethnicities were represented in this study because the department mimics the demographics of orthopaedics as a whole. Currently, 94% of orthopaedic surgeons are male and 86% are White.16 In addition, only 19% of female orthopaedic surgeons are non-White.9

Table 1 - Physician Demographic Characteristics and Practice Parameter Data of an Orthopaedic Surgery Department
Sex (%)
 Male 21 (87%)
 Female 3 (13%)
Race/ethnicity (%)
 Caucasian 19 (79%)
 Asian 5 (21%)
 Age mean (SD) 46.2 (8.4)
 Body mass index (kg/m2) mean (SD) 26.0 (4.2)
Cultural background (%)
 USA 13 (54%)
 Not USA 11 (46%)
Marital status in 2013 (%)
 Married 21 (87%)
 Unmarried 3 (13%)
 Previously divorced 3
Years of practice
 Average (SD) 13.0 (9.0)
Employment before university appointment (%)
 No 15 (62%)
 Yes 9 (38%)
Average number of publications
 Average (SD) 48.3 (59.5)
Patents (%)
 No patents 16 (67%)
 Physicians with patents (%) 8 (33%)
Company ownership (%)
 Yes 6 (25%)
 No 18 (75%)

Press Ganey Satisfaction Scores were measured on an ordinal 5-star rating scale. A selection of 16 physician-related questions was examined (Table 2). We evaluated the 5-star ratings as a dichotomous variable (receiving a 5-star rating versus receiving less than a 5-star rating). Top-box scoring is done by comparing a maximum score (5) with all other possible scores (1 to 4) and is in line with the current practice of score reporting.17 The frequency of a 5-star rating and not for each question examined is summarized in Supplemental Table 1, http://links.lww.com/JG9/A118. This study was initiated as a quality improvement project and was granted an exemption by the institutional review board.

Table 2 - Physician-Specific Press Ganey Questions
1. Overall rating of care received during your visit
2. Likelihood of recommending this care provider to others
3. Likelihood of your recommending our practice to others
4. Your confidence in this care provider
5. Extent to which the main reason for this visit was addressed to your satisfaction
6. Opportunity physician gave you to explain the reasons for your visit
7. Amount of time the care provider spent with you
8. Degree to which care provider talked with you using words you could understand
9. Explanations the care provider gave you about your problem or condition
10. Care provider's efforts to include you in decisions about your treatment
11. Provider's explanation of what to do if problems or symptoms continued, got worse, or came back
12. Instructions the care provider gave you about follow-up care (if any)
13. Degree to which the care provider treated you with respect and dignity
14. Friendliness/courtesy of care provider
15. Concern the care provider showed for your questions or worries
16. Our sensitivity to your needs

Univariate logistic regression models were used to test the association between each provider characteristic and receiving a 5-star rating (dichotomous). A P value of 0.05 or less was considered statistically significant. Statistical analyses were conducted using R statistical software.18

Results

Providers had lower odds of receiving a 5-star rating if they were (1) female, (2) of Asian ethnicity, and (3) unmarried.

Female physicians had lower odds of receiving a 5-star rating in 3 of the 16 (18.8%) questions (Figure 1). Female gender was associated with lower odds of a 5-star rating for overall care (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.47 to 0.98), offering an explanation of patient condition (OR 0.66, 95% CI 0.44 to 0.99), and friendliness/courtesy (OR 0.60, 95% CI 0.38 to 0.95).

Figure 1
Figure 1:
Chart showing that female providers are less likely to get a 5-star patient satisfaction rating. Female gender was associated with lower odds of a 5-star rating for overall care (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.47 to 0.98), offering an explanation of patient condition (OR 0.66, 95% CI 0.44 to 0.99), and friendliness/courtesy (OR 0.60, 95% CI 0.38 to 0.95).

Asian providers had lower odds of being given a 5-star rating in 9 of the 16 (56%) questions examined (Figure 2). Asian providers had significantly lower odds of being given a top rating for being recommended to others (OR 0.61, 95% CI 0.42 to 0.88), establishing patient confidence in the provider (OR 0.61, 95% CI 0.43 to 0.87), spending enough time with the patient (OR 0.65, 95% CI 0.44 to 0.97), talking in terms the patient could understand (OR 0.69, 95% CI 0.51 to 0.95), offering an explanation of patient condition (OR 0.63, 95% CI 0.45 to 0.88), including patients in treatment decisions (OR 0.63, 95% 0.44 to 0.91), giving instructions for follow-up care (OR 0.66, 95% CI 0.48 to 0.92), being friendly/courteous (OR 0.65, 95% CI 0.45 to 0.95), and showing concern (OR 0.62, 95% CI 0.43 to 0.90).

Figure 2
Figure 2:
Chart showing that Asian providers are less likely to get a 5-star patient satisfaction rating. Asian providers had significantly lower odds of being given a top rating for being recommended to others (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.42 to 0.88), establishing patient confidence in the provider (OR 0.61, 95% CI 0.43 to 0.87), spending enough time with the patient (OR 0.65, 95% CI 0.44 to 0.97), talking in terms the patient could understand (OR 0.69, 95% CI 0.51 to 0.95), offering an explanation of patient condition (OR 0.63, 95% CI 0.45 to 0.88), including patients in treatment decisions (OR 0.63, 95% 0.44 to 0.91), giving instructions for follow-up care (OR 0.66, 95% CI 0.48 to 0.92), being friendly/courteous (OR 0.65, 95% CI 0.45 to 0.95), and showing concern (OR 0.62, 95% CI 0.43 to 0.90).

Unmarried providers had lower odds of receiving 5-star ratings in 6 of the 16 (38%) questions examined (Figure 3). Unmarried physicians also had lower odds of being rated highly for addressing the reason for the visit to the patient's satisfaction (OR 0.73, 95% CI 0.58 to 0.92), allowing the patient the opportunity to explain their reasons for the visit (OR 0.63, 95% CI 0.44 to 0.90), talking in terms the patient could understand (0.65, 95% CI 0.44 to 0.96), making efforts to include patients in treatment decisions (OR 0.61, 95% CI 0.38 to 0.96), treating patients with respect and dignity (OR 0.62, 95% CI 0.42 to 0.91), and being friendly/courteous (OR 0.56, 95% CI 0.36 to 0.88).

Figure 3
Figure 3:
Chart showing that unmarried providers are less likely to get a 5-star patient satisfaction rating. Unmarried physicians also had lower odds of being rated highly for addressing the reason for the visit to the patient's satisfaction (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.58 to 0.92), allowing the patient the opportunity to explain their reasons for the visit (OR 0.63, 95% CI 0.44 to 0.90), talking in terms the patient could understand (0.65, 95% CI 0.44 to 0.96), making efforts to include patients in treatment decisions (OR 0.61, 95% CI 0.38 to 0.96), treating patients with respect and dignity (OR 0.62, 95% CI 0.42 to 0.91), and being friendly/courteous (OR 0.56, 95% CI 0.36 to 0.88).

Provider age, body mass index, years in practice, cultural background, previous divorce, basic science research, location of employment before university employment, company ownership, number of patents, and number of publications were not significantly associated with 5-star rating for any of the questions examined (Supplemental Table 2, http://links.lww.com/JG9/A119).

Discussion

In this study, we explored physician characteristics that may influence patient satisfaction scores. By reviewing Press Ganey Satisfaction Scores from all patients who rated a physician at our outpatient orthopaedic surgery clinic, we found associations between patient satisfaction scores and three generally nonmodifiable physician characteristics: sex, ethnicity, and marital status. Our results highlight that patient satisfaction scores tied to physician performance and reimbursement may be influenced by patient bias. Specifically, characteristics such as sex and ethnicity are unrelated to clinical acumen but are immediately apparent once a provider enters a room.

Our study showed that patients had 32% lower odds of giving a 5-star overall rating for a female physician. These results are consistent with similar studies conducted in primary care and obstetrics and gynecology.15 In a study of obstetrics and gynecology physicians at a large academic institution, female obstetricians and gynecologists were 47% less likely to receive a top score in patient satisfaction compared with their male counterparts.15 This is surprising because obstetrics and gynecology is one of the few medical specialties that predominantly comprises of women with 85% of obstetricians and gynecologists being female.19 Despite lower satisfaction scores in our study, a Journal of the American Medical Association study in 2017 showed that patients of female internists had lower 30-day mortality and 30-day readmission rates compared with male internists.20 Together, these data suggest that an inherent gender bias against female physicians may play a role in lower patient satisfaction scores despite equivalent or even better clinical outcomes. Although physician gender is traditionally nonmodifiable, we highlight this paradox to bring awareness to the issue and to emphasize that current patient satisfaction metrics may inappropriately and adversely affect female providers.

Furthermore, patients had 39% lower odds of giving an Asian physician a top rating in recommending the care provider to others. Other studies have shown that patient race and patient-physician race concordance are associated with patient satisfaction. For example, patients within race concordant pairs were more likely to give a top satisfaction score compared with discordant pairs.14 Patient-physician pairs of the same ethnicity/race and similar cultural background might be able to communicate in a more familiar style, leading to more satisfaction and better evaluation. In addition, it is known that physicians, like all individuals, are vulnerable to stereotypes and biases that are shaped within society, and these perceptions may affect communication. For example, physicians who have positive perceptions of patients are more likely to be patient-centered in their communication and generally have more satisfied patients.21,22 Similarly, patients who perceive that their physicians like them and care about them are more likely to be satisfied, volunteer more information, and will be compliant with their medical regimens.23,24 Such communication and empathy dynamics may explain, in part, the lower satisfaction scores observed for Asian physicians in our study. We did not assess the ethnicity of our cohort, but we can assume that the demographic characteristics of our cohort are similar to those of the surrounding population. In the counties surrounding our institution, 43% to 72% of the population is White.

These relationships are important to highlight because orthopaedic surgery is a field that struggles with diversity. In 2018, only 5.8% of practicing orthopaedic surgeons were female, the lowest proportion of any medical specialty, and 14.1% of orthopaedic surgeons were non-White.16 In a field comprised predominantly of White men, a minority healthcare provider may not fit the image patients have in mind of their orthopaedic surgeon and thus may affect patient satisfaction with a deviation from expectation. Even in our relatively diverse department, we only had one Black faculty member, highlighting a common trend in orthopaedic surgery. With this in mind, the American Academy of Orthopaedic Surgeons has increased efforts to promote diversity and inclusion in orthopaedics with initiatives through the Diversity Advisory Board. In a recent statement from Dr. Bosco, the current American Academy of Orthopaedic Surgeons President, “A more diverse academy will lead to better care of our patients, including those of color.” This initiative and our data underscore the need for increased diversity, by all definitions, within orthopaedic surgery so that today's orthopaedic surgeons can better match and relate to the patients they serve.

Our study also showed that unmarried providers were less likely to receive 5-star ratings across all satisfaction domains compared with their married colleagues. We offer that marital status is a corollary for general happiness, perceived dedication, and communication. Across cultures, it has been shown that being married has a life satisfaction benefit, improves health, and reduces mortality risk.25,26 Such factors may better allow physicians to exude a positive affect that improves physician-patient communication and positively affect patient satisfaction.27 Previous studies found a patient's perception of communication and partnership and a positive doctor approach to be the most important predictors of patient satisfaction. Patients desire a patient-centered communication style and a positive approach, and otherwise feel less satisfied and may suffer greater symptom burden.28 Moreover, married providers may be stronger communicators because constructive communication between partners is the strongest correlation with marriage satisfaction and likely permeates into clinical practice.29 These dynamics highlight the importance of communication and additionally suggest that lower satisfaction ratings may be a result of unsatisfactory physician communication skills. Certain generally nonmodifiable characteristics, such as marital status, may be indicative of modifiable physician behaviors, such as communication and empathy. Because reciprocity is key for effective communication, improving physician communication may mitigate the negative impact of patient biases while, more importantly, improving patient care.

Our study has several limitations. First, we were unable to do a multiple regression analysis to control for potential confounders given the small physician sample size. However, to the best of our knowledge, this is the first investigation of how nonmodifiable physician demographics and characteristics relate to patient satisfaction scores in orthopaedic surgery. Second, our sample lacked ethnic and gender diversity because of the inherent and limited diversity of orthopaedic surgery in general. With a larger sample, we would aim to see if these findings are generalizable among other minority groups, other medical specialties, and across institutions. Despite these shortcomings, the trends revealed from our study are striking and warrant additional investigation.

There needs to be critical evaluation of patient satisfaction scores as a healthcare metric. Ideally, a patient satisfaction score should capture the overall quality of a clinical encounter. However, our results show that traits unrelated to clinical practice are associated with lower satisfaction, and we propose that implicit bias plays an important role in this relationship. Because female and Asian physicians had lower odds of receiving a 5-star satisfaction rating, our data suggest that there may be an inherent patient preference for Caucasian male orthopaedic surgeons in our study. Hence, patient satisfaction scores may inadvertently work to reinforce and perpetuate bias despite evidence that diversity is beneficial and key to higher functioning organizations.30 Furthermore, female and minority physicians whose skills are not recognized in patient satisfaction ratings could suffer economic discrimination because patient evaluations are increasingly used for performance improvements and incentives.31 As such, it is worth questioning the utility and equity of the Press Ganey patient satisfaction survey in its current form. Moreover, these data underscore the need for increased diversity in orthopaedic surgery.

We show that nonmodifiable provider characteristics, such as sex, ethnicity, and marital status, are associated with markedly lower odds of receiving a 5-star rating on Press Ganey patient satisfaction scores. Although it is unknown why such trends exist, we propose that implicit biases may play a role in lower patient satisfaction and negatively affect the physician-patient relationship. These results highlight a need for increased diversity in orthopaedic surgery and a critical appraisal of the utility of Press Ganey Satisfaction Scores to evaluate surgeons, inform quality metrics, and establish reimbursement policies.

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Supplemental Digital Content

Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.