Keywords

Patient Satisfaction Scores, Patient Outcomes, and Burnout

The available literature indicates that patient satisfaction assessments play a complex role for women physicians, in part due to expectations of a subset of their patients that appears to be gendered [1]. There is also a growing concern that patient satisfaction scores may increase both male and female physician burnout and result in physician job dissatisfaction, attrition, and inappropriate patient care [2, 3]. The available, albeit limited, literature generally endorses better outcomes for patients of female physicians compared to male physicians in various settings [4,5,6,7,8]. Women physicians are more likely to demonstrate patient-centered skills, spend more time with their patients [9, 10], adhere to guidelines, and provide preventive care [5, 11,12,13,14,15,16,17]. Although data has suggested that these practice patterns may result in improved patient outcomes and stronger relationships with patients leading to an increase in professional fulfillment, the additional time and burden may increase the risk of burnout. Once a physician experiences burnout, the chances of medical errors are greatly increased [18, 19], which negatively impacts patient satisfaction and outcomes. It is therefore imperative to (1) recognize those physician qualities and behaviors that improve outcomes and add value and (2) further examine whether patient satisfaction scores are the best way to assess good quality care.

Patient Satisfaction Scores

Patient satisfaction has become a chief focus within healthcare organizations over the past decade. This is, in part, a response to both the Patient Protection and Affordable Care Act of 2010, which mandated that the patient experience and satisfaction become essential components of healthcare quality assessments, and the Centers for Medicare and Medicaid Services (CMS) announcement that future payments would be heavily impacted by the assessment of healthcare quality and value [20]. As a result, patient satisfaction scores are currently considered a major quality indicator. Administrators of healthcare systems commonly rely on patient satisfaction scores to both judge the success of the physicians they employ as well as a metric to compare their performance to other healthcare organizations.

Patient satisfaction scores have been directly related to clinical outcomes, patient retention, patient doctor relationships, and medical malpractice claims [21,22,23,24]. Jha and colleagues examined whether a hospital’s performance on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was related to its performance on clinical care quality indicators. Hospitals with a higher level of patient satisfaction provided clinical care which was higher in quality for all conditions examined including acute myocardial infarction, congestive heart failure, surgery, and pneumonia. Another observational study compared clinical performance, patient satisfaction, and 30-day risk-standardized readmission rates for acute myocardial infarction, heart failure, and pneumonia. This study confirmed the relationship between higher overall patient satisfaction with lower 30-day risk-standardized hospital readmission rates after adjusting for clinical quality from an organizational perspective [25].

It is, however, imperative to recognize the obvious limitations of relying on patient-reported data in isolation. Importantly, patient-reported impressions of quality of care do not always align with medical personnel’s impression of the same encounters [26]. Patients typically focus on the entire patient experience. This includes, but is not restricted to, the care provided during the visit. In fact, one study found that high patient satisfaction was associated with a higher probability of an inpatient visit, greater healthcare expenditures, and higher mortality [2]. This highlights the essential need to employ processes that evaluate both the actual medical care provided and the patient experience. Medical care outcomes, both positive and negative, must remain paramount in the evaluation of healthcare organizations. Furthermore, there is data to suggest that the utilization of patient satisfaction surveys may result in physician job dissatisfaction, attrition, and inappropriate patient care due to fear of a bad evaluation [3]. Further research is needed to confirm that patient satisfaction scores, particularly when not accounting for appropriate nuance, add positive value to the evaluation of healthcare organizations and the providers overall.

Given the emphasis that healthcare organizations place on patient satisfaction scores, there is a significant amount of research being performed to help understand the factors that define patient satisfaction and may affect scores for individual physicians. Patient satisfaction scores are influenced both by patient characteristics and physician behaviors. Four factors have been identified as being integral in defining patient satisfaction: the patient’s personal preference, the patient’s expectation, the response tendency of the patient due to personal characteristics, and the quality of care received [27].

Research has demonstrated an association between race and gender concordance, physician age, and patient satisfaction scores [28, 29]. The relationship between race concordance and higher patient ratings of care seems to be independent of patient-centered communication, suggesting that patient and physician attitudes may mediate this relationship. There is also a significant amount of research evaluating the relationship between physician gender and patient satisfaction. Investigations have focused on whether there is a relationship between a physician’s gender and patient satisfaction as well as the impact of physician and patient gender concordance on patient satisfaction. The remainder of this chapter will review the current literature and explore the relationship between patient satisfaction scores, patient outcomes, and physician gender.

Physician-Patient Communication

Women physicians with higher patient satisfaction scores are thought to incorporate stronger emphasis on patient-centered skills. These practice skills include being more attentive, providing more information and displaying more sympathy [9]. When comparing gender differences in physician-patient communication of pediatricians, women physicians typically spend more time with their patients than their male counterparts [10]. Women physicians engaged in more social exchange, more encouragement, reassurance, and information gathering with the children. This study observed that children were more satisfied with physicians of the same gender while parents were more satisfied with the women physicians [30]. Some, but not all studies, found that women obstetrics-gynecology patients preferred a female physician [31, 32]. One group of investigators videotaped primary care providers to further study whether differences exist in outpatient clinic encounters between male and female primary care physicians [12]. Although they did not demonstrate a statistically significant difference in the total time spent with patients, they did observe that female physicians engaged in more preventive services and communicated differently with their patients. This concept has been reinforced in several clinical trials. In one study involving gynecologists, after controlling for patient-centered communication, no significant gender differences remained; i.e., patient-centered communication drove patient satisfaction more than the physician’s gender. However, women physicians tended to use that style of communication more than their male counterparts. The authors encouraged further research on how to improve such communication skills for all physicians [33].

Gender Concordance and Patient Satisfaction Scores

A preference for gender concordance, a woman patient’s preference to be cared for by women physicians, has been repeatedly demonstrated. This has been verified in studies evaluating women’s choices of general practitioners [34,35,36,37], consultations for women’s health problems [38], gynecological care [39], and emergency medicine [40]. A meta-analysis performed by Janssen et al. found that many women prefer to see a woman obstetrician-gynecologist, especially when a physical examination is required [31, 32, 41,42,43,44,45,46]. There are many theories to explain the reason women prefer to be seen by women physicians. The obvious one is that women feel more comfortable with women, especially when the examination involves a detailed physical examination. In addition to the ease of undergoing a physical examination by someone of the same gender, investigators have found that gender concordance encourages improved communication, patient satisfaction, and fosters a more trusting relationship between a patient and his or her physician [10, 33, 47,48,49].

The association between women physicians and high patient satisfaction scores is not a universal finding. Interestingly, notwithstanding the overwhelming evidence that women prefer to be seen by physicians of the same sex, the relationship becomes less clear when evaluating patient satisfaction scores. In one multicenter study, the gender of the physician treating patients in an emergency room was not a significant factor in Press Ganey Evaluations by patients [50]. Another study performed by Schmittdiel et al. found that in their population, women who chose female doctors were the least satisfied for four out of five measures of satisfaction. This study evaluated a random sample of HMO members and categorized them into four dyads: female patients of female physicians, male patients of female physicians, female patients of male physicians, or male patients of male physicians. They further stratified patients on whether they had chosen or been assigned to their physician. Of all of the divisions, male patients of female physicians were the most satisfied. Female patients were more likely to have chosen their physician to be a female physician. Despite this, female patients who chose a female physician were the least satisfied patients. Of note, preventive care and health promotion practices were comparable for male and female physicians. These differences were not seen among patients who had been assigned to their physicians and were not due to differences in any of the measured aspects of health values or beliefs. This study suggests that female patients who choose their physician may have higher expectations which are difficult for physicians to fulfill [1]. In fact, when men and women physicians portrayed the same high patient-centered narrative, there was a stronger positive effect on satisfaction and evaluations for men than women physicians. This supports the idea that while higher verbal patient-centered behavior by male physicians is a marker of clinical competence, these same behaviors are considered expected behaviors for women physicians and translated into less significant effects on satisfaction and evaluations for women physicians [51]. In fact, there is evidence that male physicians may get more credit when they demonstrate the same degree of patient-centered care as female physicians [52]. (See Chap. 5 for more on gender stereotypes.)

In a small study published by Garcia et al., the authors further explored the relationship between gender concordance and patient satisfaction. The populations of patients included in this study were African American, Caucasian, and Latino adults, who received their outpatient care in university-based primary care clinics in Northern California. This study found that women in all English-proficient groups described gender concordance as important to their relationships with primary care physicians. However, Spanish-speaking patients uniformly preferred Spanish-speaking physicians [53]. This study further underscores that gender concordance may represent only one of many patient satisfiers that contribute to the complex relationship between physician preference and patient satisfaction.

Outcomes of Female Physicians

In addition to discrepancies in patient satisfaction scores based on the sex of the provider, a significant amount of attention is focused on differences in both medical and surgical healthcare outcomes based on physician gender. The following section will review and summarize the available research.

In addition to being more likely to participate in patient-centered communication, the literature indicates that women physicians are more likely to adhere to clinical guidelines and provide preventive care [5, 11,12,13,14,15,16,17]. Gender concordance has been linked to medical decision making, achievement of diabetes and hypertension treatment goals, and receipt of preventive counseling. Women physicians appear to reach the treatment goal for blood pressure, HbA1c levels in women patients, and cholesterol levels in all patients more often than men physicians [54,55,56]. A study performed by Schmittdiel et al. investigated the relationship between outcomes of risk factor modification based upon physician gender. They monitored control of HbA1c levels, LDL-C levels, and systolic blood pressure. The results demonstrated that women patients of women physicians had better HbA1c control. Although in the general population, women patients have lower levels of LDL-C and blood pressure control than patients who are men, women patients of women providers have better LDL-C and systolic blood pressure and were more likely to receive treatment intensification of all three cardiovascular disease risk factors than women patients of men primary care providers, indicating a link between gender concordance and clinical outcomes. Furthermore, women physicians were more likely than their men counterparts to intensify hyperlipidemia and hypertension therapy for their patients [4].

Similar findings have been demonstrated when evaluating the influence of physician gender and adherence to guideline-recommended treatment of chronic heart failure in patients in eastern Germany. Guideline-recommended medication use and achievement of target doses have been observed to be higher in patients treated by women physicians. Furthermore, although there was no difference in treatment for men or women patients cared for by women physicians, physicians who are men used significantly less medication and lower doses in women patients. In a multivariate analysis, female physician gender was an independent predictor of beta-blocker prescription [5].

Although research supports the idea that women physicians focus on patient-centered communication and medical care that is more likely to adhere to clinical guidelines and recommended preventive care, does this behavior translate into better clinical outcomes for patients of women physicians? This question was addressed in a study performed by Tsugawa and colleagues [6]. The investigators analyzed a random sample of hospitalized patients greater or equal to 65 years old who were treated for a medical condition by a general internist and receive Medicare fee-for-service benefits. They examined the relationship between physician sex and 30-day mortality and readmission rates after adjusting for patient, physician, and hospital characteristics. They found that patients treated by women internists had lower mortality and readmission rates compared to patients treated by internists who are men. These findings suggest that previously documented differences in practice patterns between men and women may translate into different patient outcomes. Similarly, Dahrouge et al. evaluated quality of care based on physician gender in family medicine practitioners in Ontario, Canada. They observed that patients of women physicians were more likely to receive recommended cancer screening and diabetes management. They had fewer emergency room visits and hospitalizations. Complex patients were also noted to visit the emergency room less if their physicians were women[7].

The findings of the above study were verified by authors of another study, who evaluated survival rates following acute myocardial infarctions based on the gender of the treating emergency department physician. A higher mortality was noted among women patients treated by men physicians. Men and women patients experience similar outcomes when treated by women physicians, suggesting that unique challenges arise when physicians who are men treat women patients. Even more interesting, they found that men physicians with more exposure to women patients and women physicians have more success treating women patients [57].

Studies evaluating outcomes based on physician gender have also been performed in procedure-based medical subspecialties and surgical specialties. Mehrotra and colleagues performed a retrospective cohort study in which they evaluated physician performance on adenoma detection rate after risk adjusting for differences in patient population and procedure indication. They noted that women physicians detected roughly 10% more adenomas than men physicians, supporting that women physicians had higher performance in adenoma detection [8].

Comparison studies evaluating postoperative outcomes based on the surgeon’s gender have also demonstrated small, statistically significant differences in outcomes. A population-based, retrospective matched cohort study evaluated the outcomes of patients undergoing 25 surgical procedures. Patients were matched by age, sex, comorbidity, surgeon volume, surgeon age, and hospital. Fewer patients treated by women surgeons died, were readmitted to the hospital, or had complications within 30 days than those treated by men surgeons. A stratified analysis by patient, physician, and hospital characteristics did not significantly modify the effect of surgeon sex on outcome. They did find that improved postoperative outcomes for patients treated by women surgeons were restricted to patients who have had elective operations, which might reflect better patient selection for surgery [58].

In conclusion, the available research suggests a positive relationship between patient satisfaction and patient outcomes for patients cared for by women physicians. Overall, women patients prefer to receive medical care from women physicians. Positive patient satisfaction and outcomes appear to be driven by patient-centered communication, preventative care, and adherence to clinical guidelines. The small amount of literature available suggests that women patients of women physicians may have better outcomes. Future research to further elucidate these relationships is warranted. The available data supports the value of patient satisfaction scores on a global level; however the possible role of patient satisfaction scores in contributing to physician burnout should be explored further. If a causative relationship between patient satisfaction scores and physician burnout is realized, healthcare organizations may benefit from focusing on value and outcome rather than patient satisfaction scores. Women physicians will benefit from research regarding strategies that accommodate and support their positive doctor-patient relationships and outcomes to foster professional fulfillment while not increasing physician burnout. Ultimately, both our physicians and our patients will benefit from healthcare delivery that leverages the skills necessary to create high-quality patient experiences and the best possible outcomes for our patients in the most supportive environments for our physicians. Ideally, our healthcare systems and practices should accommodate for and reward those behaviors, rather than make it harder on doctors who take that extra time and care to meet the needs of the patient.