More diverse physician population needed to match growing diversity of society

Although most patients give their physicians high marks on the Press Ganey (PG) Outpatient Medical Practice survey, racial and ethnic discordance plays a role in how high these marks are, according to researchers. In a recent study published in JAMA Network Open, they found that physician scores were higher when physicians and patients came from similar racial and ethnic backgrounds, while discordance was associated with lower physician scores.

“The patient experience is at the heart of patient-centered medical care. There have been increasing efforts not only to measure the patient experience but also to publicly share patient ratings for individual physicians, sometimes linking patient ratings to physician employment and compensation, with the ultimate goal of motivating improvements in health care delivery. The Press Ganey (PG) Outpatient Medical Practice Survey is used by many practices to evaluate the patient experience. Despite its wide use, the associations between the patient experience and patient, physician, and clinical encounter characteristics remain unclear,” wrote Junko Takeshita, MD, PhD, MSCE, of the University of Pennsylvania, Philadelphia, and colleagues.

To assess any associations between patient experience, as measured by PG survey scores, and patient-physician racial/ethnic and gender concordance, they conducted a cross-sectional analysis of 117,589 PG surveys returned within the University of Pennsylvania Health System from outpatient visits for 92,238 patients (mean age: 57.7 years; 40.1% male; 81.6% white) and 747 physicians (mean age: 45.5 years; 63.2% male; 71.4% white).

Scoring on the PG survey ranged from 1 (very poor) to 5 (very good). The majority of outpatient encounters were return visits (64.5%) and for medical (34.0%) and surgical (29.9%) specialties.

Upon analysis, Takeshita et al found the following:

  • In racially and ethnically concordant patient-physician encounters, 87.6% of physicians received the maximum score, compared with 82.1% in discordant patient-physician encounters.
  • Discordance was associated with a lower likelihood of physicians receiving the maximum score (adjusted OR: 0.88; 95% CI: 0.82-0.94; P< 0.001).
  • Lower patient experience ratings were associated with Black (adjusted OR: 0.73; 95% CI: 0.68-0.78; P< 0.001) and Asian race (adjusted OR: 0.55; 95% CI: 0.50-0.60; P< 0.001).
  • Patient-physician gender concordance was not associated with PG scores (adjusted OR: 1.00; 95% CI: 0.96-1.04; P=0.90); upon adjusted analyses, physician who were not of the same gender as their patients were just as likely to receive the maximum score as those who were (adjusted OR: 1.00; 95% CI: 0.96-1.04; P=0.90).

In further breaking down these results, Takeshita and colleagues found that among white patients, Asian physicians had lower odds of receiving the maximum score compared with white physicians (OR: 0.87; 95% CI: 0.78-0.97; P=0.01). In addition, Black physicians had a lower chance of receiving maximum scores versus white physicians, but the difference was not significant (adjusted OR: 0.79; 95% CI: 0.60-1.04; P=0.09).

White patients were the most likely to give their physician a maximum score across all physician racial and ethnic groups (range: 84.9%-87.9%; mean score: 4.80 among all physicians), and Asians were the least likely (range: 70.3%-76.5%; mean score: 4.61 among all physicians).

White (adjusted OR: 0.73; 95% CI: 0.55-0.97; P=0.03) and Asian physicians were less likely to receive the maximum score from Black patients, compared with Black physicians. For Hispanic physicians, the odds ratio was not statistically significant (adjusted OR: 0.80; 95% CI: 0.56-1.16; P=0.24).

Patients who were most likely to give physicians maximum scores were those who were older, male, married — or partnered or divorced or widowed, on Medicare or Medicaid, and those who had better self-reported overall mental or emotional health. Patients least likely to give physicians maximum scores were those who were Black or Asian, had higher education levels, and whose primary language was not English.

Higher physician rank was associated with higher odds of receiving the highest score, while older physician age was associated with lower odds. Higher odds of receiving the top score were also seen with return and procedural visits, while clinical encounters in specialties outside of medicine were associated with lower odds of doing so.

“Delivery of health care in a culturally mindful manner between racially/ethnically discordant patient-physician dyads is also essential. [PG] scores may differ by a physician’s patient demographic mix; thus, care must be taken when publicly reporting or using Press Ganey scores to evaluate physicians on an individual level,” wrote Takeshita and fellow researchers.

“This cross-sectional analysis provides new insights about the associations between the patient experience as measured by PG scores and patient-physician racial/ethnic concordance as well as patient race/ethnicity. Further investigation to understand the reasons for differential scoring across specific patient and physician characteristics is warranted. In the meantime, although we recognize the value of PG scores as a measure of the patient experience, we also encourage health care leaders, administrators, and insurers to reevaluate the appropriateness of using PG scores as a primary and reportable measure of physician performance on an individual level,” they concluded.

Promoting a more diverse population of practicing physicians in an “increasingly racially and ethnically diverse society” is mandatory, noted Antoinette Schoenthaler, EdD, and Joseph Ravenell, MD, MS, both of New York University Grossman School of Medicine, New York, NY. In their accompanying editorial, they noted that “As noted by the investigators, greater investment is needed in recruiting, mentoring, and retaining medical students, residents, and practicing physicians who identify as members of underrepresented minority groups. Training in principles of cultural humility and multiculturalism, which emphasize a lifelong commitment to recognizing one’s unique perspective and experiences and addressing biases toward others, should be mandatory for physicians of all ages, genders, and race/ethnic backgrounds,” they wrote.

Study limitations include a low survey response rate, high proportion of white patients and physicians, and the lack of generalizability to patient and physician populations with different sociodemographics.

  1. Racial and ethnic concordance between patients and physicians results in higher Press Ganey Outpatient Medical Practice Scores that rate physician performance; discordance is more likely to result in lower scores.

  2. Most patients gave their physicians high marks, but those who were Black or Asian, had higher education levels, and whose primary language was non-English were the most likely not to give physicians high marks.

E.C. Meszaros, Contributing Writer, BreakingMED™

Takeshita reported support from the National Institute of Arthritis and Musculoskeletal and Skin Diseases awarded to the University of Pennsylvania.

Schoenthaler and Ravenell reported no conflicts of interest.

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