Patient Survey Satisfaction Scores are Biased Against Protected Groups

We know implicitly that patient satisfaction survey scores are biased against women, doctors of color, and physicians who are foreign-born (or with names that make you think they are.) Every single one of us has seen the bias play out in real life — either as a witness to a colleague who has been the recipient of frank (or subtle) bias or as the recipient ourselves. We are ethically obligated to treat all, regardless of how poorly they treat us.

It’s not a secret. We discuss how to handle explicit patient racism. We discuss what tactics we can take (e.g. wearing the white coatwearing fake glasses and a bun, special name tags, acting differently and attempting to change our “resting *#&!$ face”among others) so that we can overcome this handicap. We are working diligently to improve our own organizations to mitigate against implicit bias and correct systems that perpetuate bias.  Yet, we cannot control the public and we don’t have time (or the ability) to change public biases. Patient satisfaction scores are often measured and reported as percentiles and so very small differences in scores, lead to a huge variation in force-ranked percentiles.

A small body of healthcare-specific research is demonstrating and quantifying the bias in surveys:

Isn’t it absurd that we continue to be judged by measures we know to be unfair due to the implicit bias and explicit racism/genderism of the public whom we cannot control?

It Is Illegal to Discriminate Against Protected Classes—Even If It Is Unintentional

It is illegal to discriminate against protected classes according to federal law.

  • Title VII of the Civil Rights Act of 1964 prohibits discrimination by covered employers on the basis of race, color, religion, sex or national origin.
  • It applies to and covers an employer “who has fifteen (15) or more employees for each working day in each of twenty or more calendar weeks in the current or preceding calendar year” and also prohibits discrimination against an individual because of his or her association with another individual of a particular race, color, religion, sex, or national origin, such as by an interracial marriage.
  • The equal opportunity employment section Title VII of the Civil Rights Act of 1964 has also been supplemented with legislation prohibiting pregnancy, age, and disability discrimination (Pregnancy Discrimination Act of 1978Age Discrimination in Employment ActAmericans with Disabilities Act of 1990).

Furthermore, the US Supreme Court ruled in Griggs v. Duke Power Co., 401 U.S. 424 (1971) that employment practices that do not directly discriminate against a protected category may still be illegal if they produce a disparate impact on members of a protected group, even if unintentional.

However, many physician employers currently compensate (at least a portion) and promote based on these scores.  Lower scoring physicians are required to do extra unpaid work to improve their “deficiency”.  Physicians have lost their jobs based on these scores.

This is biased.  This is wrong.  This is illegal.

What We Can Do?

We can demand that individual physician satisfaction scores should not be considered in performance evaluation.  They should not be used for compensation, promotion or termination.

How do we effect this change?  We could advocate that the patient satisfaction companies stop releasing data reports for individual physicians.  This might work.

Or we could work with the lawyers and sue to make this illegal.  This would require physicians to work together to gather evidence to make the case.  In order to interest a lawyer in this lawsuit, we would need to lay some groundwork to demonstrate duty, breach and damages.   We need to:

  • Demonstrate that patient satisfaction scores are biased.
  • Show that the use of biased scores leads to a disparate impact on protected groups (e.g. women and other minorities.)
  • Find a physician (or group of physicians) from a protected class who has suffered disparate impact due to lost compensation, lost promotion or termination based on patient satisfaction scores.  He or she must be willing to serve as a plaintiff.
  • Provide support to the physician(s) willing to bring this suit forward.

If the courts rule it illegal to use these scores for pay or promotion, it is likely that the reports will no longer be used.  It would also be helpful to find an alternative, less biased way to collect patient feedback as we all value learning from patients on how we can do better.  The NHS in the United Kingdom has implemented a different system to accomplish this that may be less susceptible to bias yet still enable physicians to learn and improve based on meaningful patient feedback.

Let’s Work Together to Get This Done

We need physicians advocating and working together as a coalition.  It is possible. 

Things you can do NOW to help advance this campaign:

  • Sign this petition so that we can show a law firm there is broad support.
  • Help us demonstrate the impact of these surveys on employment and compensation. Regardless of your gender or ethnicity, share your story about how your employment or pay has been impacted by patient satisfaction survey results. You can share anonymously.
  • Become a researcher! There is even funding from The Gender Equity in Medicine Research Foundation.
  • Get involved.  We understand that many physicians are fearful about speaking out and giving their opinions, but it is vitally important that we join together to support one another. Consider joining TIME’S UP HealthcarePracticing Physicians of America,  Doctors on Social Media, or your local physician advocacy society or group to get involved.  Together we can make a difference.
  • Share this widely!

This piece was written in a collaborative effort by Dr. Amy Cho, MD MBA (Emergency Medicine), Dr. Christina Dewey, MD (Pediatrics), Dr. Dana Corriel, MD (Internal Medicine), Dr. Torie Shatzmiller Sepah, MD (Psychiatry), and Dr. Natasha Sriraman, MD MPH (General Pediatrics and Breastfeeding Medicine), with contributions by other physicians who have chosen to remain anonymous.

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