Patient satisfaction reports are increasingly used as quality-of-care metrics in hospital reimbursement structures and in physician compensation and promotion models. Therefore, it is important to evaluate these instruments for both validity and inherent bias. The Press Ganey (PG) survey is the most widely used patient satisfaction measurement tool and the only survey approved for outpatient use by the National Quality Forum.¹ However, recent literature has suggested a bias against female physicians in patient satisfaction ratings across many subspecialties including general surgery, primary care, and gynecology.^2-4 Bias against female providers is particularly concerning in medical fields that are historically dominated by male providers, such as urology. Given the predominance of both male patients and physicians in urology, we sought to study the impact of unmodifiable physician and patient demographics on patient-reported PG survey ratings for urologists in the outpatient setting.⁵

We retrospectively reviewed 4,155 PG surveys completed between February 2020 and August 2021 for all outpatient encounters performed by 20 attending urologists (12 male, 8 female) across all subspecialties at a single academic tertiary care institution. Our primary outcome was patient-reported “topbox” overall doctor rating (topbox-ODR) score of a 9 or 10 on a scale of 1-10. The Table displays patient and physician characteristics and the results of all analyses.

Table. Results of Univariate and Multivariate Analyses of the Relationship Between Patient- and Provider-Level Covariates and Topbox Overall Doctor Rating Score

Our data raise concern that the PG survey tool may be biased. We found that female urologists had a significantly lower mean overall doctor rating (ODR) score than male urologists. Female urologists were also 58% less likely to receive topbox-ODRs than male urologists. Interestingly, female patients were 73% less likely than male patients to give topbox-ODRs. While male patients were significantly more likely to give topbox-ODRs to male urologists than they were to female urologists, female patients were less likely to give topbox-ODRs to both male and female urologists. While we cannot speculate on why female patients provide lower survey scores than their male counterparts, our results suggest that urologists who primarily treat female patients are particularly at risk of bias. This includes female urologists, who see a higher proportion of female patients,^6,7 and urological subspecialists in female pelvic medicine and reconstruction or voiding dysfunction.

We suspect that, in addition to gender-based biases, patient diagnosis and care expectations may also disproportionally skew physician scoring. Our data showed that oncologists were 3 times more likely to receive topbox-ODRs than urologists of any other subspecialty. Meanwhile, physicians who had been in practice for <10 years were more likely to receive better scores. One can imagine that patients are more likely to give higher PG survey ratings to urologic oncologists who inform them of no evidence of disease after oncologic surgery than they are to a voiding dysfunction specialist who counsels that the pain of interstitial cystitis can be managed but not cured. This discrepancy likely explains our finding that oncologists are more likely to receive higher scores.

Our results are the first of their kind in urology. We found that female, more experienced (>10 years in practice), and nononcologic urologists each had lower odds of achieving top PG physician ratings. We also found that female patients were less likely to give top PG ratings compared to male patients, regardless of the sex of the urology provider. Male urologists who care for male patients appear to be at the least risk of bias in PG physician ratings, while female urologists who care for female patients appear to be at the highest risk. While further multi-institutional studies are needed to confirm our findings, we believe that our results highlight the need to de-emphasize the impact of PG scores on physician compensation and promotion decisions until additional research is done.