Story by Jodi Duckett
Image by Shutterstock/Vectorstudi
Jacob Zureich is testing how doctors handle the positive and the negative.
How do you motivate a physician to improve his performance? Not by a negative performance review, according to new research by Jacob Zureich, assistant professor of accounting at Lehigh Business.
With healthcare costs in the United States higher than in most highly developed countries and the quality of care measurably lower, there’s increased focus on finding ways to improve. One strategy gaining popularity is performance report cards, which grade physicians on their outcomes.
Zureich has found that while performance report cards have been successful in some areas—such as social responsibility and restaurant hygiene—the results in healthcare have been mixed. Specifically, data from his recent study shows that while positive feedback is beneficial for surgeon performance, negative feedback results in no improvement or is detrimental.
The study, set for publication in the journal Management Science, states:
“Overall, it is concerning that physicians fail to use negative feedback effectively, with severe consequences on patient health. Even more concerning are the systematic reductions in patient outcomes that can result from negative feedback. This supports a behavioral theory: people protect their ego by by ignoring and discounting the validity of the negative feedback.”
Zureich’s research specialty focuses on how to measure and incentivize employee performance to achieve organizational goals. Understanding how individuals respond to new performance information has been a longstanding inquiry in accounting.
For the healthcare study, Zureich worked with Manasvini Singh of Carnegie Mellon University. Singh is Zureich’s wife, and the couple started their research in 2020 when they were working from home during the COVID-19 pandemic.
“We’re a really good team for this paper. Manasvini is a health and behavioral economist who studies how physicians make decisions. I study performance feedback and incentives,” says Zureich.
The two researchers focused on a surgeon report card created by ProPublica, a highly regarded nonprofit journalism organization. The report card grades all surgeons who performed one of eight types of low-risk elective surgeries. The grades were released online in July 2015.
Zureich and Singh linked the ProPublica report-card grades for each physician to clinical data on all patient encounters in the state of Florida from 2012–2016 to examine how objective indicators of physician performance—rates of 30-day readmission and in-hospital mortality—changed after the release of the report card. The study was designed to isolate the physician’s own influence on patient outcomes by using statistical techniques to account for other factors outside physician control, such as comorbidities.
“We wanted to know if the ProPublica release resulted in a change of performance,” says Zureich.
“What we found is that physicians who got positive feedback on their report card improved their performance. But, those physicians who received poor grades didn’t change or improve their behavior.”
A final part of the study was to conduct experiments with lay people to determine if similar feedback produced similar results in the average person. It did. “That tells us it is not something unique to physicians,” says Zureich. “Physicians are people like everybody else. We’ve found that there’s some kind of broadly applicable behavioral phenomenon that causes these effects.”
People generally struggle with negative feedback, Zureich says, and physicians are no exception. Instead of motivating them to do better, the negative feedback demotivates them. The researchers suggest designing feedback interventions that better mitigate counterproductive behavioral responses. Possibilities include pairing negative reviews with a positive plan of action that provides a sense of orientation towards the future, instead of the past, or providing clear incentives for improvement.
Zureich says the study results were not entirely surprising because of previous research on the impact of negative feedback. “But physicians are unique because they are highly motivated and have high self-esteem. If anyone could handle the negative feedback, we thought it would be them.”
Why it Matters
“We are trying to understand how feedback systems can help physicians improve themselves and help improve healthcare,” explains Zureich. “This is especially important in the United States, where we seem to be struggling.”