Patient rankings: Why patient feedback should affect our delivery of care but not our pay

At our core, surgeons are physicians, not technicians. Stedman’s Medical Dictionary defines a surgeon as a “physician who specializes in surgery.”1 As physicians, we are healers. In fact, the word “physician” is derived from the word “physic,” which in turn comes from the Old French word “fisike” from about the 12th century, which refers to the concept of “natural science and the art of healing.”2 Historically, the ill have placed tremendous trust in their healers, for better or for worse. What might not be readily apparent, however, when considering what defines a physician is the important role that healers play as educators.

Closer inspection reveals that medical and surgical practice and education within the U.S. are similar fields. Both involve a special relationship between an educator (physician/teacher) and a learner (patient/student). Importantly, both continue to face challenges regarding cost-effectiveness and performance evaluation. The crux of the issue lies in the idea that the learner has the ability to provide critical feedback that may enhance educator performance. This suggests that the learner and educator can switch roles—an idea not often acknowledged in either field. This article addresses how patient feedback should be incorporated into the delivery of quality health care and how education reform is helping to set a preliminary example for medicine to follow.

The educator-learner relationship

The task of a teacher partially relies on the quality of information that he or she brings to the classroom. Just as crucial is the method by which the teacher delivers that information to the students. A teacher with a wealth of knowledge who cannot speak the language of the students will invariably fail at his or her task. Conversely, a communications expert with no knowledge of basic science will have minimal success in teaching chemistry. Therefore, if either the quality of information or the method of delivery is poor, the successful development of the teacher-student relationship will suffer. Similarly, with each patient encounter, a physician must not only possess an impressive fund of knowledge, he or she must also effectively convey that information to the patient, such as explaining the meaning of a diagnosis and the treatment plan. This challenge is compounded by the limited time allotted for these patient encounters as well as the frequently tense environment that often accompanies someone who is ill, uncomfortable, and anxious.

In the last 10 years, education reformers across the U.S. have been redoubling their efforts to improve teaching quality, and for good reason. In a report comparing 12 countries, including the UK, France, Japan, and Canada, the U.S. took a significant lead over others in the amount spent on education per school-age child. However, of the 12 countries surveyed in this report, the U.S. ranked only ninth and 10th in standardized science and mathematics scores, respectively.3 Similarly, the U.S. is the leader in the amount spent per person on health care costs compared with all the other member nations of the Organisation for Economic Co-operation and Development (OECD), a conglomerate of 34 nations.4 Yet in a recent National Institutes of Health-sponsored study, when compared with 17 other wealthy nations, the U.S. occupied the bottom of the list in nine measures, including infant mortality, heart and lung disease, sexually transmitted infections, and adolescent pregnancies.5 What these rankings suggest is a discrepancy between the amount spent on education and health care and the measured outcomes in these two areas. Although the factors contributing to these discrepancies are innumerable, there is good logic in studying the relationship between the educator and learner, for it is this relationship that essentially defines the practice of both medicine and education.

Evaluating performance

Recently, debates have been waged regarding the use of student performance and standardized test scores to evaluate the effectiveness of teachers. However, while test scores may indicate whether a school system is successful, these scores do not identify specific opportunities for improvements.6

Serendipitously, while investigating test-score discrepancies between African-American and Caucasian students in a small Ohio suburb, Ronald Ferguson, an economist at Harvard University, Boston, MA, employed the use of a survey for students to evaluate their classrooms. Unexpectedly, Mr. Ferguson found that there was in fact a great deal of agreement between the student respondents, with African-American and Caucasian students in agreement. However, between classrooms, the variance of the survey opinions occurred in the perceptions of the teachers. As an example, one teacher was consistently evaluated by his students as having difficulty explaining material and seemingly ignoring confused pupils. In contrast, another teacher from a different classroom was surveyed consistently in a positive manner, and students in that classroom expressed that they generally liked being there.6

Subsequently, student surveys have found their way into larger-scale applications. In particular, Thomas Kane, a professor of education and economics at the Harvard Graduate School of Education, Boston, MA, applied Ferguson’s student survey concept in a study funded by the Bill and Melinda Gates Foundation in 2009, investigating 3,000 teachers in seven U.S. cities. Kane found that survey results correlated with year-end test-score improvements, and since then, the student survey has gained considerable credibility in education reform and is currently used in multiple school districts across the nation.7

Surgeon evaluations are based largely on board certification, membership in the American College of Surgeons, and the facility where the surgeon has privileges.7 Although these are rigorous standards that maintain a high caliber of surgeons in the U.S., these standards do not necessarily address physicians’ abilities to communicate with their patients. Patient-physician communication has become increasingly recognized as a critical component in successful treatment. Patients who are more effectively educated by their physicians have been shown to be more compliant with therapy and more likely to modify their lifestyles according to their physician’s recommendations.8,9 Better communication has also been correlated with improved patient outcomes, including measures such as blood pressure, blood glucose levels, and emotional health.8

Surgeons pride themselves on rigorous training, discipline, and sacrifice in order to provide quality care to their patients. However, they may lose sight of the fact that therapeutic success also depends on patients’ willingness to accept surgeon education along with their own discipline and sacrifice to put the knowledge into practice. Effective communication is a key component that unifies the physician and patient, allowing each to learn from the other.

Need for further study

Overall, patient feedback for surgeons is vital in that it provides an opportunity for a surgeon to improve on multiple levels. However, its role in physician reimbursement should depend on whether positive patient feedback correlates with better patient outcomes, and this must be validated by future research.


  1. The American Heritage Stedman’s Medical Dictionary. Boston, MA: Houghton Mifflin Company; 2008.
  2. LLC. Available at: Accessed September 10, 2013.
  3. USC Rossier. U.S. education spending and performance vs. the world. Available at: Accessed September 4, 2013.
  4. Kane J. PBS Newshour Online. Health costs: How the U.S. compares with other countries. Available at: Accessed September 4, 2013.
  5. Biron CL. U.S. health worse than nearly all other industrialised countries. IPS News [press release]. Available at: September 4, 2013.
  6. Ripley A. Why kids should grade teachers. The Atlantic. Available at: Accessed September 4, 2013.
  7. American College of Surgeons. Looking for a qualified surgeon. Available at: Accessed September 4, 2013.
  8. Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ. 1995;152(9):1423.
  9. Bull SA, Hu XH, Hunkeler EM, Lee JY, Ming EE, Markson LE, Fireman B. Discontinuation of use and switching of antidepressants. JAMA. 2002;288(11):1403-1409.

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