Since moving into our current home, my family has gone through three washing machines. The first was left by the prior owners… a stackable small machine reminiscent of a European apartment so small that two appliance doors could not be simultaneously opened. The quality was as expected… the clothes came out as if Dick Van Dyke pulled them straight from a London chimney. We then found a “top of the line” machine from a reputable appliance store, which also made us feel good since its renewable energy system provided a small tax deduction. This was still quite expensive, but we quickly realized the clothes didn’t always come out “washed” either. Its cycles “saved the planet”, but its eco-efficiency couldn’t’ seem to remove kid-stains our local ecosystem created, and we even noticed some new holes in the fabric. We finally changed to our current machine for which we’ve been pleased.
But what do most people do when they purchase a washing machine that doesn’t live up to their expectations? They rate it online. One star- “The machine didn’t perform as advertised… my clothes are still dirty…”. The machine is an innate object for which the blame falls without objection. And the outcome is not at all complex… clean versus dirty is pretty easy to determine.
However online rating sites judge just about anything imaginable these days… including neurosurgeons. Patients can now rate their physician on numerous dimensions… Of interest, most physician ratings are either, 5 stars… “he was the best”, or one-star… “run, don’t walk”. But what does a one-star rating say about the physician? Is this physician an incompetent imposter of a surgeon?
A recent study from the Journal of Neurosurgery Spine assessed the association between patient ratings and quality of the postoperative outcome. Of a sample of 647 patients undergoing lumbar spine surgery, unsatisfied patients tended to be younger, have lower self-reported mental health, and lower preoperative global health. They tended to be disaster surgical cases from the start. However, the patients’ rating of their spine surgeon did not correlate with their functional outcome, which measures the actual efficacy of the surgical intervention. Whether a good or bad rating, there was no association with outcome.
Unfortunately, survey ratings allow patients to rate their experience based on factors largely unrelated to their surgical care or true functional improvement following surgery. Google, Healthgrades, or Angie’s List weren’t designed for this. Yet, future patients only see this patient’s subjective perspective, without any accompanying surgical quality data.
In the end, neurosurgeons are not like washing machines. Just because surgery does not remove the spots off a Dalmatian, doesn’t mean the surgery itself was a failure. It may just mean those spots can’t come off. Outcomes are complex, influenced by economic strain, psychological factors continued poor overall health… Pain is also multi-factorial and individually categorized. Some patients desire complete and permanent pain resolution, while others are satisfied as long as minimal discomfort is controllable. However, this work also does not diminish the significance of a patient experience. Neurosurgeons should strive for good ratings, but it would just be more helpful for public reporting to incorporate something the surgeon could better control… the objective functional improvement from the surgery.
Rabah N et al. The association between patient rating of their spine surgeon and quality of postoperative outcome. JNS Spine. December 2020.