LAUSR

Dr Gregory House and Dr Peter Benton, of the popular television dramas House and ER, respectively, are gruff and sometimes arrogant and misanthropic characters. Part of what attracts viewers to these characters is the intriguing divide between their poor interpersonal skills and their technical brilliance and superb patient outcomes. A degree of divergence between subjective and objective measures of physician quality has long been recognized.1,2 However, recent studies have refocused attention on the potential associations between patient satisfaction and clinical outcomes.3,4 The study by Cooper and colleagues5 in this issue of JAMA Surgery contributes to the evidence base by identifying an association between surgeons’ histories of unsolicited patient observations and their rates of postoperative complications. Surgeons in the top quartile of unsolicited patient observations averaged a complication rate 13.9% higher than surgeons in the lowest quartile. Among the study’s strengths are its large sample (more than 800 surgeons and 32 000 patients across 7 sites) and extensive effort to control for patient and surgeon characteristics. The results challenge us to ask how a surgeon’s communication skills and style may affect quality and outcomes. The nature of the connection between a surgeon’s proneness to both unsolicited patient observations and complications is likely complex. For example, if surgeons with poor interpersonal skills attract lower-quality teams, their ability to achieve the best outcomes may be compromised by factors largely unrelated to their individual performance. Another possibility is that the root cause of multiple unsolicited patient observations among surgeons is an underlying characteristic, such as poor training, that also affects their performance on a range of quality measures. If so, then even though the associations observed between selected measures are strong, remediating one factor will not affect the others unless the underlying problem is addressed. In sum, despite the researchers’ impressive adjustments for potential confounders, some important ones may remain in play. Issues of causality aside, the association the study identifies between unsolicited patient observations and surgical complications may still be valuable to know. A key question is what advantage, if any, this association offers compared with actual complication rates as a marker of quality. Unsolicited patient observations are a useful predictor for medical malpractice claims because such claims occur rarely for any given physician.6 (By contrast, the volume of unsolicited patient observations in the study—a mean of 10.6 per surgeon during the 24-month study period—is striking.) However, surgical complications do not suffer from this limitation: they are common, and readily observable by hospitals. The study’s greatest utility may lie in helping to disrupt the perception, still prevalent among clinicians, that unsolicited patient observations are “soft,” overly subjective measures that are not associated with the quality of health care. Growing evidence of the connection between unsolicited patient observations and complications may prompt skeptics to reexamine their views. And although quality efforts should continue to address rates of complications, this study suggests that frontline clinical and patient-services staff may have additional opportunities to intervene. Previous work by Pichert et al7 has demonstrated that simple interventions with surgeons who incur multiple unsolicited patient observations, carefully timed and implemented, can be effective.