Methods: Between July 2022 and June 2024, a total of 147 patients (96 males, 41 females; mean age: 56.1±14.7 years; range, 19 to 93 years) who underwent lung resection and completed an anonymous questionnaire sent via e-mail or cell-phone were included. Demographic data of the patients, surgeon"s educational and medical background, advertisements and popularity, age and sex, appearance and communication skills, and surgeon"s working center were evaluated.
Results: "Spending adequate time with patients" had the highest score, while "the distance between surgeon"s center and patient"s home" had the lowest score. In general, criteria about surgeon"s appearance and communication skills, and surgeon"s working center had significantly the highest rates, whereas those of surgeon"s advertisements and popularity had the lowest rates (p<0.05). Recommendation by another doctor or family doctor was insignificantly more important than by non-medical person. Patients were not influenced with internet reviews or scoring about the surgeon, presence of surgeon"s personal web page, or social media accounts, or age/sex of the surgeon (p>0.05).
Conclusion: Turkish patients mostly take into consideration the attitudes of the surgeon rather than surgeon"s reputation and professional experience, while selecting a thoracic surgeon. Surgeon-patient interaction is highly important for Turkish patients. Social media and advertisements are not important criteria in the selection of thoracic surgeon in Türkiye.
To the best of our knowledge, there is no study showing the criteria that patients pay attention while choosing a thoracic surgeon in the literature. In the present study, we aimed to assess which factors are important in patient's selection of a thoracic surgeon in Türkiye.
The questionnaire form
The survey was generated using a SurveyMonkey
web tool (SurveyMonkey, San Mateo, CA, USA). The
questionnaire form consisted of two sections. The
first section included questions about the patient"s
demographic data (age, sex, marital status [married,
single or divorced/widow], child status [Yes/No],
educational background [primary school, secondary school, high school or university], working status
[retired/working], health insurance type [social/private
security], income status [low, middle or high] and
residential place [urban/rural]). The participants were
divided into four groups according to their ages (young
age [19-44 years], middle age [45-60 years], elderly
age [61-75 years] and senile age [>75 years]).[8] They
were also classified in three groups based on their
income status (low-income [less than hunger line],
middle-income [among hunger line and poverty line]
and high-income [higher than poverty line)].[9]
The second section had 24 questions regarding the selection of a thoracic surgeon. In 22 of these questions, participants were asked to rate on a scale of 1 (not important at all) to 10 (very important). The remaining two questions featured multiple choice responses concerning the age (<40 years old, between 41 and 55 years old, or >55 years old) and sex (male/female) of the surgeon, and were to be answered if the participant rated the relevant question ?6. The questions in this survey were modified based on previous studies.[2,5,10-12] The questions were categorized as domains related to surgeon's educational and medical background (G1), surgeon's advertisements and popularity (G2), surgeon"s age and sex (G3), surgeon's appearance and communication skills (G4), and surgeon's working center (G5).
Statistical analysis
Statistical analysis was performed using the IBM
SPSS version 26.0 software (IBM Corp., Armonk,
NY, USA). Descriptive data were expressed in mean
± standard deviation (SD), median (min-max) or
number and frequency, where applicable. Normality
test was performed using the Shapiro-Wilk test. The
independent t-test was used to compare two groups
and one-way analysis of variance (ANOVA) test was
conducted to analyze the differences for multiple
groups. A p value of <0.05 was considered statistically
significant.
Table 1. Participant"s demographics
Table 2 demonstrates 22 selection criteria in descending order of patient"s ratings. Top five factors rated the highest by the patients were as follows: spending adequate time with patients (7.9±1.5), giving detailed information about the disease and treatment (7.8±1.4), ease of scheduling an appointment with the surgeon (7.6±1.5), surgeon"s manner (communication skills, good-humor, kindliness) (7.4±1.4), and reputation of the center where the surgeon works (7.1±1.5). The five factors rated the lowest by the patients were as follows: the presence of personal web page (5.3±2.8), internet reviews/scoring about the surgeon (5.2±2.8), actively involved in medical research (5.1±2.7), participating on television, internet or radio programs (5.1±2.2), and the distance between surgeon"s center and patient's home (5.0±1.8).
Table 2. Ratings of 22 selection criteria based on the anonymous survey
Table 3 outlines the ratings of domains. Criteria about surgeon's appearance and communication skills had the highest rates, whereas those of surgeon's advertisements and popularity had the lowest rates. There were no significant differences among the ratings of the selection criteria in the G1, G2, and G3 subgroups (p>0.05). However, participants significantly gave higher rates to the criteria about G4 and G5 (p<0.0001).
Subgroup analysis
Surgeon"s educational and medical background
domain (G1):
Patients graduated from high school or
university, or patients having private insurance took
surgeons" educational and medical background into
consideration while selecting a surgeon (p=0.01 and
p=0.02, respectively). Middle-aged and older-aged
patients preferred surgeons with international board
certification (p=0.03). Senile-aged patients paid less
attention to the surgeon's participation to scientific
activities (p=0.01). Academic title of the surgeon was
not an important selection criterion for senile-aged
patients (p=0.002). However, it was important for
patients having private insurance (p=0.01) and with
high-income (p=0.0003).
Surgeon's advertisements and popularity domain (G2):
Recommendation of the surgeon by non-medical
individuals (friend, family member or another
patient) was not a selection criterion for the patients.
Recommendation by another doctor or family doctor
was important only in patients graduated from high
school or university, and patients with high-income
(p=0.03 and p=0.05, respectively). Patients were not
influenced by internet reviews or scoring about the
surgeon, the presence of surgeon"s personal web
page, or social media accounts (Facebook, Twitter
or Instagram) (p>0.05). Surgeon participation in
television, internet or radio programs was important
for younger patients and patients with private
insurance (p=0.001 and p=0.05, respectively).
Surgeon's sex and age domain (G3):
The surgeon's age was not important for the
patients. Thirty-five out of 51 female patients (69%)
responded that the surgeon"s sex was an important
selection criterion. Of them, 28 (80%) preferred a
male surgeon. Besides, 31 out of 42 patients with
low-income (74%) paid attention to the surgeon"s sex,
and 28 of them (90%) would consider seeking a male
surgeon.
Surgeon"s appearance and communication skills
domain (G4):
Male patients paid significantly more attention
to the surgeon's personal care and hygiene (p=0.03).
Patients living in a village cared more about the
time the surgeon gave them in the outpatient clinic
(p=0.006).
Surgeon"s working center domain (G5):
Private insurance coverage at the center was only
important for the patients having private insurance
(p<0.0001). Patients graduated from high school
and university, patients having private insurance, and patients with high-income paid attention to the
appearance and environment of the center where the
surgeon works (p=0.003, p=0.0001 and p<0.0001,
respectively). Also, the reputation of the center was
a selection criterion for the patients graduated from
high school and university, and patients with private
insurance (p=0.005 and p=0.003, respectively).
Easy and early appointment was preferred by the
patients graduated from high school and university,
working patients, and patients having private insurance
(p=0.05, p=0.05 and p=0.03, respectively). Although
the distance between the surgeon's center and the
patient"s residential place had the lowest score, a
surgeon working in a nearby center was preferred
for senile-aged patients (p=0.0001), retired patients
(p<0.0001), patients with low-income (p=0.02), and
patients living in the city center (p=0.02).
The surgeon's educational and medical background are usually the most important criteria of selection.[6,15] The rates about this domain in our study were not high. However, we demonstrated a significant correlation between the higher educational level of the patient and the thoracic surgeon"s educational and medical background, consistent with the literature.[3] It may be because patients who achieved higher levels of education place an increased value on the quality of training their thoracic surgeon received.
International board certification is another major selection criterion in general[5,14] or in older or educated patients.[6] This certification demonstrates that a surgeon can practice his/her profession outside of the home country. Thus, it is considered to be a prestigious characteristic by some patient populations. Besides, older patients mostly preferred an academic surgeon and actively participating in medical researches.[6] Gusho et al.[10] reported that older patients searched surgeons working in an academic center. In our study, we found that middle-aged and elderly patients significantly preferred a thoracic surgeon having international board certification. Senile-aged patients did not care about whether their thoracic surgeon had an academic title or actively participated in medical researches. Academic title was the preferred criterion for patients having high income or private insurance. This can be attributed to economic reasons, since these groups of patients have the ease of access to the surgeons having academic titles (Professor or Assoc. Prof.), a significant number of whom work in the private sector.
A surgeon can either be recommended by the patient's family members and friends, or by another doctor or family doctor.[15,16] Hoerger and Howard[17] reported that 75% of the patients favored recommendations by a family member or friend. Contrary to this, 58% of the patients chose their physicians according to recommendations by another physician or family doctor.[1] Similar results were published demonstrating the importance of recommendation either by a family member or friends,[5,6,11] or by another physician and family doctor.[4,10,18] In our study, thoracic surgeon's recommendation scores were not significantly important. However, the score of recommendation by another physician or family doctor was higher than that of recommendation by a family member or friend (rank 8 vs. 1 5). We found that patients with higher education levels mostly relied on another physician or family doctor"s recommendation in choosing a thoracic surgeon. A patient usually develops a long-term relationship with a family doctor in patient's and his/her family's care; therefore, there may be a stronger bond between patients and family doctors, causing a patient to give more priority to the family doctor's recommendations. Another reason may be that as the patient's level of education increases, they place more importance on professional help.
In the current study, a thoracic surgeon's social media status (social media accounts, personal web page, participation in television, radio or internet programs) had the lowest scores. This may be because the reliance on close circles (advice from families, friends, and physicians) is more important than the social media for information.[19] Numerous studies have reported the insignificance of social media in surgeon's selection.[5,7,11-13] It has been concluded that the least preferred surgeon is the "social media" famous surgeon.[6] Few studies have demonstrated the importance of social media and the presence of a surgeon's personal web page.[2,4,16]
Although the use of the internet and social media has been increasing to access healthcare information procurement globally, enabling the sharing of information, personal experiences, thoughts and ideas,[19] our findings indicate that Turkish patients in this study still place higher importance on advice from close social and professional circles than on social media sources. Physicians mostly use social media and the internet to promote their services and qualifications to attract potential patients and improve their reputation through physician online rating systems.[20] These systems are important for patients with high-income and younger patients.[18] However, our patients did not care much about the internet reviews and scores about the thoracic surgeon. We agree with the hypothesis of Manning et al.,[5] indicating that many websites for physician ratings did not necessitate voters" identities, and this reinforced the concern for manipulation of ratings, jeopardizing accurate patient guidance and a physician's reputation.
Furthermore, we observed that younger patients paid more attention to the thoracic surgeon's participation in television, radio and internet programs. Social media is unquestionably a rising force, particularly for the younger generation, while the importance of social media decreases in older patients.[21] This may be due to the fact that young individuals use the internet more during the day compared to older individuals, both for just surfing and for research about any topic. Younger patients mostly select a surgeon according to the social media advertisements or ratings and reviews.[6,10,21]
Blasier[22] speculated that increasing surgeon age might contribute to diminished cognitive and physical performance. Increased age is a risk factor for coronary artery bypass grafting and pancreatectomy, but not for lung resection and esophagectomy.[23] We demonstrated that the age of the thoracic surgeon was insignificant in the selection, as previously reported.[3,7,11,13,14]
Controversies exist about the preference of the surgeon's sex. It has been shown that female patients mostly prefer a female physician,[24] or either male or female patients choose a male surgeon.[3,16] Nonetheless, in general, most reports have reported that the physician's sex was an insignificant selection criterion.[4,7,12,14,18] In our study, the sex of the thoracic surgeon was not important overall. However, some subgroups of the patients (females and patients with low-income) responded they would prefer a male surgeon. Thoracic surgery in Türkiye has traditionally been a male-dominated specialty, and this may lead to the impression that thoracic surgery procedures are best suited to male surgeons.
Patients prioritized the surgeon's attitude over reputation and experience.[13] Patients mostly paid attention to the thoracic surgeon's appearance, manner, communication skills, and spending adequate time with them.[2,11,13] This demonstrates the importance of surgeon-patient interactions in the selection of a thoracic surgeon. Surgeon's personal care and hygiene are also important criteria.[11] We revealed that male patients significantly paid attention to the surgeon's personal care and hygiene. Doctor's personal care and appearance are features possibly increasing the doctor's value in the eye of the patients. Similarly, in our study, male patients might have accepted the doctor's personal care and appearance as a role model, compared them with their own, and made their choices accordingly.
The manner and friendly attitude of the physician are among the positive selection criteria.[5,6,11,12] Besides, the physician's communicative skills and style of giving understandable information about the disease and treatment increase the chance of selection.[13] Our patients rated higher scores for these criteria. Another important criterion of selection is how much time the surgeon spends with the patient,[12] which was the mostly rated criterion by our patients in our study. It was shown that patients from suburban settings more highly valued how much time the surgeon spends with them.[12] In our study, patients living in a village cared more about the time the surgeon gave them in the outpatient clinic. In rural locations, there is a strong reliance on social fabrics.[18] Mutual communication is an important part of these social fabrics. Therefore, a patient living in a rural area might have chosen a physician who spent enough time with him/her.
The main non-surgeon factors in the selection of the surgeon are the quality, cleanliness, and reputation of the hospital.[3,6,10,11,16] In particular, older patients prefer a physician working in a hospital with a high reputation.[2,12] In our study, patients with higher education, high-income, and private insurance looked for a thoracic surgeon working in such hospitals. It may be due to the economical superiority of these groups of patients, or the belief that "a better surgeon works in a high-quality hospital".
Patients usually prefer a physician for whom they can get an easy and early appointment.[5,10,13] This similar preference was particularly significant for the patients with higher education and private insurance and working patients in our study. Hometo- hospital distance is also another selection criterion of the surgeon. Several studies reported that patients preferred physicians from nearby hospitals.[5,15] Besides, Shackley et al.[25] showed that some patients were so unwilling to travel further that they would wait several months for surgery, if they could receive treatment close to home. Our study revealed that a surgeon working in a nearby center was preferred for senile-aged patients, retired patients, patients with low-income, and patients living in the city center. We believe that the reason for choosing a thoracic surgeon who works in a nearby hospital may be to avoid the economic burden that transportation costs may create in these patient populations.
Although this is the first study to examine the criteria patients look for while choosing a thoracic surgeon in our country, there are some limitations. The first limitation is that the number of patients in our study is relatively low. Multi-center studies can be conducted to reach a larger number of patients and thus yield more meaningful results. The second limitation is that it would be better to have the patients to fill out the questionnaire before the operation, since the answers given by the patients who had complications in the postoperative period and those who did not may cause bias.
In conclusion, this study can be regarded as a pioneering study in our country. Our study results demonstrated that attitudes of the surgeon rather than the surgeon's reputation and professional experience were considered highly significant while choosing a thoracic surgeon. This finding highlights the importance of surgeon-patient interactions in the selection. Surgeons and hospital systems should prioritize surgeon-patient interactions. This can be done by making interpersonal skills training a priority for surgeons/physicians, or by integrating patient feedback into hospital systems. Patients mostly take care of the recommendation from another doctor or family doctor while searching for a thoracic surgeon. With respect to expanding the practice or maintaining a favorable reputation, it may be beneficial for a thoracic surgeon to contact referring physicians, which contributes to the continuity of the treatment. Social media and advertisements are not important criteria in the selection of a thoracic surgeon. Conducting this study in different regions of Türkiye and combining the results would provide more precise and clear results regarding the criteria to be considered while choosing a thoracic surgeon in Türkiye.
Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Author Contributions: Idea/concept, data collection, control/supervision: O.D.; Literature review, data collection: U.T.; Design, analysis/interpretation, writing, critical review, control/supervision: M.O.Ö.; Literature review, critical review: B.A.; Critical review, control/supervision: Ş.K.
Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.
Funding: The authors received no financial support for the research and/or authorship of this article.
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