Nearly every hospital in America now asks its patients a question that no sane person has ever asked a friend: Would you recommend us?
It arrives a few weeks after discharge, in an envelope or an email, along with its relatives. Did the doctors listen carefully? Was the area around your room quiet at night? Were the room and bathroom kept clean? On a scale of zero to ten, how would you rate this hospital? I have never understood what a yes to the big one would mean. Nobody recommends a hospital the way they recommend a plumber. Nobody says to a friend, “If you ever need a chest tube, I know just the place.” The friend does not want the chest tube. That is the whole difficulty. Ours is a business whose customers arrive hoping never to come back, and we have decided to measure their satisfaction anyway, which is how we have arrived at the present arrangement. We are graded on whether people enjoyed being ill.
I should be fair to the survey, because I read mine. A hospital where nobody explains the new medications is a worse hospital. A nurse who does not answer the call light is a problem the patient can report better than I can. If a man leaves with a prescription he does not understand, I would rather hear it from a form than from the emergency department three days later.
But consider what we are asking him to rate. He came in with heart failure. He was woken at four for blood, at five for vital signs, and at six by someone who introduced himself and asked the questions the patient had answered the night before. He was kept from eating for a procedure that was postponed to the afternoon, then to the next day. He received a diuretic, which is to say that someone had reorganized his morning around a bathroom. He shared a wall with a monitor that alarmed whenever his neighbor moved. He got better. Then he went home, and the hospital wrote to ask how it went.
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The scoring makes it worse, and every physician reading this has sat through the slide. In the numbers that get reported, and paid for, only the top box counts. When the choices are Never, Sometimes, Usually, and Always, only Always goes in it; Usually goes in a different box, where it does the patient no harm and the hospital no good for that number. On the overall rating, only a nine or a ten counts. An eight, which most people would consider a compliment, goes in the other box too, which is a grading scheme that would get a schoolteacher fired. A patient who says his doctor usually listened, which may be the most generous, honest assessment of any human being, did not know he was sitting an examination on the hospital’s behalf.
And the things that please patients are not reliably the things that help them. The man with a cold who wants antibiotics, and gets them, is a satisfied man. The woman in pain who wants a stronger pill, and gets it, is satisfied for a while. The physician who says no has done the harder and better thing and will be rated accordingly. A large study some years ago found that the most satisfied patients spent more on care, spent more on prescription drugs, and were more likely to die. It could not say why. The people who design satisfaction surveys appear to have taken it as a challenge anyway.
Hospitals have responded as hospitals do. There are scripts. Staff are taught to say “I have the time” while standing in the doorway, which is where people stand when they do not have the time. There are whiteboards on which the day’s goals are to be written, provided someone can find the marker. Lobbies have been renovated to resemble hotels, though the guests are discouraged from staying. Somewhere there is a committee on the patient experience, and it meets, and the patients are not invited, because they have gone home, which was the experience.
None of this is foolish on its own. Sitting down with a patient is a good idea. The oddity is what has happened to the reason. We no longer sit because the patient deserves our attention; we sit because someone has found that it makes him more likely to report receiving attention. I have done it. I have sat down in a room because I was told sitting makes a visit seem longer, and it does, and the visit was not longer. I have said, “I have the time.” I have looked at my scores, and I have minded.
What the survey cannot tell us is the thing he most came for. Nobody asks, on a scale of zero to ten, whether the diagnosis was right, or whether the doctor who said no was correct to say it, or whether the room was quiet at night because the patient was finally breathing well enough to sleep. The survey asks about the room. The breathing is not on the form.
He fills it out at his kitchen table, a few weeks out. He marks the noise as bad, the doctors as usually attentive, and the hospital as an eight, and he presses send. Somewhere, that eight will become a number on a chart, and somebody will be asked how to make it a nine. He gets up and goes about his afternoon and does not think about his breathing on the way.
Gurdev Singh is a physician-writer whose work centers on one idea: Most misunderstandings don’t occur because no one spoke, but because meaning did not transfer. Singh studies the gap between what is said and what is heard, especially in high-stakes settings such as illness, aging, and difficult decisions, and explores how trust is formed or lost within seconds, why reassurance sometimes increases distress, and how presence can succeed where explanation fails.
Singh writes literary nonfiction, research-informed essays, and fiction, and gives talks on empathy, communication, and human dignity. The aim is not to teach scripts, but to deepen awareness of what people carry away from an encounter, because that, more than information, shapes outcomes. In Singh’s words, “Where words end, meaning begins.” Singh’s writing appears on Substack at The Two Wells.
