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Practice Extender


For better or, maybe, worse, patients are judging your care online

When patients rate you on Internet sites, it’s not necessarily the end of the world. It is an opportunity to apply your most valued clinical skill: listening.

March 2011 · Vol. 23, No. 3

CASE: Unfairly labeled and now unnerved

Dr. Y, your colleague, calls you; she’s distraught. She performed a Google search of her name and found what she describes as a hateful review on a physician-rating Web site from someone claiming to be her patient. The reviewer declared that Dr. Y. was “rude” and interested only in “pushing one drug.”

“She must be a shill for a drug company….”

You’ve referred many patients to Dr. Y, and you’ve always heard wonderful things about her care. You know that she has never accepted pharma money for lectures or research.

“What should I do?” Dr. Y pleads with you.

We physicians probably don’t think twice about looking up reviews and ratings of hotels and restaurants. But many of us balk at the thought of our professional services being reviewed in such a manner. We’re aware that patients discuss their care, of course, but the Internet— well, that provides a megaphone of global reach for what was once mere water-cooler chat.

And reading angry words in print hurts more than hearing them secondhand.

With the Internet hosting more than 30 sites that rate health-care providers and hospitals, most of us can expect to be reviewed at some point. Only about 15% of people report consulting online physician reviews, however, and fewer than 5% have posted an online review themselves.1,2

What do you need to know about these sites and their potential to have an impact on your practice? Here are some important observations and pearls from the literature and from my experience at the receiving end of ratings.

Types of physician online rating

The first step in navigating the morass of Internet review and rating sites is to understand the types of sites that you’ll encounter.

Angie’s List. This site rates all kinds of services, including physicians. Membership requires registration and a fee. A member can post a review of a given physician every 6 months. Although the names of reviewers are not posted, they are available to the physicians being reviewed—if they ask.

Free Web sites that require registration of some kind. These are general review sites, such as www.yelp.com or specific sites for physicians, such as www.DoctorScorecard.com, which states that a reviewer is allowed to rate a given physician only once.

Free Web sites that don’t require registration. One simply finds the physician’s name and either clicks on the number of stars or writes a review, or both. Two examples: www.vitals.com and www.drscore.com. These sites claim to limit the number of reviews: vitals.com, one review a month; drscore.com, one a quarter. A spokesperson for drscore.com, claiming that such information is proprietary, declined to tell me how, without the controls offered by registration, the site prevents a physician or an angry patient from stuffing the ballot box.


How valid are online reviews?

You might think that the patients most likely to rate a physician or post a comment about her (or his) care are ones who are unhappy with their medical care. You would be wrong: 70% to 90% of online ratings of physicians are positive.3,4 It’s unclear if the positive-negative division of ratings varies between Web sites that require registration (and therefore have a greater degree of accountability) and those that do not. A recent informal sampling of sites reveals that most physicians have five or fewer reviews on any one site—a sample far too small for the rating to be considered valid or to offer meaningful feedback to a physician.

What can I do to protect my reputation?”

Good question. The answer is multifaceted.

  • Give your patients an opportunity to provide feedback after an appointment. If they can off-load to you at, or immediately after, their visit, they may be less inclined to post damaging comments elsewhere. And you might actually learn valuable information about your practice and your staff— and how convenient parking is.
  • Consider an anonymous survey for the patient to complete before leaving the office or to mail back in a stamped envelope.
  • Does the idea of a third-party Internet ranking site appeal to you? Find one that allows you to create a profile and have your staff direct patients to that site.
  • Develop a robust Internet presence. Web content that is under your control is more likely to appear at the top of the first search-engine response page (SERP)—thereby pushing potentially negative reviews out of this prime real estate (links that appear on the bottom half of the first page of search results, and beyond, are far less likely to be viewed or clicked). If your Web site isn’t listed first, consult with a search engine optimization specialist about trying to change that. Other ways to generate positive hits on the first SERP? Use Twitter (as long as you are using a version of your name as the username); start a blog; and write guest posts on other Web sites.
  • It’s possible to register with all the physician rating sites and receive alerts when you are mentioned, but that could be time-consuming. This strategy is also unlikely to be productive: First, not all sites allow rebuttal or other feedback from physicians. Second, even if you were able to respond, what you can say is limited by HIPAA. Last, although you can flag malicious content for removal, what you consider malicious and what the site administrator considers malicious could differ.

For the fictional Dr. Y., whose story was told at the beginning of this article, this is the best possible answer to her dilemma: Leave the review alone. It’s an opinion, and while hurtful, it isn’t slander and is unlikely to meet the requirements for removal. However, it might be wise to follow up with the bullet-point recommendations I’ve made, above.

Can you muzzle your patient population? One company, Medical Justice, Greensboro, N.C., provides practices with a patient contract that allows the physician to retain copyright to patients’ online comments. The contract doesn’t preclude posting, but the physician is free to remove negative comments. The company’s product was described by its founder and chief executive officer in an article in the December 2009 issue of OBG Management (“Should you worry that patients will use the Web to grade you?,” at www.obgmanagement.com).

Even if—and that’s a big “if”—patients are willing to sign on the dotted line, it’s unclear how such a contract could stop anonymous posting. And, by analogy, would you eat at a restaurant where you were required to turn over copyright to your online comments before you saw the menu?

Here’s what I do

I’m a believer in physician ratings: If I’m doing a good job for my patients, I like to know that. And, if there’s room for improvement, I can change or fix something I do only if I know about it.

My physician group has had a patient survey in place for several years. It’s similar to the CHECKBOOK/CSS program, although it is accomplished by mail.

I’m proud that I receive high scores from my patients. Whenever I find that some facet of my ratings is slipping, I redouble my efforts. Online, 70% to 90% of my reviews are positive, which is in line with physicians’ experiences reported in the literature that I cited for this article.

Most negative opinions in medicine stem from communication difficulties

As a parent of two medically fragile children who has spent a greater part of 7 years at the other end of the stethoscope, I understand this only too well. So I strive to provide the kind of service that I would want from my providers. I ask my patients if:

  • they understand my recommendations
  • they agree with the management plan
  • there is anything else I have not addressed (and not while I have my hand on the doorknob!).

If I sense that my patient is unhappy, I ask her what’s wrong, and I do my best to allay her fears or mitigate her problems that are under my control. last, I’m not afraid of online reviews—although my preference is for a scientifically valid questionnaire with a focus on achieving adequate numbers.

I believe that, when patients search for health information, they deserve accurate content not only about their health condition but about their physician, too.—Jennifer Gunter, MD

Other models that are worth considering

The United Kingdom’s National Health Service (NHS) operates a health-care rating site (NHS Choices; www.nhs.uk), where, among many other services, patients can provide feedback about both physicians and hospitals (anonymous if desired, although an e-mail address is required for validation).1 What’s unique about NHS Choices is that it is moderated; there are specific ground rules for providing ratings; and physicians are encouraged to respond to individual ratings.

In several geographic markets in the United States, Consumer’s CHECKBOOK/ Center for the Study of Services (CHECKBOOK/CSS), a not-for-profit consumer education organization, has piloted an online survey of physicians. Patients are sampled randomly from the enrollment of a list of insurers and invited to participate. The system verifies that the patient being surveyed has made a visit to the physician in question during the past year.

CHECKBOOK/CSS uses questions developed by the US Agency for Healthcare Research and Quality. The reports generated by the system are based on a statistically valid number of surveys (on average, 49 completed surveys for one physician). They are available without charge to the public at the organization’s Web site (www.checkbook.org/patientcentral).

A recent perusal of CHECKBOOK/CSS in one market easily found an “above average” rating for a member of the OBG Management Board of Editors….

Let’s make this a useful thing

Here is what we can say with reasonable certainty, based on observation:

  • Most online reviews are positive
  • Most physicians have far too few ratings on any one Web site to approach a meaningful degree of scientific validity
  • Lack of accountability on many ratings Web sites raises the specter of sham negative or positive reviews. The CHECKBOOK/CSS model that I described appears to address many of these concerns.

Most patients have valuable comments and opinions about their medical care; we should remember that listening is our most important clinical skill. Finding a way to make online feedback valid and productive for both patients and physicians should be a goal for our professional societies.

We want to hear from you! Tell us what you think.

References

1. Lagu T, Lindenauer PK. Putting the public back in public reporting of health care quality. JAMA. 2010;304(15):1711-1712.

2. Fox S, Jones S. The social life of health information. Pew Internet and American Life Project Web site. http://www.pewinternet.org/Reports/2009/8-The-Social-Life-of-Health-Information. aspx. Published June 11, 2009. Accessed January 12, 2011.

3. Lagu T, Hannon NS, Rothberg MB, Lindenauer PK. Patients’ evaluations of health care providers in the era of social networking: an analysis of physician rating websites. J Gen Intern Med. 2010;25(9):942-946.

4. Lopez A, Detz A, Ratanawongsa N, Schillinger D, Sarkar U. What do your patients say about you on the internet? A thematic analysis of online reviews of primary care physicians [abstract]. Presented at: 33rd Annual Society of General Internal Medicine Meeting; May 1, 2010; Minneapolis, MN.

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