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Clinical Reviews


Should you worry that patients will use the Web to grade you?

With an anonymous mouse-click on a “frowny face,” anyone can tarnish a reputation that it took you decades to build. But some find pluses to being rated.

December 2009 · Vol. 21, No. 12

IN THIS ARTICLE

The authors’ firm offers legal services to physicians who want to curtail unauthorized commentary on the Internet about the care they provide.

CASE: Accusatory comments from a nameless source

A small-town ObGyn discovers an online surprise: a claim by an unidentified patient that he caused the stillbirth of her infant. Convinced that the allegation is false, he strives to uncover the patient’s identity and counter the charges. Only after months of litigation is he successful. The patient in question was particularly noncompliant with prenatal care: She continued to consume alcohol and smoke throughout the pregnancy.

Could this kind of smear on a reputation happen to you?

Professionals have long gone to extreme measures to protect their reputation. In the early days of the Republic, gentlemen defended their honor with violence. Remember Alexander Hamilton? After his allegedly defamatory comments about longtime rival Aaron Burr appeared in a New York newspaper, Burr killed Hamilton in a duel.

We are fortunate that an attack on our professional reputation no longer needs to be addressed with violence—but we have other challenges to overcome. Scandalous comments can now be posted instantly, worldwide. Such comments can be uploaded anonymously by anyone who has a computer and a vendetta. Under Section 230 of the Federal Communications Decency Act, Web sites that serve as platforms for blogs enjoy complete immunity—even when those blogs are malicious.

With a mouse-click, a person can anonymously tarnish a reputation that took decades to build. Such musings include “He is a butcher who should be in jail” or “He’s a rotten doctor and a thief.” Hosting Web sites have no legal responsibility for content. Even if a physician can determine the blogger’s identity—itself a challenge—the doctor must hold his tongue because of privacy laws.

The Web sites that purport to “rate” physicians are hardly repositories of substantive information on which to base life-and-death decisions. Some use the sophisticated metrics of “smiley faces” or “frowny faces” to characterize doctors. The great majority of sites admit that they cannot confirm that the poster is even a patient.

One thing is evident: Most of these sites exist to make money. Observe the ads for erectile dysfunction drugs that straddle the posts. The more salacious the posts, the more eyeballs and dollars for the owners of the site and the sponsors of the ads.

Is there a solution that can protect physicians?

In response to this worsening problem, we developed an agreement for physicians to use with patients to prohibit online rating of the physician without the doctor’s assent. The document was unveiled in 2007 as a bilateral privacy agreement, but it has evolved to encourage ratings on sites that embrace minimum standards of fairness and balance. This is accomplished by having the patient transfer copyright to commentary to the treating physician. If a post is fraudulent or defamatory, the doctor has a tool to enable its removal.*

The initial agreement received much attention—and some criticism. Opponents refer to it as a gag order that impedes free speech. “What are they trying to hide?,” goes the insinuation. “Patients should have a right to know what kind of care they can expect to receive from a doctor,” plead others.

We agree: Patients have a need and a right to know what kind of care they can expect from a physician. But we reject the premise that anonymous, undocumented comments posted on a Web site whose owners are unaccountable for what is said produce this information. We do believe that patients are entirely qualified to provide impressions, but such Web sites are being used as surrogate, supposedly objective measures of quality of care. In that role, the sites have failed.

*EDITOR’S NOTE: The authors presented documentation of the use of their firm’s agreement in medical practices. No participating physician contacted by OBG Management agreed to be interviewed for this article, however.

A physician is not a roofer

Selecting a physician is different from hiring a roofer. First, some measure of the success of medicine depends on the patient. Adherent patients fare better than nonadherent ones. A roofer asks only that the customer pay for services provided. If that roofer asked the customer to pay and, in addition, layer the caulk, the comparison might work, but that’s not the case.

Second, health care is rarely provided by one source. A patient’s care is more often collaborative than the product of an individual. Think how many doctors are involved in treating a patient hospitalized for a few days.

Third, more frightening is that many hospitalized patients cannot even identify their physicians. In a survey released earlier this year, three quarters of patients were unable to name anyone in charge of their care. Worse, of those who provided at least one name, 60% gave an incorrect answer. The survey included more than 2,800 patients. 1

Last, it is difficult for a patient to evaluate a physician’s judgment and technical prowess objectively. Patients can offer useful subjective information about many aspects of a physician’s skills, such as ability to communicate, but other areas, such as deep technical skills, are less than clear. With the roofer, it’s easy: Either the roof leaks or it doesn’t. Evaluating the details of a gynecologic oncology procedure—well, that’s another matter.

Do you agree with the author?

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A business model for rating physicians online: Angie’s List

Until 2008, Angie’s List (www.angieslist.com) was known primarily for its reviews of plumbers, handymen, and other contractors. But in March 2008, the Web site rolled out 40 new categories of service providers—all of them related to health care.

The result: 10,000 physician reviews in the first month.

“We just saw a tremendous amount of interest,” says Mike Rutz, Vice President of Angie’s List Health—so much interest that the company increased the number of health-care categories to 150 shortly thereafter, including one for ObGyn care.

Angie’s List is a pay-to-use service with roughly 1,000,000 members in the United States. It differs from other physician-rating sites in other respects as well: Reviews are not anonymous, and any physician who receives a negative review is given the opportunity to respond. In fact, a physician can sign up, free of charge, to be notified when a review goes up on the site. Although the member’s name is not posted on the individual review, it is recorded so that any disputes can be clarified.

“We do have some doctors who say, ‘These people are not my patients,’” Rutz reports. When this happens, Angie’s List can consult its database and resolve the issue definitively.

How is the physician rated?

A patient gives her physician a grade, ranging from A to F, in eight categories:

  • availability
  • office environment
  • punctuality
  • staff friendliness
  • bedside manner
  • communication
  • effectiveness of treatment
  • billing and administration.

The eight scores are averaged to yield an overall grade.

When a member seeks information on health-care providers in her locality, she sees only the overall grade at first. She clicks through this screen to view the full report.

Rutz believes that most patients have the expertise to judge effectiveness of treatment. “They absolutely know whether the treatment was effective,” he says. He does concede that “the patient is the most important participant in her health care” and does have an impact on the success or failure of treatment. Angie’s List has no plans to remove effectiveness of treatment from the rating categories.

Physicians can encourage positive reviews

Physicians aren’t penalized for encouraging patients to give them a positive review on Angie’s List—in fact, that strategy is encouraged.

“More information is better,” says Rutz. “The folks that are encouraging reviews are usually the folks providing the best service.”

There is an added bonus to positive reviews: Providers who have the best grades and the most reports rise to the top of the list, gaining prominence on the site.

At the same time, there are mechanisms in place to prevent a health-care or other service provider from “gaming the system,” Rutz adds. It is not acceptable for a physician or a member of his or her staff or family to file a review.

So is Angie’s List good news for physicians?

Jeffrey Segal, MD, does not think so.

The problem is that the site requires paid membership, Dr. Segal, founder of Medical Justice Services in Greensboro, NC, says.

“Because of that, [Angie’s List] will never really accumulate more than a handful of reviews on any given doctor; particularly given the number of free sites. And since the average doctor sees over 1,000 patients a year, we do not believe three or four reviews can ever mean anything substantive.”—JANELLE YATES, SENIOR EDITOR

How rating sites need to change

You may conclude that we oppose online rating of physicians. We do not. We understand the desire to know as much as possible about a provider’s abilities. We merely appeal to online rating sites to adhere to minimum standards that promote a responsible system for both physicians and patients.

Here are our recommendations:

  • Ensure that every potential rater who claims to be a patient of a particular physician really is one.
  • Require a meaningful number of raters. Given that the average physician sees 1,000 to 2,000 patients in a year, ratings that involve only two or three patients are meaningless. Forty or 50 ratings are another story. Comments could be collected until a threshold number is reached. They could then be published.
  • Require patients to stick to areas in which they are expert—namely, subjective impressions. A physician’s personality, staff, and communication skills are fair game. Skill at performing oophorectomy—out of bounds. However, should a patient wish to have the physician’s technical skills reviewed by a trained professional, all the better.

If such standards are met, patients who are searching for information about a physician will be able to tease information from background noise, and physicians will feel more comfortable asking their patients for feedback. And patients’ observations can be used to advance patient safety.

For example, to deputize the patient as a partner in preventing spread of infection and wrong-site surgery, a survey can ask: “Do you recall if the doctor washed her hands before she examined you?” (The answer is informative only if the office asks the patient, upfront, to make this observation.) Another question: “Did the doctor ask you to mark your name on the affected limb before surgery?”

The feedback loop will either confirm great performance or serve as a strong motivator for fast improvement. Both physicians and patients must participate to make the health-care system better.

Should you lose sleep over a bad review?

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