Rated negatively online? What’s a physician to do?

How should professionals respond to physician-rating websites?

By — Posted Aug. 8, 2011.

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An increasing number of websites invite patients to rate physicians and clinics as they would restaurants. Doctors are asking if there is a fair way to react against undeserved, unfavorable comments. Is it ethical to fight back against these websites?

Reply: George Bernard Shaw once quipped, "All professions are conspiracies against the laity." This may be an unpleasantly adversarial view of the relationship between physicians and their patients, and Shaw didn't conjecture about what might happen if the laity were to strike back. But consider the recent case of a Minnesota neurologist who felt compelled to take legal action against a patient's son who had posted dozens of negative reviews about him online. The case leaves the impression of a medical profession suddenly playing defense against hypercritical, Web-savvy patients.

Physician-rating websites enable patients -- and their families and friends -- to say pretty much anything they feel like saying about physicians, who find themselves in a quandary. Moral norms regarding patient privacy -- not to mention the burden of Health Insurance Portability and Accountability Act regulations -- make it ethically problematic for physicians to respond to online reviews that damage their reputations. In response, some have felt that legal action is the only possible answer, while others sought to issue gag orders, effectively asking patients to promise not to discuss their treatment online.

These legal and confrontational responses highlight the significance of physician-rating websites: They represent a culture clash between the traditional, hierarchical medical profession and the more open, democratic social media. For that is what rating websites are: a form of social media, just like Facebook and Twitter, and they have been common across most other sectors of the economy for some time.

In some ways, the medical profession is just catching up. College professors have had to put up with for years. Many authors, filmmakers, restaurateurs and hoteliers believe they have had their reputations impugned on Amazon, IMDb, Yelp! and TripAdvisor, respectively. Ratings websites have become an integral part of the democratic culture of social media -- everyone gets a "say" and, implicitly, everyone's say is worth as much as everyone else's.

Which is where the problems start, because a defining element of the medical profession is precisely that physicians' say about medicine is worth more than everyone else's. Medical knowledge is less subjective than film criticism; it is evidence-based and deals with dangerous and deadly subjects. The monopoly that the profession claims over the domain of medical knowledge is not merely mercantile protectionism but stems from a moral duty to protect patients from the harms of medical misinformation.

Hence the clash of cultures. Offline, the physician is viewed as both professionally qualified and morally obligated to make the best judgments about a patient's health. In some social media spaces, however, patients are, to use a buzzword, empowered to describe their health in their own terms to an audience not of medical professionals but sympathetic lay peers. In this online environment personal experience (that of the patient) is sometimes valued more highly (more authentic and less mediated by professional stricture) than the expertise of the physician. This clash of cultures is incendiary enough when it comes to explicitly scientific questions -- such as vaccine safety -- that have caused online debate. But when it comes to more subjective issues -- such as a physician's demeanor -- the scope for conflict is only exacerbated by the lack of editorial review or disinterested judgment that characterizes much social media content.

Practical advice on this clash of cultures depends on our understanding of why some patients feel the need to use physician-rating websites. The flippant answer would be that patients feel they got bad treatment and wish to complain. This, however, does not tell why they chose to do so through social media.

The more telling answer lies in the way in which contemporary American health care, with its emphasis on the autonomous, responsible and empowered patient, increasingly treats that patient as a consumer of goods rather than a recipient of services. These consumer-patients are turning to rating sites because they do not feel they are being heard when they have a complaint or concern about their treatment. Traditional complaint or concern procedures, especially within large hospitals and health care systems, are notoriously complicated (Would you know how to file a complaint at your hospital?) and often seem weighted toward damage control and public relations management rather than engaging with patients/consumers.

Whether this characterization is fair or not, many consumer-patients believe it and, feeling powerless in the face of bureaucracy, take to the Internet to express their frustrations and anger. They do this because it is what modern consumers do: express themselves through social media. We cannot, in 2011, conceive of patients as customers and then be surprised if they blog about their customer experience.

Thus, the best way for physicians to avoid damaging online confrontations with their patients is to ensure that their patients -- customers, if you will -- feel they are being engaged. This seems both conceptually obvious and operationally tricky at the same time.

Helping patients to be heard

It is outside the purview of this article to outline consumer engagement strategies for health care professionals, but it is always advisable to start by doing some research: Ask your patients how they want to make their voices heard within the health care system and what procedures or results would make them feel that someone is listening. Physicians can do this informally, as part of the clinical encounter or, more formally, through surveys and focus groups.

Some clinics routinely send follow-up satisfaction surveys to patients after their visits. This research may be time-consuming, but it is certainly worthwhile if it mitigates the impact or attraction of physician-rating websites. One action guaranteed to make patients feel that their voices are not important, of course, would be to ask them to sign a gag order forbidding them to discuss their treatment in public.

The other piece of practical advice for physicians is to accept that rating websites are here to stay, at least for the foreseeable future. The occasional unfavorable review must be seen as a cost of doing business in the age of social media.

Most physicians will not encounter the level of damaging commentary aimed at the Minnesota doctor. These websites are not always a threat to physicians' reputations. They can act as amplifiers of word-of-mouth recommendations and burnish the standing of physicians among patients' online peers. Patients who feel genuinely engaged may be motivated to post good physician reviews, or disagree with negative ones. After all, a recent study found that most online physician reviews were, in fact, positive.

Daniel O'Connor, PhD, Johns Hopkins Berman Institute of Bioethics, Baltimore

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