Sunday, May 12, 2013

Internet reviews about doctors: threat or opportunity?

This is an article which I wrote for the Indian Journal of Medical Ethics. This was a comment on the paper, Daniel Strech. Ethical principles for physician rating sites. J Med Internet Res. 2011;13(4):e113). doi:10.2196/jmir.1899

For most doctors (though perhaps not for the readers of this journal), the field of medical ethics remains an abstract subject which is of interest only to academics. However, ethics is applied to the resolution of conflicts in real life. This interesting paper uses the timeless principles of medical ethics to help to resolve a very modern conflict: how can we make sure that physician rating sites serve a useful purpose without causing harm?

The introduction of the Internet has already changed the way most of us find information, make phone calls overseas, keep up with the news, stay in contact with our friends, book airline tickets, etc. It has already had a major impact on the doctor-patient relationship in the United States, and it is just a matter of time before it  plays an equally important role in the lives of Indian doctors and patients. While the technology has many benefits, it creates conflicts as well, because it gives patients a much bigger say in their own medical care – a concept most doctors feel threatened by, because it is so unfamiliar and new. One of the controversial areas is the sprouting of physician rating sites, which allow patients to rate, comment on, and discuss doctors' performance online, visible to everyone. This can be a mixed blessing, especially when patients are not happy with their doctors and use these rating sites as a platform to vent their frustrations.

This is a timely paper, because there are now many physician rating sites. Some have been created by private agencies, while others have the blessings of government organisations and health insurance companies. Although these have attracted a lot of attention from patients as well as the popular press, there has been very little discussion about these sites in medical journals, even though they are likely to have a significant impact on the way we practise medicine. While government and health insurance company representatives are vocal in their support for these sites because they believe they encourage transparency, many physician representatives argue against them because they are worried that they could compromise physicians.
This paper purports to have two aims. First, it offers a structural framework which can be used to debate the ethical principles behind these sites, thus providing a useful starting point for further decision-making and discussion: what should physicians and policy decision-makers take into account when discussing the sites and their impact on the doctor-patient relationship?

Because there is very little direct evidence of the harms and benefits of these sites, this paper also discusses how evidence from the related area of public reporting of physician performance can help to guide research in this new field.

The paper uses the three basic ethical principles of patient (and physician) welfare, patient autonomy and social justice.

In theory, the availability of information about the quality and competence of physicians (as assessed subjectively by their patients) can help patients stay away from bad doctors, thus helping them to get better medical care and enhancing patient welfare. The provision of online doctors' report cards encourages transparency of medical performance, and this could also result in greater public trust in the healthcare system.

While discussing the principle of welfare, the authors remind us that we also need to consider the impact of these sites on physicians' well-being. While the majority of reviews of these sites appear to be positive, negative reviews can cause both psychological and financial harm to the doctors concerned.
Physician rating sites also encourage patient autonomy, because they empower patients with information. The authors look at this benefit through the interesting prism of improving the patient's health literacy at three different levels: functional, interactive and critical.

As regards the third principle of social justice, the fact that these sites are online means that only patients with access to the Internet can use these services. This means they can actually worsen the digital divide between the haves and have-nots.

The most interesting question these sites raise is: do they provide reliable and useful information? Or is it possible to game these sites, as a result of which the ratings can no longer be trusted? Can doctors manipulate them by requesting their happy patients to provide positive reviews? Or can disgruntled patients ruin a doctor's online digital reputation by posting negative, biased and dishonest reviews about him/her on multiple sites? How can patients trust the information that these rating sites provide? And what can doctors do when they encounter negative ratings which they feel are unfair and biased?

The most useful nugget of information I found in this paper is tucked away in a table, which describes the five basic conditions which need to be met in order for a physician rating site to be useful. These include: transparency, justification, participation, minimum conflicts of interest, and openness to revision. Most sites have not been able to meet these conditions. Indeed, there is a lot of scope for improvement in how these sites are created and maintained, and paying attention to these basic principles will help to ensure that the next generation of physician rating sites provides value for all stakeholders in the healthcare ecosystem.
I enjoyed reading this paper because it discusses an issue which is very close to my heart. However, I feel the author has done his readers a disservice by unnecessarily complicating the issue. He has used a rather formal, heavy style so that making sense of the article is an uphill task. Just because this article is written for an academic journal does not mean it should be hard to understand. Perhaps the fact that the author is from a non-English speaking country may explain why the language is not lucid.

After reading this article I encourage physician readers to google their own names to see what their patients are saying about them. It is going to be increasingly important for doctors to manage their online digital reputation, because whether we like it or not, our patients are going to talk about us. We must learn what our patients feel about us. Ignorance is not bliss; in fact it can actually be harmful.

Patients have always had opinions about their doctors; after all, this is how a doctor's reputation develops. Traditionally, this was by word of mouth, a slow process, and it could take a doctor a lifetime to build a reputation. Physician rating sites have accelerated this process dramatically.  However, while many patients will swear by their doctor, there will be others who will swear at them.

While it is all very well to take the moral high ground when talking about the right of patients to freely express their opinion about a doctor, I can vouch from personal experience for the fact that negative reviews can raise one's hackles quickly. While some such reviews may be well-deserved, others are unfair because they have obviously been penned by disgruntled patients, venting their bile. Others may even be planted by the competition.

Can we censor these sites? Let us not fool ourselves; the horse has left the stable. It is a fact that we will need to learn to live with patient complaints – including the ones posted online on doctor rating sites, for all to see.

The good news is that these doctor rating sites can actually help doctors to become more patient-centric. Hopefully, we will start treating our patients better, because we know they can harm our reputation by going online and posting negative reviews. Doctors should read the patient feedback stories at doctor rating sites to educate themselves as to what patients want from their doctors. The good news is that what patients want from their physicians is not all that different from what good physicians want to offer their patients. Patients are generally not unreasonable, high-maintenance consumers; they simply want doctors who care, listen, and know what they are doing. By reading the positive ratings, doctors will have role models of good physicians to emulate, and by reading the negative ratings, they will learn what to avoid. Smart people learn from the mistakes of others, and we can learn a lot about what a medical encounter feels like from the patient's perspective by browsing through these websites. They will help us become more empathetic doctors if we are mature enough not to take the negative ratings too personally.

In the big picture, these rating sites are a great opportunity for the medical profession to be open and transparent with patients. Medical associations should set up doctor rating sites to ensure that the basic information which patients need about a doctor (clinic location, credentials, professional qualifications and so on) is available. Also, these sites will be comprehensive because they will provide information on all doctors. If these are seen to be fair and frank, patients will be happy to refer to them as an authoritative source of information on doctors, rather than waste hours scouring dozens of unreliable and incomplete sites. It is also a good way of identifying the bad eggs in our profession, those who end up giving all of us a bad name. Even though we know who these are, we often prefer to participate in a conspiracy of silence and to turn a blind eye to their antics. Rating systems will allow the truth to come out in the open more quickly, helping with self-regulation of the profession.  The Medical Council could take cognisance of repeated complaints about a doctor, and take action to prevent problems from flaring up.

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