Word of Modem

Google any physician’s name, and a slew of information will turn up about him or her: Bios, CVs, bibliographies, listings. Information from all of these is collated, quantified, run through algorithms, and then displayed cleanly anywhere it is accessed. But it’s not just the objective facts and figures that people want when they Google a doctor; they want opinions too, a glimpse of other patients’ experiences before they decide to make that appointment.

It’s a clear trend — a sort of self-sustaining service journalism for the modern, plugged-in, world. People will log on to Yelp or Amazon to voice complaints or compliments, for filet mignons that were overcooked, hotel rooms that smelled funny, televisions that malfunctioned after the first use, books they couldn’t put down. Patients are doing the exact same thing with doctors they’ve seen.

While online reviews aren’t an exact science, the factors that go into them “mean a tremendous amount to a patient but often are never addressed or even considered by a doctor.”

— Elliot Levy, MD, clinical professor of medicine, Division of Endocrinology, University of Miami School of Medicine

Earlier this year, the Journal of the American Medical Association published a research letter that acknowledged this trend of rating doctors online. Lead author David A. Hanauer, MD, of the University of Michigan, in Ann Arbor, wrote, “Patients are increasingly turning to online physician ratings, just as they have sought ratings for other products and services.” Elliot Levy, MD, a clinical professor of medicine in the Division of Endocrinology at the University of Miami School of Medicine, Miami, Fla., pointed out that while online reviews aren’t an exact science, the factors that go into them “mean a tremendous amount to a patient but often are never addressed or even considered by a doctor.”

Patients as Consumers

While doctors may or may not be considering online reviews, patients certainly are, with more and more publishing their voices in cyberspace forever, no longer by word of mouth, but word of modem.

“In our study, we found that a majority of the public was aware of such sites, and about a quarter had visited them,” says Hanauer, whose primary interest is clinical medical informatics, especially working with clinical data in electronic medical records. Among those visiting the sites, about one-third reported choosing a doctor based on good ratings and a third avoided one due to bad ratings.

“Our survey was conducted almost two years ago,” Hanauer says, “and my assumption is that overall awareness and usage is continuing to increase. Doctors should care about them because the public is using them to make decisions on selecting a doctor.”

“I see patients, and in the first few minutes I know they’ve researched me, because they tell me. Patients want the names of doctors you’re referring them to, and they’ll research them.”

— Clark Perry, DO, endocrinologist, Community Physician Network, Indianapolis

Hanauer’s assumption is correct. Trends show that 80% to 90% of consumers say they check online reviews before they buy or hire anything. “Healthcare services are among those things consumers are reviewing,” says Cheryl Reed, of Angie’s List, a paid subscription review site. “This isn’t something embraced only by younger, tech-savvy people. It’s pervasive and can be greatly insightful.”

Patients are responding to the fact that healthcare is becoming more competitive, says Clark Perry, DO, an endocrinologist with the Community Physician Network in Indianapolis, and ultimately, it all comes down to “What differentiates us?”

“I see patients, and in the first few minutes I know they’ve researched me, because they tell me,” says Perry, who also points out that physicians should be aware when giving referrals. “Patients want the names of doctors you’re referring them to, and they’ll research them.”

In 2010, Shaili Jain, MD, a psychiatrist at the Veterans Affairs Palo Alto Health Care System in California and an assistant professor at the Stanford University School of Medicine, published commentary in the New England Journal of Medicine titled “Googling Ourselves — What Physicians Can Learn from Online Rating Sites.” The article is an irreverent and insightful look into the process of Googling yourself, from the initial anxiety of clicking on a site to see what your patients have said to the relief at seeing good reviews or disappointment in reading a bad one. Jain writes that sites such as “RateMDs, Vimo, and RevolutionHealth, offer patients an opportunity to rate physicians on their helpfulness, knowledge base, interpersonal skills, and punctuality. This has become a popular online activity, with hundreds of physician reviews appearing daily.”

Jain notes this practice of patients advocating for themselves through these reviews, writing that proponents of these sites see “patients as consumers who have a right to express their opinions about services they pay for.”

“Patients more and more don’t view themselves as just patients blindly following their doctors’ referrals blindly,” Reed says. “They’re consumers looking for doctors who will treat them with respect and offer them efficient, friendly service.”

Rants and Raves

The natural assumption is that people tend to leave more negative reviews on these sites, that patients will only go to rant about how they were treated poorly or unfairly, often as a form of catharsis, and they never visit the site again. “I suspect people tend to write bad reviews much more frequently,” says Allison B. Goldfine, MD, of Harvard Medical School, in Cambridge, Mass. This assumption was underscored even in the satirical newspaper, The Onion, in an article titled “Physician Shoots Off A Few Adderall Prescriptions to Improve Yelp Rating.”

Of course, this suspicion could be the reason that many doctors historically ignored or even discouraged online reviews, thinking that the review sites would comprise nothing but ill-informed, meaningless complaints that could do nothing but unfairly harm their reputations.

Indeed, a quick glance at some sites will turn up phrases like “worst doctor ever” and “I wouldn’t let him/her treat my hamster,” but these aren’t the norm, according to Reed. “Actually, the majority of healthcare reviews on our site are positive,” she says of the physician reviews on Angie’s List. “More often than not, the negative is with the office staff, not the actual medical treatment given.”

Hanauer and his team found similar results: 54% reported leaving a positive rating, while 19% left a negative rating. And while reviews like “worst doctor ever” might not be the most helpful or meaningful, some patients do take the time to go into detail about their experiences, raving about how the staff made them comfortable, or ranting about how the staff made them feel “like a criminal.” Reviews like these can potentially provide teaching moments to physicians who decide to take their patients’ stories to heart.

Jain writes that it’s the stories like these that are the most helpful; the rave reviews inspiring her to “work harder and better” for her patients, and the rants about physicians being arrogant or failing to listen she reads “with regret because [she knows] they are not implausible.”

“I feel like the proverbial fly on the wall,” Jain writes. “I’m discovering what patients think makes a good doctor, what they value and deem essential to high-quality care, and what gets them really riled. These patients don’t hold back, and their tales make for refreshing reading, a sea of patients’ voices telling me how it really is.”

“Listen In, Learn, and React”

Jain points out in her commentary that critics of review sites see the entire system as “fundamentally flawed,” because there can be a lot of obstacles to navigate when dealing with negative reviews. The anonymity of these sites makes it hard to guarantee that the reviewer is even a patient and not someone with a grudge against the doctor or worse, just some “troll,” who posts deliberately provocative messages to cause mayhem. Physicians have no opportunity for rebuttal because they are bound by privacy laws, and a handful of ratings may not be quite representative of a doctor who sees hundreds of patients a year.

In actuality, a lot of the negative reviews have nothing to do with medical advice at all, so the physicians then have no expertise over the patients, who may be complaining about the nurses who were rude to them on the phone or never even bothered to call them back, the doctors who were distracted by personal phone calls, the unacceptably long wait times. (All of these complaints were actually voiced on Angie’s List, and each reviewer ended up having positive things to say about the medical consults themselves.) And yet, none of these things requires an advanced degree to address, just an acknowledgement of the problem and a willingness to fix it.

“Physicians — or a designee — can learn a lot about what’s working and what’s not,” says Reed, “and possibly where they can make back-office improvements to help with the overall experience.

“For years people have chatted about their healthcare experiences,” she continues. “Online reviews give those being reviewed a way to listen in, learn, and react.”

Still, negative reviews seem inevitable, especially now with the ubiquity and accessibility of these sites. A physician may make a mistake, may say something wrong during an exam, or the patient may simply be having a bad day. But patients are not unreasonable; they just want to feel respected and have a doctor who cares at a time when they’re most vulnerable. “See through the patients’ eyes,” says Perry. “Patients expect to be treated at a certain standard.”

The solutions then, seem obvious and simple, but only when the physician is aware of the problem(s), and that is more increasingly accomplished by reading and digesting patient reviews.

“I suppose the best way currently to counter negative ratings would be to try to get more positive ratings,” Hanauer says,” but this of course can lead to additional bias. But this is partly why doctors should care about the ratings. If nothing else, they should be thinking about how patients can get an unbiased, representative view of their practice, given that online doctor rating sites seem to be here to stay.”

— Bagley is the associate editor of Endocrine News. He wrote
about the highlights of ICE/ENDO 2014 in the August issue.

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