Balancing Shared Interests of Patients and Doctors Frequently Asked Questions:
(1) Do physician rating sites provide fair accounts? The vast majority of these sites do not. Although, at the prompting of Medical Justice, this may be changing. Effective healthcare is a partnership between patient and doctor manifest by shared responsibility. This is different from a meal at a restaurant or watching a movie. There, the customer is ordinarily a passive "spectator."
In healthcare, the patient has an important role to play. If a patient posts that, after his operation, the wound opened, that looks bad. And, it's easy to point the finger at the doctor. After all, he performed the surgery. But, if you now know that the patient went back to work as a construction-worker on the second post-op day against medical advice, the analysis changes. An honest accounting would give complete information. Half a story is just as likely to misinform as inform.
(2) Isn't transparency a good thing? Yes. We believe the day is coming when useful ratings, accessible by the Internet, will be the norm. Patients want good information. That makes eminent sense. But, facts matter. The current crop of physician rating sites just do not pass the test. Picking a good book or a restaurant on a rating site. Probably OK. The stakes are not particularly high if you get it wrong. Those who pick a doctor based on anecdotal reports on a single episode of care on a physician rating site: caveat emptor. And far too many patients do indeed rely on these sites.
Ultimately, the issue of ratings distils to one very important question. How does one go about picking a talented doctor? That is generally what consumers are hungry for. Our recommendation is to get all stakeholders - doctors, patients, payers, government, etc. to define outcomes in a way where people can use the information to take effective action. Half-hearted measures by only one or a handful of stakeholders is unlikely to benefit consumers. Nonetheless, outcome measurement of clinicians and institutions is a reachable goal.
(3) Can't online commentary provide constructive feedback to physicians? There are now over 40 physician rating sites. Most allow anonymous posts and are focused on a one-way dialogue between the poster and the public. The physician is not brought into the conversation. Nor can he comment because of existing healthcare privacy laws. Most of the time the doctor is not aware of the criticism or, if he is, who the patient even is. If the intent is constructive criticism, posting anonymously on the web (on sites a doctor does not regularly monitor) is probably the least effective way to accomplish that goal.
(4) Aren't these Agreements just a way for physicians to protect themselves? No. patients are free to post online. The Agreements merely provide a way for doctors to address fictional or slanderous posts. Given that patients have multiple venues to vent and demand accountability, we believe when viewed in light of the totality of the circumstances, this is not unfair.
(5) Most people agree that the most important measurement should be quality of care. But can't patients weigh-in on other measures, such as punctuality and ease of making an appointment? Yes. Of course, virtually all patients, when asked, state that their primary concern is competence and sound judgment. They want to get better. If a doctor is incompetent, does it really matter if he is punctual? And if a physician is highly skilled, could it be that he was late because he was spending more time with the patient in the slot before; a "courtesy" he extends to his patients with the most complex problems. So, while we do not object to patients measuring such items, we do question their overall relevance.
(6) What about quality of care? That is the most important measure. Measuring outcomes will help enable a transformational healthcare system. A recent article in Journal of American Medical Association stated (Conway P, Clancey C. Transformation of Health Care at the Front Line, JAMA. 2009; 301(7):763-5.
For patients, the current transparency efforts often have little useful information for decisions regarding a specific disease and selection of clinician or treatment option.
Current measures often focus on individual patient-clinician interactions at a single point in time and, therefore undervalue teamwork and patient outcomes over time. ...measures need to focus more on patient's recovery over an episode of care, such as hip fracture through recovery.
In addition, a collaborative process of measure developments and implementation that involves clinicians and patients should be pursued. Patients are critically important to inform public performance reporting efforts intended for patients' use. A poorly designed measure would serve to demoralize clinicians and fail to improve patient care.
The science of measure development and effective implementation to improve healthcare warrants substantial support.
To recap, we agree that a transformational healthcare system will rely on valuable input from patients and physicians. Let's do it right.
(7) Isn't the Internet here to stay? Of course. And ultimately it will be a tremendously useful tool to help patients make informed decisions about choosing their doctor and treatment. Anything with a benefit comes with risk. We accept highway accidents as the price we pay for being able to get from point A to B faster than a horse and buggy. But, in 2009, the risks of choosing a doctor based on anecdotal ratings posted on doctor rating sites are far greater than the benefits.
(8) What is the media saying about online reviews/commentary? The media has been front and center in exposing more generally how damaging unsubstantiated Internet reviews/commentary can be; precisely because most web site owners do little if any policing and they have resisted any accountability.
For more information on the media's read on the subject:
Yelp and the Business of Extortion 2.0
(February 18, 2009); Yelp is a review site which includes reviews of doctors.
Slimed Online (Two Lawyers Fight Cyber-Bullying)
Conde Nast March 2009 Issue
(9) What do patients have to say about Mutual Agreements? The Program was initiated early in 2007. Only a handful of patients among tens of thousands have expressed any concern. The vast majority of patients are entirely comfortable with this paradigm.
A typical patient reaction:
From: Emory W. Howard
Sent: Friday, February 20, 2009 6:39 AM
To: info@medicaljustice.com
Subject: Fox News Article
As a patient, I would like to express my support for physicians regarding the posting of physician reviews on the Internet. You accurately pointed out that anyone can post anything, factual or not and malicious postings can easily be placed on this web site so as a patient, I would not be able to use the information because the reviews may be garbage information thus a patient could actually be misled. I believe you are on the right path to discourage these web postings. I wish you much success.
Thank you, Emory Howard
(10) Are Mutual Agreements a "gag order"? Not at all. A gag order is court mandated and is intended to prevent any communication whatsoever. Patients are free to speak with friends, family, other healthcare providers, hospitals, lawyers, Medical Licensing Boards, and more. The list is long. Such a long list encourages further communication effective channels.
The most recent iteration of the Mutual Agreement encourages patients to provide valid feedback; particularly on sites that meet minimum standards for credibility. Patients are free to post online. In the rare event the feedback is not constructive, doctors have a tool to address fictional or slanderous posts.
This has been a moving target, but the marketplace has responded with meaningful and substantive options. Since Spring, 2009, a number of consumer health sites have actively approached Medical Justice asking for guidance on how to work with both doctors and patients. These sites have already implemented or are implementing such standards. Standards include general verification the poster is a patient. Wikipedia followed a similar path. At one point they allowed anonymous posts. Their credibility was questioned. Their policy changed requiring those who post to first register. Now, Wikipedia is perceived as being more credible than before. Doctor rating sites are going through a similar evolution.
(11) What if I really have a bad outcome and I want to warn others? There remain many venues to file legitimate complaints against healthcare providers including State Boards of Medicine, obtaining redress in court, communication with hospital peer review committees, and more.
Not all bad outcomes result from negligence. Most do not. Regardless, we believe patients do need and still have multiple venues to assist them in making this determination and obtaining a potential remedy.
(12) Is the threat of online commentary being abused for personal gain? Yes. It takes years to build a reputation. It can be destroyed by a mouse-click. The following are quotes from letters sent by patients to different physicians.
April 2007:
....Please be advised I am giving you one last opportunity to make things right by refunding my entire payment of $X within 14 days. In return, I am prepared to do the following: ..Have no future interaction with CBS investigations; discontinue online postings regarding you or your clinic.
October 2007:
...You have 30 days to do the following. ..Provide me with a full refund of all fees paid to you. If I do not hear from you within that thirty day period, I will commence actions that will include the dissemination of the factual accounts of my experience with you at [various message boards related to plastic surgery].
October 2008:
...If you intend to continue to try to collect monies...I intend to share my experience of you and your practice on Internet reviews and rating sites online...
(13) Will physicians who embrace these agreements refuse to see a new patient if that patient is uncomfortable signing the document? Since 2007, the vast majority of patients who have been asked to sign such an agreement have done so. If a new patient seeks care for an elective condition, and the patient is not comfortable agreeing to the provisions in the Mutual Agreement, the doctor may recommend that that patient seek care elsewhere. The doctor may also make a judgment call and accept this patient into his practice. To recap, the Agreement does not prohibit online posts. It merely gives the doctor a tool to address fictional or slanderous posts.
That stipulation does not apply to emergent or urgent care. In that situation, the doctor treats the patient. Period.
(14) Have physicians asked existing patients to leave their practice if that patient is uncomfortable signing the document? A doctor might ask existing patients to refresh their paperwork every year or so. If a long term patient refuses to sign that agreement, for whatever reason, it would be unusual for the doctor to terminate the long term relationship for that reason alone. Long-term relationships become long-term for a reason. They are built on trust. Like marriages, once they have passed an early threshold, they are more likely to have longevity.
