I have just finished taking my last major exam of medical school – Step 2 of the boards (including Step 2 Clinical Skills, or CS, which costs 1200 bucks, requires you to travel to one of a few cities in the country hosting it, and is sealed by a EULA that forbids me from talking about what the test was like), and am winding down my medschool career in the next few weeks. It’s about 2 weeks from Match Day (the 19th), when I’ll find out for sure where I will spend the next 5 or so years of my life. I’ll be sure to have a post up a little after noon that day when I find out what the answer is. And then, around May 17th, graduation day, I’ll be a medical doctor, ready to start internship (also known as the hardest year of your life).

One of the things I’ve found universal to all medical students is that we really want to be good doctors when we are finished with our training. I don’t think I’ve ever met a medical student who was in this career for the money (you’d be crazy), or for other selfish reasons. They tend to be hard working, dedicated, humble people who, if anything, are sickeningly sincere about wanting to help other people. Maybe that’s just my school, but my experience is, these folks want to do good in the world.

But another universal is that not all doctors will be able to avoid making mistakes. Doctors are human, they all will eventually make errors, and the goal of any profession dedicated to improving the human condition should be constant self-reflection and efforts at self-improvement. This is not a simple thing to do however. Medicine is complex, and quality of medical treatment is very difficult to assess. We’ve discussed before, using metrics in medicine is challenging, and often rather than studying medical quality you end up merely assessing the social demographics of the physicians’ patients.

So it is with interest that I see reading boingboing that lots of people are upset because some doctors are forcing their patients not to rate them on sites like RateMD.com by having them sign a contract forbidding them from doing so.

The arguments for and against this practice are fascinating. We tread into the mucky waters of free speech, free enterprise, the practice of medicine, and the practical problem of assessing physician quality…

More below the fold…

First, from the article we have two opposing valid arguments:

The anonymous comment on the Web site RateMDs.com was unsparing: “Very unhelpful, arrogant,” it said of a doctor. “Did not listen and cut me off, seemed much too happy to have power (and abuse it!) over suffering people.”

Such reviews are becoming more common as consumer ratings services like Zagat’s and Angie’s List expand beyond restaurants and plumbers to medical care, and some doctors are fighting back.

They’re asking patients to agree to what amounts to a gag order that bars them from posting negative comments online.

“Consumers and patients are hungry for good information” about doctors, but Internet reviews provide just the opposite, contends Dr. Jeffrey Segal, a North Carolina neurosurgeon who has made a business of helping doctors monitor and prevent online criticism.

Some sites “are little more than tabloid journalism without much interest in constructively improving practices,” and their sniping comments can unfairly ruin a doctor’s reputation, Segal said.

Segal said such postings say nothing about what should really matter to patients — a doctor’s medical skills — and privacy laws and medical ethics prevent leave doctors powerless to do anything it.

Already we’ve got problems. A doctor’s reputation is everything, and if someone wants to anonymously bad mouth them, or even non-anonymously bad mouth them, there is very little they can do about about even if it may devastate their practice. A physician would be forbidden by ethics, and law (HIPAA), from even responding to such a charge. You can not discuss the details of a patients care, even though the patient can freely criticize it online. So we start with an inequality in speech. Patients may criticize, but doctors’ hands are tied in terms of defending themselves from such speech.

Segal’s response is therefore to try to handicap the patient’s free speech in order to re-establish equality in the relationship:

His company, Medical Justice, is based in Greensboro, N.C. For a fee, it provides doctors with a standardized waiver agreement. Patients who sign agree not to post online comments about the doctor, “his expertise and/or treatment.”

Doctors are notified when a negative rating appears on a Web site, and, if the author’s name is known, physicians can use the signed waivers to get the sites to remove offending opinion.

From a practical standpoint, such an endeavor is doomed from the start. You will never win against a motivated human by trying to censor them. Physicians may comply because their livelihood, and medical license are dependent on a strict code of ethics which forbids the discussion of patient’s medical care. However, the patients have a lot less to lose, can easily deposit comments anonymously (as long as the companies aren’t subpoenaed for poster IPs – anonymity is fleeting), and if they have an axe to grind, they will find a way to get their information out there into this wonderful new medium of the internets. Further, this is different from the old word-of-mouth reputation a doctor gained in that once people can speak anonymously they shielded from any ethical responsibility to be truthful, fair, or reasonable in their criticism.

It used to be your friend might say, “don’t go to him, he’s a moron” and you could judge for yourself based one what you know of your friend to come to a conclusion about what such a criticism actually means. Word of mouth is also attached to a person, and people will be less inclined to lie given that may blow back and damage their own reputation. Commenting on the internets someone may say, “don’t go to him, he’s a moron, and I know he beats his wife” and how would you know it’s not true? Knowing nothing of the source most people’s default would be to avoid such a physician, and an innocent person could suffer horribly at the hands of one disgruntled patient.

Worse, since the system has no standards for providing evidence of allegations, this anonymity undermines legitimate criticism. When people post careless invective, it damages the legitimacy an information source would hopefully be trying to provide. After all, what if the doctor really is a moron, and people shouldn’t be going to him? If he’s say, very popular with his patients because he gives out oxycontin like candy, prescribes antibiotics for viral illnesses, but couldn’t diagnose a serious condition like a heart attack to save his life he may have wonderful ratings. Think about it, the first two patient populations have the drugs they want, they’re happy. The third patient is dead and can’t comment on RateMD.

From a practical standpoint, the censorship route seems to fail as well, but at the same time the founder of this RateMD service is being obtuse:

John Swapceinski, co-founder of RateMDs.com, said that in recent months, six doctors have asked him to remove negative online comments based on patients’ signed waivers. He has refused.

“They’re basically forcing the patients to choose between health care and their First Amendment rights, and I really find that repulsive,” Swapceinski said.

While I don’t think censorship will work, it is perfectly valid for people to be contractually obligated not to disclose information. After all the doctor is restricted, and I understand from a fairness perspective why some would want to equalize this relationship. People have a right to free speech, but they also have a right to contract, even to restrict their own rights in exchange for a service. While the EULA fanatics at BoingBoing totally have a point about the tendency of many companies to take people’s rights away by contract at a whim, that doesn’t mean there can never be a good reason for asking someone for non-disclosure. The question is, are there good reasons for a contract restricting speech in this instance?

We can fight this one out in the comments, as I’d like to bring up a separate issue. Do such services even provide valid information by which one may judge a doctor?

Lenore Janecek, who formed a Chicago-based patient-advocacy group after being wrongly diagnosed with cancer, said she opposes the waivers.

“Everyone has the right to speak up,” she said.

While she’s never posted comments about her doctors, she said the sites are one of the few resources patients have to evaluate physicians.

The American Medical Association has taken no position on patient waivers, but President Dr. Nancy Nielsen has said previously that online doctor ratings sites “have many shortcomings.”

Online doctor reviews “should be taken with a grain of salt, and should certainly not be a patient’s sole source of information when looking for a new physician,” she said.

We have to think long and hard about what types of incentives rating doctors online generates. Even sophisticated attempts to reward doctors based on performance are highly flawed. When you reward physicians for better outcomes, you don’t always get better outcomes. Instead what you see is that physicians that serve the rich, the young, the educated, the healthy, and the compliant are rewarded (also those who defraud the rating process). They have great outcomes. However, the doctors treating, the poor, the unsophisticated, the elderly, the sickest, and the most difficult patients come out looking like hell. Those patients tend to have worse outcomes. But we don’t want to reward people for either choosing, or being fortunate to have, easy patients. It’s a terrible dirty secret but yes, many hospitals and doctors select patients that won’t damage their statistics. The result is hospitals that do take everybody – academic medical centers, city hospitals etc. – end up looking worse even though they may very well have better doctors treating far more challenging patients. In fact, when you control for patient morbidity, teaching hospitals tend to actually perform better than private hospitals – probably because when disasters do happen they have so much experience with the sickest of the sick.

Let’s think about it, what incentives does online rating generate? I would posit that patients are largely not reliable to judge their physicians medical competence. Instead they can only look at their own personal outcomes, whether or not they liked their doctor, and how long they spend in the waiting room. And guess what, there are expected complications, and not all outcomes will be good, no matter how great your physician is. A good doctor will spend time explaining this to her patients, but even so, it’s amazing how often this part of the doctors spiel is forgotten after a patient has been told they need surgery, or chemo, or have a new diagnosis of a serious disease. Also, a doctor who makes you wait isn’t in the back doing bong hits – they’re with patients who need them too. Finally your review it is also dependent on the sophistication of the patient, and their personality. Some people won’t like you, that’s life, and some people are just jerks, but jerks need good medical care too.

I worry that in an era where people may damage a physician’s reputation by such superficial criteria as how long someone spent in the waiting room (not to dismiss this as a problem but…), or whether or not they liked their doctor’s personality, or even whether or not they were satisfied with their care. Lots of patients are very unsatisfied with you when you do the right thing, or as is the with many patients, even the best doctor in the world might not have had a good outcome because there is an expected failure rate, and complication rate, of most medical interventions. The result of such a database of complaints is evidence by anecdote – the worse kind – and ultimately a crummy source of information about almost anything. Patients will love incompetent doctors who they like and do what they want, but will punish good doctors who might be less personable or *gasp* not give out pills like a gumball machine. You will therefore be judging your physician not based on any high quality data, but on anecdotes from the disgruntled.

The incentive that is created by such is system is therefore once again for physicians not to treat the difficult patient, or the poor patient, or someone who is just a jerk. The incentive will be to keep your patients moving rather than maybe stopping and spending the time with patients when they really need you. They will want to treat easy patients, patients who are nice, and never in a million years someone on medicare or medicaid. And worst of all doctors will be afraid to do what is right, even if it means really pissing off your patient. This happens more than you would believe. If you’ve ever had to admit someone to a hospital against their will for suicidal behavior, or confront them over their drug use, or refuse to give them the treatment they want because the Google told them they have kuru, you’ve gotten patients angry with you. Sometimes permanently pissed.

Hopefully, you’ll do a good job explaining things to your patients, and they’ll understand, but a lot of times they simply can not or will not understand. They’re angry because they didn’t get what they want or you told them what they didn’t want to hear. The problem is good medicine is not being a pill dispenser, or being your patient’s best friend, or not ever making anyone angry. Being a good doctor means you do what is right, what is medically indicated, and in your patient’s best interest – even if they have a different idea of what that is, and even if they’ll never forgive you for it. I don’t think accumulating anecdotes online will reward the good physician, instead, I think it will hurt them.

Comments

  1. #1 mandrake
    March 9, 2009

    if there really is a case where the patient thought he/she had kuru, that’s a story I want to hear… I can’t imagine – no, sadly, I can.

  2. #2 jayh
    March 9, 2009

    Being asked to sign such an agreement would be a real red flag to me as a potential patient, suggesting that I should be looking somewhere else (sort of like a pre-nup divorce agreement). we also know that medical boards etc. are often very slow to do anything about problem doctors.

    Quite frankly, most people don’t bitch about their doctor, especially in public, so for a doctor to get lots of complaints, suggests indeed there is some smoke there. In fact, a good doctor (or mechanic, or plumber) would probably do well to encourage people to rate them. Everyone knows internet rating services have their degree of malcontents, but the satisfied clients are in a position to improve the doctor’s reputation.

  3. #3 Jim
    March 9, 2009

    Quote: ‘Quite frankly, most people don’t bitch about their doctor, especially in public, so for a doctor to get lots of complaints, suggests indeed there is some smoke there.’

    The problem I see with your view is that it is so easy for one person to make multiple comments from multiple email addresses. A doctor could get a bad rating from one obsessed patient or family.

    But on the other hand, I don’t think attempted censorship will work. It seems to me the best solution is to teach the public that the internet is not an automatic source of honest or reliable information.

  4. #4 catgirl
    March 9, 2009

    The unfortunate fact is that some doctors are not good doctors. Even if a doctor is good at treating illness and injury, the attitude really makes a difference. I’ve had several bad experiences with doctors (and many good ones). I once had to beg a doctor to do a strep culture on my throat, which came back as positive. I had a dentist who got annoyed at me for being in pain while he was drilling a cavity, and was mad that I was choking on the water that his assistant wasn’t suctioning properly. I even had a doctor who prescribed me a strong antidepressant (with plenty of side effects) for a symptom (heart palpitations) that was later found to be caused by hypothyroidism. The reason he misdiagnosed me is because he simply refused to listen to my other symptoms once he had made up his mind. I wish I could have avoided these three doctors altogether, and warn other people about them.

    However, these ratings should certainly not be anonymous. At minimum, the client should have to register and account and use a screen name if they don’t want to post their full name on the internet. I also think the ratings should be limited to the doctor’s attitude, and not include the doctor’s competence, which the public is not qualified to judge, as you said in your post. Arrogance isn’t just a minor annoyance, and it can affect treatment in some cases. And if I have a choice between two competent doctors, the less arrogant one deserves my business more.

  5. #5 Diane
    March 9, 2009

    Seems to me like the medical community needs to figure out how to get patient feedback in the loop.

    My Doctor’s profile on the hospital’s page tells me zippo about how this person is as a communicator or a problem solver when conditions resist the easy-to-prescribe treatments.

    Doctors have immense power over their patients. Patients are expected to turn over a huge amount of potentially uncomfortable information to their doctors. Medicine is not the only complex, highly technical field on the planet, and your people skills are part of your job. I don’t want someone I don’t like doing my yearly Pap smear, thanks.

    Feedback on products on Amazon would be useless if it were just people on the fringe on either side providing it. It is only useful because LOTS of products have LOTS of ratings from LOTS of different people who use different types of sentence construction. (And you can spot it when one person is making the same or similar comments over and over again.)

    If the medical community welcomed feedback, doctors and hospitals could use the feedback to improve their own practice, the feedback received would be helpful to patients looking to better understand the strangers to whom they may be entrusting some very uncomfortable information, and the increased volume of information would improve robustness against outliers.

  6. #6 Micah S.
    March 9, 2009

    I would feel no compunction about signing their contract, receiving care, then writing whatever I want wherever I want to. They and their unenforceable contract can see me in court.

  7. #7 Bruce
    March 9, 2009

    Some sort of feedback mechanism is required. No matter what. Are online comments useful? Probably not, but we as a society need something. How many of us have horror stories of misdiagnoses? My brother-in-law had a problem with his leg. His GP diagnosed it to be an infection, yet it turned out to be a thrombosis, which another doctor caught and got him into surgery right away. The worst part is that he never left any feedback with his original doctor about a very real life-threatening misdiagnosis. An anecdote? Yes. But it’s a perfect example of how a more comprehensive commenting and rating system needs to exist.

    As a teacher I get student evaluations all the time. You always get one or two students who just didn’t like you and try to trash you on the eval. But you look at the trends. If most of the class complains about a certain aspect of the class, you address it.

  8. #8 Beth
    March 9, 2009

    I’m having an issue similar to this with my father right now- he’s mad at the doctors because he’s had 2 (different) tests come back inconclusive on a health problem he’s having and now he has to go back in for more invasive tests. I understand his frustration, but I’m like “Dad, wouldn’t you rather they actually figure out what’s wrong with you as opposed to just guessing?”
    Patients can be annoyed even when you do all the right things, and online rating systems like this scare me because so many people will write without understanding the issues.

  9. #9 hmd
    March 9, 2009

    Bruce’s examples are instructive ones.

    An anecdote about a doctor missing a diagnosis tells us little about how good the doctor is. Especially for the layman. Perhaps a thrombosis is hard to diagnose? I don’t know, and I’m sure Bruce’s brother doesn’t know. But anecdotes like these need to be turned into data – which requires a systematic way to collect them. Online comments won’t do that.

    Student evaluations are uniformly collected from all students, which makes it possible to look at trends. They can be useful for some things, not so much for others. How could medical outcomes be treated systematically to measure quality?

  10. #10 Kagehi
    March 9, 2009

    Problem with “patient feedback” is also making sure its from patients, and that they don’t have an agenda. We have a hospital here, the only one in a thousand miles, which is badly run, under staffed, has all private rooms, which royally screws up some people’s medical coverage, and a whole host of other problems, not the least of which that some of the doctors are… less that steller. Most them a few people have stated that they would rather for shipped in a gurney by helicopter, or drive themselves to Vegas of Phoenix, rather than have to be treated for most things “locally”. People with emergencies are more likely to go to a local clinic than the hospital, because they can get seen in 2-3 minutes at the former, while it might be 3 hours at the hospital, and that is with relatively few patients waiting. Its a damn mess.

    That said, one local doctor advocated building a “new” hospital, to deal with the population increase and problems the old one had, but since that would be “competition”, they, and all the loyal patients of the wackos at the existing hospital, went on a campaign to try to get his license pulled, his business ruined, and *did* manage to cause him enough issues that the plans to build a new one got dropped.

    There has to be some sort of control on “legitimate” reporting, or its as meaningless as the idiot things online where enough votes on some site will get book X removed from the “these are nice books everyone should read”, list, and complete garbage elevated to the “top 100″. Rating doctors is no different, and far more damaging, if someone actively promotes groups of people into abusing it. Our local doctor almost went out of business and all that was over some lies posted in the local papers, and word of mouth. Add in some “rating” system…. I really don’t trust the things.

  11. #11 MarkH
    March 9, 2009

    Maybe the problem here is my reporting bias. After all I come from the angle that I’m interested in protecting the innocent from harm. Something that is generally valued as a virtue in this country is that we would rather see 100 guilty go free than see an innocent man convicted. Well, when there are no controls on the information, no way to verify, I’m thus concerned about damage to the innocent.

    Further, this conversation evinces the Rashamon-type problem we experience here. Thrombosis might be quite hard to diagnose. And all of us make mistakes. The question is whether that negative anecdote represents your experience, or the reality of the care that physician routinely provides. All physicians will be wrong, all will miss things from time to time. Should someone’s reputation be ruined because their error is simply made more public?

    Anecdotes are not data. They say nothing about the overall quality of care that physician provides. You may be angry forever over such an error but a lot of us recognize physicians are human and this shit happens. Very few people will ever bother to write a post about everything that doctor has done right. Nor should they really, because that’s just their job. The bias is for people to be shit on.

    I have a family member, also a doctor, interpreting the medical system from the patient side right now. It’s been a catastrophe. A missed biopsy, trauma causing difficult reads in further analysis etc., finally it’s getting resolved. But they understand because they realize that the practice of medicine is imperfect. It’s hard to hit the truth every time, mistakes will be made and it isn’t because of incompetence but the fact that medicine is complicated to practice and things aren’t perfect. Every time I write an article about something like this the doctor-bashing anecdotes come out of the woodwork like they mean something. There are two sides to all of these stories and, please don’t be offended people, I take them with a huge grain of salt.

    Further you fail to recognize the converse effect, that a physician who is incompetent, but knows how to game the system, could dilute their negatives with sockpuppets or some other type of inflation as occurs on Yelp. The information is biased, unscientific, and unreliable. It should not be used to judge anything.

    Anecdotes do not make data, they just make for trouble. There are no standards here, and these are people’s lives and livelihood at risk. I don’t think we’ve had a serious discussion about how such feedback could be provided in a way that legitimately controls for slander, Rashamon, and anecdotal bias.

  12. #12 jay
    March 9, 2009

    I am troubled by the ‘exeptionalism’ of this argument.

    People read ‘review’ all the time. You can find criticism (deserved or not) of books, automobiles, companies, contractors, etc. They know better than to take everything at face value, but even so, what is the risk, that some gullible people might not come in as patients? True it dredges up a lot of muck (for everyone) but it also makes it hard to hide poor attitude behind ‘professional protocol’. And probably to me, being handed a contract to sign is the very first evidence of a poor attitude.

  13. #13 Stephen
    March 9, 2009

    Could you instead make patients waive their right to privacy as purely as regards rebuttals or clarifications of reviews?

    The only reason this is different to rating cars or teachers is that the doctors can’t reply as a car maker or teacher could.

  14. #14 Stephen
    March 9, 2009

    Oh, and as an aside – of the two high school friends I had who started medicine and completed it, one was purely for the money (he was taking golf lessons on the side so he’d be able to fit in) and the other was largely because it was a prestigious career. Neither seemed particularly interested in helping people and talk about their patients in much the same way as I talk about my IT users…

  15. #15 Alex Besogonov
    March 9, 2009

    MarkH: Yes, the plural of ‘anecdote’ is not ‘data’.

    Then why not publish real data? Make your statistics public. Say, the number of correctly and incorrectly diagnosed diseases, the top mis-diagnosed diseases etc.

    With proper precautions it should be fairly safe.

    I don’t know about the USA, but in my country these data are routinely gathered (but not published, alas). So it’ll be just a relatively small step.

  16. #16 MarkH
    March 9, 2009

    Alex, in my links I explain why even the “real data” is problematic. It discriminates based upon socioeconomic factors and penalizes doctors who treat the poor, sick, old etc.

  17. #17 Alex Besogonov
    March 9, 2009

    That can be factored into the equation. Also, there probably should be adjustments for doctors treating exotic diseases, etc. No one’s saying it’s going to be easy :)

    Besides, Google is going to be big on the electronic medical records front. And all relevant data can be, probably, mined from patient records.

    So it’s fairly easy to imagine Google MD Rank in addition to Google Page Rank.

  18. #18 Erasmussimo
    March 9, 2009

    I am quite certain that the contracts blocking such reviews are the wrong way to approach the problem. It is fundamental to an economy that people be able to obtain information about any goods or services they seek to obtain. Without such feedback, the system just doesn’t work. Moreover, the complaints of the patients are deserving of exposure. I very much doubt that a patient will claim misdiagnosis unless the patient found out from another doctor what the true ailment was.

    I think it would be appropriate to take measures to insure that sockpuppeting does not occur. But I have seen many online rating systems, from books to movies to eBay sellers to hair dryers. And yes, I have seen some truly vicious comments. In fact, I myself am in a position of some prominence in my field, and am therefore often the topic of some online discussions taking place without my knowledge. On one memorable occasion, a friend alerted me to a comment suggesting that I deserved to have a rusty railroad spike shoved up my ass. And yes, comments like this are injurious to my reputation, and they do reduce the chances of my obtaining various kinds of business. However, I have never even considered retaliating, responding to, or attempting to limit such discussions. I’m a grown boy and I can take criticism, even vicious criticism. Ferchristsakes, this is the Internet! What do you expect? Academic papers? People are free to speak publicly about anything and everything, and a lot of them say really nasty things. If somebody wrote an article in The Grand Institutional Journal of My Field of Work, criticizing me up one side and down the other, I’d sit up and take notice. But comments on the Internet? Who’s going to take every single comment seriously? On the Internet, nobody knows you’re a dog. Would you take medical advice from a dog?

    However, the statistical average of such comments is useful. If I read 50 evaluations of Dr. Smith, all of which call him an arrogant SOB, I’m going to take that seriously. If I read just one such evaluation, I’ll chalk it up as a fluke.

    Remember too that the patient *is* the best person to provide an evaluation of the doctor’s ability to communicate effectively with patients, and that the ability to communicate effectively with patients *is* an important evaluative metric.

    Next, consider this from the reverse view: what kind of patients will be steered towards a doctor. If you as doctor have 50 evaluations, most of which are positive and a few of which are negative, and somebody reading those evaluations is foolish enough to pay too much attention to the few negative ones, do you as a doctor really WANT to have such a patient? Think of this evaluation as a free service to you that shouts to the world: “All you jerks and assholes! Stay away from Dr. Smith!!!” Wouldn’t you pay good money for that kind of service? Doesn’t this suggest that the AMA should subsidize such a service? ;-)

    There is an underlying tone here that I think important to point out to you: an unjustified assumption of superiority. You the doctor think you know what’s best for the patient and that the patient *doesn’t* know what’s best for him. That’s not quite true. You the doctor know the best medical treatment for the patient. You don’t know what’s best for the patient, because the patient defines the quality of medical care in their own subjective value system. Yes, the world is full of dumb rubes who need to be told what’s best for them, but the educational level of patients is steadily rising and patients are getting better at understanding the capabilities and limitations of medical science.

    I’ve been around long enough that I have dealt with a goodly number of doctors. A few of these I adore as brilliant healers. I have had only a handful of unsatisfactory experiences, none of which I consider serious. The worst of these was a doctor who prescribed valium for chronic headaches. It worked, but when I finally realized what the drug was doing, I threw it away and never went back to him. So I have nothing serious to complain about.

    However, I once had a vet who killed one of my cats through gross incompetence. She first diagnosed “irritable bowel syndrome.” Then she diagnosed it as untreatable stomach cancer. We rushed him to another vet, who diagnosed — I can’t remember the medical term — it was equivalent to “fat in the liver”. But it was too late, and the cat died. Had we treated the cat properly at the outset, he would easily have survived. I dearly wish that I could have looked up this vet on an Internet service and learned more about her. She’s still in business, although from the number of cars in her parking lot, I suspect that she doesn’t have much business. I just wish I could warn the world about her. She’s probably still killing cats. I spoke with another local vet about her and asked if anything could be done, and he said that, short of filing an official complaint with the board, there wasn’t anything anybody could do.

    The best solution would be an officially endorsed evaluation system run by the AMA, with doctors encouraging their patients to provide feedback, anonymity for patients, and some editorial control over the material. If somebody writes a scathing, foul-mouthed denunciation, the editor would strip out the profanity but leave the other content untouched.

  19. #19 Ryan Cunningham
    March 10, 2009

    “Should someone’s reputation be ruined because their error is simply made more public?”

    If these systems start catching on, a single anecdote will not ruin someone’s reputation.

    Gag orders are not the way to go. Patients have enough trouble trusting doctors these days. Throwing overt coverups into the mix is just asinine.

  20. #20 MJ
    March 10, 2009

    I think that there’s a difference in patients commenting on office services and physician demeanor, versus patient care. In the patient care category, it’s significantly more likely that only disgruntled patients will post, and those should be taken with a grain of salt.

    On the other hand, information about office staff, wait time, and physician demeanor are all totally valid when reported by patients. For routine care, I might assume that all board certified physicians are competent, but would really value information about whether there was routinely a long wait, or whether it was pleasant to deal with the doctor and his or her staff.

    Unlike physician qualifications that can be ascertained, at least in part, by education, residency, and board certification, as well as state malpractice/board of medicine databases, there are no resources to figure out if the environment of a doctor’s office is one you’ll be happy with.

    While this may be of small import with specialists that are seen rarely, a large part of having a good relationship with a primary care doctor comes from factors other than the objective quality of the medical care provided.

    I do think this may come with a corollary for patients: if you like your doctor and think that he or she provides great care, post on yelp, or on another site. The cure for bad information is more information.

  21. #21 AT
    March 10, 2009

    In NYC there are a plethora of doctors, and most people I know will give raving reviews to a doctor that they have found to be a good doctor, but it does not happen very often. So right now there are very few places for someone to choose a doctor like they choose all their other services. Every time I have to choose a new doctor whether it be a specialist or a new PCP I have to guess that the doctor is good. Which like in every other field the good ones are few and far between. And you usually find out who is a bad one after the fact. A patient deserves to have more information about the doctor, not just their phone and what insurance they take and other bits of information that are not helpful in whether you will get quality care there. I think opinion sites are a great idea in general, and I think they work for universities, products and doctors. Many doctors have now distilled their practice to its smallest essence, for a variety of reasons, and most patients don’t want that. Maybe, if doctors are forced to confront patients’ complaints, they will have to have other criteria when thinking themselves as physicians. It isn’t just having a degree or seeing patients, it takes a lot of skills that need to be developed that most current doctors are ignoring. In the meantime patients are suffering because of it. No one wants to return to a horrible doctor, so if you can’t find a new one because you are restricted by zip code or insurance, you just avoid going, or you suffer through bad care because you don’t think you can get better. I am not just talking about the podiatrist who had to ask my nurse whether or not Xrays could see through my cast, but making eye contact, letting me explain why I am there, not blowing off my questions; treating me like a human. Those things are also part of being a doctor. There will always be reviews that are horrible for no reason, but anyone who reads reviews knows that and examines the reviews they read.

  22. #22 Zetetic
    March 10, 2009

    This is REALLY a minefield! The only way it would really work as a valid assessment of a provider is to require ALL patients to respond. Otherwise, it’s extremely biased by the squeaky wheels who only have a complaint!

  23. #23 Bruce
    March 10, 2009

    It’s definitely an interesting scenario where each party feels like they are at the mercy of the other.

    Perhaps we should work together! *Floaty hearts*

    A better system does need to be in place. A post-visit survey? Should we send in people like the secret shoppers and have them report back? Secret patients?!?

  24. #24 Anonymous
    March 15, 2009

    A lot of folks want to bash their state medical board for being slow and unfairly biased in favor of the physician, but they exist to review your complaint and determine if your perception of poor medical care is accurate. They are the ones who know if thrombosis is difficult to diagnose or can determine if the 3-hour wait you experienced was due to a patient emergency or poor office management. Even if nothing is “done” to the doctor, just having a visit from a board investigator will get their attention, and maybe they’ll do something about that office management.

    You might not be able to find out if other people have complained against a doctor, because often those may be spurious or motivated by anger or ignorance, and the same goes for malpractice settlements, which often do not indicate actual occurrences of malpractice, but if there are enough complaints about the same thing, then the licensing board is in a position to do something about it.

    This is more effective perhaps than rating a doctor on an Internet site if your true goal is to “be sure this never happens to anyone else” and not “punish the doctor.”

  25. #25 Richard
    March 17, 2009

    I have tried using the Medical Boards before, but I quickly learned that they seem to take care of their own, and most complaints are not made public. I think the rise of these doctor ratings or reviews sites that cater to patients needs like RateMds and MyDocHub have a role to play in the health care ecosystem. Don’t get my wrong, they should not be used solely to pick a doctor, but hearing from others is comforting.

  26. #26 Richard
    March 17, 2009

    I have tried using the Medical Boards before, but I quickly learned that they seem to take care of their own, and most complaints are not made public. I think the rise of these doctor ratings or reviews sites that cater to patients needs like RateMds and MyDocHub have a role to play in the health care ecosystem. Don’t get my wrong, they should not be used solely to pick a doctor, but hearing from others is comforting.

  27. #27 Chris
    March 19, 2009

    Previewing your Comment
    Erasmussimo is right. I detect a hint of arrogance in the young doctor-to-be. It seems to be an occupational hazard. Yes, there are a lot of dumb patients who will treat their doctors as gods, swallowing every prescribed pill without even knowing the name of it, never realizing that the terrible side effect they are having is coming from that pill. (I have been prescribed pills that cause cancer, at least in lab animals, and never been told that fact by my doctor.) But the arrogant doctor likes these “compliant” patients. Those patients will take the high dose statins and get the low cholesterol scores that will get the doctor bonuses. Yes, I read this morning that this is just what some insurers are doing, paying doctors for “results”.

    Then there are other patients who have studied their disease, lived with it, and read books, PubMed, and the PDR. They may even know more about what they need and don’t need than the doctor does, believe it or not, because they’ve got just their own body to worry about and are highly motivated. Doctors have hundreds of diseases and bodies to worry about and very little time to devote to one patient. When these more aware patients question their doctor and he dismisses their concerns, they feel even more powerless and go write a negative comment about the doctor on some website. The doctor gets upset because he can’t control them, and he is a person who likes to be in control.

    The power in a doctor-patient relationship is very unequal. Patients have to lie there naked, often in pain, worried and fearful. They have to give up their privacy and become child-like, particularly in a hospital situation, waiting for the great and powerful doctor to admit and discharge them, give them pain meds, etc. They have to pay large sums of money for the prescription writing powers the government has given the MD, even though they may know perfectly well what drug they need and even though people in other countries can walk into a drugstore and buy most drugs over the counter.

    Even if the doctor’s snap diagnosis is wrong, they know his diagnostic OPINION is in their medical record forever. Right or wrong, that diagnosis can haunt them, causing health insurers to increase their rates or to outright reject them. Most other doctors who will see their medical record will assume that they have this disease and shut their minds to any other possibility, compounding the error for years, causing suffering for the patient. With the new electronic health records, they will never be able to rid themselves of a wrong diagnosis, as it will follow them everywhere.

    And you worry about a few patients writing bad reviews about you online, reviews which only a tiny percentage of people will ever look at? A doctor who would ask me to sign a gag order is one I would avoid. It’s a sure sign that he has had quite a few bad reviews and is arrogant enough to think he can control my free speech as well as my body.

  28. #28 Marie
    March 22, 2009

    While there are inherent pitfalls in online reviews right now, I do think it is an important start in medical consumerism. Improved communication and clearer expectations are things that can only be good for patients AND doctors.

    I have a chronic illness that will require me to have a relationship with a neurologist for the rest of my life. Four years into my diagnosis, I am on my third neuro.

    Every patient has different needs, in addition to the need for good medical care. I am a nurse and my need is to feel as though I am in partnership with my physician. My first neuro was a condescending asshole. The second was an otherwise kind woman who needed to be in charge. My present doctor is a good fit. He is respectful of my autonomy and presents options, not mandates.

    It is helpful to have some sort of system so you do not have to waste time going to doctor after doctor when you are already sick. Again, it’s not perfect. But I think a fair person will look for balance in an online review and take ranting with a grain of salt.

    By the way, the best way to find a good doctor? Ask a nurse.

  29. #29 dan sichel
    March 27, 2009

    More information is always better. A free market depends on free information, like pricing (which the AMA says it is unethical to advertise), and quality of service. No difference here between a mechanic and a doctor, knowing their demeanor and past outcomes are useful. Doctors naturally oppose this as it imposes consequences on errors, rudeness, and overcharges. If you are a good doctor, charging reasonable rates, you should welcome this if you want your practice to grow. On the other hand, if you have something to hide….

  30. #30 Nathanael Nerode
    April 7, 2009

    “Rating” (numbers) are not useful…but *reviews* — descriptive and detailed — are eminently useful. As with movie and food reviews, they are vital. Any doctor who tries to prevent his patients from reviewing him should have his license revoked.

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