Online doctor reviews: not ready for prime time yet

It sounds like a useful idea: online ratings that help consumers sort through their choice of doctors and pick the one who’s the best match.

In real life, though, the concept doesn’t seem to have flourished as well as expected. An intriguing piece published this past weekend in the New York Times explores why this would be the case for what writer Ron Lieber calls “the highest-stakes choice of service provider that most people make.”

Litigation is one obvious concern. Patients don’t want to be sued for posting an online review that may be negative. In case you think this would never happen, think again: A Duluth, Minn., man was sued by a neurologist after making critical comments on three consumer rating sites about the doctor’s bedside manner. The case was thrown out by the St. Louis County District Court but the Minnesota Court of Appeals ruled this January that a jury should be allowed to decide.

Sometimes patients worry their anonymous comments will be recognized and that there’ll be retaliation in some form, Lieber wrote. He spoke to an Angie’s List customer who “said she would never talk negatively about her doctors on the site because there were only two decent hospital systems where she lived and she didn’t want to end up blackballed by doctors at either.”

The biggest issue I’ve seen, however, is that most of the online rating sites simply aren’t that robust. I’ve browsed through RateMDs, which purports to have more than a million consumer-written reviews of physicians in the United States and Canada. A search for Minnesota physicians revealed very few reviews for any doctors outside the Minneapolis-St. Paul area and most of the doctors had fewer than five reviews posted for them – not a particularly strong sample size and not very useful if you don’t live in the metro area.

And what should the average doctor-shopper make of comments such as “Best pediatrician I have ever encountered!” or “not helpful, bizarre comments and behavior”? Without context, it’s difficult to judge, making the value of many of these reviews limited at best.

Certainly there are more objective rating sites online – for instance, HealthGrades, which provides information on both physician and hospital quality. But again, most physicians outside the metro area have only a small number of reviews, or none at all. (I also noticed the lists don’t seem to be updated when doctors retire or leave the community. How would someone who’s new to town and in search of a doctor be expected to know this?)

Nor are most of the online rating sites very helpful when it comes to judging physician quality on the basis of outcomes or best practices. Here in Minnesota, Minnesota Community Measurement seems to come the closest to reporting how medical practices stack up overall in outcomes and the use of evidence-based medicine. But either I’m a klutz or the site is overly cumbersome, because I’ve found it difficult and time-consuming to truly use effectively. And although it could probably guide consumers to a quality medical clinic, it doesn’t really help them choose an individual doctor, a decision that often comes down to personal values, preferences and communication styles.

Studies examining actual consumer use of online rating sites are rather thin on the ground. One survey, conducted in 2008 by the Center for Studying Health System Change, found that only about 10 percent of the 13,500 adults who were queried turned to an online rating site to help them find a new primary care doctor. The majority relied on old-fashioned word of mouth from family and friends.

What’s a consumer to do? Lieber writes:

Until a single one-stop shop exists for both reviews and data that are fair and useful, we are left with one another. The problem with asking friends for a doctor recommendation is that even if they are a lot like you, they may not have any idea whether the doctor is a good clinician or not.

Careful readers can probably find some sites with listings for certain doctors that in number and detail add up to a useful measure of many of their skills. But you may not know anything about whether the reviewers are people similar to you.

In light of all this, it’s curious to see policymakers continuing to forge ahead with all kinds of online data, from hospital performance to outcomes to patient satisfaction. Not that the trend isn’t welcome; we need more – not less – data and public reporting. Sharing the data is no guarantee, however, that consumers will be able to use it effectively, or indeed whether they’ll use it at all. It seems that in spite of all their promise, the online rating sites still aren’t quite ready for prime time.

The online sport of provider-bashing

I belong to an online community where the hot topic last week was doctor-bashing – more specifically, whether it’s OK to name names when patients are criticizing an individual physician or institution.

The discussion started innocently enough with a posting from someone who wasn’t happy with the care a relative received at a large hospital somewhere on the East Coast. Then things escalated. Accusations were made about only telling one side of the story. Names were named. Folks got angry. A moderator stepped in and started editing names out of posts, resulting in cries of censorship.

I’m not sure the argument was resolved to anyone’s satisfaction. But it points to a thorny modern-day issue: the use of online forums to exchange recommendations (or warnings) about individual providers and the ethics of truth-telling vs. smear campaigns.

It seems to be human behavior to compare notes about health care providers. Even the Neanderthals probably sat around the fire and griped about the caveside manner of their local shaman. To the degree that interactions with a health care provider often are highly individual and tend to be colored by emotion, it’s logical that people would want to know if others have had the same experience. Similar experiences can help validate people’s perceptions that Dr. X or Hospital Z is [insert failing of your choice].

It’s one thing, though, to grouse among a small circle of friends and family, and quite another to broadcast your dissatisfaction online where the whole world can see.

There are plenty of Internet forums where this takes place. At RateMDs.com, you can see the good, the bad and the ugly – mostly neutral to good reviews but also more than a few that are negative and even scathing. Healthcare Scoop, a Minnesota site, is a little more sedate (it has its own code of conduct) but has a similar purpose in giving consumers a place to swap stories and information.

Yes, names are named – otherwise what’s the point? No, there’s no way to verify whether commenters are actually being truthful or whether they’re biased or telling only part of the story.

Physicians and, to a lesser extent hospitals, often feel threatened by this, and rightfully so. It’s hard for them to defend themselves against anonymous online comments, and in any case they’re generally barred by privacy regulations from responding. Some attorneys have gone so far as to suggest that physicians ask their patients to sign a contract agreeing not to comment online about the doctor. Sometimes, physicians fight back with a lawsuit, as a Duluth neurologist recently did after being criticized by a patient’s son for his bedside manner (although this particular case apparently didn’t involve online commenting).

The larger question, it seems to me, is whether consumers truly benefit from sharing personal stories and experiences, good or bad, that they’ve had with health care providers. There are plenty of caveats, to be sure. A rating site might contain only one or two reviews of an individual physician – hardly enough information with which to draw any conclusions. If a patient or family member is upset about the care they’ve received, you don’t know how accurate their perceptions might be. Sometimes people misunderstand a situation, or their emotions simply are running a little too high. Under these circumstances, does it unfairly tarnish someone’s professional reputation if names are named?

Naming names can have another impact that’s not as readily recognized: undermining the confidence of someone who has chosen a particular hospital or physician and causing them to question whether they’ve in fact made the right choice. At the very least, it might prompt patients and families to search for faults that aren’t really there, and thus unwittingly erode the relationship.

But there’s another side to this: the value of honesty and disclosure. As one of the participants in my online group said, "Why would we have a double standard – OK if people have something nice to say and not OK if they have something critical to say? There are times when patients/families really need to hear an honest opinion."

Despite the growing prevalence of online ratings for physicians and hospitals, word of mouth remains a significant force in helping people choose a provider. Online ratings don’t always capture nuances that might matter to patients. One or two bad reviews don’t necessarily constitute a trend, but consistently low or lukewarm ratings can help signal deeper issues – for instance, a physician who’s not a good communicator, or a hospital that’s not responsive to problems that crop up during a patient’s stay. To many consumers, this is important to know.

For the record, I’m not a fan of bashing. If you have something negative to say, you can say it without resorting to insults or anger. There’s nothing inherently wrong, however, with criticism. If providers are too thin-skinned about it, they risk losing an opportunity to identify areas that need improvement. Inevitably, it sometimes means names are going to be named, and the responsibility that comes with this applies to both sides of this particular fence.

Photo: Wikimedia Commons