August 23, 2015
“Physician Rating Web Sites: Ethical Implications”
Julie Balch Samora, MD, PhD; Scott D. Lifchez, MD; Philip E. Blazar, MD; The American Society for Surgery of the Hand Ethics and Professionalism Committee
There are currently more than 60 physician rating Web sites. In an analysis of 4,999 online physician ratings, the 10 most commonly visited PRWs were found to be HealthGrades.com, Vitals.com, Yelp.com, YP.com, RevolutionHealth.com, RateMD.com, AngiesList.com, Checkbook.org, Kudzu.com, and ZocDoc.com. Yelp and Healthgrades appear to be the most trusted Web sites by patients. Three respondents specifically mentioned Yelp as a Web site that had an algorithm that tended to highlight negative reviews. Many of these Web sites had not contacted the physician, office, or hospital for permission to report or requested any data from the rated entities. Online information may misrepresent background information, qualifications, or professional performance. Only 4 of the 8 busiest PRWs were found to have accessible and reliable data pertaining to orthopedic surgeons in a major metropolitan region. In this study, there was insufficient user-generated content, lack of an orthopedic surgery designation, or a high rate of incomplete submissions.
There are many ethical questions that arise with the creation and expansion of PRWs. Physicians and professional organizations have argued that they have been misrepresented by PRWs and that they have been abused by angry patients or competing practices. A systematic review performed by Emmert et al found the major shortcomings of PRWs to be incomplete databases, few ratings, unstructured patient opinions, lack of a reference standard for surveys, lack of validity of scoring systems, data that do not reflect the actual quality of the physician, potential for abuse due to anonymity, inability of physicians to respond to negative reviews, and lack of evidence of effects on physician performance or patient outcomes. We found many of our respondents felt that they had also been misrepresented by PRWs, with 62% of respondents observing inaccuracies in their online profiles, and 53% receiving a critical comment about their practice that was objectively false.
There is evidence suggesting manipulation. Most rating sites do not require authentication of raters. Some physicians have posted reviews about themselves, which both undermines the validity of these sites and demonstrates deficient ethics of the providers who wrote their own reviews. None of our respondents acknowledged posting positive reviews about themselves. However, 1 respondent reported an investigation that found that a negative comment had been posted by a local competitor.
In a study of online reviews of 500 urologists, the composite rating was based on scores from an average of 2.4 submitted ratings. One-sixth of practicing U.S. physicians received at least 1 rating on RateMD in 2010. Because there are so few ratings, 1 low score could potentially lead to a severely low overall rating. Several respondents felt that the small sampling of reviews cannot possibly lead to accurate evaluations.
Most ratings have been found to be generally positive. Nonetheless, one-third of the current survey respondents had asked satisfied patients to submit reviews. Ethically, this practice raises questions. It is not clear whether this is simply the online equivalent of asking satisfied patients to refer their friends or if it crosses an ethical line, because adding more positive ratings will dilute the impact of negative ratings. Is there an obligation or expectation to solicit ratings from all patients or a representative cross-section? There are physicians who are actually handing out comment cards that can later be posted to PRWs. Apparently, there are also companies that directly contact physicians and physician offices with offers to improve ratings for a fee.
Regardless of the incomplete databases, few reviews, and lack of validity, a national survey found that 35% of respondents selected a physician based on good ratings on PRWs and 37% had avoided a physician based on bad ratings. Almost 40% of our respondents felt that the Web sites changed referral patterns. However, only 17% of respondents felt that PRWs had direct negative effects on their practice. Many open-ended responses reflected that respondents truly had no understanding what effects ratings produce.
One of the dilemmas as a treating physician who receives an undesirable rating is the relative inability to provide feedback. When responding to negative reviews, patient anonymity must be protected and remain in compliance with the Health Insurance Portability and Accountability Act of 1996. Oftentimes, there is no opportunity for rebuttal, because patient confidentiality must be maintained.
There have been lawsuits filed by physicians who felt they had suffered damages from reviews. Dr. David McKee, a neurologist from Duluth, MN, sued Dennis Laurion, the son of a former patient, alleging that statements Laurion published online defamed him. In McKee v. Laurion, 2013, the Minnesota Supreme Court found that Dennis Laurion had the right to call Dr. McKee a “tool.” The laws of defamation generally favor those individuals who post the untoward comments, because freedom of speech is privileged. If there are no specific details provided and the posts are generally subjective and mere generalities, the writer is protected by law. Even Web site operators are often immune to lawsuits.
It is expected that PRWs will play a major role in health care in the future. The National Health Service in the United Kingdom has encouraged patients to rate their general practitioners through a National Health Service–run Web site. It is unclear whether there will be a uniform reporting system in the United States or whether these online ratings will influence patient-referral patterns or quality improvement.
In 2012, the Affordable Care Act implemented a policy to withhold funds from hospitals that do not have high patient-satisfaction scores. Two-thirds of poorly performing hospitals (with higher numbers of readmissions, complications, and death) had highly satisfied patients based on Hospital Consumer Assessment of Healthcare Providers and Systems scores. In a prospective cohort study, patients who reported being the most satisfied with their medical care actually had higher health care and prescription costs, higher odds of inpatient admissions, and higher mortality rates than patients who were not as satisfied. We may witness the development of a similar policy for individual providers.
Providers have started to take a more active role in the development and management of PRWs. The California Orthopaedic Association contacted Healthgrades with the goal of improving accuracy of information, subspecialty information, and personalized practice information. It is early in the process, but Healthgrades did make major changes to its review site, even creating a section to enable physicians to input personalized information about their practice. Similarly, the Wisconsin Collaborative for Healthcare Quality, a nonprofit coalition of health systems, medical groups, hospitals, and health plans, has voluntarily collected and provided information to Consumer Reports. These data are the foundation for ratings in this region.
The main limitation of this study is the low response rate of 12%. These data, therefore, may not accurately represent the views of the entire ASSH membership.
Professional organizations such as the ASSH have the opportunity to take an active role in online physician rating. Well-developed PRWs can provide both qualitative and quantitative feedback and new insights on the perceptions of patients. Some of the opportunities suggested to reduce bias and harm to physicians include making the ratings first available when they have reached a certain minimum number, which may thereby reduce the impact of extreme opinions. Furthermore, assuring accuracy of information, providing physicians the opportunity to respond to negative comments, and enabling the removal of fraudulent posts will be of paramount importance to ensure factual data. We suggest that in the near future, professional societies will play a more active role in the area of online physician rating and recommend the creation of a task force within our societies to assess the development, management, implications, and ramifications of PRWs.
There are multiple ethical conundrums that PRWs pose, which will need to be more fully evaluated. Providers should take an active role in the creation and implementation of quality PRWs so as to ensure quality and accuracy of information.