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Professional News
Accuracy May Be Casualty in Online Physician Reviews
Psychiatric News
Volume 42 Number 20 page 7-25

The course of the doctor-patient relationship does not always run smoothly, but it runs a lot more publicly now than in the days before the Internet.

Web sites where patients post candid reports of their experiences with doctors are proliferating. Their goal is to reveal peoples' opinions of doctors' personalities or competence and inform prospective patients trying to choose a physician. Many remarks are positive. One site owner says that's the case for 70 percent of the comments posted on his site.

However, the negative comments seem to draw greater attention, anxiety, and ire.

Once upon a time, a patient with a complaint might write to the local medical society or state licensing board or call a malpractice lawyer. There were high thresholds for those steps, though. An offense had to be sufficiently egregious to warrant consideration for disciplinary action or litigation.

The new ratings Web sites present a much lower bar for patients, who need only a computer and a desire to let the world know what they think of their doctors (M.D.s Not Boarding E-Mail Bandwagon discusses another way patients communicate with doctors).

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Skimming through half a dozen such sites suggests that patients who complain do so less about botched appendectomies than about customer-service issues. Complaints about doctors' rudeness, patronizing attitudes, too-brief office visits, and brusque office staff abound. That may leave psychiatrists particularly vulnerable, since their specialty includes a lot of physician-patient interaction.

"Psychiatric patients with severe personality or psychotic disorders may not be the most objective reporters, but even the best psychiatrists have patients who leave for arbitrary reasons," said John Luo, M.D., an associate clinical professor of psychiatry and director of consultation-liaison psychiatry at UCLA Medical Center, who writes about applying technology to psychiatric practice for PrimaryPsychiatry.com.

The Web comments, no matter their degree of truth, hardly represent a valid survey of either patients or physicians. Many sites have long lists of doctors, but relatively few that have been rated and fewer still with more than one comment. Searching one site under the Baltimore ZIP code that includes Johns Hopkins, for instance, led to a list of 100 psychiatrists, but only four reviews—all positive.

"I'd like to see a more representative sample, too," said John Swapceinski, co-founder of RateMDs.com, which he said receives about 600 to 800 new reports each weekday. "We can't rely on the medical profession to give patients a venue for their views, so we display what we have now. There's an unmet need for this information."

Epidemiology aside, unfriendly comments never make enjoyable reading for their targets, as a few examples suggest.

"You will leave feeling no better but maybe worse because he is not empathic," wrote one patient of a psychiatrist—thoughtfully adding: "His receptionist is nice."

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Some postings contradict each other. One patient complains that her psychiatrist is "austere" and "unfriendly," while another says the same doctor is "compassionate, caring, kind, effective, and no-nonsense."

Yet another patient posted negative comments about a third psychiatrist. Contacted by Psychiatric News, this psychiatrist (who requested anonymity) said he could guess who the patient might be, although he had not seen or read the posting himself. He believed the comments came after he confronted certain manipulative behaviors by the patient.

This psychiatrist regretted that a patient felt bad about the care he provided, but felt the public comments have not harmed his practice. He was equally philosophical about his options to respond.

"There's nothing I can do about it," he said. "Suing is just as hostile and would probably only make things worse."

In fact, several roadblocks probably prevent the emotional satisfaction of knocking down one's critics in court, said Nancy Wheeler, J.D., a Maryland attorney in private practice and coordinator of APA's legal information and consultation plan. That's what she told another APA member who thought that a troubled expatient was writing scurrilous things about him on several Web sites, possibly leading to a loss of some expected referrals.

"For one thing, most of these postings use pseudonyms, so it's hard to prove who's doing it," said Wheeler, recalling the old line about how" on the Internet, no one knows you're a dog."

Furthermore, the law on defamation, libel, and slander makes clear that" truth is a defense," said Wheeler. Statements that can be refuted by the public record—like court judgments or licensing board actions—are one thing. Opinions are something else and give the writer much more leeway under the First Amendment.

In addition, the Communications Act of 1996 states that Internet service providers cannot be sued for any allegedly defamatory statements. The Web sites all make a point of citing this shield, but many also have systems for reviewing remarks before they are posted.

"We employ human reviewers to read all ratings as they come in and use guidelines to avoid libel or simply far-fetched statements," said Swapceinski. His site also uses a "red-flag" system that allows any reader—presumably including the physician in question—to send the comment back to the reviewers for another look.

"Maybe 5 percent get flagged, and of those, 10 or 20 percent are removed or edited," he said. "We also use a computer program that looks at the sender's address and other information to remove multiple ratings from the same source."

The Web sites may serve a purpose if they stimulate greater discussion of patient satisfaction among doctors and the people they treat, suggested the psychiatrist quoted above. "You can get real feedback from patients," he said.

Swapceinski agreed: "If doctors polled their patients and posted the results online, they could put me out of business."

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Another site, HealthGrades.com, which began as a hospital rating system, doesn't use written patient comments for physicians and has a very different business model. The site contains a database of all 650,000 physicians practicing in the United States, with information on their training and board status and any state or federal disciplinary actions against them. Visitors to the site fill out a" patient experience survey" covering convenience, knowledge and skill, shared decision making and communication, outcomes, and whether the patient is likely to recommend the doctor to others. The responses are aggregated into ratings, but specific comments aren't posted. Thus far, they have received about 150,000 survey responses.

Doctors can't opt out or change their survey reports but can add things like subspecialties or research publications to their profile. Unlike other sites, HealthGrades.com charges visitors $29.95 to download a doctor's profile. Physicians can also pay a "minimal" sum to HealthGrades.com, which it would not disclose to Psychiatric News, to make their profiles available free to site visitors, presumably increasing the number of potential patients who see the profile, said Scott Shapiro, vice president for corporate communications and marketing for HealthGrades.com, in an interview.

Physicians may simply have to adjust to a world in which anyone can make any statement available for anyone to see, said Luo. "Part of the problem is that there are too many sites, so it's hard to tell what's valid or useful. It's like trying to pick out which car dealership to visit."

If it is any comfort, physicians are not the only ones dealing with publicly posted opinions of their work. Swapceinski also started Ratingz.net, a group of Web sites that rates 13 categories of products or services from veterinarians to child-care providers to car mechanics to prescription drugs—and lawyers, who, as a group, might be even less happy about their reviews than doctors.

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The following are addresses of some of the Web sites that post ratings of physicians:

Columns by John Luo, M.D., are posted at<www.primarypsychiatry.com/aspx/articledetail.aspx?articleid=1154>.

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