Ethics Document: Confidentiality Key in Responding to Reviews

“He was late for the appointment, seemed distracted and uninterested in what I had to say, and never made eye contact.”

In the age of the internet, everyone and everything are fair game for criticism: log onto Yelp or a similar online review portal, and you are likely to see that your favorite hotel, restaurant, or landscaping service has at least one scorching bad review, along with the glowing ones.

Physicians, including psychiatrists, are no exception, and any number of websites—such as HealthGrades.com, Vitals.com, or RateMD.com—provide patients a venue for rating their doctors. Any physician, especially one with a large caseload, is liable to run across at least one bad review.

“It’s a common concern,” said Charles Dike, M.D., vice chair of the APA Committee on Ethics and associate professor of psychiatry in the law and psychiatry division at Yale University. “People are aware of these rating venues, and even physicians who have never felt themselves victimized by a bad review worry about it.”

But responding to bad online reviews can be especially tricky for psychiatrists, who have a bedrock ethical commitment to patient confidentiality. A new resource document published by the APA Committee on Ethics seeks to provide some guidelines for when and how to respond to negative reviews and—perhaps more importantly—when not to respond.

Dike said a crucial takeaway from the resource document is that psychiatrists cannot respond to a negative review in any way that might publicly disclose that the individual is or ever was a patient. And anything published online is “public.”

“If you indicate publicly that you are or were the person’s psychiatrist, you have broken the law and acted unethically,” Dike said.

But a second, equally important takeaway is not to overreact to one bad review. “Doctors take their roles seriously and tend to believe they are doing a really good job,” Dike said. “Even one complaint can be quite damaging and demoralizing. But we have to caution them not to overreact in the moment to one bad review. It can be extremely hard to just watch these reviews online and not feel like there is a form of redress.”

In cases where the identity of the reviewer is obvious, and the psychiatrist wants to respond, Dike urges psychiatrists to take the discussion offline. “You might have the opportunity to respectfully address the individual’s concerns in the privacy of your office, being careful not to come across as confrontational,” he told Psychiatric News.

As the resource document states, “Where possible, the psychiatrist may work together with the patient to formulate concrete steps to alleviate concerns and preserve the therapeutic relationship. Entering these conversations from a place of compassion and empathy impresses upon the patients that their treatment experience will improve.

Oftentimes, acknowledging and addressing the issue that resulted in a negative review leads the reviewer to voluntarily remove or revise the review on their own.”

(The document also cites statistics from an article on a business website about responding to negative Yelp reviews, stating that a third of negative reviews are positively revised “when you take the time to respond to the upset customer.”)

Multiple Negative Reviews? Take Notice.

What about when a psychiatrist is receiving a number of bad reviews from different sources, many of which appear to register similar complaints?

In that case, it may be time to take notice. “If there are many complaints similar in nature, this represents an opportunity for the physician to reflect on his or her practice, thoughtfully explore why the complaints are happening, and attempt to change one’s approach,” Dike said.

It is possible that a review may contain factual inacuracies, in which case review sites typically have protocols and procedures for removal of such material. But even then, caution is advised.

According to the resource document, “If making use of the relevant procedures would require the psychiatrist to reveal any confidential information, including whether the person posting the materials was or was not treated by the psychiatrist, the psychiatrist is prevented from using them by both the legal duty to protect patient privacy (for example, under the Privacy Rule of the Health Insurance Portability and Accountability Act [HIPAA]) and the physician’s ethical duty to not reveal a patient’s personal or health information without the patient’s explicit, informed permission.”

Finally, there are ways for physicians to be proactive about patient feedback. By encouraging patients to post reviews, physicians may be able to populate a website with enough positive reviews to dilute the impact of one or two negative reviews. Alternatively, they can solicit feedback in a nonpublic venue.

The resource document also recommends the following:

• Provide mechanisms for patients to submit feedback directly to their psychiatrist (for example, paper surveys that can be handed to the receptionist or slipped into a locked survey box in the waiting room, or electronic tablets in the waiting room that link directly to a patient satisfaction questionnaire). This approach fosters open communication between the psychiatrist and patient and allows them to discuss grievances directly before escalating to an online commentary.

• Post information in waiting rooms instructing patients on how to submit online reviews about their experience (for example, “If you would like to publicly review the service we provided, please go to [link], where you can do so anonymously”).

These solicitation practices are ethical “so long as the same information and opportunity to comment is given to all patients without coercion, and no patient is directly asked to provide a review,” according to the document.

Ultimately, Dike said, patient feedback can improve one’s practice. “Physicians need to really know how their patients feel about their experience,” he said. “If enough patients have an opportunity to express their opinion, that can provide real data to reflect on your practice and make constructive improvements.” ■