Great pair of articles in the Paper Of Record (in the Business, not Health, section) on Friday looking at websites that rate doctors (here and here). The gist: you can get a wealth of reviews on pretty much any restaurant you live near through various sites, but very few docs have multiple reviews of them online. The first link goes into some depth as to why this is so, and concludes with the thought that the only way to get more accurate info about the doctors is to have more people put up more reviews. Which is true, although since many people already put up Tolstoy-length reviews of their local coffee shop, it stands to reason that people are still a bit uncomfortable about doing the same with docs.
The only guess I can hazard is that most people still put docs into a different category of job than those that are both clearly customer-service oriented and, for lack of a better word, capitalist. Hairdressers, auto mechanics, electricians and the like exchange services out of a specialized knowledge for cash; priests, teachers, and docs also do that but are in some sense responsible for our souls. Rating a priest seems like an exceedingly odd thing to do, and I suspect that doc ratings haven't caught on for a similarish reason.
That said, it seems reasonable to assume that sites like RateMDs.com and the doc section on Angie's List will inexorably gain adherents and the practice will become more widespread. Not every physician--based on the comments in the second NYT article--is delighted about this. "The biggest problem is that it is the patient point of view which is often emotionally charged and not fully informed. If I tell a patient they have cancer and they don't like the diagnosis, am I rated poorly because 'that's not what I wanted to hear'?...I often ask the complaining patient 'Did you get better?', 'Is your loved one still alive?' and then which was more important to you, staff friendliness or the outcome?" wrote Doc Matt. (A delightful reply came from Miriam in Queens, who wrote, "You mean I can't have both?" One does wonder about Doc Matt's bedside manner when he explains that he "often asks the complaining patient" about their critiques: how many complaints does he get?!)
Such condescending attitudes weren't the only ones in evidence, but these and other comments do highlight the anxiety ratings are capable of promoting. From my own experience in professional chit-chat with colleagues, many more of us are worried about getting a malpractice lawsuit than a bad online review, but that could just as easily reflect the kind of doctoring I do (that is, not outpatient clinic-based) than it does the general mood of practicing docs.
One good point made in the comments that surprisingly didn't find its way into the articles dealt with the lopsided rules by which docs and reviewers can approach the online rating system. Patients can say whatever they wish in a review, but docs are bound by confidentiality, and are unable to respond if they feel they have a misleading review. However I'm not sure that any but the most thin-skinned docs would respond to bad reviews anyway, since it would likely make matters worse from a marketing standpoint, and just might indicate an underlying problem with feedback that lots of patients associate with certain kinds of docs in the first place.
The articles are good and informative, though journalist Ron Lieber does include one unintentional howler by noting that "the American Medical Association speaks for most doctors". While undoubtedly an important organization to reckon with, the AMA ain't all that, a topic we've previously covered here. But in terms of the overall ointment, it's a pretty small fly.
--br
UPDATE: I received a comment from a reader who feels as if a doctor was responsible for their spouse's death. The reader named this physician and the medical group for whom the physician works. I won't publish the remark: I cannot verify the information and thus can't in good conscience allow a direct attack on a particular physician onto my blog. The reader is more than welcome to circulate the story on the websites above, but here I can't sanction specific accusations without the ability to verify the veracity of the claims. I tried to send an e-mail to this person directly but no address comes up on the link. If you wish to discuss further, please leave another comment with your address. I'm happy to entertain thoughts about tough times with physicians but my rule is to keep names out of it (as I wrote about experiences with one of my father's physicians here). I am sorry for your loss. Best, Billy
It's easy to rate restaurants: I get feedback on their quality immediately and I've been to hundreds of restaurants, so I have a good sense what the good ones are.
ReplyDeleteWith doctors, there's asymmetry of information. I go to the doctor, she gives me advice, and I rarely have any idea how good the advice is, sometimes only learning it's bad months later, like the doctor who missed my torn rotator cuff. So I can rate them on friendliness and on wait times and ease of scheduling appointments, and not much else, and have little to compare them with.
I agree that there's an "asymmetry of information" relating to evaluating the technical aspects of a doctor's performance, a point that several doctors stressed in the comments section of the Times article. The same is no less true for my being able to rate my electrician or my auto mechanic. But most people want their docs to be able to be approachable, reasonably prompt, fairly accessible and emotionally empathetic--all things for which any patient could offer a fair critique.
DeleteI think most patients understand that it's very difficult to evaluate a doctor's knowledge base and expertise. There's a great story in Jerome Groopman's "How Doctors Think" where Groopman himself, a full Professor of Medicine at Harvard and an obviously talented clinician got totally snookered by several orthopods when he presented with funky wrist pain; only after finding the right doc did he understand the answers of the previous docs were technically inept. In other words, even for those with a pretty high level of expertise, it's hard to be an accurate judge of that aspect of doctorhood. But most gossip that I hear about bad-experience-this or bad-experience-that with a doc has to do with someone's comfort level, and I think that's a very reasonable thing for patients to evaluate...and I'm a touch surprised that you, free marketeer that you are, don't appear to fully agree.
I think the general concern that people who make the "technical expertise can't be evaluated" argument have is that they're going to find some very highly rated doc who is strong on social skills but low on actual medical knowledge. Since the quality control of physician training is relatively high, I don't think that's a major concern, although I would carve out an exception. Lord help me for saying this as I may rain down derision on my head, but the one field in which I would hesitate to seek a doc is Family Medicine. I don't think it is possible for them to be superior in competence to their Internal Medicine or Pediatric counterparts--and indeed think it's more likely than not to be less competent--but without doubt these docs are among the most patient-friendly in the biz. Based on my experience teaching, students interested in Family Medicine are among the least driven in terms of academics and most driven in terms of the pastoral aspects of care. Possessing the latter qualities is great, but lacking the former qualities not so helpful if your patient has Brougada Syndrome and winds up dead because you didn't catch it on the EKG.
I thought about mentioning this in the main article, but there are two areas where online info about docs (not "reviews" per se) can be useful for laypeople to technically evaluate performance, and it deals with surgeons. For moms looking at OBs, they should be able to find out C-section rates of a given OB relative to her peers if that's important to them. Second, if someone's going in for routine surgery, it's reasonable to look up postoperative infection rates on a given surgeon (though this info is probably pretty hard to find right now, though I suspect it's coming). I would not recommend that anyone try to evaluate a surgeon by "outcomes data", i.e. how many patients die or have complications under a given surgeon's knife, since nobody has yet figured out an apples-to-apples comparison of the patients undergoing surgeries. This holds true for non-surgeons as well. Docs at large, academic medical centers are typically willing to take on cases that community docs won't touch, which means that the patient base at an academic center is sicker and more likely to have a higher mortality rate, but frequently the technical skills of such docs are higher, not lower, than their community counterparts.