Online physician reviews: is there a place for them?

Web-based physician ratings are increasingly popular but imperfect proxies for clinical competence. Yet they provide valuable information to patients and providers when taken in proper context. Providers need to embrace the reviews and use them to enact positive change in order to improve the quality of our patients' experience. Patients need to realize the limitations of online ratings, particularly with smaller sample size and be discerning about the reasons behind the review.

Introduction

Web-based physician ratings systems are becoming increasingly popular as the internet becomes more ensconced in our culture and crowd sourcing is used to select services.1–3 Yet, despite the rise of online physician reviews, the debate about their utility continues without a clear consensus or a complete understanding of their influences and implications.4 Unfortunately, one of those influences is an increasing physician and patient distrust.5 While many patients seem to appreciate the added information from online reviews, many physicians are skeptical or fearful of their impacts.6 Online reviews can help patients find a particular physician and prepare for future visits with a chosen provider.7 However, many physicians worry that these platforms will hurt their practice if negative reviews are received.8 The differing views between physicians and patients towards these reviews are not surprising but the contrast is stark nonetheless.9

Who is using online reviews?

It has been reported that up to 60% of people use web-based physician rating systems in choosing a physician and that the number of ratings online have been increasing.2 Intuitively, patients who have used platforms in the past will use them in the future.10 Some studies suggested that younger patients have more experience with web-based physician rating systems.8 Younger patients may be savvier with the internet as it becomes an integral part in our culture and upbringing.8,11,12 Younger patients may have increasing awareness with respect to newer technologies and know how to navigate through various platforms as they generally have higher internet consumption compared to the past. Furthermore, more women than men, educated patients, insured patients, and patients with chronic disease/multiple comorbidities use web-based physician rating systems.8,10 Elaborating on these findings, the most important factor in using web-based physician rating systems was health care utilization.8,10 Patients who have multiple comorbidities will require close relationships with physicians and are more likely to use these review platforms since they will have more doctor visits compared to healthier patients. Knowing who uses web-based physician rating systems is useful from a physician’s perspective (Table 1).

Table 1

Characteristics of patients who use web-based physician rating systems

Younger (Age <65)FemaleEducated (College Degree > High School Degree)InsuredPatients with chronic diseasePatients with disabilitiesPatients with multiple comorbidities

Note: Data from these studies. 8,10

How useful are online reviews?

In response to the increase in the number of patients who search the internet for health information, multiple platforms for web-based physician rating systems have been developed.13 Some of these platforms are specific to the field of medicine such as “ratemd.com” or “webmd.com”, while others like “yelp.com” are all-encompassing review websites documenting customer satisfaction. These websites contain various information regarding physician demographics, including licensure/education information, professional/hospital affiliations, years of experience, languages spoken, all in addition to ratings and reviews (Table 2).13 Often, these platforms will provide structured reviews for patients when they provide a rating. All provide an anonymous means to evaluate a physician, ancillary staff, and the entire office experience. These reviews evaluate the physician by criteria such as availability, punctuality, bedside manner, and the perceived clinical care they provide. In addition to actual physician–patient interactions, patient experiences with facility location, costs/billing, and staff characteristics contribute to these ratings (Table 2).14 Many websites provide a breakdown of grading for these various categories as well as a text box to answer freely. This transparency of information is what patients are hoping for when choosing a doctor.5 However, studies have shown reviews are often affected by office wait times, ancillary staff, and bedside manner.11–16 Physicians who have busier practices and are seeing a larger volume of patients may have shorter periods of time to spend with each patient resulting in lower ratings.14–19 However, web-based physician rating systems can be beneficial from a patient’s perspective. It provides an open forum for a patient to offer an evaluation of a physician and their practice. Future studies regarding rating systems from a patient perspective would be beneficial to see what is important in a physician and their practice.

Table 2

Variables found on various web-based physician rating systems

General characteristics of physician/practice	Reviewable characteristics by consumer
GenderSpecialtyArea of Expertise/Clinical InterestsConditions TreatedHospital AffiliationAddresses of OfficesPhone NumberEducationResidencyFellowship if ApplicableLicenses/Certifications/Professional AffiliationsPublications/AwardsLanguages SpokenYears of ExperienceInsurance AcceptedBackground check (probationary status/malpractice claims/sanctions/board actions)	AvailabilityPunctualityBedside Manner/TrustworthinessKnowledge/Clinical CompetenceCommunication/Patient EducationTime Spent with PhysicianAncillary StaffSchedulingOffice Environment/Parking/LocationBilling/CostsRecommend to Other PatientsAbility to Leave General Comments

Note: Data from these studies.13,14

Some physicians utilize online ratings as a feedback tool.15 Constructive criticism can identify areas of need in a practice to help better serve patients.5 For example, physicians can introduce quality measures in response to patient reviews. Some physicians have addressed logistical issues in their office, including the way test results were distributed or how incoming mail was handled.12 Others have streamlined their appointment scheduling process in response to patient experiences.15 Some physicians have implemented patient reminders in their office infrastructure and adopted guidelines/treatment pathways in response to reviews.20 All these factors can help the patient experience, especially in someone with chronic diseases/multiple comorbidities who visit physicians more frequently than a healthier patient. Physicians who embrace the consumer mentality to facilitate easier patient access help engender trust which is key in building the doctor–patient relationship.3,4

How accurate are online reviews?

Web-based ratings are an imperfect proxy for clinical competence.17 Many different outcomes have been used including probation, board certification, education, malpractice claims, mortality, infection, and readmission rates.17,21 However, most studies show a weak correlation at best or no correlation at all between web-rating and these outcomes. Physicians will often use these studies to justify their claims that online reviews are lacking.21 A recent study evaluated surgeon-specific outcomes including infections, readmissions, and revision surgery for total knee replacements with ratings on web-based physician rating systems.21 It found no correlation between surgeon outcomes/clinical competence with the online rating suggesting that these ratings are not influenced by physician competence but rather factors such as cost, wait time, and ancillary staff. While physicians assess quality of care by clinical outcomes, patients may perceive quality of care/clinical competence differently and reflect such in web-based ratings.21

Another concern regarding online physician ratings is the sample size. When reviewing these websites, most physicians will only have a handful of reviews despite seeing thousands of patients.18 A recent study identified that most physicians did not have more than 1 review on any of the platforms.14 A small sample size of reviews could introduce a significant bias which is concerning and can negatively affect a physician’s practice.

The ethical implications of anonymous reviews are also troubling.5,13 There is concern that erroneous reviews could be purposely recorded to damage a doctor’s reputation and practice.22 The majority of negative reviews were not associated with actual clinical factors rather issues like parking at the facility, wait time till the appointment, and short physician–patient encounter.14 Physicians cannot respond to these issues on web-based rating platforms without violating patient confidentiality. However, some physicians have responded to these negative reviews in an attempt to clear their name and violated Health Insurance Portability Accountability Act of 1996 (HIPPA) laws in doing so.6 These health care providers responded to various negative reviews and revealed patients’ diagnoses, treatments offered, and other confidential health information pertaining to the patients’ care without their permission. In an attempt to justify their work via web-based physician rating systems, these health care providers ultimately violate HIPPA laws.6 In one instance, a hospital was fined $275,000 by responding to a negative review and violating patient’s privacy.4

Other physicians have been accused of filling out their own reviews or paying for reviews from patients.23 These reviews were noted to have a different narrative than other typical reviews. They included information pertaining to titles held by the physician as well as ancillary services offered by the practice such as on-site laboratory or radiology.14 The anonymous nature of these rating systems provides no screening process of the reviewer. This has led some to question whether these websites should have more thorough review policies, authentication, and enforcement.13,23

Certainly, reviews need to be considered in its context they are written. Ratings may not comment on a physician’s clinical competence or decision making and rather be based solely on practice’s logistical issues. Studies show that most patients use the information as part of the process of evaluating and choosing a physician but it is by no means the only factor they consider.7,24 It will be important that as web-based physician rating systems grow and become more popular, patients should be discerning when reading reviews. Patients will need to assess the style of writing used in the review to ensure it is not a physician-written review for advertisement. Patients will need to use these reviews as a part of their decision of choosing a physician as a review/rating will not entirely depict the quality and skills of a physician.

Is there room for improvement?

In the setting of web-based physician rating systems, one of the major concerns is the anonymous nature of the reviews. These reviews are not risk-adjusted and furthermore do not provide a way for physicians to respond to negative criticism. Creating a platform that has some feedback mechanism for physicians that is HIPPA compliant would provide a way to validate these reviews and prevent fraud (Figure 1).4,19 A physician may be competent and have great clinical outcomes; however, a patient-directed rating system can be biased by factors such as parking at a facility and wait times. As patient care has a wide array of attributes, creating a rating system that balances out clinical outcomes with facility amenities/ancillary staff would be beneficial (Figure 1).5 Physicians can act upon logistical issues to improve their practice while their clinical reputation is not viewed unfavorably by the public.

Figure 1

Positive versus negative of web-based physician rating systems.4,5,13,23Note: Data from these studies.4,5,13,23

Abbreviation: HIPPA, Health Insurance Portability Accountability Act.

As these review platforms grow over time, it will be interesting to see how regulatory bodies may take these reviews into account. Research on the effect of web-based physician rating platforms will need to expand as well. Future research will need to address potential ways to rate physician decision making and what performance metrics are associated with positive reviews. While there are studies that address objective criteria, it is difficult to assess a physician’s decision making. One study found physicians on probation to have lower ratings on these review platforms.17 Probation was handed down by the state medical board for various infractions and this status was used as a substitute for clinical competency. However, using a more reliable metric may aid assessing physician decision making as not all physicians are on probation. Ultimately, future studies will need to be designed in a longitudinal fashion to assess if web-based physician rating systems reflect quality of care.

Conclusion – are they going away?

Online reviews are only on the rise and are likely here to stay but they have limitations.2,7 They are not best used to identify surgeon skill, decision making, or outcomes.18,21 However, when taken in context, they provide useful information to the health care consumer in evaluating wait times, ease of access, and other factors that have a degree of importance to patients.18,19 These results can be used as a feedback mechanism to improve a health care provider’s practice and help provide better care without compromising any patient-protected health information (Figure 2). As the internet becomes more integral in our lives and online reviews increase, the potential to help shape future review platforms rely on health care providers. Future web-based review platforms will evolve as new forces are introduced that affect society. Recently, social media has become integral in today’s society and may correlate with patient feedback.25 However, its impact on physician reviews is unknown. As other technologies develop in the future, the possibility of these applications being integrated with online physician reviews is indefinite. As health care providers, we should be embracing and helping to improve the reviews so by proxy we are improving our care and gaining patient trust.5,13

Figure 2

How physicians can use web-based physician rating systems.