I listen to a lot of NPR. This is largely due to an unalloyed loathing of most of the music in vogue right now, as well as the brain-melting blather sprinkled between the computer-generated “songs.” (I have also caught myself thinking things like “kids these days” and lamenting the programming on MTV, so it’s only a matter of time before I’m yelling at said kids to get off my lawn.) There’s one decent music station to listen to as I drive to and from work, but otherwise it’s NPR or whichever CDs I have in the car. (Yes, I still listen to CDs. See above re: rapidly antiquating tastes.) However, I also just really, really like the content on offer. At any given moment, chances are I can turn on NPR and find a show I like.
Some time I ago, I was listening to “Car Talk” (yes, I like “Car Talk” too) and one of the guys made mention of their sponsors, one of which is Angie’s List, a site that allows users to rate local service providers. What caught my ear was the addition of doctors to the list. In addition to mechanics and contractors, suddenly I was subject to consumer reviews online. I… did not enjoy learning of this change. I’m skeptical of anything that blurs the line between patients and customers, of which this is a prime example. Appropriate medical care sometimes means making “customers” unhappy, and being penalized for this in a public forum is an unwelcome prospect.
Dan O’Connor of the Johns Hopkins Berman Institute for Bioethics wrote about doctor-rating websites recently. (H/t the Dish.)
Physician-ratings sites are, fundamentally, a form of social media, and social media are how consumers exchange information with one another. As healthcare organizations and their employees (physicians included) strive ever more to conceive of their patients as consumers, so should there be no surprise when those patients start to act like any other customer does: talk about their experience online. College professors have lived with the depredations of “RateMyProfessor” for longer than many of us care to imagine now; and the same goes for the authors whose work is reviewed by readers on Amazon, the directors and actors who get slated at IMDB, the restaurateurs who feverishly check Yelp! for reviews, and the hotel managers who obsess over TripAdvisor, looking for PR crises to nip in the bud. This is the brave new world of Internet democracy, enabled by social media. Physician-ratings sites are a part of that world and it is one in which, implicitly, anyone’s opinion is as valid as anyone else’s.
That strange sound you can hear is the medical profession choking on its own monopoly of expertise.
I jest, of course, but to a serious point. The problem is that a defining characteristic of the medical profession is precisely that the opinion of a physician actually is worth more than everyone else’s – at least when it comes to medicine. It’s the same for any other profession: legal, clerical, professorial, you name it. The animating idea of a profession is that, within a field of knowledge, members of that profession know best.
I don’t think it is overweening hubris to say that I know more about medicine than the vast majority of my patients. I went to medical school, and they didn’t. (I am perfectly happy to admit profound ignorance when I take my car in to a mechanic, when my computer acts weird or when dealing with specialized problems in almost any other area of life.) Problems arise when what I have been taught and trained to do or say conflicts with an intractable demand on the part of a patient/parent. Said patient, if I decide not to acquiesce, leaves thinking I’m a quack and an asshole. Particularly motivated patients may choose to vent their spleen publicly and anonymously.
Now, you may agree that I am a quack and an asshole. You are perfectly free to say so in the comments on this blog, and I will let the comment stand. But in this forum I can defend myself in a manner closed to me at the doctor-rating sites. O’Connor acknowledges this:
The regulatory elephant in the room is, of course, HIPAA, which places serious limits on the abilities of physicians to discuss patient (or consumer) information – and thus prevents doctors from engaging openly with their patients in social-media spaces. However, HIPAA does not necessarily forbid physicians and healthcare organizations from being more open with their communications processes and procedures, nor from using social media to present a more open and engaged face to the world. And yes, horrifying as it may seem, this can mean joining Twitter, as many excellent, engaging physicians have done.
HIPAA makes it impossible for me to counter what may be said about me publicly. There’s next to nothing I can do if an angry patient goes to every single site and gives me a crappy rating, complete with rant.
(By the way, our practice does have a Twitter account. It sits all but dormant. For the life of me, I can’t think of how a medical practice could usefully engage with Twitter. What of value can be said with fewer then 140 characters, or with sufficient novelty to keep people interested? But what do I know? I still listen to CDs.)
O’Connor concludes by, in essence, telling us to suck it up and accept it. And he’s right. I may lament how much patients have become customers (and I think O’Connor is wrong to imply that this is how doctors want it, instead of it being an unfortunate side effect of how physicians get paid these days), but it’s not going to change back. The culture of medicine has changed in ways that I like, and there are going to be lots of changes I don’t. This is one of them.
I’ve made my peace with this for a couple of reasons. Firstly, it helps to be empathetic. As much as I may try to be communicative and open with patients, there is an asymmetry of power in the physician-patient relationship. I can order medications or tests, and my patients can’t. For those who are truly convinced that they need an MRI or an antibiotic, a refusal on my part will be very frustrating, no matter how much I may try to explain. The asymmetry of a doctor-rating site may feel like a corrective.
However, I don’t really worry about these sites any longer, because I don’t think they matter all that much. I know most of my patients like me, because they tell me so and they keep coming in for their appointments. Happy patients tell their friends, and have much more sway than some anonymous comment online. If your practice is suffering because of the critical mass of online commentary, chances are there are plenty of other signs that you’re doing something wrong.
I can’t think of how a medical practice could usefully engage with Twitter.
I can’t think of how *anyone* could usefully engage with Twitter. But what do I know? I still use my cell phone to call people.
@patient42 the test came back positive #itsgoingtofalloff
Russell – thanks for such a considered and insightful response to my post. I agree with you – it’s definitely not hubris for you or any other physician to say you know more about medicine than most of your patients. You guys, by dint of your professional education, are the experts. I think, though, that the conflict happens not only in cases where, as you say, patients have a demand you do not think should be fulfilled, but where patients have a ‘competing’ expertise, such as in how the disease or condition in question actually impacts their everyday life. I think patients often tend to vent when they feel that this quotidian expertise is not being heard, rather than when physicians won’t give them a CATscan or whatever.
My apologies, also, if I gave the impression that I believe that physicians want to view patients as customers. My intention was, as you note, to imply that the system constructs patients thusly, and that physicians often merely act in accordance with the system.
And I agree wholeheartedly with your last point: patients usually complain for a reason.
Thanks for stopping by to comment, Dan. I’m glad you appreciated my response.
I think, though, that the conflict happens not only in cases where, as you say, patients have a demand you do not think should be fulfilled, but where patients have a ‘competing’ expertise, such as in how the disease or condition in question actually impacts their everyday life. I think patients often tend to vent when they feel that this quotidian expertise is not being heard, rather than when physicians won’t give them a CATscan or whatever.
This is an interesting way to frame it. I wouldn’t have thought to define a patient’s subjective experience of their illness as “expertise,” per se. However, that’s what it really boils down to, I suppose. They know what it’s like to live with their symptoms, and I don’t.
This is one major way in which being a parent has made a difference in the kind of pediatrician I am. When I can clearly relate to parents who are at their wit’s end because their kid won’t sleep/eat/stop coughing, it helps them believe what I say when I don’t provide when they came in seeking.
> This is the brave new world of Internet democracy,
> enabled by social media.
Generally, I find that internet commentary regarding the performance of a contractor, doctor, professor, etc., is highly useless. When you come across a substantive comment, it’s usually immediately recognizable as such because they are so rare.
> However, I don’t really worry about these sites any
> longer, because I don’t think they matter all that much.
Yeah, they don’t really. If anything, the value of reviews has plummeted as these reviewing sites have become more common.
There’s a radio commercial I hear a view times a day advertising a service to (somehow) make Google rank positive comments about your business higher than negative ones.
I know some people who don’t like “Rate my professor”, but it doesn’t bother me too much. A big part of doing my job correctly is giving honest assessments of the students’ abilities and accomplishments. The majority of them do fine really, but as you can imagine, giving such assessments doesn’t exactly endear you to all of them. It’s a good sign if some of them think you’re a hardass. Where I think it becomes a problem is with universities that assess the instruction based solely on the level of “student satisfaction” reflected in the end of the year surveys. I usually do really well on those because I care a great deal about my classes and they pick up on that- however, I don’t like the idea that education should be assessed based on how pleased the consumer was with their experience. With Rate my professor, I can’t see how it’s any different from what students have always done when they talk about what classes to take and which ones are too hard.
In terms of medicine, I’ve long wanted to write a satirical story about the first “wikihospital” where your surgeries could be performed under the direction of the collective wisdom of the internet, instead of by those elitist medical professionals.
Please write that story. That story would kick ass.
Something to take into account as well, maybe:
http://www.slate.com/id/2297933/pagenum/all
Voila! Monday’s post material.
Dr. Wife would love for some negative feedback, particularly involving patients who can’t get the valium they want, to stop the flow of drug-seeking patients trying to hit the “new doctor” up for a prescription. It’s also worth noting that this is the next step in the evolution of word-of-mouth, which has been going on forever. She’s gotten good and good-bad word of mouth. Good wom that attracts patients, good-bad that has lead to a drop in the number of drug-seekers.
Incidentally, one of those doctor-rating sites put up our home address and phone number. Very uncool.
The empathy issue is interesting in obstetrics. A lot of older male doctors don’t have it. Some of the female doctors don’t, either (maybe because they had easy pregnancies). And, of course, everyone gets exhausted with the TPB (Tired o’Being Pregnant) patients. One of the doctors who left a couple years ago apparently declined patients on their first pregnancy, or who had previously had a miscarriage.