Bad reviews

Hotels, restaurants, auto services, hair salons, schools – even playgrounds – are all subject to online reviews. Many Australians have turned to the collective wisdom of the internet to make decisions on where to eat, travel, shop and work, and increasingly, which doctor to trust with their healthcare needs.

As a search tool, the internet is a fantastic way for medical professionals to reach potential patients and let them know about their practice and what they offer. But, of course, as an interactive environment, the internet also provides patients with a means of communicating their healthcare experience with other potential patients. And it’s not always positive feedback.

Just how important are online reviews? Statistics from the US company Invesp reveal that 90% of consumers read online reviews before visiting a business, and 88% of consumers trust online reviews as much as personal recommendations.

While it’s difficult to find statistics specific to healthcare in Australia, a 2012 survey conducted in the US found that 42% of respondents had used social media to access health-related consumer reviews. And a more recent survey in 2015 found 16% of patients at the Mayo Clinic had visited a doctor rating website.

According to MDA National, the most common website their members seek advice on is RateMDs, which is hosted overseas. In Australia, Whitecoat – which was developed and launched by private health insurer NIB in 2013 – also includes an online provider directory, as well as more than 250,000 customer reviews of medical practitioners. “Think TripAdvisor but for health care” boasts its website. And there’s HealthEngine, a national medical directory that includes an online booking system and ratings.

According to Dr Sara Bird, MDA National’s Manager, Medico-legal and Advisory Services, “if you look at the data – the limited research that’s been done – the vast majority of ratings on these sites are incredibly positive.”
A 2010 review of 33 doctor rating websites found 88% of comments were positive, 6% were negative and another 6% neutral.

The number of negative reviews, however, appears to be climbing. Avant’s Senior Medical Officer, Dr Penny Browne, indicated negative online reviews are a growing area of concern for members and the MDO is increasingly fielding calls from distraught doctors.

“You can postulate as to why, but across the board there is a 15% increase in complaints against doctors and this is really just another mechanism – a modern mechanism – for bringing up complaints against doctors. And it’s kind of an easy one. It’s immediate and you can do it anonymously – so you can see it’s an easy option for someone who is aggrieved to bring their concerns about a doctor.”

For the doctors featured in these negative online reviews, the effect can be devastating.

“I find these matters cause the most enormous distress to doctors,” Dr Bird said. “It’s probably one of the things where it’s hardest to try and reassure doctors. It seems to really hit a nerve with them. The fact that it’s out there on the internet for everyone or anyone to see seems to bring a level of humiliation and upset and anger.”

Dr Bird added that she’s heard from doctors getting up at 3am every night and logging onto the sites to re-read the review and look for new reviews.

Part of the frustration is that, according to MDA National, most practitioners find doctor rating websites fundamentally flawed.

Medical groups question how a handful of ratings can properly represent an adequate assessment of a doctor who may see thousands of patients over the course of his or her career? As well, the anonymous nature of these websites means there is no way to verify the patient’s identity, or even check whether they are a patient, someone with a grudge, or even a colleague who is in competition with them.

MDA National also questions a patient’s ability to assess a doctor’s clinical expertise. Waiting times, a curt disposition, or higher fees may spark patient ire, but they are not indicative of a practitioner’s skill as a doctor. A 2015 study in the Journal of the American Medical Association found no evidence that doctor rating websites were associated with clinical quality measures.

Dr Browne says doctors take criticism particularly badly, in part, because of all the reasons that they are a doctor in the first place. “They are high-achieving, perfectionistic personalities. And really doctors don’t want to do people harm, they want to do the best by their patient. I think, feeling that the patient couldn’t bring their concerns back to them, and would rather write on some social media site is really, really offensive to a doctor.”

What can you do?

“Option number one is to do nothing and wait,” Dr Browne said. “And ultimately, hope that other patients put something positive on the website. But that can be quite difficult, particularly if it’s quite painful and very hurtful. But that would be the top of the list if you can bear it.”

She stressed that, as medical professionals, doctors really have their hands tied when it comes to responding to negative reviews online. Maintaining patient confidentiality is a paramount concern and a primary constraint. As well, they can’t counteract bad reviews by putting positive patient testimonials on their own website or social media sites.

The second option is to respond to the patient – either online or directly – to address their concerns.

According to Dr Bird, “There are limited circumstances where it may be appropriate to write something in response. A lot of the bad reviews are from people who are angry about wait times, parking, crap chairs in the waiting room. So if you’ve introduced a new appointment system to reduce waits, or you’ve bought new chairs for the waiting room, there’s no problem in responding to those sorts of things, which is along the lines of what hotels do in TripAdvisor.”

She cautioned doctors who respond online to be careful not to breach patient confidentiality; to not respond while angry; and to ensure their reply is caring and demonstrates a willingness to improve.

“In my anecdotal experience, if you can identify the patient – and sometimes you can’t – there often is value in contacting the patient and saying, look I’ve seen your concerns and I’m really sorry to read about them, can we discuss.”
In both instances, doctors are encouraged to contact their MDO before they respond to the patient’s review.

If the comment violates the website’s terms of use or conditions, the doctor has the option of utilising the website’s policy to have it removed.

According to Dr Browne, “We have had some success in trying to get the owner of the website or the review site to actually take down the comment if it’s particularly egregious. But that has to be balanced with, is that a reasonable comment to make?

MDOs caution that doctors who write to websites asking for comments to be removed can sometimes draw more attention to the adverse rating. There have been cases where letters sent to the website proprietor were published to further embarrass the doctor.

The last course of action – and this would be reserved for extreme cases – would be to threaten or commence defamation proceedings.

But defamation suits are notoriously difficult to win. ‘Defamation of character’ is the term used to describe when a false statement is written or spoken about an individual with the intent of harming or slandering their reputation. To win a defamation case you must prove that what was said or written about you is not true; and that the other person said or wrote the false statement with the intent of causing you harm.

Finally, it is only considered defamation of character if the statement has actually caused you harm, not if it has the potential to cause you harm. In order to win the claim, you are going to need to prove that the false statement has ruined your reputation.

Defamation is tricky to prove, as patients can always claim that the comments were ‘honest opinion’, rather than a statement of fact.

[For an extreme example of defamation, read our profile of A/Prof Munjed Al Muderis]

Going forward

If we have established that online reviews are the modern word-of-mouth, then maybe – as a profession – we need to rethink how we respond to this brave new world.

“I think the profession should control it,” Dr Bird said. “I think we should be managing this rather than allowing the rating groups to control it.”
She cited the UK’s website iWantGreatCare.org as an example. Launched in 2008 by founder Dr Neil Bacon, the service collects information from patients about the quality of care they received from their doctor and other healthcare professionals. While the website initially evoked a backlash from doctors, the medical community has since come to embrace it as an effective way to improve patient experiences and measure the quality of service.
In many ways, HealthEngine is quite similar.

Started in Australia by doctors, HealthEngine is primarily a directory and booking site, but its number of patient reviews is growing. Some practices have upwards of 150 reviews.

A key point of difference is that each review is made by a patient who has actually used the service, as verified by the site’s booking system.

As part of HealthEngine’s revenue depends on practices subscribing to be a part of its service, it’s not in the website’s interest to have too many bad reviews. As a result, it does not list reviews of clients that fall below 80%.
The alternative to supporting an online review site run by medical professionals – is to let the private health insurance industry increase their dominance in providing this information. In 2016, Bupa and HBF announced a joint venture with NIB to expand Whitecoat to cover all specialists, with reviews and a guide to gap fees. The concern, as outlined by the AMA and other health experts, is that these services might lead some hospitals and doctors to steer clear of more difficult cases to protect their target ratings, which, in turn, would lead to care being denied to some of the country’s most vulnerable patients.