The Washington Post recently carried this story about the proliferation of websites in the US where patients rate and comment on doctors. The article examines the pros and cons of such sites, and also debates a move by some doctors to require patients to sign agreements that prohibit online postings or commentary in any media outlet “without prior written consent.” Critics have called these “gag orders”.
The article ends on this revealing comment from one doctor. “I’d love to have a Web site where I could complain about patients,” she said. “All doctors would.”
Croakey asked a range of people in the Australian health sector for their views on the merits, or otherwise, of such sites and whether any were available here.
Dr Peter Arnold pointed out this site for gynaecologists and obstetricians in NSW and this one, but they look more like advertising than anything. He also noted that some doctors’ websites (like this one) have testimonials but adds that he expects they seldom include “testimoanials”.
Health consumer advocate Michele Kosky has heard of similar websites in Australia, and that medical practitioners aren’t too happy about them. She says this UK website asks useful questions like,
- Did you trust the doctor?
- Did the doctor listen to you?
- Would you rcomend him/her to someone else?
Sally Hodgkinson, of Cancer Voices NSW, says this US site includes lists for Australia by state. “I found a few of the doctors I had seen over the years on the site,” she said.
Croakey asked various health experts for their views on whether such sites are useful:
Consumer health advocate Carol Bennett (Consumers Health Forum)
I think the capacity to have accurate and relevant information about health providers available to consumers clearly enables better informed choices and thereby empowers health consumers. The key downside is whether the information available meets these requirements of being both accurate and relevant.
The experience of online merchants like Ebay has refined how appropriate ratings of service providers (sellers, buyers) can enable people to feel more comfortable using the service. It may even have a positive impact on service levels particularly for those prepared to provide on line reviews. For example, often Ebay sellers will have statements on their sites asking disgruntled customers to give them a chance to address their concerns before posting negative ratings. Ebay have mediation and dispute resolution services for all customers that they manage independently. Without some kind of mediation and capacity to redress concerns, I am not sure that simple comments based websites are particularly useful.
Patient safety expert Associate Professor Merrilyn Walton (University of Sydney)
NO, they are not useful. I think these sites have developed in the USA because of weak regulations – we have the state health care complaint commissions which have established track records for handling complaints for consumers. There is also the drafted complaint mechanisms for the national health professional boards to come into effect 1 July 2010.
Rating doctors is hard – a good bed side manner may mean patients love the doctor but he or she could be incompetent or exploitative – I am reminded that many doctors struck off had scores of letters from patients saying how wonderful they are. I am not saying they should not exist but that we should not use them as any indicator of fitness to practice.
Much of the information and health activity patient’s need to help make judgements about the quality of their health providers is obscured from public view. Information about peer review, morbidity and mortality meetings, quality assurance audits and medical record reviews are not yet available. Litigation fears, misunderstanding of confidentiality, professional sovereignty have had negative impact on open communication.
Until patients and doctors are genuine partners it will be difficult for patients to have sufficient accurate information to enable them to make judgements about competence. The evidence shows that micro activities impact on consumers choices more than macro level data. The neighbour’s experience, the quality of the last encounter and current stories in the media are known to influence patients’ decisions.
Changes in practice at the doctor-patient level are required before consumers can make sense of information at the macro level. Sharing information with patients and encouraging them to be active participants will help bring about partnerships. Only after patients feel comfortable questioning their surgeons face-to-face will they be ready to trust and use public reports. (taken from my chapter Walton M Public reports: putting patients in the picture requires a new relationship between doctors and patients. In Informed Consent and Clinician Accountability: the ethics of auditing and reporting surgeon performance, ed. S. Clarke and J. Oakley. Cambridge: Cambridge University Press 2007 (pp.65-76).
Surgeon Professor Guy Maddern (University of Adelaide)
I think helping patients decide who they should see for particular conditions is an appropriate piece of information to have. The difficulty is, of course, that particular expertise in particular areas of care may not necessarily be the same for all practitioners. If one looks at the surgical example, a surgeon may be extremely good at performing colonic surgery but have little interest or desire to treat oesophageal cancer, yet both areas would be in his ambit of training.
The problem is very much how a doctor presents himself, and a well appointed office with delightful and helpful staff and a punctual surgeon who has ample time to describe all aspects of the intervention may, in fact, not be highly experienced or capable in the area.
On the other side of the coin, a monosyllabic individual with a grumpy secretary may provide excellent technical interventions and outstanding outcomes. The problem, therefore, is having information that not only reflects the bedside manner of the doctor and the presentation of his facility, in particular punctuality, responsiveness and the like, but also has some reference to the outcomes that the patient can experience from the individual surgeon.
Many surgeons take on very difficult and challenging cases which will inevitably have less impressive outcomes that than the more straightforward, simple cases performed on relatively fit younger patients.
I think for these sites to carry any real validity, the outcomes need to also be available. The problem is, this information is possible to obtain for short-term outcomes such as length of hospital stay, morbidity and mortality during the hospital experience, but is largely unavailable for the longer term outcomes such as long-term survival following cancer surgery or long-term mobility and function following orthopaedic interventions. This data is difficult and expensive to collect and, even if reliably obtained from one practitioner, is hard to compare with others if they are not also routinely collecting them.
Retired GP Dr Peter Arnold
I cannot immediately think of any pros at all – this is essentially anecdotal stuff and we are supposed to be in a scientific age of evidence-based medicine. I see no value at all in anecdotes by grateful patients As a judge once said on a Medial Tribunal: “It would be a very poor doctor who could not produce 100 references as to good character!”
Worse still is the self-promotion now common-place since Mr Brereton abandoned the restrictions of advertising in NSW. Pointless ego-boosting, commercial puff!
Health consumer advocate Michele Kosky (Health Consumers Council WA)
I think sites like this would be helpful to consumers who are seeking the best treatment and care for themselves and their family. Patients use the site as a mechanism to rate physicians and the site could provide a credible forum for those discussions
It would be so good for public/private hospitals (our hospitals) to hear directly from patients and famililies how their service is travelling and what needs to improve.
There is a risk of course that people in grief/trauma may defame a medical practitioner or untruths or vexatious comments will be posted but a properly managed website seems to me to have more benefits than downside in a way its long overdue..
Health services research expert Dr Mary Haines (Sax Institute)
I’m not sure I would give much weight to the score or the content of the sites (certainly not as a researcher, and probably not as a consumer) because of the unedited nature of them, bias of people who would take the time to do it (it would be hard to judge whether comments were from a ‘crank-pot’ with an axe to grind making a comment about their doctor), the scales for satisfaction are probably not valid.
As a consumer, I would give it as much weight as ‘eatability’ when choosing a restaurant (ie not MUCH, I go on my experience or those I actually know)
We know that when surgeons get outcome data about their patients they respond well and change practice (this guy in Dundee has done research looking into that).
Of course there is the related example of Dr Foster in the UK of people looking up performance of hospitals etc by procedure on indicators (but not caring etc). Though some think that those data are have been used more by manager and doctors rather than consumers. Perhaps the next step is increase consumer literacy so they can understand these metrics.
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Croakey also asked these contributors for their top criteria for evaluating doctors and other health professionals:
Carol Bennett, Consumers Health Forum
The usual expectation of health professionals is that they firstly do no harm, secondly treat people with respect and dignity, thirdly provide quality services that address the needs of health consumers.
Patient safety expert Associate Professor Merrilyn Walton (University of Sydney)
Do they listen and ask questions?
Do they provide you with information that is factual (not their opinion) and in a way that you can understand?
Do they seek to understand your concerns and respect your decisions?
Surgeon Professor Guy Maddern (University of Adelaide)
Probably the most important aspect in choosing a doctor or, in the case of a surgeon, should be that the patient can have a reasonable and comprehensive discussion with them and feel that they have listened to their concerns and, at the same time, provided them with clear information which they can consider, either at the time of the consultation or subsequently. Similarly, once treatment has been delivered, an open channel of communication needs to also have been maintained so that any concern regarding the progress in the post-operative period is explained and managed.
But underlying all of this, of course, is the need for competence and appropriateness. For example, in surgery, sometimes the most important decision is to not operate rather than to operate. It is disappointing when patients then reject the advice and seek out a practitioner who will perform an operation that is probably ill-advised and inappropriate. Again, the ultimate criteria should be the long-term outcome.
If a surgeon has superb rapport with the patient but does an inadequate procedure that leads to an early death or serious complication then it is doubtful that the patient would be happy with the intervention that occurred. We should aim to have doctors and healthcare professionals who convey clearly and execute skilfully their craft and have this measured in an objective and ideally impartial method. At the moment this is a difficult and probably insoluble problem.
Retired GP Dr Peter Arnold
Either you trust a professional or you don’t – doctor, accountant, lawyer, whatever – that is the essence of professionalism.
As for GPs, you ask (a) family (b) neighbours (c) local pharmacists for personal recommendations, then you pay a visit for something simple (I usually recommend a blood pressure check for men, a breast check or Pap smear for women) and you see for yourself whether or not the doctor is thorough (asks why you want it done, family history etc) or simply does what you ask for and shunts you out of the door.
As to specialists, ask your GP and family and neighbours and friends about their experiences, check which hospitals they work at. See if they have public hospital and/or university appointments.
Evaluating a GP – experience of personal attention, continuing care
Evaluating a specialist – qualifications, college fellowship, hospital appointments, GP’s opinion
Pathologists and radiologists – not evaluatable – invisible
Physios – very difficult to evaluate – so much of what they are treating gets better with time anyway.
Evaluating a nurse – kind manner, appreciating that each patient is different, attention to detail
Health consumer advocate Michele Kosky (Health Consumers Council WA)
Consumers in WA have reported they judge a medical practitioner on
- Clinical Competence
- Communication
- Compassion
- Continuity of care
Health services research expert Dr Mary Haines (Sax Institute)
Here is a link to Diane Watson’s HARC presentation on public confidence in the hospitals system
Slide 21 – shows some data from NSW about what underpins patients ratings of satisfaction with overnight hospital care. (more related data in slides 22,23 and 24 from NSW)
Slide 30– that was what a large population study of Canadians said they wanted to know about health care
Sally Hodgkinson, Cancer Voices NSW
My own view would be that the best way to rate doctors – for example breast surgery specialists is by the number of patients they see/treat in a year.
I have a feeling that while it would be good to have such information it is likely to end up like the school league tables argument in NSW, though of course it would be different in that it would not be mandatory nor legislated, unlike the school league tables issue.
If Croakey readers would like to make other suggestions for choosing and evaluating doctors and other health professionals, we’d love to hear them…
There is no right or wrong answer in this. From a GP point of view, you need to communicate efficiently with patient. You need to do proper medicine, including preventative medicine. A ten minute consult is not long enough to do anything properly unless you already know the patient very well. Those that have consults at least 15 minutes long could be expected to be more likely to do things properly and take the time do preventative stuff. If your GP only spends ten minutes with you, best find someone else. If they don’t do preventative stuff, find someone else. If they don’t seem to care about what you are saying, find someone else.
– What about people who do not have access to the internet and find it hard to get access? Seems to me that little has been said about this.
– What about people who can’t really be bothered to ‘rate’ their doctors even if they know they are bad? (these people really do exist, especially those who strongly feel that their comments will NOT be taken seriously into consideration.)
– How many bad ratings does it take for alarm bells to sound?
– Do people know of the current relevant avenues where they can lodge a complaint or raise issues, if need be?
I believe that in a computer mediated programme like this everybody shoul be able give his advise to a problem. It should be left to the indvidual who takes the advise to assess the appropriateness of the answer.
Sometimes those who are not doctors give good advise., while the advise given by doctors may be difficult to be interpreted.
The internet will be used by an individual when he is unable
to contact his doctor.
Every body has his own doctor and always he can visit his own doctor later.
Sometimes I have seen that those who suffered from a disease or are suffering from a disease giving advise. This is good .
Interaction of this nature will make ,every one globally achieve good health care, and that is what is needed.
And many who ask questions know much about their problem, and they would definitely get a consolation reading the answers.
There id definitely no need to rate doctors who appear on the web.
But there are ways when anybody feels that a doctor’ s advice is incorrect he should be able to bring this to the notice of Yahoo, or make his own unbiased comment.
If doctors would provide their own credible ratings websites like HealthcareReviews.com would not be so popular with patients. They want it both ways, they suppress internal review and try to discredit external rating services.