contested reputations
Via Marginal Revolution – why the Internet lacks reliable reviews of doctors.
[G]etting in the faces of the previously untouchable professional class has inevitably led to legal threats. He says he gets about one each week over negative reviews and receives subpoenas every month or two for information that can help identify reviewers, who believe they are posting anonymously.
Over at Angie’s List, service providers have sued reviewers, whose names are known to the company, “a handful” of times, according to the company. Angie’s List has paid their legal fees in the past, but a co-founder of the site, Angie Hicks, said she could not commit to doing that in every case in the future.
None of the litigants at Angie’s List have been doctors so far, but that doesn’t mean they are thrilled with her health reviews. “They told me that ‘patients aren’t smart enough to figure out whether I’m a good doctor,’ ” she said. “But I told them that these conversations have been happening all along.” The only difference with the site, she pointed out, is that the doctors get to listen in.
Some doctors have silenced patients anyway. Several years ago, a physician reputation management service called Medical Justice developed a sort of liability vaccine. Doctors would ask patients to sign an agreement promising not to post about the doctor online; in exchange, patients would get additional privacy protections.
This struck me as the height of audacity, and when I shared my feelings with the company, I was informed that the agreements had outlived their usefulness. What neither its vice president of marketing, Shane Stadler, nor its founder and chief executive, Jeffrey Segal, told me, however, was that the company had retired the agreements in the wake of a lawsuit related to them and a complaint filed with the Federal Trade Commission.
Medical Justice has now turned 180 degrees and embraced the review sites. It helpfully supplies its client doctors with iPads that they can give to patients as they are leaving. Patients write a review, and Medical Justice makes sure that the comments are posted on a review site.
Health services industries need to be reviewed. Patients would benefit tremendously by getting more high quality information about how doctor’s offices work (e.g., how long is the wait? do you see a different doctor every time?). I remember when my family moved to Evanston finding it really difficult to locate a good doctor’s office that met all of our family’s needs. I’m still not completely happy with our doctor, but the switching costs are sufficiently high that behavioral inertia has taken over.
Accountability in the medical field is a problem, especially now that doctors offices have begun to fully embrace the market logic, which means that from the patient’s perspective you’re treated more as a customer and less as an individual. But doctor’s resistance to monitoring, as could be had with anonymous review sites, is completely understandable from their perspective. They want the profits that the market logic/business model brings, but they also want to maintain their professional autonomy and discretion. Once you introduce patient feedback into that process, the profession begins to lose some of its autonomy.
Ah, but therein lies a bit of the problem, B. What is the name of your doctor, with whom you are not completely happy? The practice? What are specific reasons for the unhappiness? I’d be reluctant to share myself, because there’s a non-zero chance I’m going to spend some time with the legal system about it.
So…if a person with strong support, as a now-senior faculty member at a major university, with resources and resourcefulness, would nevertheless feel uncomfortable rating your doctor publicly, what hope have the rest of us?
So the problem is accountability, yes, and doctors’ resistance, true, but it is also the case that ‘patient feedback’ requires patients to, well, feed back..
Peter
March 12, 2012 at 5:30 pm
Ah, but who says I haven’t already left an anonymous review? I think that’s the most effective way to disseminate this kind of feedback, using a site that is similar to Ratemyprofessor. I would feel fairly comfortable sharing my feedback in that way.
I am really less interested in blasting my own doctor’s office, with which I’m reasonably happy with but not completely satisfied, than I am in the phenomenon of creating a market that doesn’t work as effectively as it might because it’s difficult to get full information about quality. We don’t realize how important reputations are to functioning of markets until you have one where reputations are not easily communicated.
brayden king
March 12, 2012 at 6:05 pm
I think we would also have to recognize that any process to measure accountability would require various stakeholders to agree on the system that is developed to measure performance. We professors are aware of sites like RateMyProfessor, which include anonymous reviews from a tiny percentage of all students. None of us would be willing to allow RMP to be used as a way to evaluate our performance. We’d quickly point out the problem of representativeness on these sites. Heck, some academics I know are hesitant about the use of standard university/college course evaluations to monitor their performance, especially given the evidence about some of the variables that correlate with high scores on student evaluations. As Brayden rightly points out, we too don’t like to give up our autonomy or discretion as a profession.
Having worked in program evaluation of human services and educational programs, I have become keenly aware of the increased emphasis on accountability, as well as the hesitations of organizations–mostly nonprofit and government-affiliated–to submit to the new accountability standards being placed on them by virtue of their acceptance of funding–funding which typically comes from other nonprofits (i.e. United Way, foundations, etc) or government agencies at a higher level, either state or federal.
It often boils down to what metric or set of metrics is going to be used to evaluate performance, and whether the organizations receiving funding actually have the capacity to produce the evidence required of them. At the same time, there are questions about whether the metrics chosen by the funders are appropriate for the organizations receiving funding as well as well as questions regarding the consistency of accountability standards across funders.
Bringing it back to the the accountability of doctor, it seems like there would be a lot of issues at stake. What criteria would be used to evaluate the performance of doctors, and how would those criteria be prioritized? For instance, is seeing a different doctor each time as important as the quality of service they receive each time? Furthermore, are these criteria more important than the short-term and long-term health outcomes for the patients that receive medical services from various doctors and medical officers? How are these weighted relative to wait times? Other questions would emerge regarding what the system of evaluation would look like and who would be responsible for collecting the information? From what pot of money? And how would ensure that this process is systematic and fair to both doctors and patients?
It also would be more difficult to develop accountability standards for doctors if there are not financial incentives for them to participate in evaluation. In program evaluation, it is clear that funders are expecting organizations that receive funding to demonstrate that they are using the funding in the appropriate ways. And recipient organizations are willing to do it because they money they receive is contingent upon their willingness (though it should be pointed out that many organizations think performance evaluation is important and do it without being required to do so) In fact, much of the movement toward accountability standards and program/performance evaluation was motivated by high-profile stories of wrongdoing by recipient organizations. What would make doctors willing to subject themselves to a new accountability process unless the money they received was somehow contingent upon it. Though you could imagine insurance companies playing a role in developing a system that rewards doctors for good performance, of which patient satisfaction might be one of many measures.
With all that said, I think a process of evaluation and accountability is an interesting idea and an important one. I often envisioned systems similar to trip advisor for doctors or other service providers, where information would be available to us as consumers. And as Brayden points out, doctors are moving to more market-oriented logic, and treating us like consumers anyway. We as patients could make moves to be consumer advocates. Maybe if the system was used in higher volumes, we would hopefully begin to see more accurate information (i.e. crowdsourcing). and we as consumers would be able to discern which doctor or medical office would work for us given a higher volume of ratings. I know I don’t give every comment I read about hotels on trip advisor the same weight.
Scott Dolan
March 12, 2012 at 7:01 pm
Sorry for the Rate My Professor’s mention. I had started writing my response and was interrupted. Only to finish it at a later point. I hadn’t seen Brayden’s comment. But I still think something like RMP only works if it gets a high volume of use.
Scott Dolan
March 12, 2012 at 7:12 pm
Re: Doctor autonomy. I read this post by Prof. King and then the next post by Prof. Rojas on the victory of the Pro-Life movement in the Midwest. Now, what’s interesting is that Prof. King talks about physician autonomy and how it is a not-insignificant source of power that physicians jealously guard (medical sociology, etc.). Now, my question is how is it that physician autonomy and authority doesn’t win them the freedom to practice abortions in the Midwest but it does elsewhere?
Maybe the answer is obvious to everyone else, but I wonder why it is that physician autonomy is not respected on abortions in the Midwest when it is in other medical topics
andy
March 13, 2012 at 2:35 am
@Brayden, who says if you left a review, it’s anonymous? Do you think that if a doctor checks his rating site and sees that two months ago, someone gave him three of five stars and commented, “His waiting times aren’t too bad, but he was distracted and miswrote my prescriptions, and I had to call back and forth to his office five times from the pharmacy before we got it all straightened out”, that he doesn’t know who left the comment? Isn’t pretty much anything significant enough that a reviewer might remark on it, well, remarkable enough the doctor in question will recognize which case it was?
Peter has the right of it: doctors don’t have to do much at all — or really anything — to discourage patients leaving feedback, because doing so risks violating one’s own anonymity.
Minder
March 13, 2012 at 2:53 am
You will note that we do not have this problem in other markets where the customer pays the provider directly.
With the university, the professor is paid the same regardless of student outcome – which is largely unmeasured – and the student pays the same regardless of who teaches the class, or how well they do that. (You can call it “autonomy.” I call it “lack of accountability.”)
In medicine, likewise, the insurance company sets the standards. To the doctor, the patient is just billable meat. That may be what Brayden King meant by being treated as a customer rather than an individual. But I point out that in other markets, success comes specifically from individualization. It is in the doctor’s office (and the university classroom) that individuality is lost because of the payment mechanism.
Michael Marotta
March 15, 2012 at 6:27 am