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Journal of Medical Practice Management
2012, May/June
By: Jeffrey Segal, MD, JD, FACS

The world has changed. Patients, now euphemistically called consumers, head to the Internet before choosing their doctor. In 2012 there are over 80 doctor rating sites inviting patients to post their experiences. These posts, in aggregate, do have an effect on business. Managing one’s reputation (particularly a doctor’s online presence) has never been more critical.

The problems associated with doctor review sites are well documented. First, most posts are anonymous, so it is impossible to determine whether the post was authored by a real patient, or someone posing as a patient. Who would pose as a patient? Someone with an axe to grind. A disgruntled employee. A competitor. An ex-spouse. Even an online reputation management company promising to “fix” a problem for a fee – a problem that company created as an excuse for your business.

Next, if there’s a wisdom of the crowds, there’s no crowd. The average review site has 0-3 reviews for any given doctor. The average doctor sees anywhere between 1,000-2,500 patients a year. This is a big gap. In general, the sampling on sites is not representative of a doctor’s practice.

In the U.S., the antidote to offensive speech in the U.S. is more speech. But, doctors cannot post the medical record on a web site to correct a misleading account. Doctors are foreclosed from responding because of HIPAA and state privacy laws.

Good medicine is not always popular. Patients sometimes request antibiotics for viral syndromes. They may ask for more pain medication than the doctor believes is necessary. The list of unrequited patient expectations is long. An unhappy patient with a mouse and broadband connection can create significant reputational damage.

The Internet is also a double edged sword. The Internet can promote one’s practice. Doctor reviews are weighted heavily by the major search engines. Doctors who invite their patients to post reviews – and have many reviews – can control the “real estate” on page one of organic searches. More on that shortly.

A Bad Review. What Now?

It’s impossible to have perfect scores forever. A bad review is inevitable. First, don’t over-react. Read that again. Give it perspective.

You can’t make everyone happy. The public at large knows that. A simple opinion about customer service is not defamatory. If patients want to write about poor bedside manner, a gruff front office, rotten parking, or long wait times in the waiting room – let them. That is fair game. And often it is the only way to get reasonable feedback on what your patients perceive, and how to fix problems.

Here’s a documented review about the Ritz Carlton. The Ritz Carlton provides excellent service and has a stellar reputation. And everyone knows that.

This hotel is a genuine piece of crap! I have stayed at some bad hotels and while this is not the worst I have ever seen it is pretty bad! This has to be the worst Ritz-Carlton in existence. I would suggest burning this hotel down before staying at it. The rooms suck, there is no gym or pool. …. The wall paper was falling off the walls in my room and my friends were staying in a room where they received a breakfast menu from housekeeping that had the pages stuck together by chewed bubble gum!…This place is horrible, I would suggest one of the trendy boutique hotels in Old Montreal! 1

Ouch.

If your rating is, in general, positive, there is often little reason for concern. Many believe that a collection of excellent ratings punctuated by a couple of bad ratings is perceived as being more credible than uniformly good ratings. In other words, a couple of negative ratings (among many positive ratings) may actually have the unintended consequence of increasing the positive perception of positive ratings.

Next, if the review is entirely unfair or inappropriate, determine if it violates the site’s Terms of Use. Many sites have formulated rules constraining how reviewers should behave. For example, on many sites, (1) reference to drugs or alcohol; or (2) abusive, objectionable, inflammatory language is prohibited. If the posting violates the Terms of Use, you can submit a respectful letter to the site, drawing their attention to the language of the post. They are not obligated to take it down, but might be persuaded to honor their Terms of Use policy. Civil discourse in a respectful tone is more likely to be effective than inflammatory threats. Some sites will respond to a persuasive tome. Others will not. Each site is different.

If you have an idea who wrote the post, it might be productive to reach out to that patient. Recently, a dentist was graded an “F” by an ex-patient. The poster alleged the dentist “over-diagnosed” the number of cavities; the implication being the dentist was only concerned about money. This ex-patient went to another dentist – who might have added gasoline to the then nascent fire. The original dentist looked at the chart to make sure he had not made any diagnostic mistakes. He had not.

The dentist wrote the patient. Selected excerpts follow:

A patient brought to my attention a review you recently wrote. We really want all of our patients to have a positive experience with our office and it’s clear you were not satisfied. I respect everyone’s right to voice their opinion. But, your review stung.

I reviewed your chart and saw that we diagnosed four cavities and recommended treatment. From the review, I see you went for a second opinion and that dentist disagreed with my diagnosis. No healthcare practitioner gets it right 100% of the time and I am no exception. That said, I used your review as an opportunity to double check the record to see if I missed anything. I also had the record reviewed (confidentially) by 2 peers. Each agreed with my diagnosis.

It was never my intention to disappoint you and for that please accept my apology. Given the information above, I would appreciate it if you would amend or remove the review you posted. It’s ultimately your decision and please receive this as just a request. I would be happy to speak with you directly about this. And if there is something I can do to reverse your initial impression of our office, I would welcome the chance to do so.

The patient responded positively to this overture – and did indeed update the “grade” to an “A.”

Pro-Actively Managing One’s Online Reputation:

A negative review has impact is it’s the only review on a site. But, an isolated negative review mixed within a sea of positive ratings is diluted. The literature suggests most patients are happy with their doctors. Tehrani, et al.2 published an article summarizing findings of validated online patient satisfaction surveys. They concluded the great majority of patients reporting their satisfaction online are highly satisfied with their outpatient medical care. The overall patient satisfaction rating was 9.28 on a scale from 1-10. Of the 14,984 ratings, 10,510 (70.1%) were 10s and another 2,291 (15.3%) were 9s. By deputizing one’s patients to post reviews, honest feedback is obtained, customer service issues can be remedied, and the inevitable negative review will generate less anxiety.

Coaxing one’s patients to post feedback is a challenge. There are over 80 doctor review sites. No matter how well intended, patients often forget about the request when they get home. Or, if they post, they may post to sites that have zero impact on your online reputation. One service that addresses this dynamic is e-Merit3. There, patients are provided an e-Tablet device (such as an iPad) in the office to anonymously provide feedback via survey. With patients’ permission, their comments can be uploaded to various doctor rating sites. The response rate is dramatically better than relying on patients remembering to participate when they leave your office. Further, the system can identify customer service challenges, ideally solvable, before they mushroom into visible reputational problems.

Other solutions touted by reputation management service providers include: (a) creating webpages with “competing” positive content to drive negative content to deeper pages on search engine results4; and (b) “bread and butter search engine optimization5.

What Not To Do?

Suing a website or patient for defamation should rarely, if ever, be pursued. There are exceptions, of course. In December, 2011, an Arizona jury awarded a $12 million judgment to two doctors after a local jazz singer posted critical Internet reviews of their practice and aired multiple complaints to the state Medical Board. 6 But, most doctors who sue alleging online defamation do not win.

Websites, for the most part, are immune from the tort of defamation. Section 230 of the Communication Decency Act, a federal law, provides review sites a safe harbor to display posts. To prevail in a suit for defamation, one must sue the actual poster. That poses more challenges. The vast majority of posts are anonymous. One would obtain a “John Doe” subpoena to identify the IP address of the source of the post. That entails significant work, a healthy amount of cash, and a lawsuit – alleging defamation – that is likely to prevail on the merits. This qualifier, “likely to prevail on the merits” is daunting. To prevail in such a lawsuit, the doctor must prove that the poster uploaded a false statement which damaged his reputation. Statements of opinion do not count. And truth is a defense to a charge of defamation. If a patient states “The doctor communicated poorly and did not seem to care about me one iota” – that is treated as opinion, and not actionable. If a patient states that Dr. X is not even Board certified, and he is indeed board certified, that does qualify as a false statement, and is arguably actionable. Most online rants are catalogued as “opinion.”

While a given review might qualify as legal defamation, a doctor should resist the reflex to sue. A lawsuit will convert an obscure item on a Google search into page one news. That is, a lawsuit might have the unintended consequence of publicizing the post even more than before. Further, the legal process moves slowly and is unpredictable. There are times when a lawsuit is the only tool left to achieve a reasonable long-term result; but, it should be the exception, and not the rule.

Other Details:

Rounding out odds and ends:

  1. Don’t pay patients (or provide discounts) for reviews. If you do, the patient must clearly disclose that he received material consideration for the review. This rule was memorialized in the Federal Trade Commission’s “Guides Concerning the Use of Endorsements and Testimonials in Advertising.”
  2. Be careful about responding to reviews. Some mistakenly believe if a patient has posted, he has waived any expectation of privacy. That is not true. You are still bound by HIPAA and state privacy laws not to disclose any protected health information. That said, many posts are anonymous and related to customer service. Sometimes, it is possible to respond without violating privacy standards.

Summary:

Online reviews do impact a doctor’s business – for better and for worse. In general, more reviews are better. Most reviews are either positive or constructive. An isolated negative review generally has limited impact, as long as it is diluted by a sea of positive reviews. If a significant number of reviews are negative, attention should be paid to analyze the content of such criticism, and whether it can be remedied. It often can.

References:

1 Virtual Tourist. The Ritz Carlton Montreal. http://www.virtualtourist.com/hotels/North_America/Canada/Province_of_Quebec/Montreal-906413/Hotels_and_Accommodations-Montreal-The_Ritz_Carlton_Montreal-BR-1.html (accessed January 16, 2012).

2 Tehrani A, Feldman S, Camacho F, Balkrishnan R. Patient satisfaction with outpatient medical care in the United States. Health Outcomes Research in Medicine. November 2011. 2: e197-202.

3 www.emerit.biz (accessed January 16, 2012).

4 www.reputation.com (accessed January 16, 2012).

5 http://reputationmanagementx.com (accessed January 16, 2012).

6 Arizona Republic. Scottsdale doctors awarded $12 million in defamation case. http://www.azcentral.com/community/scottsdale/articles/2011/12/16/20111216scottsdale-doctors-win-lawsuit.html (accessed January 16, 2012).

Reprinted with Permission from The Journal of Medical Practice Management May/June 2012, Copyright 2012, Greenbranch Publishing, (800) 933-3711; www.mpmnetwork.com


A note from Medical Justice Services, Inc…

There are many third-party marketing vendors that help doctors navigate these waters safely. A word of caution – not all of these third-parties are HIPAA-compliant, so when investigating, ask the right questions. One physician-based online reputation management service, eMerit, has our endorsement. To learn more about their take on doctor reputation management, visit eMerit.biz.

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