Normally I focus articles on my oculoplastic practice in Denver. My writings usually focus on eyelid surgery such as blepharoplasty, orbital surgery such as graves disease or tear duct problems. Today, however I wanted to write an article about online reviews and how it is affecting the practice of medicine, particularly the practice of medicine by younger doctors.
One of my colleagues told me about a particularily damaging review that made no medical sense but made him out to be the most uncaring doctor in the world. It was not based on science, or anything wrong he did. The surgery had a 90% success rate. He informed the patient of this and then he performed the surgery perfectly. The patient was part of the 10%. It didn't work and she was pissed. So she took it out the only viable way she could as a patient...by destroying her doctor online.
Online reviews for doctors are here to stay. It is part of medicine and I don’t think it will change. That being said, there are several things that the presence of patient online reviews do that is in fact damaging to the care of patients in Denver and the rest of the country. In each of these examples, I will cite direct quotes from physicians I have personally heard concerning each topic over the previous four years.
1. Focus on Showmanship not results
“Sometimes I spend extra time on the exam even when I already have nailed the diagnosis so that patient thinks I am really doing a thorough exam”
Physicians are pretty smart. Experienced physicians are super smart. There are times when an experienced physician can walk in the room, take one look at a patient and know exactly what is going on. That is what med school ,residency and years of experience teach us. That being said, the average patient doesn’t know or really appreciate that. They want the physician to spend time talking, touching and examining them. It is part of the experience which has nothing to do with them getting better but everything to do with them feeling better about their appointment. I have had colleagues who spend extra time listening to the heart of a patient, extra time performing unnecessary tests during an eye exam, or extra time palpating the prostate when it is clear the patient has prostatitis by history. This is all so the patient perceives the doctor “is spending extra time with them” so a good review will be put online. The patient feels better if the doctor is checking more. Somehow being able to diagnose a rare disease across the room is of no value unless it is accompanied with a 30 minute "smoke and mirror" exam.
2. Turn away patients for fear of bad reviews
“I knew if the surgery didn’t work she was going to destroy me on an online review so I told her to go to a different doctor”
There are patients who you get the sense that they are tough. Guess what? Patients are people and there are people who can be explained 100 times the risks or success rates of a surgery and if it doesn’t work write terrible reviews of you online. Surgeons used to take on those patients to “prove them wrong” or “take on a difficult case”. Now those patients may be turned away as a “difficult patient” or be told “it seems your expectations and I are no aligning”.
I had a colleague who had a more difficult patient with a blocked tear duct. He offered to open the tear duct and went over at length that the surgery has a 90% success rate and it sometimes doesn't work. Guess what? It didn't work and she ripped him on online reviews. There is no recourse he has. He can't comment on the "reply" section that "I decided against my better judgement to take you on as a patient so i could help you and you screwed me over....one star for you". The next time it would better for him to decline that patient, not because it is less likely for their surgery to work but because if it doesn't it will negatively affect his practice. Is that good in medicine? I don't think so.
3.Not going into “happy patient” fields
“Man who wants to go into ER medicine. It seems like everyone is just pissed at them”
If you look at reviews of pain doctors, they are usually terrible. Why is that? Most patients who are going to see pain doctors are either a. In pain and can’t get their pain medicine fast enough b. are pain seeking and are about to be denied pain medicine from the doctor c. are about to get addicted to pain medications and are told they are about to be weaned off them. What happens? Terrible reviews. Specialities that are more challenging like Pain medicine or Emergency medicine may have people shy away from joining because of this constant negative reinforcement they get. Why not go into a specialty that is more happy? Reading negative reviews online is something that bother doctors. We went into this profession to help people and part of that experience is feeling appreciated (like any difficult job). More medical students will go into fields over time that have higher rates of appreciation and success reflected in their online reviews. If it is tied into payments to physicians then it will happen for sure..no brainer.
4. Focus on “high success” procedures in their own field
“Why do something scary like an orbital decompression when I can just do a blepharoplasty? I get paid almost as much. The patient is happier and my practice grows”.
Each specialty has more difficult surgeries and also chip shots. In oculoplastic surgery, I would say a functional blepharoplasty is more of a chip shot than an orbital decompression for Graves disease or orbital fracture repair. Doctors who are tired of bad reviews for difficult cases will simply not do them. There are “oculoplastic surgeons” in Denver who do not perform orbital surgery…only blepharoplasty for simple reason…happy patient, easier procedure, and good reviews. Taking on tough cases feeds one’s sense of “being a good doctor or a tough doctor”. Your colleagues may respect you but does that matter if you have 1.5 stars on healthgrades?
5. Offer unnecessary testing
“If a patient comes with an eye movement problem and you don’t order some test, they are going to leave pissed”
In adults, there are “mini strokes” to the eye muscles that give the patient double vision for three months and it usually gets better over 3 months. That being said, at the initial exam if you just tell a patient it is going to get better in 12 weeks most likely, they tend to not like that. To quote a patient I once had, she told the front desk after the exam for this medical condition “He didn’t even do anything”. The data shows overwhelmingly that patients prefer more testing. They believe more was done. This of course is not in their best interest in terms of cost but also of exposing them to complications from a test. Cat scans have radiation exposure. Spinal taps can lead to infections. There was an older neuro-ophthalmologist I worked with in DC who would give an MRI to almost every patient who walked through his door. He told me that “patients liked it better”. Giving an unnecessary test so the patient feels “everything is done” is good temporarily but not good in the long run for them.
6. Give unnecessary medicine
“If a patient comes to see you they want to leave with something. That’s why I give artificial tears to almost everyone”
This has the same reasoning as the previous issue. Patients always want a medicine for something even if there is no medicine for it. In ophthalmology we use artificial tears. Other than in dry eyes, it is a great “medicine” to give the patient. Getting glorified water for the eye makes the patient feel better, gives them something to do as their eye disease improves and is feels their doctor visit was not in vain. This is the precise reason that antibiotics are overprescribed.
I have had patients who want more botox than is needed at a visit. This can result in resistance in the botox and eventually it not working for them. If I turn them down for their own good, I risk a bad review. If they see someone else who gives them what they want, they may give them a great review even if it screws them down the road. What would most doctors do in that situation over time?
7. Spend time encouraging patients to write reviews instead of focusing on their health, taking their medicine, quit smoking
“I have to beg all my normal patients to write reviews so it cancels out the eventual lunatic who will come eventually. If I don’t my ratings will be terrible”
Often if a patient has a good experience with a doctor, they don’t write a review unless they are asked. If a patient is very unhappy they will write a review. So if one of my colleagues sees 10 patients and only the one unhappy patient writes a review it will appear that their satisfaction is 1 out of 5 stars. To counter it, they have to beg their other patients to write good reviews to cancel out that 10th patient. It happens all the time. In some offices, they in fact make patients fill out a review before they leave the office. This is time where it could be spent on more important things like …..the health and well being of the patient. The fact that this is even on the psyche of most physicians shows the focus is turning away from treatment and good outcomes.
As can be seen, the road to online reviews may be paved with great intentions but can have many untoward effects. The bottom line is that it is extremely difficult to determine a good physician from online articles, reviews or ads. Even word of mouth can be difficult. A physician who is a terrible clinician but is caring may be perceived as a better doctor than one who is excellent medically but has a bad bedside manner. I am fortunate (and lucky) to have decent online reviews but I know for a fact that these 7 points affect all physicians especially young ones who are in tune to the online world. I would hope patients would want doctors to do things that are in the best interest of their patients not online reviews but as can be seen from the Wells Fargo debacle, if a certain outcome is desired, humans will do what it takes to achieve it. If 5 stars are the goal, who cares what i give them is in the patient's best interest. Right? It is something to think about.