Online reviews have become an increasingly popular method for rating virtually any business or service. However, there are problems when it comes to rating physicians online, especially psychiatrists, because the doctor–patient relationship is not parallel to the business–consumer relationship. The psychiatrist–patient relationship is even more unique, especially when the patient is receiving involuntary care. Physicians have a fiduciary duty to their patients to uphold certain ethical principles. In fact, a patient's demands may sometimes conflict with these values, which can be a cause of an unhappy experience.
This article discusses the positive and negative features pertaining to online reviews of psychiatrists, and defines what measures psychiatrists may take to deal with online reviews. We also propose areas of change for the future.
A 70-year-old woman with schizophrenia was admitted to inpatient psychiatry on a 72-hour hold. Her neighbors had called the police after noticing her weight loss and bizarre behavior. On admission, she was paranoid and responding to internal stimuli. During her stay, it was discovered that her daughter had been taking advantage of the patient financially, and was emotionally abusive to her as well. As a mandated reporter, the physician filed an Adult Protective Services (APS) report. A few days later, the daughter called the hospital and was enraged about the report. She filed an official complaint with the hospital, alleging physician misconduct, stating that the physician had falsified records and statements. She also began sending emails to the physician and leaving voicemails, making personal attacks toward the physician. An online review was also posted at approximately the same time, with similar verbiage to the hospital complaint. The physician contacted the website and asked them to re-evaluate the online review, which was subsequently removed.
Like many other businesses and professions, medicine is becoming increasingly consumer-driven, and online reviews are a natural evolution of this trajectory. Some positive features of online reviews include increased patient autonomy,1 more feedback for doctors, and improved standards of care.2–4 However, many physicians fear that such websites encourage negative reviews4 or even extortion.5 There is also an inherent conflict of interest with regard to website traffic, because more sensational reviews lead to heavier web traffic; thus, there is little incentive for websites to remove negative reviews.6
Many times, the criteria used for rating the physician include nonmedical factors (eg, office staff or wait times).1 Rating sites can also be manipulated, as many do not require authentication of the user as the actual patient. An unscrupulous competitor could even write and post a negative review, making these websites completely untrustworthy.7
Consequences of Negative Reviews
Although there is no consequence for the website or patient for posting an untrue or negative review, the consequences for the physician are numerous. It is disturbing to learn there is false, negative information on the Internet about one's professional self, some of which may even attack the physician's character and could be considered defamation or harassment. There are also financial consequences,1 as insurance companies and potential employers are now looking at these sites.8
Patient satisfaction scores are now a focus in health care and are used as an indicator of a physician's performance and sometimes even used to determine hospital funding.9 Data are collected despite the fact that high patient-satisfaction scores have been correlated with higher odds of inpatient admission, greater expenditures, and higher mortality.10 Because of this, physicians have reported increased job dissatisfaction, job attrition, pressure to inappropriately prescribe antibiotics or narcotics, and pressure to order unnecessary tests or admissions due to concerns that they need to generate high patient-satisfaction scores.11 Physicians are now sometimes more selective when accepting patients, avoiding high-risk patients to improve their ratings. One could postulate that the same is true for physician ratings online, as the need to generate higher scores may threaten a physician's clinical integrity. Such practices could even potentially harm patients and lead to irresponsible management of health care resources.11,12
In psychiatry, the situation becomes increasingly complex. For psychiatrists who work in a private practice setting, there is a certain level of expectation by the patient for payment of service. Yet, just as in any other field of medicine, it can often be counter-therapeutic to give in to the demands of patients. Sometimes, it is a psychiatrist's duty to set limits.13 This is particularly true in the treatment of patients with borderline personality disorder. In such patients, their internal emotional experience is chaotic, vacillating between extreme emotions of idealizing and devaluing, often leading to explosive reactions and unstable relationships. For these patients, such limit-setting could be fuel for the fire that leads them to write negative reviews online.
The Nuances of Involuntary Treatment
Many psychiatrists work on inpatient units, at state hospitals, or at correctional facilities, all situations in which the patient is on some sort of legal (often involuntary) hold. Such patients have met a legal commitment criteria reviewed by a civil court. Common among such patients are psychotic illnesses such as schizophrenia, schizoaffective disorder, or psychosis in the setting of a mood disorder. Psychotic patients often experience paranoid or grandiose delusions centered on their treating psychiatrist. Making matters worse, psychiatrists often must petition the court to medicate patients with psychiatric medications against their will when patients refuse psychiatric medications. Such interactions can sometimes lead to a contentious doctor–patient relationship. Although psychiatrists are not above being rated, it can be argued that it is not prudent for people who are acutely psychotic to write online reviews of their doctors. A clinical context might be helpful for the reader to understand the basis for the review, but such contexts are not provided by these websites.
In the illustrative case presented here, it was the daughter who wrote the review, not the patient. The review was written in retaliation of the clinician filing an APS report. As mandated reporters, physicians are obligated to file abuse reports on children, dependents, and elders when there is reasonable suspicion that abuse has occurred. The daughter posted damaging and untrue information about the physician online, even though the physician was doing her job and adhering to principles of sound patient care.
Fair and Balanced Accountability
Physicians should be held accountable to practicing and upholding good standards of care, but we maintain that there are more constructive ways of providing feedback. Posting a negative, emotionally charged review may not lead to a change in practice. Instead, submitting formal complaint forms to the hospital, which are reviewed by administrators and supervisors, can lead to feedback provided in a constructive way, which may positively affect practice. Another option would be contacting the state medical board or joint commission for investigation of complaints by patients. In fact, evidence shows that feedback is most effective when provided over a period of time by an authoritative source.3
Recommendations to Protect Your Practice
We recommend that physicians educate themselves about online reviews and learn what can be done when an untrue or negative review is posted. All physicians should conduct Internet searches on themselves quarterly.6,8,14 If a physician discovers a negative review, it may be prudent to notify one's malpractice carrier to alert them of any potential legal action to be initiated by a patient or family member against the physician. It is sometimes possible to have the review removed by contacting the website directly; this may be successful if the review violates the website's terms of service.6,15 It is recommended to take screenshots of the original date and time of the review as well as after the review is removed for your records. Such copies will have a digital timestamp, which will be necessary if any litigation ensues.16 Also, if a similar situation happens in the future, the physician has documented proof of the prior review and evidence that it was removed.
If the website refuses to remove an untrue or unfair review, a physician could write a response to the review, but there could be potential Health Insurance Portability and Accountability Act (HIPAA) violations. It may be impossible to prove who actually wrote the review in the first place, and responding could inadvertently reveal protected information about another patient's encounter. Therefore, it is advised to keep the responses general and nonspecific.6,17 It may also be advisable to contact one's malpractice carrier before responding to make sure that no HIPAA violations will be made.
Alternatively, legal action could be pursued by the physician if the online reviews are deemed defamatory; however, such cases are difficult to prove in court and often end up just creating more problems.6,18 Even if the physician is victorious, the case may later be referred to repeatedly in articles and legal journals, potentially making the negative review permanent.19
As a psychiatrist, it is desirable to cultivate a positive online image. It can be beneficial to maintain a personal website and include positive testimonials from patients, especially in private practice.4,6 Currently, there are a few services available that help with a physician's online image or negative reviews.6
Lastly, medical professional societies should lobby to protect physicians from false or negative online reviews and create legislation to hold these websites more accountable for their content.12 Perhaps such legislation could mandate that reviews not be anonymous, or perhaps patients should have to show proof of appointment to post a review. This could help ensure that only patients are writing reviews of their physicians. Also, websites could require that a minimum number of reviews (positive, negative, or both) be reached before they are released to the public, so as to have a more representative sampling.1,20 Reviews could also be more carefully moderated, as is the case with Britain's National Health Choices website.21,22
Physician rating websites are an inevitable part of life that physicians will continue to face in their careers. In the current system, the negative consequences that result from these websites appear to outnumber the positive qualities. Such websites may be especially problematic in psychiatry, especially in the field of involuntary psychiatry. In such cases, a more formal complaint system is likely to be more effective than anonymous reviews posted on the Internet. We advocate for physicians to have more awareness and education about these websites, and to know that there are options they may pursue if negative reviews are discovered. Finally, medical professional societies may be able to advocate for physicians and even possibly change the way reviews are handled on the Internet.
- Strech D. Ethical principles for physician rating sites. J Med Internet Res. 2011;13(4):e113. doi:10.2196/jmir.1899 [CrossRef]
- Bacon N. Will doctor rating sites improve standards of care? Yes. BMJ. 2009;338:b1030. doi:10.1136/bmj.b1030 [CrossRef]
- Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. Systematic review of the literature on assessment, feedback, and physicians' clinical performance: BEME Guide No. 7. Med Teach. 2006;28(2):117–128. doi:10.1080/01421590600622665 [CrossRef]
- Terlutter R, Bidmon S, Röttl J. Who uses physician-rating websites? Differences in sociodemographic variables, psychographic variables, and health status of users and nonusers of physician-rating websites. J Med Internet Res. 2014;16(3):e97. doi:10.2196/jmir.3145 [CrossRef]
- Levitt v Yelp!, 765 F3d 1123 (9th Cir 2014).
- Review Concierge. Online review survival course. https://reviewconcierge.com/docs/online-review-survival-course/. Accessed October 21, 2016.
- Samora JB, Lifchez SD, Blazar PE. Physician-rating web sites: ethical implications. J Hand Surg Am. 2016;41(1):104–110. doi:10.1016/j.jhsa.2015.05.034 [CrossRef]
- Pasternak A, Scherger JE. Online reviews of physicians: what are your patients posting about you?Fam Pract Manag. 2009;16(3):9–11.
- Affordable Care Act, 42 USC §18001 (2010).
- Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction. Arch Intern Med. 2012;172(5):405–411. doi:10.1001/archinternmed.2011.1662 [CrossRef]
- Zgierska A, Rabago D, Miller MM. Impact of patient satisfaction ratings on physicians and clinical care. Patient Prefer Adherence. 2014;8:437–446. doi:10.2147/PPA.S59077 [CrossRef]
- Sabin JE. Physician-rating websites. Virtual Mentor. 2013;15(11):932–936. doi:10.1001/virtualmentor.2013.15.11.ecas2-1311 [CrossRef]
- Little J. The therapeutic use of ‘no’. Australas Psychiatry. 2015;23(2):136–138. doi:10.1177/1039856214568225 [CrossRef]
- Gorrindo T, Groves JE. Web searching for information about physicians. JAMA. 2008;300(2):213–215. doi:10.1001/jama.2008.44 [CrossRef]
- Kropf S. Three steps to remove a negative online patient review. http://www.psychiatrictimes.com/blog/three-steps-remove-negative-online-patient-review. Accessed October 21, 2016.
- Easton P, Klaff T. Organization of Legal Professionals. Making your screen shot count. http://www.theolp.org/page-1343001. Accessed October 21, 2016.
- Kropf S. Responding to negative online patient reviews: 7 tips. http://www.psychiatrictimes.com/blog/responding-negative-online-patient-reviews-7-tips. Accessed October 21, 2016.
- McKee v Laurion, 825 NW2d 725 (Minn 2013).
- Hilden J. The Minnesota Supreme Court rules for the defendant in a suit alleging online defamation. https://verdict.justia.com/2013/02/20/the-minnesota-supreme-court-rules-for-the-defendant-in-a-suit-alleging-online-defamation. Accessed October 24, 2016.
- Lagu T, Lindenauer PK. Putting the public back in public reporting of health care quality. JAMA. 2010;304(15):1711–1712. doi:10.1001/jama.2010.1499 [CrossRef]
- Emmert M, Sander U, Pisch F. Eight questions about physician-rating websites: a systematic review. J Med Internet Res. 2013;15(2):e24. doi:10.2196/jmir.2360 [CrossRef]
- NHS Choices: Our terms, conditions, and policies. http://www.nhs.uk/aboutNHSChoices/aboutnhschoices/termsandconditions/Pages/termsandconditions.aspx. Accessed October 24, 2016.