Give it 5 stars: How doctor ratings affect your health care

Give it 5 stars: How doctor ratings affect your health care
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Consider a fantastic experience at a restaurant with delicious food, timely customer service, and amazing ambiance. A diner may feel compelled to give that business a five-star rating on Yelp. It exceeded expectations and the restaurant can benefit from the power of a positive online review. 

Now consider a visit with a physician. What would make it a five-star experience? And how would excellent service be defined in the medical setting?  

As a physician, my goal is always to deliver effective and empathic health care to all of my patients. My goal is not to receive a high rating. Due to bias, subjectivity and other motivations, the random online patient ratings system is a hinderance, not a reliable guide, to good health care.

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For many Americans, the end of the calendar year means they have already met health insurance deductibles and out-of-pocket maximums. This can make medical services less expensive and lead patients to search online for new physicians. However, in deciding on a doctor, patients need to be cautious not to confuse customer satisfaction with evidence-based, patient-centered care.  

When making decisions about their health, patients are acting increasingly like typical consumers, who value online ratings. According to a 2018 study from NRC Health, “92.4% of consumers use online reviews to guide most of their ordinary purchasing decisions.” The survey revealed that “59.9% of patients say they’ve selected a doctor based on positive reviews, and nearly the same percentage (60.8%) of patients say they’ve avoided doctors based on negative reviews.”  

These trends have huge implications for the quality of health care in the U.S., since patient ratings depend on often-inaccurate — and potentially biased — patient perceptions, rather than on more objective measures of good medicine.   

Research shows that patient ratings tend to be biased against female and minority physicians. A 2018 study in the Women’s Health Issues journal showed that “women gynecologists are 47% less likely to receive top patient satisfaction scores compared with their male counterparts owing to their gender alone.”

Another 2019 study in Health Equity found “significant difference in patient satisfaction scores between underrepresented and white physicians.” 

Additionally a 2018 paper in the Journal of General Internal Medicine shows the different expectations that patients have for female and male physicians. “Female patients tend to seek more empathic listening and longer visits, especially with female physicians.” As a result, patient satisfaction with female physicians is “subjected to gendered stereotypes and expectations with hidden rules for appropriate behavior.” 

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Even if this implicit bias is overlooked in physicians, online reviews for products and services are hardly reliable. 

Recently the skin care brand Sunday Riley settled with the Federal Trade Commission after the company was accused of posting fake reviews of their products on Sephora's website for two years. Thirty percent of Amazon product reviews also were found to be falsified by Fakespot, which analyzes online ratings for accuracy.  

But the rippling effects of a fake review of body lotion pales in comparison to fake reviews of physicians, who deal with life and death.  

In spite of this, the NRC study showed that 83 percent of patients trusted online ratings and reviews more than personal recommendations. Yet patient reviews on heavily trafficked sites, such as Vitals.com, Healthgrades.com, and WebMD.com are not vetted for accuracy. There is no verification that reviews are even written by actual patients.  

This means that anyone — an angry former employee or a grumpy neighbor — can tarnish a physician’s online reputation and sway potential patients with the click of a button. Conversely, there is nothing preventing associates of physicians from posting fake positive reviews.   

Due to federal privacy laws, there is little recourse for physicians who are faced with negative online reviews. Unlike other businesses, physicians cannot respond to comments posted online because it violates patient privacy to simply acknowledge someone is a patient. This leaves doctors particularly vulnerable to personal and professional attacks.  

When a Miami plastic surgeon attempted to sue two patients earlier this year for what he described as inaccurate reviews, he received negative press and additional negative reviews (that may or may not have been from actually patients).   

Perhaps most importantly, though, high patient satisfaction scores have been linked to worse care. Motivation to achieve a high rating can influence doctors to prescribe unnecessary treatments and order unwarranted tests. Patients can use the threat of a poor online rating to leverage their requests. 

A 2018 study in JAMA reported that telemedicine patients who received an antibiotic for a respiratory tract infection (e.g. a “cold”) gave high ratings. This is concerning since respiratory tract infections are usually viral and rarely warrant antibiotic use, which can lead to dangerous outcomes for patients. 

Recently a Washington state physician sued her former employer, Kaiser Permanente, alleging “the way the company used patient satisfaction scores hurt her career and incentivized doctors to over-prescribe painkillers.” Evidence shows that patient satisfaction has played a role in the opioid epidemic.   

This intense focus on patient ratings is a factor contributing to physician burnout, which also negatively affects patient care. Many doctors are under pressure to see more patients with shorter appointment times, but still maintain excellent “customer service.”

Patients may not know or understand that a physician may be running late not because she is rude, but because she was comforting a patient with a new cancer diagnosis. It’s hard to imagine that this empathetic doctor deserves a poor online rating, but there is nothing preventing this result.

The consensus from physicians themselves is clear: there is an active petition with over 40,000 signatures to remove online ratings from Yelp and Healthgrades.com. 

To be sure, checks and balances on physicians are undoubtedly important. While physicians take an oath to “do no harm,” no industry is free from bad actors. If in doubt, see “Dr. Death” podcast for an extreme example of this malpractice. Monitoring by state medical boards and hospital quality assurance committees are traditional ways to ensure patient safety.  

When seeking medical care, patients can view online reviews with the understanding that they can be flawed, biased and subjective. Patients deserve the best healthcare possible and need to understand good ratings do not always lead to good doctors. Save the stars for the restaurants, not the physicians.      

Lisa Ravindra is an assistant professor of Internal Medicine and a primary care physician at Rush University Medical Center in Chicago. She is a Public Voices fellow through The OpEd Project.