Essays

Essays June 2009

Don't Make Me Gag

Steven Lewis

Would you commit in writing not to slag your physician on the internet? A US company called Medical Justice (MJ) is hawking a waiver form that gets patients to foreswear anonymous posts to doctor rating websites. I'm your doctor, you're my patient. If you have problems with me or my staff, tell us, tell your friends and family, tell anyone you want through the usual channels. But put it in writing that you won't post it to the internet.

The internet is a pretty big windmill to tilt against, but MJ claims 1000 doctors have signed on. The pitch is that the muzzle pact protects doctors from anonymously posted and inaccurate portrayals of their courtesy, promptness, morals, and clinical skills. The lawyer in the MJ website video recounts the story of an anonymous post implying that a physician was a child molester. Though the post was a malicious plant from a competitor, not a patient, apparently US law exempts Internet Service Providers from liability in such cases, and they cannot be compelled to remove the alleged defamation.

This is ugly and outrageous stuff. But the proposed remedy is ethically objectionable in principle and foolish in practice. The flaws are as follows.

First, Medical Justice argues that rating doctors is not the same as rating barbecues. This is formally true: I cannot libel the barbecue, and in any case the barbecue doesn't care. (The manufacturers do, but somehow they have not yet demanded censorship in return for the privilege of purchasing their goods.) MJ goes on to describe the doctor-patient relationship as a precious union of equals whose sanctity and trust are violated by the specter of anonymous rating. This is patent nonsense: there is a major power imbalance between the parties. The rating sites are popular precisely because the vast majority of patients don't have the nerve to challenge their doctors face-to-face and fear the consequences if they do so.

Second, the internet free-for-all has been with us for a decade, and it has created an endless stream of opinion, advice, and rating. Of course it is full of garbage, lies, rantings and ravings. It is also a treasure trove of facts and shrewd observations that skewer privilege and reveal truths absent from the increasingly concentrated mainstream media. The bees have burst from the hive and there is no getting them back inside. There is no better advertisement for doctor rating sites than the attempt of doctors to suppress them.

Third, like Othello and Lear, MJ mistakes a friend for an enemy. Most people think better of their doctors than their doctors' performance warrants. The overwhelming proportion of assessments on www.ratemds.com are positive. An avalanche of evaluative literature shows that overall physician performance is in fact mediocre by the standards of evidence-based practice. Misprescribing is rampant, it takes weeks to get an appointment, adverse events abound in hospitals, and mental health problems are underdiagnosed and ineffectively treated. Physicians come off far better on the web-based rating sites than in scientific practice profiles. They should be demanding patient ratings, not proscribing them.

Fourth, the public can learn something from the ratings. Themes tend to repeat in both the critical and laudatory commentary. When 8 patients tell you that doctor X prescribes penicillin for everything, I doubt they're lying. When 20 of 40 assessments of doctor Y mention misdiagnosis, I'd bet the farm that there's a lot of misdiagnosis going on. When every one of 32 posters says Dr. Z cares, listens, and explains, I believe that of Dr. Z. Many of the postings are balanced, nuanced, and thorough. The critics in particular tend to give reasons for their judgments. Some are scathing and even cruel, but the savage commentary is usually reserved for those who have committed truly barbaric acts.

Fifth, physicians should welcome the feedback, especially if it is anonymous. Patients are disinclined to ruffle their doctors' sensibilities. I like my family doctor, Mick Jutras of Saskatoon, as do 29 of 32 raters here. He is intelligent, thoughtful, and a good communicator. I did not change my mind because one patient wrote, "He sucks. Totally ignorant. Rude." But I have never had the jam to tell him that same-day access should be the norm*, that the lab test result communications are erratic, or that it is perplexing that Toyota summons my car for screening but his highly automated practice doesn't invite me for the tests that are supposed to be so vital to my well-being. (My optometrist and dentist pester me relentlessly.) Nor has he ever surveyed me. Both he and I have let him down on the quality improvement front. If I thought he and his partners would read the internet ratings carefully and recognize that the negative feedback is the wellspring of improvement, I'd log on and write.

MJ claims to be in favour of objective physician rating systems, meaning, no doubt, rating systems that they control or endorse. Their real fear is that patients will pay more attention to each other than to the insiders' guild. Don't pay attention to the unwashed who have the gall to write about a condescending ass who interrupts after 20 seconds and can't tell a virus from a bacterium. We'll do the rating and ranking of our own.

But what about malicious content? Yes, it's a problem, and potentially harmful to the innocent. There are remedies aside from squashing your patients' freedom of expression. The rating sites open their doors to physician comments and rebuttals. Smart ones, like Saskatoon urologist and medical blogger extraordinaire Kishore Visvanathan, have actually embraced the concept and the technology as a learning tool. Patients can respond to others' posts. Site surfers should be invited to report suspicious content to the administrators or directly to their doctors.

Above all, keep some perspective. False positive opinions far outnumber false negatives. A patient bent on vengeance has many ways to sully a reputation. And the public are not idiots: if they are at all open-minded about the merits of a doctor, they will read all of the posts and judge on the basis of the body of evidence presented.

If I ran a doctor rating site, I would add a new category: has your physician ever asked you to sign a MJ-type gag order? If the answer is yes, go elsewhere if you can.

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* Except for the time we were both at a fundraiser with excellent and abundant alcohol

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