Why are hospitals and physicians scared of online reviews?

By Zachary Landman, MD
12:51 PM
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At a recent meeting I attended of healthcare executives and industry vendors, the topic of online reviews came up. Almost immediately, there was an audible collective groan.

“I hate reviews. . .I mean, who uses them?” voiced one ACO executive.  Another added, “They’re always negative...and nearly always crazy.” As if it was a Sunday afternoon football game, a physician jumped on the pile with, “And they’re never even about the doctor anyway!”

Is this true? Are online physician reviews usually negative? Do they rarely discuss physician practices and do they offer little value to other patients? Our data collected over three years from 5 million patients and their review patterns supports other research in this area, both scientific and less so. All suggest that the vast majority of physician ratings are positive, more often than not discuss physician characteristics, and offer significant value to potential patients. So, why is there such a misconception?

First, let’s consider the initial point – whether physician reviews are typically positive or negative. This idea primarily stems from the fact that most physicians suffer from sampling bias. When we searched 200 randomly selected (based on a NPI number generator) physicians and entered their name into a Google search, 96% had fewer than 10 cumulative reviews on the first page of search results and more than three-quarters had fewer than 3. We didn’t move on to the second page since greater than 94% of all internet users never go beyond the first page of search results (and some industry research even suggests that more than half click the top link alone.)

When physicians and healthcare organizations have so few reviews, it typically means that considerable activation energy was required to post a review. Therefore, online ratings tend to systemically sample powerful or emotional experiences that galvanize the patient to action, and more often than not these are negative ones. The result is that when a physician or healthcare organization then sees a review about themselves or their organization, it often times reads, “Worst Doctor Ever!!!” (and as if the patient’s frustration wasn’t already evident, these reviews typically entail multiple explanation points and parts that are written entirely in capital letters…just to ensure that one can’t gloss over the anger). These public floggings interpreted as “frustrated patient seeking revenge” imprint a powerful memory on the one being reviewed.

And as all doctors have experienced at one time or another in medicine, individual experiences can sometimes outweigh even the most powerful contradicting evidence. For example, I admit that I hate using the typically safe and widely prescribed antibiotic Bactrim because one of my patients experienced an extremely severe, unpredictable, and rare (<1.5 cases per million) reaction called Stevens-Johnson Syndrome. In medicine, I have at least multiple alternative antibiotics from which to choose. With reviews, the only practical alternatives are marginalizing their worth or attempting to remove them (both methods of which are largely unsuccessful and carry ethical issues).

Okay – so even if doctor reviews are largely positive when correctly sampled, do they reflect the physician, or simply the physician’s habitat (support staff, office furniture, technology, etc.)? Well, the truth is that it’s both since patient experience cannot be easily distilled. Just as patients cannot be expected to gauge a physician’s diagnostic aptitude, they cannot be expected to determine what percentage of their overall perception of the encounter stemmed from timeliness, cleanliness, bedside manner, diagnosis, or treatment. This is why detailed physician review surveys often offer very little additional insight. The correlation (or “r” value) is tightly correlated between each and every domain. That means that if the physician was an hour and a half late, it will likely hurt his or her bedside empathy score as well, and vice versa. So, while it may be frustrating to know that a patient’s experience of timeliness may be the same whether it stemmed from a scheduling anomaly, an emergency, or generally accepted tardiness, it should be comforting for providers to know that patients are largely forgiving.

For example, one aspect in our data set that surprised us is that the words “even though” which imply there was a problematic aspect to the encounter were mentioned at the highest frequency in 5 star reviews.  Upon closer inspection, these 5 star reviews often cited the physician’s ability to cope with daily hiccups. A few 5-star examples read:

“…was very kind to accommodate me even though he said I didn't really have the appointment that I had scheduled” or “Even though they had quite a few patients this morning, they took very good care of me and I was out of there in a little over 2 hrs” or lastly, “Even though he didn’t have time to answer all my questions, he made me feel comfortable and welcomed.”

As you can see, when physicians are able to adjust, patients feel appreciated and valued – characteristics which lead to positive perception and great reviews.

So, after the encounters are done and the reviews posted, do patients actually use them? Well, a recent study by Deloitte suggests that about twenty-five percent of all Americans are comparison shopping on the web and seventy-five percent say those comments and reviews are generally fair. Clearly, choosing a physician, healthcare plan, or a hospital is a complex process and involves multiple variables from location to word-of-mouth reputation, but it’s clear that reviews are here to stay and will only become more important.

Once the sample bias is overcome and healthcare systems and physicians understand that reviews can work for them and with them more often than against them, we will see a much more concerted effort toward truly patient centered care. Until then, I expected that we will largely continue to wait.

And if as on cue to contrast “patient-centered” with “Medicare-centered” care, the meeting breezed through the topic of online reviews and moved onto a topic which everyone agreed was of the utmost importance – HCAHPS scores.