I have just finished taking my last major exam of medical school – Step 2 of the boards (including Step 2 Clinical Skills, or CS, which costs 1200 bucks, requires you to travel to one of a few cities in the country hosting it, and is sealed by a EULA that forbids me from talking about what the test was like), and am winding down my medschool career in the next few weeks. It’s about 2 weeks from Match Day (the 19th), when I’ll find out for sure where I will spend the next 5 or so years of my life. I’ll be sure to have a post up a little after noon that day when I find out what the answer is. And then, around May 17th, graduation day, I’ll be a medical doctor, ready to start internship (also known as the hardest year of your life).
One of the things I’ve found universal to all medical students is that we really want to be good doctors when we are finished with our training. I don’t think I’ve ever met a medical student who was in this career for the money (you’d be crazy), or for other selfish reasons. They tend to be hard working, dedicated, humble people who, if anything, are sickeningly sincere about wanting to help other people. Maybe that’s just my school, but my experience is, these folks want to do good in the world.
But another universal is that not all doctors will be able to avoid making mistakes. Doctors are human, they all will eventually make errors, and the goal of any profession dedicated to improving the human condition should be constant self-reflection and efforts at self-improvement. This is not a simple thing to do however. Medicine is complex, and quality of medical treatment is very difficult to assess. We’ve discussed before, using metrics in medicine is challenging, and often rather than studying medical quality you end up merely assessing the social demographics of the physicians’ patients.
So it is with interest that I see reading boingboing that lots of people are upset because some doctors are forcing their patients not to rate them on sites like RateMD.com by having them sign a contract forbidding them from doing so.
The arguments for and against this practice are fascinating. We tread into the mucky waters of free speech, free enterprise, the practice of medicine, and the practical problem of assessing physician quality…
More below the fold…
First, from the article we have two opposing valid arguments:
The anonymous comment on the Web site RateMDs.com was unsparing: “Very unhelpful, arrogant,” it said of a doctor. “Did not listen and cut me off, seemed much too happy to have power (and abuse it!) over suffering people.”
Such reviews are becoming more common as consumer ratings services like Zagat’s and Angie’s List expand beyond restaurants and plumbers to medical care, and some doctors are fighting back.
They’re asking patients to agree to what amounts to a gag order that bars them from posting negative comments online.
“Consumers and patients are hungry for good information” about doctors, but Internet reviews provide just the opposite, contends Dr. Jeffrey Segal, a North Carolina neurosurgeon who has made a business of helping doctors monitor and prevent online criticism.
Some sites “are little more than tabloid journalism without much interest in constructively improving practices,” and their sniping comments can unfairly ruin a doctor’s reputation, Segal said.
Segal said such postings say nothing about what should really matter to patients — a doctor’s medical skills — and privacy laws and medical ethics prevent leave doctors powerless to do anything it.
Already we’ve got problems. A doctor’s reputation is everything, and if someone wants to anonymously bad mouth them, or even non-anonymously bad mouth them, there is very little they can do about about even if it may devastate their practice. A physician would be forbidden by ethics, and law (HIPAA), from even responding to such a charge. You can not discuss the details of a patients care, even though the patient can freely criticize it online. So we start with an inequality in speech. Patients may criticize, but doctors’ hands are tied in terms of defending themselves from such speech.
Segal’s response is therefore to try to handicap the patient’s free speech in order to re-establish equality in the relationship:
His company, Medical Justice, is based in Greensboro, N.C. For a fee, it provides doctors with a standardized waiver agreement. Patients who sign agree not to post online comments about the doctor, “his expertise and/or treatment.”
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Doctors are notified when a negative rating appears on a Web site, and, if the author’s name is known, physicians can use the signed waivers to get the sites to remove offending opinion.
From a practical standpoint, such an endeavor is doomed from the start. You will never win against a motivated human by trying to censor them. Physicians may comply because their livelihood, and medical license are dependent on a strict code of ethics which forbids the discussion of patient’s medical care. However, the patients have a lot less to lose, can easily deposit comments anonymously (as long as the companies aren’t subpoenaed for poster IPs – anonymity is fleeting), and if they have an axe to grind, they will find a way to get their information out there into this wonderful new medium of the internets. Further, this is different from the old word-of-mouth reputation a doctor gained in that once people can speak anonymously they shielded from any ethical responsibility to be truthful, fair, or reasonable in their criticism.
It used to be your friend might say, “don’t go to him, he’s a moron” and you could judge for yourself based one what you know of your friend to come to a conclusion about what such a criticism actually means. Word of mouth is also attached to a person, and people will be less inclined to lie given that may blow back and damage their own reputation. Commenting on the internets someone may say, “don’t go to him, he’s a moron, and I know he beats his wife” and how would you know it’s not true? Knowing nothing of the source most people’s default would be to avoid such a physician, and an innocent person could suffer horribly at the hands of one disgruntled patient.
Worse, since the system has no standards for providing evidence of allegations, this anonymity undermines legitimate criticism. When people post careless invective, it damages the legitimacy an information source would hopefully be trying to provide. After all, what if the doctor really is a moron, and people shouldn’t be going to him? If he’s say, very popular with his patients because he gives out oxycontin like candy, prescribes antibiotics for viral illnesses, but couldn’t diagnose a serious condition like a heart attack to save his life he may have wonderful ratings. Think about it, the first two patient populations have the drugs they want, they’re happy. The third patient is dead and can’t comment on RateMD.
From a practical standpoint, the censorship route seems to fail as well, but at the same time the founder of this RateMD service is being obtuse:
John Swapceinski, co-founder of RateMDs.com, said that in recent months, six doctors have asked him to remove negative online comments based on patients’ signed waivers. He has refused.
“They’re basically forcing the patients to choose between health care and their First Amendment rights, and I really find that repulsive,” Swapceinski said.
While I don’t think censorship will work, it is perfectly valid for people to be contractually obligated not to disclose information. After all the doctor is restricted, and I understand from a fairness perspective why some would want to equalize this relationship. People have a right to free speech, but they also have a right to contract, even to restrict their own rights in exchange for a service. While the EULA fanatics at BoingBoing totally have a point about the tendency of many companies to take people’s rights away by contract at a whim, that doesn’t mean there can never be a good reason for asking someone for non-disclosure. The question is, are there good reasons for a contract restricting speech in this instance?
We can fight this one out in the comments, as I’d like to bring up a separate issue. Do such services even provide valid information by which one may judge a doctor?
Lenore Janecek, who formed a Chicago-based patient-advocacy group after being wrongly diagnosed with cancer, said she opposes the waivers.
“Everyone has the right to speak up,” she said.
While she’s never posted comments about her doctors, she said the sites are one of the few resources patients have to evaluate physicians.
The American Medical Association has taken no position on patient waivers, but President Dr. Nancy Nielsen has said previously that online doctor ratings sites “have many shortcomings.”
Online doctor reviews “should be taken with a grain of salt, and should certainly not be a patient’s sole source of information when looking for a new physician,” she said.
We have to think long and hard about what types of incentives rating doctors online generates. Even sophisticated attempts to reward doctors based on performance are highly flawed. When you reward physicians for better outcomes, you don’t always get better outcomes. Instead what you see is that physicians that serve the rich, the young, the educated, the healthy, and the compliant are rewarded (also those who defraud the rating process). They have great outcomes. However, the doctors treating, the poor, the unsophisticated, the elderly, the sickest, and the most difficult patients come out looking like hell. Those patients tend to have worse outcomes. But we don’t want to reward people for either choosing, or being fortunate to have, easy patients. It’s a terrible dirty secret but yes, many hospitals and doctors select patients that won’t damage their statistics. The result is hospitals that do take everybody – academic medical centers, city hospitals etc. – end up looking worse even though they may very well have better doctors treating far more challenging patients. In fact, when you control for patient morbidity, teaching hospitals tend to actually perform better than private hospitals – probably because when disasters do happen they have so much experience with the sickest of the sick.
Let’s think about it, what incentives does online rating generate? I would posit that patients are largely not reliable to judge their physicians medical competence. Instead they can only look at their own personal outcomes, whether or not they liked their doctor, and how long they spend in the waiting room. And guess what, there are expected complications, and not all outcomes will be good, no matter how great your physician is. A good doctor will spend time explaining this to her patients, but even so, it’s amazing how often this part of the doctors spiel is forgotten after a patient has been told they need surgery, or chemo, or have a new diagnosis of a serious disease. Also, a doctor who makes you wait isn’t in the back doing bong hits – they’re with patients who need them too. Finally your review it is also dependent on the sophistication of the patient, and their personality. Some people won’t like you, that’s life, and some people are just jerks, but jerks need good medical care too.
I worry that in an era where people may damage a physician’s reputation by such superficial criteria as how long someone spent in the waiting room (not to dismiss this as a problem but…), or whether or not they liked their doctor’s personality, or even whether or not they were satisfied with their care. Lots of patients are very unsatisfied with you when you do the right thing, or as is the with many patients, even the best doctor in the world might not have had a good outcome because there is an expected failure rate, and complication rate, of most medical interventions. The result of such a database of complaints is evidence by anecdote – the worse kind – and ultimately a crummy source of information about almost anything. Patients will love incompetent doctors who they like and do what they want, but will punish good doctors who might be less personable or *gasp* not give out pills like a gumball machine. You will therefore be judging your physician not based on any high quality data, but on anecdotes from the disgruntled.
The incentive that is created by such is system is therefore once again for physicians not to treat the difficult patient, or the poor patient, or someone who is just a jerk. The incentive will be to keep your patients moving rather than maybe stopping and spending the time with patients when they really need you. They will want to treat easy patients, patients who are nice, and never in a million years someone on medicare or medicaid. And worst of all doctors will be afraid to do what is right, even if it means really pissing off your patient. This happens more than you would believe. If you’ve ever had to admit someone to a hospital against their will for suicidal behavior, or confront them over their drug use, or refuse to give them the treatment they want because the Google told them they have kuru, you’ve gotten patients angry with you. Sometimes permanently pissed.
Hopefully, you’ll do a good job explaining things to your patients, and they’ll understand, but a lot of times they simply can not or will not understand. They’re angry because they didn’t get what they want or you told them what they didn’t want to hear. The problem is good medicine is not being a pill dispenser, or being your patient’s best friend, or not ever making anyone angry. Being a good doctor means you do what is right, what is medically indicated, and in your patient’s best interest – even if they have a different idea of what that is, and even if they’ll never forgive you for it. I don’t think accumulating anecdotes online will reward the good physician, instead, I think it will hurt them.
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