When a Patient Trashes You Online
“Hitler should have burned this doctor. Then we wouldn’t have to deal with this scum doctor.”
This inflammatory snippet was a real review that appeared on a well-known physician review Website. Welcome to the sometimes harsh world of the Internet.
Consumer reviews have long permeated most industries. Healthcare is the most recent entry. Online reviews are changing how patients provide feedback and even how patients choose their doctors.
Traditionally, patients found their doctor the old-fashioned way: by getting a referral from another doctor, a friend, or a family member. According to one survey of 50,000 patient reviews, 25% of patients now find their doctor on the Internet (Segal J. Unpublished data. 2014). This includes physician selection based on online reviews.
The number appears to be growing. Even if patients find their doctor in the traditional way, they are still going to the Internet to validate their decision. Physicians who ignore what is said about them on the Internet do so at their peril.
The collection of problems associated with online reviews is well known, but doctors can—and should—take control.
A Direct Rebuttal May Actually Be Illegal
Because of the Health Insurance Portability and Accountability Act (HIPAA), as well as state privacy laws, physicians are legally prevented from responding to negative commentary online. In the rest of the consumer world, if a person posts a negative comment on the Internet, the business can typically tell its side of the story.
Half a story is not the same as a full story, particularly when it concerns physicians. If a patient writes that his wound opened up three days post-op, that is a different story from “three days post-op, against the advice of the surgeon, the 350-lb patient went back to work digging ditches, and his wound opened up.”
Does this mean that doctors cannot respond online? The answer is: Sometimes yes, sometimes no. HIPAA prevents a “covered entity” (ie, a physician) from disclosing protected health information without the patient’s consent or unless authorized by law. Some doctors assume that if patients publicly disclose protected health information on their own, doctors are free to respond. This is not accurate. The reason is simple: The doctor does not have the patient’s permission to disclose protected health information—regardless of whether the patient did so first on her own.
Furthermore, there is no explicit authorization embedded in the HIPAA or Health Information Technology for Economic and Clinical Health (HITECH) statutory language that allows a physician to disclose patients’ health information. So be careful. The fines associated with making inaccurate assumptions about what HIPAA does and doesn’t permit can be steep.
In one real-world example, a patient posted the following on Google:
“Dr X was really rude on my first consultation. Before scheduling any sinus or polyps operation, I didn’t want to make any decisions, as I didn’t have great contact with him. He was really angry and used such phrases as ‘What did you say?’ and ‘I’m going to do an operation, and the only thing that doctors need to do before…'”
The patient’s two-star review included what appeared to be his real first and last name.
The doctor responded:
“Hi, Davy. I’m sorry you think I came across as rude or angry. I was really concerned about you as a patient, and my concern may have been misinterpreted as anger or rudeness. Just for your information, I don’t perform sinus surgery. I was trying to treat you nonsurgically, and then, if need be, I would have referred you to a competent professional who performs this surgery.”
Although reasonable people can disagree about the efficacy of this type of response—a lawyer might argue that the doctor appeared to blame the patient for his misinterpretation—the doctor made a mistake that is inarguable: He publically disclosed that Davy was indeed his patient. This is a HIPAA violation.
To avoid running afoul of HIPAA, a better approach might have been to respond:
“While I do not perform sinus surgery, when I see patients who might benefit from sinus treatment, I typically offer nonsurgical alternatives. If those treatments fail, I generally refer to ENT surgeons.”
Here, the doctor would have been responding to the public at large by discussing his general treatment philosophy—not to specifics affecting a particular patient. The semantic distinction may seem subtle. From the standpoint of HIPAA, the distinction is essential.
The public responds positively to doctors who take criticism seriously and do their best to remedy any problems. Doctors can often respond online, as long as they do not reveal protected health information—including acknowledging that the patient who posted a negative review was their patient.
Sometimes it’s best to take the conflict offline. An orthopedic surgeon was recently slammed on the Yelp Website. The poster noted her daughter was there only for a surgical second opinion. The orthopedist said that conservative treatment was an option and sold her a brace—which, he admitted, might not be covered by her insurance. The reviewer continued that her daughter was an athlete and that conservative treatment was not desirable. And, yes, her insurance did not pay for the brace.
The orthopedist wrote a private letter directly to the patient’s mother in which he said:
“I saw the review you posted on Yelp. I respect everyone’s right to voice their opinion. But your review stung. I want to make it right. I believed, in good faith, that your daughter was not interested in surgery and there was a conservative option, a brace, which would allow her to walk and run without her knee giving way. That was why I offered the brace—as an alternative option to surgery. In any event, I apparently misinterpreted. For that, please accept my sincere apology. Also, I have enclosed a check for the full amount you paid for the brace—a brace that was essentially unused.”
The patient’s mother changed her review to five stars. The doctor’s letter to the family turned a negative to a positive.
Be Alert for Teaching Moments
As physicians, we are obligated to put our patients’ interest first. This means we do not always give patients precisely what they want. If a patient demands antibiotics for a clear-cut viral infection, the conscientious doctor should explain why antibiotics are not indicated. Nonetheless, if that patient is unhappy with the explanation, she might slam the doctor online. Responding in a HIPAA-compliant fashion is a good way to educate the public and potentially turn a negative situation into a positive one.
For example, one fertility doctor found a review alleging she dropped the ball by failing to order an inexpensive lab test. The patient was unable to get pregnant on multiple in vitro fertilization cycles. She ultimately transferred her care to another doctor, who ordered this test, discovered an abnormal result, and placed the patient on baby aspirin, and the happy outcome was a pregnant patient.
The first doctor responded online to the negative review posted by the patient, and used the opportunity to educate the public.
“The hypothesis that thrombophilia causes infertility is controversial,” she wrote. “In fact, the weight of evidence suggests that thrombophilia does not cause infertility. The American College of Obstetricians and Gynecologists and the American Society of Reproductive Medicine have published position statements/practice guidelines specifically recommending against thrombophilia testing except in cases with a personal history of thrombosis or a first-degree family member with a known clotting abnormality (thrombophilia). It is important to stress that even in those situations, the treatment of thrombophilia is to prevent blood clots (eg, pulmonary embolism) during pregnancy and not for treatment of infertility/reproductive failure. If it were just a matter of ordering blood work and there were zero consequences from false-positive results, that might be a different story. But it is well established that the use of anticoagulants is not without risk. Maternal death is a potential preventable complication related to the inappropriate use of these medications.”
Doing the right thing is not always equivalent to doing as the patient wants. This divergence can manifest as backlash online. Doctors can respond by educating the public as long as confidential patient information is not revealed in the process.
The Solution to Pollution Is Dilution
Although most doctors see 1000-3000 patients a year, they are defined by only a handful of online reviews.This means that what is posted online may not be representative of a practice. It’s been said that one happy patient tells one person; an unhappy patient tells 10.
How does a doctor combat the unhappy patient who tells 10 others? A long-standing truism in the operating room applies to the online world: The solution to pollution is dilution. If a practice deputizes its patients to post reviews online, the world will have a more representative picture of that practice. Doctors can, and should, formally ask their patients to post reviews of the care they received at the practice. But most patients, even though well-intended, fail to follow through. The happy patient is busy. He or she has moved on. Of course, the unhappy patient may find the time to post online.
Technology can help. Some services that specialize in physician reputation management will email links to patients to make it convenient for them to post reviews about their experiences with a given physician or practice. Other services provide iPads® for patients to use in right the office, so they can offer reviews of their doctors before they leave and their impressions are fresh. The practice itself can then post the reviews online.
Encourage Patients to Review You Online
It’s best if reviews are not filtered, rather than cherry-picking only positive reviews. The public understands that no one can make 100% of patients happy 100% of the time. If reviews are filtered, and only five-star reviews make their way online, the public will discount this as “marketing material.”
If you ask patients for reviews, it’s illegal to provide anything of value for those reviews. This includes discounts, free services, or even entry into a raffle to win a prize. The Federal Trade Commission (FTC) notes that if any such consideration is offered to a reviewer, that consideration must be disclosed in the review. In the medical world, both doctor and patient would incur liability if this disclosure were not made.
Here’s what a review might look like to comply with FTC regulations:
“Dr Smith got out of bed at 2 AM to save my life. I can’t thank him enough. Full disclosure: Dr Smith paid me $25 to write this review. Regardless, I am still thankful.”
The better path is not to pay for reviews.
The online world is here to stay. Patients are increasingly making healthcare decisions based on what they read on the Internet. Some online challenges are unique to healthcare. Doctors should respond to online criticism—privately to the patient, if the patient’s identity is known, and publicly, if it can be done in a HIPAA-compliant way.
Doctors should also encourage patients to post reviews about their experiences online. A range of technology solutions can make this challenge less daunting. The more reviews a doctor has online, the less likely an inevitable negative review will create lasting reputational damage.
There is no more cost-effective marketing program than a critical mass of positive online reviews from your patients.