By Dan O’Connor

 

“All professions are conspiracies against the laity,” George Bernard Shaw once quipped – but what happens when the laity strikes back?

 

I speak, of course, about physician-ratings websites, those increasingly popular online spaces where patients can (cover your ears, gentle listener) rate their physician. Smelling salts all ’round at the American Medical Association, a statement from which august body said:

 

“Some allow postings to be published anonymously, and there is no guarantee that the opinions about a physician even come from that physician’s patient. People may express dissatisfaction on these forums because they wanted a medication that wasn’t medically necessary, or because they didn’t receive a prescription or service that was delayed or denied by their insurance company.”

 

Such is the general concern amongst practicing physicians, that these websites are an unfair representation of the experience most patients have, and that, with HIPAA and other regulations lurking in the background, it can be difficult to know how to respond when a reputation is impugned. A recent study seems to reaffirm these suspicions, claiming that physician-ratings websites are both biased in the way that doctors are selected and likely to exaggerate consumer opinion.

 

In spite of the fact that other studies have found that many ratings sites are actually full of either of useless or largely positive information, and despite sage advice that physicians perhaps need not worry so much, physician-ratings websites continue to stir up controversy and resentment within the medical profession.

 

To which other professions – from restaurant and bar owners, to construction contractors and interior designers – could be forgiven for playing the world’s tiniest violin.

 

Physician-ratings sites are, fundamentally, a form of social media, and social media are how consumers exchange information with one another. As healthcare organizations and their employees (physicians included) strive ever more to conceive of their patients as consumers, so should there be no surprise when those patients start to act like any other customer does: talk about their experience online. College professors have lived with the depredations of “RateMyProfessor” for longer than many of us care to imagine now; and the same goes for the authors whose work is reviewed by readers on Amazon, the directors and actors who get slated at IMDB, the restaurateurs who feverishly check Yelp! for reviews, and the hotel managers who obsess over TripAdvisor, looking for PR crises to nip in the bud. This is the brave new world of Internet democracy, enabled by social media. Physician-ratings sites are a part of that world and it is one in which, implicitly, anyone’s opinion is as valid as anyone else’s.

 

That strange sound you can hear is the medical profession choking on its own monopoly of expertise.

 

I jest, of course, but to a serious point. The problem is that a defining characteristic of the medical profession is precisely that the opinion of a physician actually is worth more than everyone else’s – at least when it comes to medicine. It’s the same for any other profession: legal, clerical, professorial, you name it. The animating idea of a profession is that, within a field of knowledge, members of that profession know best.

 

This idea is in direct, if not always conscious, conflict with the open, democratic culture of social media. And this conflict – which we have already seen start to play out in the debates over the accuracy of health information online – will only increase in the coming years as the insulated, authority-respecting culture of the medical profession increasingly finds itself at odds with an Internet culture where a possibly dubious authenticity and personal experience are valued over academic degrees and institutional titles.

 

Now, I’m not claiming that the culture of the Internet is better than the culture of professions – or even that they are necessarily incompatible or antithetical (although as it stands they seem at least difficult to reconcile). Rather, I am merely pointing out that this social-media genie is not going back into the bottle. It’s true that physician-rating sites are not the kind of patient communications and feedback that physicians and healthcare organizations are used to; but it’s also true that they are not going away. Physicians are scientists, and if they aren’t already aware,  might be well advised to accept as a scientific fact that social media – and the open culture of conversation that goes with it – have changed the way people are able talk about their lives, including their healthcare.

 

For physicians, the key to dealing with this new world is to understand why patients (and their families and friends) turn to the ratings sites. The answer is simple: We have turned ‘patients’ into ‘consumers’ and these new consumers often feel that their voices are not heard by the medical profession – social media gives these consumers a bigger voice in a healthcare system in which they are often otherwise not heard. Criticizing or complaining about your care in a hospital is a difficult endeavor – I mean, where do you even start? Who do you talk to? The physician you are complaining about? Their line manager? Who even is the line manager? Add to this the concern that complaints about care will result in reduced care and we develop a portrait – fair or not – of a bureaucratic communications procedure which is geared towards damage control rather than listening. And it is a portrait which, I think, many patients/consumers recognize – and so they go online, because that’s what consumers do, now.

 

Traditional, top-down forms of communication (TV ads and press releases) simply do not cut it for most consumers in the age of social media. If a brand or an organization proves incapable of actively engaging with their consumers (as opposed to merely broadcasting at them), those consumers now have the space, tools and platforms – social media – to voice their concerns to an audience of sympathetic peers who will listen. Savvy brands and organizations realize that they need to be a part of the conversations that their customers are having.

 

So should physicians – and healthcare more generally – follow suit? Is it even possible?

 

The regulatory elephant in the room is, of course, HIPAA, which places serious limits on the abilities of physicians to discuss patient (or consumer) information – and thus prevents doctors from engaging openly with their patients in social-media spaces. However, HIPAA does not necessarily forbid physicians and healthcare organizations from being more open with their communications processes and procedures, nor from using social media to present a more open and engaged face to the world. And yes, horrifying as it may seem, this can mean joining Twitter, as many excellent, engaging physicians have done.

 

In the end, a lot of this culture clash comes down, not just to the differences between a hierarchical profession and a radically horizontal Internet, but also to the way in which the medical profession defines patients. The current vogue – and a welcome one, in many ways – is to see patients as active participants in their care, rather than as passive recipients. This perspective, which intersects with personalized medicine, sees patients as engaged and empowered to make and direct their own healthcare choices. In short, it is a commercial model which turns the patient into a consumer of goods rather than the recipient of a service. With this increasingly common construction of patient-as-consumer (and bioethicists’ fetish for “autonomy” has much to answer for there) comes the inevitable: Patients will act like consumers, and these days, that includes using social media to discuss consumer experiences.

 

Physicians’ concerns about ratings websites are legitimate – especially when it comes to anonymity and the burdens of HIPAA – but the profession cannot have it both ways. You cannot, in the age of social media, turn someone into a consumer and then be surprised if they blog about it.

 

 

Dan O’Connor – Research Scientist, Faculty, Johns Hopkins Berman Institute of Bioethics. Dan has two main research areas: the ethics of social media in healthcare and historicising the ethics of emerging diseases

 

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4 Responses to “Social Media and the Idea of the Medical Profession”

  1. Fabulous, funny analysis. Thank you. A few questions, please.

    Won’t most of these concerns pale in comparison to the customer satisfaction component of Value Based Purchasing which will be statistically valid and hit doctors’ bottom lines because of Medicare reimbursement rates? ACA reform.

    There are positives for doctors, even in the current environment. Most business use social media dings as a way to surface and fix problems. Will doctors ever see this as an opportunity?

    Won’t the coming surge of evidence based protocols flatten out the “I’m god” point-of-view anyway?

    Aren’t customer ratings valid, in that the other side of this is that doctors make real mistakes all the time? The Chinese Wall of professionalism is used, wrongly, to hide this.

    Didn’t a lot of the HIPPA thinking come out of patient fears about un-insurability and un-employability from insurance companies or employers discovering pre-existing conditions? U. S. ACA health reform resolves some of those concerns. Might HIPPA laws change in response?

  2. gregor says:

    No mention of cost? There seem to be plenty of doctors and dentists out there who are willing to rip off patients with exorbitant rates, relying on their fears but also on the fact that they are unlikely to shop around.

    Pricing transparency for standard procedures would go a long way to helping those of us who are uninsured or on high deductible plans choose a facility.

  3. Dan O'Connor says:

    Scott, thanks for you comment (and the kind compliment)! You pose some interesting questions, which I’ll try to answer in sequence:

    1) I don’t know enough about Medicare reimbursement rates to give a definite answer here, but my understanding is that the putative customer satisfaction component of VBP may be fairly insignificant in the grand scheme of things. VBP – or even Comparative Effectiveness Research – are frequently touted as threats to physician incomes, but I think, to be fair, many physicians understand that they are needed to combat the glut of wasteful procedures which contribute to spiraling healthcare costs.

    2) Again, I think many physicians *do* see the advantages of using social media to (ahem) promote their brand. I can think of several excellent social media savvy physicians on Twitter, for example. It may be best to view it as ‘just another industry’ getting to grips with the new information environment: some parts of the industry will adapt more quickly than others.

    3) I don’t think the ‘Im God’ point-of-view is really all that prevelant. Sure, there are some arrogant physicians, but it’s my view that the vast majority of them are, by and large, scientifically minded practitioners who genuinely seek the best for the patients. What *is* interesting about the ‘evidence based protocols’ is how they may impinge upon patient freedoms (to chose procedures) as much as upon physician’s freedoms to prescribe. I’d be interested to know what you think about this possibility?

    4) I think it is important to understand that there is a difference between ‘ratings’ and ‘complaints’. Patients turn to the blunt instrument of 1-out-of-5-stars when they do not feel that are being listened to. So, I don’t think ratings are necessarily invalid, but I think they have less validity (and less utility to all sides) than a properly engaged patient-physician relationship.

    5) Ah, HIPAA… my very least favorite subject ever! Quite correct regarding the insurance/employabiity origins of HIPAA, and so logically, with those fears removed by ACA, you’d imagine that HIPAA would be revised accordingly.

    \Logically\, alas, is rarely how regulation and legislation works. There is so much invested in HIPAA from a governmentality point of view now, that I think it would be difficult to alter it in any meaningful way without causing serious political uproar. Besides, even if the employment/insurance issues have gone, the underlying privacy concerns remain.

    Cheers

    Dan

  4. Dan O'Connor says:

    Gregor – thanks for commenting. I think you make an excellent point about cost transparency, especially for people paying our of pocket or the uninsured. Interestingly, cost transparency was floated by some Republican policymakers as a way of reducing costs – the idea being that we would have less uneccesary procedures if we knew how bloody expensive they are. Although it would seemingly only work if everyone were independently insured rather than as part of a group.

    Cheers

    Dan

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