Will doctor rating sites improve standards of care? Yes
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1030 (Published 17 March 2009) Cite this as: BMJ 2009;338:b1030
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Patients must always have a say and we as doctors should always listen
to their feedback. However, an open forum where anyone can send anything
in writing without revealing identity is a dangerous thing. Most doctors
are not Shipman of this world. Most doctors work hard providing a good
quality care to their patients and most errors are due to systems failure.
Most of us may and probably will get good feedback even in an
anonymised feedback. However, there is a good saying in my mother tongue
‘with human beings you do 10 good things they may not remember but you do
one bad thing they won’t forget it.
Medicine is a risky profession and as doctors we will make mistakes,
we will not always be able to meet our patients’ expectations and patients
may not like our advice about their life style, their weight, their
smoking. Patients may get upset when we suggest that there may be Psycho-
somatic reasons for their symptoms or worst of all patients may get upset
when the doctor refuses to prescribe antibiotic for simple viral
infection. They may then post some destructive messages on the website to
take out their anger and frustration.
As doctors we are very proud people and we have a tendency to take
even one destructive comment much more seriously and if it is on the web
then it is usually a permanent record which the whole world can see and
this can destroy some very good doctors reputation for many years to come.
So, I find it difficult to support these ventures which can destroy many
innocent doctors’ lives.
There is a simple solution and doctors can ask for feedback in any
anonymised way after their consultation or management of the patients. Ask
patients for any suggestions for improvement. Only the appraiser and the
doctor must have an access to these feedbacks. Appraiser should discuss
the feedback with the doctor and discuss the ways and means of improving
the quality care, communication, patient involvement and so on. This would
help doctors, patients and the NHS.
Competing interests:
None declared
Competing interests: No competing interests
One problem with patients assessing doctors is the basis for
determining who is
"good" or not. And this is associated with the patient's emotional
response as
much as to the physician's clinical abilities.
Some people don't like doctors who make they get weighed every time
they go
in, or who feel they are being "nagged' about things they don't consider
important.
People may not like a physician who doesn't agree with them that
aromatherapy or magnets or yeast or radiowaves are harmful or helpful.
If healthcare were all about machines--the patient as a machine with
a problem
and the physician as a glorified mechanic--then a ratings system might
work.
But the human factor--what we like, what we respond to, what we believe in
--
is a huge and highly individual component.
Competing interests:
None declared
Competing interests: No competing interests
Patient rating websites like HealthcareReviews.eu are thriving
because the medical establishment continues to operate without any serious
scrutiny and oversight. They do not provide a ratings and reviews
themselves for the public, usually do not even bother with internally
available ratings and have the gall to oppose public rating websites.
These websites fill a need for patients for public disclosure of a doctors
abilities.
Competing interests:
None declared
Competing interests: No competing interests
I read Neil Beacon’s and Margaret McCartney’s articles with great
interest.1,2
Such doctor rating sites must be approached with caution.
First, there is evidence that the publication of ranking data does in
fact risk causing doctors to avoid high-risk patients. For example, in a
postal questionnaire involving general surgeons in the UK, 71 out of 289
consultants (24.6%) said they would avoid high-risk patients if surgeons’
performance tables were introduced.3 When a very similar questionnaire was
sent to 57 cardiothoracic surgeons in the UK, 12 (21.1%) said they would
avoid high-risk patients as well.4
Second, although patient feedback is extremely important, like all
rating systems, it must be subject to strict quality controls if it is to
be productive.
1 Bacon N. Will doctor rating sites improve standards of care? Yes.
BMJ 2009; 338: b1030.
2 McCartney M. Will doctor rating sites improve the quality of care?
No. BMJ 2009;338:b1033.
3 Kessaris N, Tekkis PP, Saunders MP, Boyle NH. Consultant views on
surgeons' performance tables and sequential monitoring. Annals of the
Royal College of Surgeons of England (Suppl) 2005;87:358-360.
4 Kessaris N, Tekkis PP, Perry-Kessaris A. Surgical performance
assessment: a comparison of views from general surgical and cardiothoracic
consultants. BJS 2005;92(Suppl 1):105.
Competing interests:
None declared
Competing interests: No competing interests
At the risk of sounding trite, if we want feedback from a
consultation, why don't
we simply use what is in front of us, simply ask the patient. If you think
it went
badly or well, they may feel the same, this will not only confirm or
refute our gut
feeling but more importantly tell us why. This will provide
contemporaneous
constructive criticism, without hiding behind a facade of digital
anonymity and
allowing the patient and their opinion to feel valued. Everyone hates
feedback,
positive feedback makes us cringe and negative feedback makes us bitter.
Yet
feedback we must if we are to grow as physicians, put the patient first
and stop
letting history repeat itself.
Competing interests:
None declared
Competing interests: No competing interests
Bacon's website will do nothing to help patient care. That is not its purpose. It is intended to make money for its owner apparently at the expense of the reputation of doctors.
The posts put on the site can never be validated as accurate, and are
therefore
worthless. This is a problem in two directions. Vexatious posts by
patients who
were given good advice, but advice they did not like, may put critical
comments.
These comments are a poor reflection of the quality of care they received.
Will a
malingerer appreciate being denied another sick note, an addict
painkillers or an
obese patient weight loss drugs? Bacon would probably argue that the
doctor
should provide good advice and win the patient over to the appropriate
treatment. In a 7 minute consultation?
On the other side, if another Shipman had a post placed on IWGC to
the effect
'This doctor killed my mother with an overdose of morphine', that post
would be
removed. Yet that information might be perfectly true.
Interestingly, one doctor whose name is missing from IWGC is Dr Neil
Bacon. I
guess he is not an unqualified believer in the benefits of feedback and
reflection.
Competing interests:
I do not see patients and
successfully complained to the
Information Commissioner to get
my name off IWGC.
Competing interests: No competing interests
For the last four years Patient Opinion has been running a feedback
site where patients, carers and staff can share the story of their health
care in the UK. Patient Opinion focuses on feedback about services rather
than individuals doctors. We have learnt a lot about the benefits of this
kind of feedback.
In the light of this experience we obviously agree with Neil Bacon that
web-based feedback from patients, carers and service users about health
services is coming and will have an important role in the future.
Exactly what that role will be is as yet unclear since, as Margaret
McCartney points out, there is very little research on the effect of web-
based feedback about individual either services or doctors. Given the fact
that web-based communication such as email, blogging and twittering is
known to differ significantly from traditional paper and speech-based
communication it is probably unwise to extrapolate too much from studies
about the utility of feedback that looked only at traditional survey and
rating formats.
Perhaps the most important thing to hold onto is that web-based
feedback from patients is coming. How it is collected and the business
model underlying the platform will almost certainly shape how effective it
is. So given the rate at which the web is changing it is important that a
range of providers are out there testing out which works best.
Competing interests:
I am a GP and founder of Patient Opinion
Competing interests: No competing interests
Doctors have plenty of sources of feedback. Patient satisfaction
surveys are
conducted regularly, clinical competence is regularly fed back via
hospital
letters, and if you work in partnership with others, then feedback is
regular.
Patients are also able to give feedback, and they do. Indeed if
patients are
unhappy they will see another doctor or register with another practice.
There might be web-based ways of encouraging feedback that would be
useful and valid, but iwantgreatcare.org is not it. Indeed the database is
wildly
inaccurate, with little connection with real life, and there are instances
of
retired doctors or those who have emigrated on the site. It also allows
dead
doctors to be reviewed.
The possibility of anonymous feedback from disgruntled patients is
endless
(addicts who have been refused their benzodiazepines, those who have been
refused certain lifestyle drugs), and there is no comeback available to
the
doctor who is unfairly criticised.
There is a serious risk of vulnerable doctors to have their mental
health
damaged by negative feedback.
Dr Bacon's site is not fit for purpose, and should be scrapped.
Competing interests:
None declared
Competing interests: No competing interests
In new Zealand patient satisfaction surveys are used routinely in the
assessment process for attaining the FRNZCGP qualification. The average
overall satisfaction score achieved is 86%. Doctors who score below 80%
satisfaction ratings usually are found to have significant problems with
their consultaton skills. Doctors in the fellowship training program are
strongly encouraged to use and reflect on lessons learned using this tool
and in my experience they find this a very useful tool. I believe quite
strongly doctors need to be more open and honest about receiving feedback.
Particularly as their performance comes from the best source, our
patients. The experience from the patieint surveys is that patients are
very honest about their assessment of a doctor's skill & in my
experience they are usually right.
Competing interests:
None declared
Competing interests: No competing interests
Are we ready?
Anonymous public opinions of doctors via web-based platforms may
provide key learning opportunities for clinicians, who are not
appropriately addressing their patients’ concerns and expectations.
However, the reality is that an inadequately health literate population
impedes such a system from working properly.
Patients who are fully aware of their health needs, knowledgeable
about reasonable expectations and limitations of a doctor in addressing
those needs, and able to set aside subjective feelings when reviewing
their doctor, are well positioned to provide accurate and useful feedback.
Low health literacy is as much a problem of developed countries as the
developing world.[1] Surely, empowering patients by improving their health
literacy is a logical pre-requisite, before we start asking them to judge
their doctor.
Reference:
1. Coulter A and Ellins J. Patient-focused interventions. A review of the
evidence. Report by the Picker Institute August 2006. Available at
http://www.pickereurope.org/Filestore/Downloads/QEI-Review-intro.pdf -
accessed 04/04.2009
Competing interests:
None declared
Competing interests: No competing interests