You are being watched: panopticons in healthcareBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.h6777 (Published 02 February 2016) Cite this as: BMJ 2016;352:h6777
- Ben Wessely, MA student in social work,
- Clare Gerada, general practitioner, London
Ben Wessely and Clare Gerada consider the effect on medical practice of online rating websites
In the late 18th century the British philosopher Jeremy Bentham proposed a design for a prison, the “panopticon,” in which a single watchman could observe any of the inmates at any time. The fact that the inmates would not know who was being watched at any moment meant that they would act as though they were always being watched. The ideas behind Bentham’s panopticon have parallels with the constant scrutiny and observation to which doctors are now subjected, though the principle of central inspection, surveillance, and monitoring is becoming ubiquitous across UK society in the digital age.1
Online healthcare rating websites such as PatientOpinion (www.patientopinion.org.uk), IWantGreatCare (www.iwantgreatcare.org), and NHS Choices (www.nhs.uk) allow patients to rate services and individual healthcare professionals, though currently few patients use them. A 2012 study in London reported that 15% of people were aware of doctor rating sites but that only 3% had used them.2 Similar rates of use have been reported in the United States,3 where more than 90% of the comments left are positive and there is little evidence of negative reviews.45
To understand doctors’ thoughts about websites that allow patients to rate them, one of the authors (BW) conducted group discussions, focus groups, and semi-structured qualitative interviews at a series of listening events for NHS staff in 2014 and 2015.6 Doctors at the events suggested that, despite their low popularity, these websites had great influence on doctors’ practice. They said that they feared that withholding non-evidenced or unnecessary treatment might mean disgruntled patients leaving negative comments.
The effect of rating websites on health professionals has also been examined in the United States. In a study of 155 doctors 78% reported that patient satisfaction surveys moderately or severely affected their job satisfaction.7 In addition, 28% had considered quitting their job or leaving the medical profession and 20% reported their employment being threatened as a result of patient satisfaction data.
The findings of the US survey also indicated that rating websites led to a change in clinical behaviour. Almost half of the respondents believed that pressure to obtain better scores promoted inappropriate care, including unnecessary prescriptions of antibiotics and opioids, tests, procedures, and admissions to hospital. A third (34%) reported that they had unnecessarily admitted a patient to hospital because of patient satisfaction surveys, and 18% endorsed a procedure that they believed to be unnecessary. Research also indicates that patients report lower levels of satisfaction with general practices that have a cautious approach to antibiotic prescribing.8
On rating websites patients do not restrict their comments to doctors’ technical skill or knowledge.9 They reflect on whether they had a “good emotional experience” and on doctors’ personality, empathy, politeness, and ability to listen.1011 They also comment on car parking facilities, the comfort of the waiting room, waiting times, and the ease of obtaining an appointment. The websites mean that healthcare professionals are now potentially under constant observation, extending beyond moments of formal observation.12
If websites for rating healthcare professionals mean more compassionate or better care, then the panoptic model is surely not a bad thing. But rating websites may be damaging the care of patients by a move away from the provision of evidence based medicine or treatment, in patients’ best interests, towards acquiescence to patient demand.
Policies should focus on different methods of allowing patients to give constructive feedback, rather than promoting worry and even fear among staff and organisations.
Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare: CG is a partner of the Hurley Group, an organisation that runs a number of practices and GP walk-in centres across London, and is medical director of the Practitioner Health Programme.