RESEARCH ARTICLE
An Online Review of Plastic Surgeons in Southern California Priya Lewis, BA, Emily Kobayashi, BA, and Subhas Gupta, MD, PhD, FACS Background: It has become commonplace for patients to access online reviews of physicians when making choices about health care, just as any consumer would in today's computer-dependent world. Previous studies have shown that online reviews of physicians are generally positive. However, 1 negative review has the potential to adversely affect business and reputations. Objectives: To characterize the online presence of plastic surgeons in Southern California as portrayed by physician rating websites (PRWs). Methods: An extensive online database of board-certified plastic surgeons was used to generate a list of surgeons within a 50-mile radius of Pomona, CA. Ratings from the PRWs HealthGrades.com, Vitals.com, and UCompareHealthcare. com were cataloged by number of reviews and ratings. Results: Two hundred sixty-three surgeons were evaluated with the mostrepresented cities being Beverly Hills (N = 47), Los Angeles (N = 31), and Newport Beach (N = 27). Ninety-seven percent of the surgeons were rated on at least 1 of the 3 PRWs chosen. In general, surgeons were rated highly, with a mean rating of 85%, SD, 14% (P < 0.01), with a mean of 11.0 ratings per PRW, SD 10.9 (P < 0.01). Total online ratings ranged from 0 to 222 per surgeon. The median number of total reviews was 25 and the mean rating for those surgeons above and below the median were equivocal, at 86% and 85%, respectively (P = 0.284). Conclusions: In this study, we found that plastic surgeons in Southern California have an online presence that can be influenced by their patients; they should be aware of this and conscious of their online reputations. Overall, the ratings were high, regardless of the number of reviews. Key Words: online physician ratings, physician rating websites, plastic surgery reviews (Ann Plast Surg 2015;74: S66–S70)
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rom television sets and cell phones to restaurants and movies, it is becoming harder and harder to make a decision without first polling the global online population. Current reports show that 85% of American adults use the Internet at home or work,1 and 59% say they have looked online for health information in the past year.2 Conducting a thorough investigation for a physician is a pragmatic application of a modern consumer mentality to health care. There has been a consistently increasing use of physician rating websites (PRWs) by patients.3–5 Physicians are aware of this trend and would be wise to conduct electronic “self-audits” to be knowledgeable of their online reputation, especially because these ratings are dynamic.6 A recent study showed that 69% of physicians acknowledged they had checked their profiles on a PRW, and 39% said they agreed with their rating.7 Another study found that although physicians aim to fulfill expectations, patients were least satisfied in areas that were out of the scope of physicians' or residents' control.8 This includes but is not limited to: wait times, office staff interactions, and insurance issues. Overall, studies have shown that online reviews of physicians are generally positive.4,8–10 However, the impact of 1 negative review can create an ugly blemish on an otherwise pristine reputation. This
Received August 15, 2014, and accepted for publication, after revision February 10, 2015. From the Loma Linda University, Department of Plastic Surgery, Loma Linda, CA. Conflicts of interest and sources of funding: none declared. Reprints: Subhas Gupta MD, PhD, FACS, LLU, Department of Plastic Surgery, 11175 Campus Street, Coleman Pavilion, Suite 21126, Loma Linda, CA. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7401–S066 DOI: 10.1097/SAP.0000000000000517
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negativity is virtually impossible to delete definitively. Unfortunately, most ratings are reported by a small number of patients who submit reviews.4 A study from the United Kingdom found that unsolicited comments may be more likely to include low probability but high impact events. If people have experienced extremes of care, good or bad, they are more likely to rate a physician online.8 Unlike those patients who are undergoing medically urgent procedures, many plastic surgery patients who are undergoing elective procedures have the time and opportunity to research potential surgeons. Plastic surgeons are thus subject to an especially high level of scrutiny. Furthermore, surgeons in general do not typically experience a longterm relationship with patients. It has been shown that patients may be more inclined to post ratings and comments based on a single emotionally charged encounter with a surgeon than a longstanding relationship with a generalist.9,10 Of the numerous PRWs available, Healthgrades.com is believed to be the largest ratings provider, claiming 200 million people use the company annually to research health care professionals.11 Part of the success of Healthgrades is due to the large share of the American marketplace and its affiliation with Google.12 Healthgrades is returned as one of the first Google search results with website data, including the physician's rating or number of stars, displayed directly on the Google search page. Another big advantage is that access is free and physicians can update their own profiles free of charge.12 When leaving a review for a physician, the patient must enter an email address or mobile phone number to verify the survey before it can be published online. Despite these measures to ensure fidelity, the concern remains that 1 disgruntled user will post multiple surveys. Other PRWs are similar in their approach to physician information and ratings; office and hospital addresses, insurance accepted, and number of sanctions or malpractice claims are included. Websites that are free of charge are typically advertisement supported. A limited amount of literature exists on physician online ratings. This is the first study focusing on the online evaluation of plastic surgeons. The purpose of this study is to categorize the public impression of a select population of plastic surgeons in Southern California, a generally recognized high-density area of plastic surgery practice. We hypothesize that the majority of physicians selected will be rated on at least 1 website and that the general assessment will be positive.
METHODS A list of members from the American Society of Plastic Surgeons working within a 50-mile radius of Pomona, CA was generated using the “Find a Surgeon” search feature on the website, PlasticSurgery.org. The postal code 91768 was arbitrarily chosen as a search point with a radius that reached our base institution of Loma Linda University as well as other cities with many plastic surgeons such as Beverly Hills, Los Angeles, and Newport Beach. Surgeons who had recently moved to the area and had not updated their profile on PlasticSurgery.org do not appear on the search feature and were therefore excluded from the study. The search yielded 263 board-certified plastic surgeons within the chosen geographic radius. Although not all plastic surgeons who are certified by the American Board of Plastic Surgery are members of American Society of Plastic Surgeons, the ones we focused on were duly board-certified. The PRWs included were limited to those free of charge and accessible via Google search. When manually searching for a physician Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015
Online Physician Ratings
linear regression analysis to evaluate surgeons by city was used. P values less than 0.05 were considered statistically significant.
RESULTS
FIGURE 1. Scatter plot illustrating the relationship between the number of reviews a surgeon received and the mean overall rating given.
on Google.com, the first 10 PRW results were considered the most popular. To select the PRWs to include for analysis, a sample of 8 surgeons was searched on the 10 most popular PRWs: DrScore.com, healthgrades.com, insiderpages.com, RateMDs.com, RealSelf.com, SuggestADoctor.com, thedochelps.com, UCompareHealthcare.com, Vitals.com, and Yelp. The 3 PRWs with the highest number of results were selected: HealthGrades.com, Vitals.com, and UCompareHealthcare. com. The other 7 websites were not included in this analysis because they were found to be less heavily trafficked in the population we were analyzing. These websites were reviewed comprehensively for individual ratings of surgeons. Each name on the list of 263 board-certified plastic surgeons generated from PlasticSurgery.org was manually searched by entering the name of the physician in the search field of each of the 3 PRWs. This search was conducted in September 2013. The number of reviews was recorded (number of votes), as well as the mean rating (number of “stars”). This was done for each website separately and aggregated for a total overall rating. The 4-star scale of Vitals.com was converted into a 5-star scale to match the other two PRWs by converting the number of stars to a percentage. For example, 3 stars on Vitals.com is equivalent to 75% and 3 stars on Healthgrades.com is equivalent to 60%. The data were then analyzed and the surgeons ranked by number of reviews and by mean percent rating. A favorable rating was defined as any rating of 70% or higher. Additionally, data were analyzed by city and by sex of the surgeon, using information listed on each surgeon's PlasticSurgery.org profile. Student t test for comparison of means and
Two hundred twenty-nine male and 34 female surgeons were identified with a total of 51 cities. Ninety-seven percent (256/263) of surgeons were rated on 1 of the 3 PRWs chosen. Surgeons were in general rated highly, with a mean rating of 85% (SD, 14%; median, 88%; range, 20–100%; P < 0.01). They had a mean of 11.0 ratings per surgeon across the 3 sites (SD, 10.9; median, 8.3; range, 0.3–74; P < 0.01). The majority of variation from surgeon to surgeon was in the number of reviews (σ/μ = 99%), not the mean rating (σ/μ = 16%). Ninety-four percent of surgeons with fewer than 3.5 stars (70% rating) had fewer than 20 reviews. On the other hand, 90% of the surgeons with perfect scores also had fewer than 20 reviews. Lower numbers of reviews did not forecast low ratings; linear regression analysis yielded a low coefficient of determination (R2 = 0.0035) (Fig. 1). Total online ratings ranged from 0 to 222 per surgeon. The median number of total reviews was 25 and the mean rating for those surgeons above and below the median were equivocal, at 86% and 85%, respectively (P = 0.284). Using the predetermined threshold of 70%, a total of 87.5% (224/256) of rated physicians had a positive rating. They had a mean rating of 89% (SD, 8%). The 32 surgeons with negative ratings had a lower mean number of reviews, at 7.5 versus 11.5 for those with positive ratings (P = 0.004). Fifteen of these poorly rated surgeons had less than 5 reviews on average. They also had a lower number of aggregate reviews, at 22.5 versus 34.5 for those with positive ratings (P = 0.004). The overall mean rating was 56% (SD, 11.7%). There was no statistically significant difference between female and male surgeons with regard to overall rating (P = 0.674) and overall number of reviews (P = 0.090). Both sexes had a mean overall rating of 86%. Female surgeons had a standard deviation of 13%, median of 88%, and a range of 52% to 100%. Male surgeons had a standard deviation of 14%, median of 88%, and a range of 20% to 100%. Female surgeons had 8.7 mean reviews (SD, 7.9; median, 6.2; range, 0.3–33.7), and male surgeons had 11.4 mean reviews (SD, 11.2; median, 8.7; range, 0.3–74). The most-represented cities included Beverly Hills (N = 47), Los Angeles (N = 31), and Newport Beach (N = 27). The number of plastic surgeons per city had no bearing on the mean number of reviews (R2= 0.0155) or mean rating (R2 = 0.0087) (Figs. 2 and 3). The highest represented cities were Beverly Hills, Los Angeles, and Newport Beach in descending order (Table 1).
DISCUSSION Reputation management has long been associated with public relations but is evolving to include search results, review websites, and
FIGURE 2. Linear regression with coefficient of determination showing no correlation between the number of surgeons per city and the mean number of reviews. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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FIGURE 3. Linear regression with coefficient of determination showing no correlation between the number of surgeons per city and the mean ratings.
social media.13 Fee-for-service sites are emerging that purport to scrub a business's online presence to ensure those searching will only see positive reviews and content. In America, careful crafting of online presence and reputation has become an essential part of business. The importance of this study hinges on the fact that plastic surgeons corner the surgical market on elective procedures. Consequently, their patients have many choices and competition is high, especially in southern California. This study maximized relevance by focusing on the geographic region with the densest concentration of plastic surgery practices and on the PRWs with the highest traffic from potential patients. With 97% of the surgeons in the sample radius reviewed on at least one of the sites, the prevalence of online visibility has proven to be high. The ratings were also high at 85% on average, despite the relatively low number of mean reviews. Between cities with a high or low number of plastic surgeons, there proved to be no correlation to number of reviews (Fig. 2) or mean ratings (Fig. 3). It might be deduced that, as the use of these websites increases, those with more patients will have more reviews. Future analysis might show a difference if the plastic surgeon density per capita were evaluated. An earlier study showed that for specific procedures, high-volume surgeons had better results than lowvolume surgeons and that though the number of reviews correlated with volume, the ratings did not.9 Previous studies have shown that male physicians are more likely to be reviewed and have higher ratings.3,14 However, female physicians are more likely to have professional information available on the internet than males.6 Our results show that women did have fewer reviews, 8.7 versus 11.4 for their male counterparts. Regardless, the mean rating was identical at 86%. In this specific plastic surgeon population, sex appears to play no role in patient satisfaction. Online review websites may not be the best method to assess what is truly important, clinical outcomes and safety.9 Unfortunately, staff disposition and wait times are assessed instead and can be confused for the only measures of quality health care. Formatting a patient-response survey to assess what are valid judgments on a practice can be difficult. The more questions on a PRW survey, the less likely a patient will complete the survey.10 The only question regarding medical profi0ciency on Vitals.com and UCompareHealthcare.com was whether or not the condition was diagnosed accurately. Healthgrades.com improved on this by asking the patient's level of trust for the physician, whether the physician explained the conditions well, and if they listened and answered questions. (Table 2) It can be reasoned that because most rating websites do not require the authentication of raters, online ratings may be subject to manipulation.14 Although Vitals.com had the option for free text reviews, the site did not require any sort of verification of reviewers. However, the website only allows the same computer to review a specific physician once a month. UCompareHealthcare.com also had an option for free text S68
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and a check box for reviewers to confirm they are patients. Healthgrades. com appears to be the most regulated of the three sites. They do not have an option for free text; all the survey questions are standardized. The website prevents repeat posting by asking for an email address or cell phone number to send a verification email/text before a review is posted. In keeping with the desire for greater transparency of health care and in an effort to improve quality and cost, analysis of patient feedback is growing.14 In 2011, the Center for Medicare and Medicaid Services launched the Physician Compare website, which currently displays biographical information about physicians who accept Medicare patients. Physicians who report quality measures through the voluntary Physician Quality Rating System will have their performance ratings publicly available.4,10 However, only 6% of Americans are familiar with these Center for Medicare and Medicaid Services quality measures.15 For the most part, health care ratings in America tends to be a private enterprise.16,17 In the United Kingdom, a government website exists for health care provider comparison, eliminating the need for private rating websites. The website is called National Health Service Choices and comments must adhere to a fixed set of rules; anything deemed offensive is not posted. Comments must be respectful and informative, and health care providers are encouraged to respond.15,16 Some have claimed that this system may create a selection bias towards less TABLE 1. Number of Plastic Surgeons Per City Queried on plasticsurgery.com Plastic Surgeons per City
Beverly Hills Los Angeles Newport Beach Pasadena Santa Monica Torrance Orange Encino Long Beach Huntington Beach Riverside Mission Viejo Anaheim Corona Del Mar Downey Fountain Valley Fullerton
47 31 27 13 13 11 9 7 7 5 5 4 3 3 3 3 3
Glendale Loma Linda Los Alamitos Ontario Redlands Santa Ana West Hollywood Westminster Alhambra Costa Mesa Duarte Fontana Irvine Laguna Beach Laguna Hills Manhattan Beach Marina Del Rey
3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2
San Clemente Whittier Woodland Hills Bellflower Brea Burbank Claremont Foothill Ranch Glendora Grand Terrace Lancaster Murrieta Paramount San Marino Sherman Oaks West Covina West Hills
2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015
satisfied patients.18 Also, some worry that responding to patients in a public forum could raise patient confidentiality issues.19 Nevertheless, any system where a courteous discourse between patient and physician is encouraged has the potential to relieve existing tensions and prevent damaged reputations. As previously noted, the majority of variation in this study was in the number of reviews (σ/μ = 99%), not the mean rating (σ/μ = 16%). Surgeons were generally found to be rated satisfactorily whether their online reviews were few or plentiful. Nevertheless, the worry that PRWs will be a forum for disgruntled patients to complain about minor shortcomings and, as a result, damage a physician's reputation is substantial.14 Companies have emerged that scour the internet for negative or inaccurate information and have it removed (Table 3). This service is particularly attractive to professionals that rely on the public opinion of patrons. This study is the first step in helping plastic surgeons understand the online rating marketplace. Future analysis is planned that will
TABLE 2. Content Directly from www.healthgrades.com, www.ucomparehealthcare.com, and www.vitals.com Physician Rating Website
Healthgrades
UCompareHealthcare
Vitals
Survey Questions Asked
Ease of scheduling urgent appointments Office environment, cleanliness, comfort, etc. Staff friendliness and courteousness Total wait time (waiting & exam rooms) Level of trust in provider’s decisions How well provider explains medical condition(s) How well provider listens and answers questions Spends appropriate amount of time with patients Likelihood of recommending Dr. _____ to family and friends Number of office visits you’ve had in the last 2 years Your gender Your age group What is your overall rating of this doctor? Would you recommend this doctor? How long did you wait at the office? It was easy to get an appointment The wait time was short during my visit The staff was professional and friendly My problem was accurately diagnosed The doctor spent enough time with me There was appropriate follow up after my visit Comments* Overall rating (out of 4 stars) Comments* The wait time at the office was about: Ease of Appointment Promptness Courteous Staff Accurate Diagnosis Bedside Manner Spends time with me Follows up after visit
*Free text option.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Online Physician Ratings
TABLE 3. Currently Available Reputation Management Websites Reputation Management Websites
Reputationmanagementconsultants.com Brand.com Reputation.com Integritydefender.com Reviewboost.com google.com/+/Business officialreputationmanagement.com onlinereputationcorrection.com vendasta.com removeyourname.com bazaarvoice.com Brandyourself.com
investigate the different subsets of plastic surgery practices, the number of years in practice, and the existence of a practice website.
CONCLUSIONS With the high prevalence of PRWs and the increase in their use, physicians should remain vigilant in maintaining untarnished online images. If a patient is happy with their experience, ask them to leave a review. Positive comments taken from these reviews can be used to enhance a physician's personal website. The need is emerging for medical students and residents to have training in patient satisfaction, bedside manner, and clinic management. Most importantly, maintaining an open line of communication with patients remains a key to success.
REFERENCES 1. Zickuhr K. Who’s not online and why. Pew Internet & American Life Project. 2013, http://www.pewinternet.org/Reports/2013/Non-internet-users/Summary-ofFindings.aspx, accessed on January 3, 2014. 2. Fox S, Duggan M. Health Online 2013. Pew Internet & American Life Project. 2013, http://www.pewinternet.org/Reports/2013/Health-online/Summary-of-Findings.aspx, accessed on January 3, 2014. 3. Emmert M, Meier F. An analysis of online evaluations on a physician rating website: evidence from a German public reporting instrument. J Med Internet Res. 2013;15:e157. 4. Ellimoottil C, Hart A, Greco K, et al. Online reviews of 500 urologists. J Urol. 2013;189:2269–2273. 5. Emmert M, Sander U, Pisch F. Eight questions about physician-rating websites: a systematic review. J Med Internet Res. 2013;15:e24. 6. Mostaghimi A, Crotty BH, Landon BE. The availability and nature of physician information on the internet. J Gen Intern Med. 2010;25:1152–1156. 7. Johnson C. Survey finds physicians very wary of doctor ratings. Physician Exec. 2013;39:6–8,10,12. 8. Huynh M, Lee AD, Miller LM, et al. Patients' satisfaction with dermatology residents. South Med J. 2012;105:520–523. 9. Segal J, Sacopulos M, Sheets V, et al. Online doctor reviews: do they track surgeon volume, a proxy for quality of care? J Med Internet Res. 2012;14:e50. 10. Kadry B, Chu LF, Kadry B, et al. Analysis of 4999 online physician ratings indicates that most patients give physicians a favorable rating. J Med Internet Res. 2011;13:e95. 11. Robeznieks A. The ratings game. Online physician-review sites pose legal challenges. Mod Healthc. 2012;42:32–33. 12. Gillies S, KarenZupko & Associates, Inc. Word of mouth in the digital age: online physician ratings. Am J Orthop (Belle Mead NJ). 2009;38:417–419. 13. Tozzi J. “Do Reputation Management Services Work?”. Bloomberg Businessweek (Bloomberg L.P.). 2008, http://www.businessweek.com/stories/2008-04-30/ do-reputation-management-services-work-businessweek-business-news-stock-market-and-financial-advice, accessed on January 3, 2014.
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14. Gao GG, McCullough JS, Agarwal R, et al. A changing landscape of physician quality reporting: analysis of patients' online ratings of their physicians over a 5-year period. J Med Internet Res. 2012;14:e38. 15. Lagu T, Lindenauer P. Putting the public back in public reporting of health care quality. JAMA. 2010;15:1711–1712. 16. Greaves F, Pape UJ, King D, et al. Associations between Internet-based patient ratings and conventional surveys of patient experience in the English NHS: an observational study. BMJ Qual Saf. 2012;21:600–605.
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17. Greaves F, Millett C. Consistently increasing numbers of online ratings of healthcare in England. J Med Internet Res. 2012;14:e94. 18. Greaves F, Pape UJ, Lee H, et al. Patients' ratings of family physician practices on the internet: usage and associations with conventional measures of quality in the English National Health Service. J Med Internet Res. 2012;14:e146. 19. Lagu T, Hannon N, Rothberg M, et al. Patients’ evaluations of health care providers in the era of social networking: an analysis of physician-rating websites. J Gen Int Med. 2010;25:942–946.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
An Online Review of Plastic Surgeons in Southern California Priya Lewis, BA, Emily Kobayashi, BA, and Subhas Gupta, MD, PhD, FACS Background: It has become commonplace for patients to access online reviews of physicians when making choices about health care, just as any consumer would in today's computer-dependent world. Previous studies have shown that online reviews of physicians are generally positive. However, 1 negative review has the potential to adversely affect business and reputations. Objectives: To characterize the online presence of plastic surgeons in Southern California as portrayed by physician rating websites (PRWs). Methods: An extensive online database of board-certified plastic surgeons was used to generate a list of surgeons within a 50-mile radius of Pomona, CA. Ratings from the PRWs HealthGrades.com, Vitals.com, and UCompareHealthcare. com were cataloged by number of reviews and ratings. Results: Two hundred sixty-three surgeons were evaluated with the mostrepresented cities being Beverly Hills (N = 47), Los Angeles (N = 31), and Newport Beach (N = 27). Ninety-seven percent of the surgeons were rated on at least 1 of the 3 PRWs chosen. In general, surgeons were rated highly, with a mean rating of 85%, SD, 14% (P < 0.01), with a mean of 11.0 ratings per PRW, SD 10.9 (P < 0.01). Total online ratings ranged from 0 to 222 per surgeon. The median number of total reviews was 25 and the mean rating for those surgeons above and below the median were equivocal, at 86% and 85%, respectively (P = 0.284). Conclusions: In this study, we found that plastic surgeons in Southern California have an online presence that can be influenced by their patients; they should be aware of this and conscious of their online reputations. Overall, the ratings were high, regardless of the number of reviews. Key Words: online physician ratings, physician rating websites, plastic surgery reviews (Ann Plast Surg 2015;74: S66–S70)
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rom television sets and cell phones to restaurants and movies, it is becoming harder and harder to make a decision without first polling the global online population. Current reports show that 85% of American adults use the Internet at home or work,1 and 59% say they have looked online for health information in the past year.2 Conducting a thorough investigation for a physician is a pragmatic application of a modern consumer mentality to health care. There has been a consistently increasing use of physician rating websites (PRWs) by patients.3–5 Physicians are aware of this trend and would be wise to conduct electronic “self-audits” to be knowledgeable of their online reputation, especially because these ratings are dynamic.6 A recent study showed that 69% of physicians acknowledged they had checked their profiles on a PRW, and 39% said they agreed with their rating.7 Another study found that although physicians aim to fulfill expectations, patients were least satisfied in areas that were out of the scope of physicians' or residents' control.8 This includes but is not limited to: wait times, office staff interactions, and insurance issues. Overall, studies have shown that online reviews of physicians are generally positive.4,8–10 However, the impact of 1 negative review can create an ugly blemish on an otherwise pristine reputation. This
Received August 15, 2014, and accepted for publication, after revision February 10, 2015. From the Loma Linda University, Department of Plastic Surgery, Loma Linda, CA. Conflicts of interest and sources of funding: none declared. Reprints: Subhas Gupta MD, PhD, FACS, LLU, Department of Plastic Surgery, 11175 Campus Street, Coleman Pavilion, Suite 21126, Loma Linda, CA. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7401–S066 DOI: 10.1097/SAP.0000000000000517
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negativity is virtually impossible to delete definitively. Unfortunately, most ratings are reported by a small number of patients who submit reviews.4 A study from the United Kingdom found that unsolicited comments may be more likely to include low probability but high impact events. If people have experienced extremes of care, good or bad, they are more likely to rate a physician online.8 Unlike those patients who are undergoing medically urgent procedures, many plastic surgery patients who are undergoing elective procedures have the time and opportunity to research potential surgeons. Plastic surgeons are thus subject to an especially high level of scrutiny. Furthermore, surgeons in general do not typically experience a longterm relationship with patients. It has been shown that patients may be more inclined to post ratings and comments based on a single emotionally charged encounter with a surgeon than a longstanding relationship with a generalist.9,10 Of the numerous PRWs available, Healthgrades.com is believed to be the largest ratings provider, claiming 200 million people use the company annually to research health care professionals.11 Part of the success of Healthgrades is due to the large share of the American marketplace and its affiliation with Google.12 Healthgrades is returned as one of the first Google search results with website data, including the physician's rating or number of stars, displayed directly on the Google search page. Another big advantage is that access is free and physicians can update their own profiles free of charge.12 When leaving a review for a physician, the patient must enter an email address or mobile phone number to verify the survey before it can be published online. Despite these measures to ensure fidelity, the concern remains that 1 disgruntled user will post multiple surveys. Other PRWs are similar in their approach to physician information and ratings; office and hospital addresses, insurance accepted, and number of sanctions or malpractice claims are included. Websites that are free of charge are typically advertisement supported. A limited amount of literature exists on physician online ratings. This is the first study focusing on the online evaluation of plastic surgeons. The purpose of this study is to categorize the public impression of a select population of plastic surgeons in Southern California, a generally recognized high-density area of plastic surgery practice. We hypothesize that the majority of physicians selected will be rated on at least 1 website and that the general assessment will be positive.
METHODS A list of members from the American Society of Plastic Surgeons working within a 50-mile radius of Pomona, CA was generated using the “Find a Surgeon” search feature on the website, PlasticSurgery.org. The postal code 91768 was arbitrarily chosen as a search point with a radius that reached our base institution of Loma Linda University as well as other cities with many plastic surgeons such as Beverly Hills, Los Angeles, and Newport Beach. Surgeons who had recently moved to the area and had not updated their profile on PlasticSurgery.org do not appear on the search feature and were therefore excluded from the study. The search yielded 263 board-certified plastic surgeons within the chosen geographic radius. Although not all plastic surgeons who are certified by the American Board of Plastic Surgery are members of American Society of Plastic Surgeons, the ones we focused on were duly board-certified. The PRWs included were limited to those free of charge and accessible via Google search. When manually searching for a physician Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015
Online Physician Ratings
linear regression analysis to evaluate surgeons by city was used. P values less than 0.05 were considered statistically significant.
RESULTS
FIGURE 1. Scatter plot illustrating the relationship between the number of reviews a surgeon received and the mean overall rating given.
on Google.com, the first 10 PRW results were considered the most popular. To select the PRWs to include for analysis, a sample of 8 surgeons was searched on the 10 most popular PRWs: DrScore.com, healthgrades.com, insiderpages.com, RateMDs.com, RealSelf.com, SuggestADoctor.com, thedochelps.com, UCompareHealthcare.com, Vitals.com, and Yelp. The 3 PRWs with the highest number of results were selected: HealthGrades.com, Vitals.com, and UCompareHealthcare. com. The other 7 websites were not included in this analysis because they were found to be less heavily trafficked in the population we were analyzing. These websites were reviewed comprehensively for individual ratings of surgeons. Each name on the list of 263 board-certified plastic surgeons generated from PlasticSurgery.org was manually searched by entering the name of the physician in the search field of each of the 3 PRWs. This search was conducted in September 2013. The number of reviews was recorded (number of votes), as well as the mean rating (number of “stars”). This was done for each website separately and aggregated for a total overall rating. The 4-star scale of Vitals.com was converted into a 5-star scale to match the other two PRWs by converting the number of stars to a percentage. For example, 3 stars on Vitals.com is equivalent to 75% and 3 stars on Healthgrades.com is equivalent to 60%. The data were then analyzed and the surgeons ranked by number of reviews and by mean percent rating. A favorable rating was defined as any rating of 70% or higher. Additionally, data were analyzed by city and by sex of the surgeon, using information listed on each surgeon's PlasticSurgery.org profile. Student t test for comparison of means and
Two hundred twenty-nine male and 34 female surgeons were identified with a total of 51 cities. Ninety-seven percent (256/263) of surgeons were rated on 1 of the 3 PRWs chosen. Surgeons were in general rated highly, with a mean rating of 85% (SD, 14%; median, 88%; range, 20–100%; P < 0.01). They had a mean of 11.0 ratings per surgeon across the 3 sites (SD, 10.9; median, 8.3; range, 0.3–74; P < 0.01). The majority of variation from surgeon to surgeon was in the number of reviews (σ/μ = 99%), not the mean rating (σ/μ = 16%). Ninety-four percent of surgeons with fewer than 3.5 stars (70% rating) had fewer than 20 reviews. On the other hand, 90% of the surgeons with perfect scores also had fewer than 20 reviews. Lower numbers of reviews did not forecast low ratings; linear regression analysis yielded a low coefficient of determination (R2 = 0.0035) (Fig. 1). Total online ratings ranged from 0 to 222 per surgeon. The median number of total reviews was 25 and the mean rating for those surgeons above and below the median were equivocal, at 86% and 85%, respectively (P = 0.284). Using the predetermined threshold of 70%, a total of 87.5% (224/256) of rated physicians had a positive rating. They had a mean rating of 89% (SD, 8%). The 32 surgeons with negative ratings had a lower mean number of reviews, at 7.5 versus 11.5 for those with positive ratings (P = 0.004). Fifteen of these poorly rated surgeons had less than 5 reviews on average. They also had a lower number of aggregate reviews, at 22.5 versus 34.5 for those with positive ratings (P = 0.004). The overall mean rating was 56% (SD, 11.7%). There was no statistically significant difference between female and male surgeons with regard to overall rating (P = 0.674) and overall number of reviews (P = 0.090). Both sexes had a mean overall rating of 86%. Female surgeons had a standard deviation of 13%, median of 88%, and a range of 52% to 100%. Male surgeons had a standard deviation of 14%, median of 88%, and a range of 20% to 100%. Female surgeons had 8.7 mean reviews (SD, 7.9; median, 6.2; range, 0.3–33.7), and male surgeons had 11.4 mean reviews (SD, 11.2; median, 8.7; range, 0.3–74). The most-represented cities included Beverly Hills (N = 47), Los Angeles (N = 31), and Newport Beach (N = 27). The number of plastic surgeons per city had no bearing on the mean number of reviews (R2= 0.0155) or mean rating (R2 = 0.0087) (Figs. 2 and 3). The highest represented cities were Beverly Hills, Los Angeles, and Newport Beach in descending order (Table 1).
DISCUSSION Reputation management has long been associated with public relations but is evolving to include search results, review websites, and
FIGURE 2. Linear regression with coefficient of determination showing no correlation between the number of surgeons per city and the mean number of reviews. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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FIGURE 3. Linear regression with coefficient of determination showing no correlation between the number of surgeons per city and the mean ratings.
social media.13 Fee-for-service sites are emerging that purport to scrub a business's online presence to ensure those searching will only see positive reviews and content. In America, careful crafting of online presence and reputation has become an essential part of business. The importance of this study hinges on the fact that plastic surgeons corner the surgical market on elective procedures. Consequently, their patients have many choices and competition is high, especially in southern California. This study maximized relevance by focusing on the geographic region with the densest concentration of plastic surgery practices and on the PRWs with the highest traffic from potential patients. With 97% of the surgeons in the sample radius reviewed on at least one of the sites, the prevalence of online visibility has proven to be high. The ratings were also high at 85% on average, despite the relatively low number of mean reviews. Between cities with a high or low number of plastic surgeons, there proved to be no correlation to number of reviews (Fig. 2) or mean ratings (Fig. 3). It might be deduced that, as the use of these websites increases, those with more patients will have more reviews. Future analysis might show a difference if the plastic surgeon density per capita were evaluated. An earlier study showed that for specific procedures, high-volume surgeons had better results than lowvolume surgeons and that though the number of reviews correlated with volume, the ratings did not.9 Previous studies have shown that male physicians are more likely to be reviewed and have higher ratings.3,14 However, female physicians are more likely to have professional information available on the internet than males.6 Our results show that women did have fewer reviews, 8.7 versus 11.4 for their male counterparts. Regardless, the mean rating was identical at 86%. In this specific plastic surgeon population, sex appears to play no role in patient satisfaction. Online review websites may not be the best method to assess what is truly important, clinical outcomes and safety.9 Unfortunately, staff disposition and wait times are assessed instead and can be confused for the only measures of quality health care. Formatting a patient-response survey to assess what are valid judgments on a practice can be difficult. The more questions on a PRW survey, the less likely a patient will complete the survey.10 The only question regarding medical profi0ciency on Vitals.com and UCompareHealthcare.com was whether or not the condition was diagnosed accurately. Healthgrades.com improved on this by asking the patient's level of trust for the physician, whether the physician explained the conditions well, and if they listened and answered questions. (Table 2) It can be reasoned that because most rating websites do not require the authentication of raters, online ratings may be subject to manipulation.14 Although Vitals.com had the option for free text reviews, the site did not require any sort of verification of reviewers. However, the website only allows the same computer to review a specific physician once a month. UCompareHealthcare.com also had an option for free text S68
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and a check box for reviewers to confirm they are patients. Healthgrades. com appears to be the most regulated of the three sites. They do not have an option for free text; all the survey questions are standardized. The website prevents repeat posting by asking for an email address or cell phone number to send a verification email/text before a review is posted. In keeping with the desire for greater transparency of health care and in an effort to improve quality and cost, analysis of patient feedback is growing.14 In 2011, the Center for Medicare and Medicaid Services launched the Physician Compare website, which currently displays biographical information about physicians who accept Medicare patients. Physicians who report quality measures through the voluntary Physician Quality Rating System will have their performance ratings publicly available.4,10 However, only 6% of Americans are familiar with these Center for Medicare and Medicaid Services quality measures.15 For the most part, health care ratings in America tends to be a private enterprise.16,17 In the United Kingdom, a government website exists for health care provider comparison, eliminating the need for private rating websites. The website is called National Health Service Choices and comments must adhere to a fixed set of rules; anything deemed offensive is not posted. Comments must be respectful and informative, and health care providers are encouraged to respond.15,16 Some have claimed that this system may create a selection bias towards less TABLE 1. Number of Plastic Surgeons Per City Queried on plasticsurgery.com Plastic Surgeons per City
Beverly Hills Los Angeles Newport Beach Pasadena Santa Monica Torrance Orange Encino Long Beach Huntington Beach Riverside Mission Viejo Anaheim Corona Del Mar Downey Fountain Valley Fullerton
47 31 27 13 13 11 9 7 7 5 5 4 3 3 3 3 3
Glendale Loma Linda Los Alamitos Ontario Redlands Santa Ana West Hollywood Westminster Alhambra Costa Mesa Duarte Fontana Irvine Laguna Beach Laguna Hills Manhattan Beach Marina Del Rey
3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2
San Clemente Whittier Woodland Hills Bellflower Brea Burbank Claremont Foothill Ranch Glendora Grand Terrace Lancaster Murrieta Paramount San Marino Sherman Oaks West Covina West Hills
2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1
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Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015
satisfied patients.18 Also, some worry that responding to patients in a public forum could raise patient confidentiality issues.19 Nevertheless, any system where a courteous discourse between patient and physician is encouraged has the potential to relieve existing tensions and prevent damaged reputations. As previously noted, the majority of variation in this study was in the number of reviews (σ/μ = 99%), not the mean rating (σ/μ = 16%). Surgeons were generally found to be rated satisfactorily whether their online reviews were few or plentiful. Nevertheless, the worry that PRWs will be a forum for disgruntled patients to complain about minor shortcomings and, as a result, damage a physician's reputation is substantial.14 Companies have emerged that scour the internet for negative or inaccurate information and have it removed (Table 3). This service is particularly attractive to professionals that rely on the public opinion of patrons. This study is the first step in helping plastic surgeons understand the online rating marketplace. Future analysis is planned that will
TABLE 2. Content Directly from www.healthgrades.com, www.ucomparehealthcare.com, and www.vitals.com Physician Rating Website
Healthgrades
UCompareHealthcare
Vitals
Survey Questions Asked
Ease of scheduling urgent appointments Office environment, cleanliness, comfort, etc. Staff friendliness and courteousness Total wait time (waiting & exam rooms) Level of trust in provider’s decisions How well provider explains medical condition(s) How well provider listens and answers questions Spends appropriate amount of time with patients Likelihood of recommending Dr. _____ to family and friends Number of office visits you’ve had in the last 2 years Your gender Your age group What is your overall rating of this doctor? Would you recommend this doctor? How long did you wait at the office? It was easy to get an appointment The wait time was short during my visit The staff was professional and friendly My problem was accurately diagnosed The doctor spent enough time with me There was appropriate follow up after my visit Comments* Overall rating (out of 4 stars) Comments* The wait time at the office was about: Ease of Appointment Promptness Courteous Staff Accurate Diagnosis Bedside Manner Spends time with me Follows up after visit
*Free text option.
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Online Physician Ratings
TABLE 3. Currently Available Reputation Management Websites Reputation Management Websites
Reputationmanagementconsultants.com Brand.com Reputation.com Integritydefender.com Reviewboost.com google.com/+/Business officialreputationmanagement.com onlinereputationcorrection.com vendasta.com removeyourname.com bazaarvoice.com Brandyourself.com
investigate the different subsets of plastic surgery practices, the number of years in practice, and the existence of a practice website.
CONCLUSIONS With the high prevalence of PRWs and the increase in their use, physicians should remain vigilant in maintaining untarnished online images. If a patient is happy with their experience, ask them to leave a review. Positive comments taken from these reviews can be used to enhance a physician's personal website. The need is emerging for medical students and residents to have training in patient satisfaction, bedside manner, and clinic management. Most importantly, maintaining an open line of communication with patients remains a key to success.
REFERENCES 1. Zickuhr K. Who’s not online and why. Pew Internet & American Life Project. 2013, http://www.pewinternet.org/Reports/2013/Non-internet-users/Summary-ofFindings.aspx, accessed on January 3, 2014. 2. Fox S, Duggan M. Health Online 2013. Pew Internet & American Life Project. 2013, http://www.pewinternet.org/Reports/2013/Health-online/Summary-of-Findings.aspx, accessed on January 3, 2014. 3. Emmert M, Meier F. An analysis of online evaluations on a physician rating website: evidence from a German public reporting instrument. J Med Internet Res. 2013;15:e157. 4. Ellimoottil C, Hart A, Greco K, et al. Online reviews of 500 urologists. J Urol. 2013;189:2269–2273. 5. Emmert M, Sander U, Pisch F. Eight questions about physician-rating websites: a systematic review. J Med Internet Res. 2013;15:e24. 6. Mostaghimi A, Crotty BH, Landon BE. The availability and nature of physician information on the internet. J Gen Intern Med. 2010;25:1152–1156. 7. Johnson C. Survey finds physicians very wary of doctor ratings. Physician Exec. 2013;39:6–8,10,12. 8. Huynh M, Lee AD, Miller LM, et al. Patients' satisfaction with dermatology residents. South Med J. 2012;105:520–523. 9. Segal J, Sacopulos M, Sheets V, et al. Online doctor reviews: do they track surgeon volume, a proxy for quality of care? J Med Internet Res. 2012;14:e50. 10. Kadry B, Chu LF, Kadry B, et al. Analysis of 4999 online physician ratings indicates that most patients give physicians a favorable rating. J Med Internet Res. 2011;13:e95. 11. Robeznieks A. The ratings game. Online physician-review sites pose legal challenges. Mod Healthc. 2012;42:32–33. 12. Gillies S, KarenZupko & Associates, Inc. Word of mouth in the digital age: online physician ratings. Am J Orthop (Belle Mead NJ). 2009;38:417–419. 13. Tozzi J. “Do Reputation Management Services Work?”. Bloomberg Businessweek (Bloomberg L.P.). 2008, http://www.businessweek.com/stories/2008-04-30/ do-reputation-management-services-work-businessweek-business-news-stock-market-and-financial-advice, accessed on January 3, 2014.
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14. Gao GG, McCullough JS, Agarwal R, et al. A changing landscape of physician quality reporting: analysis of patients' online ratings of their physicians over a 5-year period. J Med Internet Res. 2012;14:e38. 15. Lagu T, Lindenauer P. Putting the public back in public reporting of health care quality. JAMA. 2010;15:1711–1712. 16. Greaves F, Pape UJ, King D, et al. Associations between Internet-based patient ratings and conventional surveys of patient experience in the English NHS: an observational study. BMJ Qual Saf. 2012;21:600–605.
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17. Greaves F, Millett C. Consistently increasing numbers of online ratings of healthcare in England. J Med Internet Res. 2012;14:e94. 18. Greaves F, Pape UJ, Lee H, et al. Patients' ratings of family physician practices on the internet: usage and associations with conventional measures of quality in the English National Health Service. J Med Internet Res. 2012;14:e146. 19. Lagu T, Hannon N, Rothberg M, et al. Patients’ evaluations of health care providers in the era of social networking: an analysis of physician-rating websites. J Gen Int Med. 2010;25:942–946.
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
