Online Reviews of Physicians Valuable Feedback, Valuable Advertising Dane Hill, MD; Steven R. Feldman, MD, PhD

This is the best time to be alive in human history. Technology has objectively improved our lives in countless ways. In dermatology, this is perhaps best exemplified by the treatments we now have for psoriasis. Just a few years ago, we would have been ecstatic for Related article page 153 a cyclosporine-like drug that did not cause renal adverse effects, but now we have biologic drugs that are far safer and more effective than we would have dreamed of. Electronics have revolutionized our lives. Smart phones give us entire libraries at our fingertips, searchable by voice command; the ability to communicate on the spot with our family, friends, and medical colleagues; and countless other ways to spend our time, productively or otherwise. We have medical technologies that can peer inside the body completely unobtrusively, and we have medical record systems that remind us of needed screenings, warn us of potential harmful interactions, and, for better and worse, put the entire medical record of a patient’s care at our disposal. Despite this, it seems we are no happier, a paradox of how the human psyche is wired. In part, we are no happier because, when it comes to happiness, technology pales in importance to human interaction. Patients’ satisfaction with us, their physicians, and the care we provide is derived largely from our relationship with them and their perceptions of how much we care about them.1 We may be great at making the right diagnosis and prescribing the right therapy very efficiently (perhaps too efficiently from the patients’ perspective), but if a patient does not feel connected to the physician in a strong patient-physician relationship, it can greatly affect their perception of the care they have received. In this issue of JAMA Dermatology, Smith and Lipoff2 present an enlightening qualitative analysis of online reviews of dermatologists, revealing the extent to which patient satisfaction is related to feeling cared for. In a high-tech, fast-paced world, patients prefer a slower, more elaborate, and thorough evaluation of their health by courteous doctors and office staff members in a clean, well-run environment. In addition, higher satisfaction scores were associated with cost cognizance, competence, empathy, and respect. This is consistent with previous patient surveys1,3 and should not be surprising to practitioners, even with the far greater emphasis paid to biochemistry, physiology, and pharmacology in medical school. What is more surprising is the striking statistic that nearly 2 out of 3 of patients felt that online reviews of physicians and/or practices were, at minimum, “somewhat” important jamadermatology.com

when choosing a physician.2 This highlights the increasingly large role that online reviewing now plays and the expanding role it will play in the future as Internet-based communications continue to become more widely used. Patients now have an expanding database of reviews that can steer them toward a physician, or away from one. Because unhappy patients are more likely to make the effort to write an online comment, some practitioners may view online reviews as a negative trend, but patient-written reviews can provide excellent, personalized feedback for physicians and practices. Patient surveys used to be slow and tedious, lacking benchmarks for comparison. With constant changes in the health care system, online surveys can provide a ready source of up-to-the-minute feedback that is unique to each area and specialty. Physicians have the opportunity to regularly collect and examine online reviews to strengthen potential weaknesses in anything from perceived skill and/or knowledge to patient interactions or office flow. Each negative comment can be a gift, helping guide the physician toward providing better care. Though every critical review may not merit a change in practice, trends of similar critiques may warrant a change that can then potentially increase patient satisfaction and clinical outcomes (since outcomes depend on adherence to treatment, and adherence depends on patients’ perception of their physicians4,5). Making adjustments in the medical practice in response to feedback can also make the physician a more sought-out practitioner, increasing patient referrals in a competitive market. While online reviews are a very fast, low-cost, and efficient way to get actionable feedback from patients, those reviews expose us and the care we provide to public scrutiny, which is a very good thing. Without transparency, all patients have is personal experience and the experience of a few friends to help them decide whether a physician might be a good fit. They also have the news. Using the news can be particularly misleading because the news nearly always reports what is new and different, not what is ordinary, normal, or relevant to the person. If we relied on the media for all our information, we would think that in order to see a physician, we would be likely to have a serious medical misadventure.6 The apocryphal Mark Twain quote seems apt: “If you don’t read the newspaper, you are uninformed. And if you do read the newspaper, you are misinformed.” Accurate, unrepresentative information can be very misleading.6,7 The Wake Forest University health care system solicits patients’ comments and makes those comments, both good and bad, freely available on the medical center’s website. The com(Reprinted) JAMA Dermatology February 2016 Volume 152, Number 2

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Opinion Editorial

ments are overwhelmingly good, despite the fact that unhappy patients are more likely to comment than happy patients. But since patients who visit the medical center are overwhelmingly happy with the care they get, the bias toward reporting negative comments is not a major issue. The representativeness of the open, solicited comments is far better than what we would get from newspaper coverage, and some would even argue that having a few negative comments is a strength, giving patients confidence that the comments are a trustworthy source of information.8 Physicians have nothing to hide. We are providing better care than ever before. The information we get from online reviews, as described in this study, will help us further optimize that care, giving us insight into our strengths and weakARTICLE INFORMATION Author Affiliations: The Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina (Hill, Feldman); Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina (Feldman); Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina (Feldman). Corresponding Author: Steven R. Feldman, MD, PhD, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1071 ([email protected]). Published Online: November 25, 2015. doi:10.1001/jamadermatol.2015.3951. Conflict of Interest Disclosures: Dr Hill is supported by a fellowship grant from Janssen. The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories LP. Dr Feldman founded and holds stock in http://www.DrScore.com, a physician and clinic rating and/or patient satisfaction website. Dr Feldman is also a founder of Causa Research and holds stock in the company. Dr Feldman holds stock in the Medical Quality Enhancement Corporation and is the majority owner of the company. Dr Feldman is a speaker for Janssen and Novartis and has received grants from Galderma Laboratories LP,


nesses, particularly in regard to how people perceive the softer side of what we do. We care about our patients and will act on this knowledge. Knowing what makes people happy with their care will allow us to give patients a subjective experience of care that is every bit as great as the technologies at our disposal for improving the objective aspects of their diseases. In addition, the public airing of subjective information on our quality of care is far more of an opportunity than a challenge. Having a representative public sample of information about us will give established and potential patients alike a far better picture of who we are and the care we provide, which is far preferable to the public relying on front page medical disaster news to gauge their impressions of the medical field.

Janssen, Abbvie, Amgen, Stiefel/GlaxoSmithKline, Celgene and Anacor. He is a consultant for Amgen, Baxter, Caremark, Gerson Lehrman Group, Guidepoint Global, Hanall Pharmaceutical Co Ltd, Lilly, Merck, Mylan, Novartis, Pfizer, Qurient, Suncare Research and Xenoport. Dr Feldman also receives Royalties from UpToDate and Xlibris. No other disclosures are reported.

3. Anderson R, Barbara A, Feldman S. What patients want: A content analysis of key qualities that influence patient satisfaction. J Med Pract Manage. 2007;22(5):255-261.

Funding/Support: This study was supported in part by The Center for Dermatology Research through a grant from Galderma.

5. Renzi C, Abeni D, Picardi A, et al. Factors associated with patient satisfaction with care among dermatological outpatients. Br J Dermatol. 2001;145(4):617-623.

Role of the Funder/Sponsor: The Center for Dermatology Research and Galderma had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. REFERENCES 1. Uhas AA, Camacho FT, Feldman SR, Balkrishnan R. The Relationship Between Physician Friendliness and Caring, and Patient Satisfaction: Findings from an Internet-Based Survey. Patient. 2008;1(2):91-96. 2. Smith RJ, Lipoff JB. Evaluation of dermatology practice online reviews: lessons from qualitative analysis [published online November 25, 2015]. JAMA Dermatol. doi:10.1001/jamadermatol.2015 .3950.

4. Carroll CL, Feldman SR, Camacho FT, Balkrishnan R. Better medication adherence results in greater improvement in severity of psoriasis. Br J Dermatol. 2004;151(4):895-897.

6. Dawn AG, Balkrishnan R, Feldman SR. Systematic selection bias: a cause of dramatic errors in the inference of treatment effectiveness. J Dermatolog Treat. 2008;19(2):68-71. 7. Feldman SR. Compartments: How the Brightest, Best Trained, and Most Caring People Can Make Judgments That are Completely & Utterly Wrong. Bloomington, IN: Xlibris Corporation; 2009. 8. Segal J. Two reasons a negative online review is paradoxically a good thing. http://us8.campaign -archive2.com/?u=864ad6113ab4a20a938d1531b& id=864c295bad&e=107c3f02a0. Accessed August 29, 2015.

JAMA Dermatology February 2016 Volume 152, Number 2 (Reprinted)

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Online Reviews of Physicians: Valuable Feedback, Valuable Advertising.

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