Over the past several years, online rating services for everything from restaurants and resorts to contractors to medical professionals have grown in popularity. Online physician rating sites have proliferated— sometimes on the same sites as restaurant ratings—and are here to stay. Rating sites are popular with patients, perhaps due in part to the fact that sites appear on the first page of web search results for physicians and very often outrank the physician's own website. A Wall Street Journal poll indicates that more than 90 percent of patients value doctor rating sites.¹

Rating companies have varied functions, including rating doctors based on ease of appointments, bedside manner, wait time, courteous staffing, helpfulness, knowledge, accurate diagnosis, accessibility of parking, and time spent with the physician. In theory, physician rating sites could be beneficial. Ideally, those professionals who emphasize high quality care and a great patient experience would rank high on these sites and prospective patients would be drawn to them, while providers who don't perform as well would fall in the rankings. But this is not the reality.

Significant Concerns

One problem with physician rating sites, and rating sites for any professionals for that matter, is the lack of objectivity in most ratings and the challenge of a lay person objectively assessing a medical professional. While most people may have similar standards for a cold meal or an unreasonable wait to be seated at a restaurant, consensus regarding healthcare may be more elusive. Did a physician perform poorly if the first prescription did not completely resolve a patient's acne? If the patient goes to another physician and receives a different therapy or diagnosis, does that mean the first physician was “wrong”? Does refusing to provide a particular cosmetic therapy make the physician a responsible provider or an overbearing know-it-all?

Worse than the lack of objectivity on most rating sites is the fact that they allow anonymous postings. Anyone can say anything without repercussion. Individuals who would be more likely to demonstrate honesty and integrity when their name is on the line may not feel similar pressure when posting anonymously. And yet, favorable response to rating sites suggests that visitors will believe what they read online when it comes from apparently independent sources.

With anonymous posting, there is no way to know whether the individual posting is actually a patient. A competitor could post comments on a site in efforts to deter patients from your practice. Worse, a disgruntled former employee, family member, or former friend could post negative comments, posing as dissatisfied patients. Sometimes negative comments are personal and have little to do with the physician's professional skill; One doctor had a disgruntled family member who wanted money and posted complaints online. There are anecdotal reports of medical professionals using anonymous posts to make wild accusations against competitors, including claims of sexual impropriety.

The Bad News

It appears generally that disgruntled patients are more likely to write negative ratings than contented patients are to post a positive review, though this is not always the case. It may also be true that negative reviews seem more “dramatic” and therefore attract more of a site visitor's attention than a positive comment, though this is not proven.

As noted, it is possible for competitors to add to the negative speak on the Internet. If the anonymity of posters is problematic, so too is the “Faceless” nature of many of the rating sites themselves. It may be difficult as a physician to contact the site to attempt to correct erroneous or negative postings. Gaining access to a customer service professional does not guarantee that problems will be addressed.

Some websites have been accused of deleting positive information if physicians do not advertise on their site. A lawsuit filed in a Los Angeles federal court last year alleged that a local Yelp sales person told a merchant that negative reviews could be removed only if that merchant purchased advertising with the site. That case was dismissed, but it was revealed at the time that Yelp had previously had a policy that allowed advertising merchants to highlight a positive review at the top of their page; this option has been withdrawn.²

A Ratemd.com survey indicates that doctors who get some very low ratings (one-star ratings) may be more likely to be sued.

The Worse News

Your online reputation can be built beyond the rating sites. A patient's entire experience in a practice can be videotaped, and negative information can be posted on YouTube, for example. A video that goes viral could be viewed by thousands of people. As with negative reviews, extreme videos and comments seem to get more attention (think Charlie Sheen and Tiger Blood).

Misguided efforts to improve your reputation can turn into negative publicity for your practice. For example, if you anonymously post positive comments about yourself to online rating services, you could be caught and exposed with more negative repercussions.

Good News…Finally

There is good news, though: You can defend your reputation online. It is not necessarily difficult to do, but it does require effort and know-how.

The first step is to try to identify the source of negative comments if you can. The sites are anonymous, but certain details may be specific to an incident or case you easily recognize. Some patients voluntarily give their initials or their names on the sites. For example, one of my patients posted her unusual first name and first letter of her surname with a complaint on a doctor site. When called and confronted, she denied posting, and agreed that I could ask Google to take the comments down. Because I affirmed to Google that I had no other patients with this first name, they accepted her consent to retract the comments.

A patient in collections for failure to pay may purposefully tip their hand in a negative comment, thinking that you'll ask them to retract their comments in exchange for cancelling their debt. Do not allow yourself to be bullied. If you can identify the source of inaccurate or unfair posts, contact them, but don't feel pressured to offer anything to the patient for retracting false information.

The Bigger Picture

More important and likely more effective than countering individual reviews is to focus on building your reputation and “managing the message.” When patients send you fabulous letters about how great you and your practice are, call them and ask if you can post their letter on your website with their initials. Using initials helps lend legitimacy, and viewers are less likely to think the letters are contrived.

Put a scrap book (photo album) in your waiting room with letters from your satisfied patient base. Simply redact any personally identifying information from the letter author, unless, of course, they give specific consent for you to share the letter.

Don't wait for random patients to post comments on rating sites. Instead, recruit patients that are willing to post positive comments about you on any of the aforementioned websites. You don't have to fish for compliments. When a patient offers praise, simply say, “Thank you. Would you be willing to post your comments on RateMD?” or “We are trying to build up our comments on RateMD. Would you mind posting that?” You need not feel uncomfortable asking patients to post a positive comment they voluntarily shared with you. If you do feel awkward, perhaps staff members can be prepared to step in and ask them to post. Follow up with patients two days later to make sure they actually posted the positive comments.

A less effective but possibly more comfortable approach is an indirect one. Simply say, “Thank you! That's the kind of comment I'd love to read online.” Every positive comment you and your practice receive pushes any negative comment farther down the page (or better yet, to the next page). Strive to receive 25 positive postings for each doctor and 10 for each PA or NP every two to three months.

Simple Steps

Put a “Meet the Doctor” section on your website with a smiling, not-too-serious picture of yourself. List your hobbies and details that humanize you.

Be sensitive to potentially troublesome patients and keep an eye out for difficult personalities. The person that demands free services or is seductive is the one with whom you need to be particularly cautious. If you cannot avoid initiating a patient-doctor relationship, tread carefully throughout the course of care.

Be polite, non-threatening, and professional at all times. Never yell at a patient or anyone in your practice; A patient could be recording you and footage of your outburst could appear on the Internet without context.

It goes without saying: Do not enter into inappropriate romantic or sexual relationships with a patient.

Never, ever go after a competitor by posting negative comments about them on the Internet. Posting lies is unethical. Legitimate concerns are better handled via professional channels, rather than on the Internet.

Move Forward Proactively

Proactively establish your presence on social media sites, like Facebook and Twitter. Use these to highlight your skills and services and demonstrate your professional knowledge. Emphasize aspects of your practice that differentiate you from the competition. Be sure all posts are professional and reflect the tone of your practice.

You can also drive positive conversation by starting a blog to showcase your work and patient successes. Use the blog to publicize some of the positive comments you've heard from patients. Consider discussing ways that you strive to meet patients' needs and/or have achieved patient satisfaction in your practice. For example, “A patient came to my practice who wanted to erase 10 years, but she didn't want any laser procedures, and she had a very tight budget…” Then describe how you worked with the patient to develop a therapeutic strategy that satisfied her needs.

Consider implementing a custom YouTube channel to feature interviews with your patients and, of course, videos of yourself discussing your approach to care and your expertise.

If you receive any awards or recognition, highlight these accolades on your website, as well. Similarly, if you've received special training, advertise this. Also, highlight any work that you do educating peers and any press appearances you do, including TV spots or publication interviews.

These strategies create a baseline of positive content to counter any negative comment that comes up.³

Make Satisfaction a Goal

Finally, establish and publicize a patient satisfaction policy that • explains your philosophy of patient care, • highlights patients' rights and expectations, and • provides specific and direct contact information for patients who are not satisfied with service. Such a policy may be particularly apropos for cosmetic procedures but can apply to medical patients, as well. Importantly, the contact information provided must allow for rapid response (have a designated voicemail box for after-hours or busy time complaint calls and return these as quickly as possible). Assign a staff member to handle patient complaints and be sure that they follow through on every complaint or question.

Establish internal policies for addressing various concerns. Many problems can probably be managed without your direct involvement. Determine in advance which types of complaints will require your oversight or you want to be made aware of. Think about costs in context. It is often much less costly to provide a filler patient a “touchup” than to counter negative publicity.

Of course, some patients simply cannot be satisfied. If the patient does not have a legitimate complaint, do not be bullied into providing free services in efforts to make them happy.

You might also consider in-office or post-appointment surveys of your own. These can be done electronically, and your overall satisfaction score can be publicized on your website. A patient who feels that he or she had the opportunity to tell you that he/she is unhappy may not feel the need to publish their dissatisfaction online for the world to see. Again, if you distribute a survey, it is essential to follow-through. A complaint or concern requires follow-up.

Reputation Management Companies

Third party companies can be contracted to assist with reputation defense. A marketing consultancy company like Infogroup (inforgroup.com) can assist with all social media implementation and help establish that important baseline positive message. They can help create a consistent image for you and your practice across multiple platforms (website, social media, print and web ads, etc.).

Stellarreputations.com offers negative reputation repair for $100 a month. The company pledges to remove the negative press from the first page of search engine results. Reputation Defender charges up to $10,000 annually, depending on the business needs.

You may not need a reputation defender, but you do need to monitor the chatter. There are free tools that can help. At a minimum, set up a Google alerts for your, your practice, your industry, and locality. You can set alerts to be sent daily or weekly, and you'll be notified when your name appears online.

Computer dual verification technology is forthcoming that will level the playing field and ensure that your competitors are kept out of your online assessments.³

Stay Positive

Rating sites are a reality that physicians must confront. The best strategy to counter negative ratings is to be proactive. Update your website and use social media to establish your presence on the Internet. Have your many loyal patients post their upbeat comments on the different rating sites. Humanize yourself online with descriptions of hobbies and a casual smiling picture of yourself.

Designate someone in your office to monitor any negative speak and be prepared to act. It may take some time and energy, but you can work with comment posters (if identifiable) or rating sites to remove inaccurate or potentially damaging comments. Third-party reputation management services may be an option for some practices. Gag order waivers are flawed and probably not an ideal option.

Establish a satisfaction policy and develop specific steps for addressing possible patient complaints.

In your daily practice, always maintain the highest levels of professionalism and emphasize top-quality care. Never yell at patients or make negative or disparaging comments (you could be taped and publicized without your knowledge). Continue to establish yourself every day as the top doctor you are.

Dr. Downie has no relevant disclosures.

Jeanine Downie, MD, FAAD is Director, image Dermatology^® PC in Montclair, NJ and Assistant Attending Physician at Mountainside and Overlook Hospitals.

1. http://online.wsj.com/article/SO120292044107465659.html
2. http://www.pcworld.com/article/242708/lawsuit_accusing_yelp_of_extorting_businesses_is_dismissed.html
3. Jesitus, J. Internet Savvy. Dermatology Times, February 2011

Take Home Tips

Online physician rating sites have proliferated and are here to stay. More than 90 percent of patients say they value doctor rating sites. Worse than lack of objectivity on most rating sites is anonymous postings. You can defend your reputation online. It is not necessarily difficult to do, but it does require effort and know-how. Try to have inaccurate or damaging reviews removed. More important and likely more effective than countering individual reviews is to focus on building your reputation and “managing the message.” Proactively establish your presence on social media sites, like Facebook and Twitter. Use these to highlight your skills and services and demonstrate your professional knowledge. Establish, publicize, and implement a patient satisfaction policy.

What About Gag Order Waivers?

Gag order waivers can be obtained for a fee from companies like medicaljustice.com. By signing one of these orders, a patient agrees not to post online comments about the doctor if they are not satisfied with their care.

There can be drawbacks. Not all patients will agree to sign these waivers. Furthermore, the use of waivers can make the physicians appear overly anxious and does not prevent dissatisfied patients from posting anonymous comments or speaking with their friends, family, other physicians, lawyers or credentialing committees.

What About employee Social Media Use?

Employers have the ability to regulate and restrict employees' personal Internet use during working hours and when using company hardware and connections. Communications sent using company resources are not considered private. Furthermore, employees should not represent themselves in a professional context or on behalf of their employer unless directed to act in an official capacity. Seek legal counsel in developing formal policies; Multiple guidelines provide guidance (See below).

Employee Privacy
According to the Ohio State Medical Association's (OSMA) comprehensive Social Networking and the Medical Practice, “The general rule is that employers can check email that is written on the company property or that used the company's email account.”

It is best to have a privacy policy in place and to clarify privacy standards for all employees. According to the OSMA, this includes informing employees: Whether the company maintains a policy banning personal or objectionable use; Whether the company monitors the use of the employee's computer or email; Whether third parties have a right of access to the computer or emails.

Furthermore, employers should state whether they advise employees of privacy policies and have patients sign a form indicating that they have read and received the policy.

Patient Privacy
HIPAA privacy rule violations by current employees have implications for employers, notes the ECRI Institute. They recommend training on privacy and associated protocols for all employees. Have employees sign an acknowledgment that they received training and that they understand obligations.

Potential violations by former employees are an additional area of concern. Generally the previous employer is not liable for the former employee's violation, but if there is evidence that the individual never received HIPAA education, the former employer could be held liable. If a practice becomes aware of a violation by a former employee, they should take action.

—PD Staff

Social Media Policy Resources
AMA Policy: Professionalism in the Use of Social Media
• www.ama-assn.org/ama/pub/meeting/ professionalism-social-media.shtml
ECRI Institute Healthcare Risk Control: Social Media in Healthcare
• www.ecri.org/EmailResources/HRC/eSource/AdSup4.pdf Mayo Clinic Center for Social Media
• http://socialmedia.mayoclinic.org/
Ohio State Medical Association Social Networking and the Medical Practice
• http://www.osma.org/files/documents/tools-and-resources/ running-a-practice/social-media-policy.pdf
Social Media Governance Policy Database
• http://socialmediagovernance.com/ policies.php?f=4#axzz1ntH4OcUI