Ugh, I've Been Yelp'd!

Dr. Dayan, I hate to tell you this but a negative review just posted,” my social media manager blared out to me recently. “Ugh…what a sinking feeling,” I thought. Talk about feeling like a total failure. I try hard to make every patient happy, and it hurts when I have failed. I still haven’t developed thick alligator skin callousing me enough to detach emotionally. I am deflated. But I recognize it is a necessary discomfort to view all criticisms. And if I am honest with myself there are times when my team and I could do things better. For that reason I believe reviews can serve a positive purpose for medicine and me in particular. So I jump into the deep end of a cold pool of words… but this time I quickly realize something. These frigid words can’t be true! I’ve never rented a laser and even more confirming: I wasn’t even in practice in 1996! This must be a fake review!

This is not the first time we have noticed this from the bowels of these on-line review sites, and I am not the only one. According to a Harvard Business School study, up to 16 percent of Yelp restaurant reviews submitted may be fake and are screened out.¹ According to a working paper from the Harvard Business School, fake reviews are often based on economic forces, and restaurants subject to increased competition are more likely to get phony negative reviews.1 Over the last few years that we have been monitoring our social media mentions, we have noticed many reviews that are impossible to be authentic. I have been cited as performing a procedure on a day when I can prove I was out of town, or the nameless allegedly maimed complained about a disastrous outcome from a procedure that I don’t even do. So on Yelp alone we have flagged and protested seven seemingly phony one-star reviews of which three have been taken down. The other four, Yelp in its self-assigned roles as judge, jury, and executioner, believes meet its secretive vetting criteria. Therefore, they refused to take these reviews down—including the one about a procedure allegedly done before I was even in practice!

Yelp’s response to our protest: “We’re writing to let know that we … evaluated {the} review… that you recently flagged. We decided at that time to leave it up after carefully assessing it against our Content Guidelines.”

Carefully assessing it? You have got to be kidding me! Doesn’t it seem a little suspicious when a person posts a negative review 19 years after the fact? This can’t be fair. So I contacted an attorney who specializes in reputation management to inquire about options. But to my dismay he told me, “As a practical matter, Yelp has repeatedly refused to remove numerous reviews that contain demonstrably false factual statements. Because Yelp has federal immunity from liability for reviews posted by third-parties, the site cannot be sued. Moreover, during the past three years, letters to Yelp have been unsuccessful.”

However, Yelp has not an ounce of hesitation hiding the 12 five-star reviews that they have deemed un-worthy.

When we get a negative review, it affects our practice. Other patients may feel permission to pile on. Just after the review mentioned above posted we saw a patient five years after her surgery demanding her money back. Our website’s “contact us” inquiries go down 37 percent the week after a negative review.

For better or worse, Americans seek out health information on the internet. According to a 2012 Pew research study, 72 percent of internet users looked online for health information within the past year, and 20 percent of internet users have consulted online reviews of healthcare providers and treatments. But are patients getting a fair representation of the service they can expect to receive? Only a small minority—three to four percent—of internet users have posted experiences about healthcare providers or treatments.² So who are the vocal minority that posts their experiences? There are a multitude of forums in which to rate physician experiences but no review site is better at coordinating a cult-like atmosphere than Yelp. Their branded reviewers are affectionately known as “Yelpers.” One of the credentials necessary to become a Yelper is that you have to be a frequent reviewer, and while I suspect the vast majority of Yelpers have honest intentions of providing valuable feedback to the community, others have famously learned how to prolifically mudsling from behind a mask of anonymity. Yelp’s proprietary and secret methods of judging legitimacy are intended to weed out small business owners from gaming the system by having their confederates write falsely positive reviews, which Yelp proudly mentions they successfully screen. Yelp recognizes their criteria may result in some of the positive reviews unfairly being taken down, but that is the nature of their review processes. However, their algorithm also allows a small select group of narcissistic “Yelpers” to be disproportionally and perilously empowered. And empowered, they are, a one-star difference on Yelp can mean a real difference in revenue.¹

At my request, my social media expert looked deeper into Yelp and excitedly told me that we can throw a party for Yelpers to invite this entitled clique into our offices and show them a good time. Read Dr. Dayan’s assessment of Yelp events; Download the Practical Dermatology® app or read online.

We decided against that, so a Yelp sales associate let it be known that Yelp is a great place for small business owners to advertise. For the low price of 1,000x the standard online rate and 100x the premium that national advertisers pay, I, too, can shout my praises!³

Advertising “protection” allegations are not specific to medicine: others have sued claiming that Yelp extorts their small businesses. But they lost on that count in San Francisco’s 9th circuit court of appeals.⁴Billion Dollar Bully, a documentary depicting the practices and aftermath of Yelp’s reviews and policies on small business, may have had an impact on Yelp’s stock, which sunk 4.5% soon after the trailer’s release (Reuters 3/19/15). A Yelp spokeswoman said, “the claims have no merit,” and that the film’s director, Kaylie Milliken, had a history of trying to mislead consumers on Yelp.

It appears for now the legal system has determined that Yelp’s practices do not constitute extortion. The more important question perhaps to ask: Is Yelp serving the public well?

As physicians we are particularly disadvantaged. We are healthcare stewards first and foremost, and any other motive including economic gain should not interfere. This is completely opposite all other businesses. Because we have a fiduciary responsibility to always act in the best interest of our patients, sometimes we have to refuse to treat or not provide a requested drug or procedure when not medically or ethically warranted. In other words we have to disappoint some patients to do the right thing. This is counter to normal business practice where the “customer is always right” mantra.

Unlike the customer at the dry cleaner or restaurant, the average patient may find it difficult to nearly impossible to fully understand the logic and reasoning behind our decision-making processes. It takes four years of medical school and years of residency before we gain the knowledge necessary to make difficult decisions. We can try our hardest to explain it to a disgruntled person, but some will not be able to comprehend, want to hear, or accurately relate the story to their peers. Add to this that as aesthetic physicians we see a body dysmorphic population that can reach 30 percent.⁵ Additionally, whereas other small business owners have the right to defend their reputations and have successfully publicly exposed malicious Yelp reviewers,⁶ we are bound by medical ethics and HIPAA laws, with boundaries that still remain unclear. We are often advised that the best response is no response; Beat out the negativity by drowning it out with positive review. The problem is most happy patients move on and don’t take the time to report their contentment. And, even if they do, they are unlikely to jump through the hoops to become a “Yelper.”

On the heels of the court’s decision, we have to learn to live in such an environment. And perhaps there is a good: we all can benefit from negative criticism that keeps our egos in check and our practices focused on meeting patient expectations.

Clearly, it is we who will have to adapt to a new form of communication to meet the increasingly flat world, where authority and status is more likely to be challenged than revered. However, as physicians we are trained expert educators; Per-haps one of our emerging roles is to educate patients about the true science—or lack of science—at work here. Physicians must voice a strong message to the public that outcomes vary based on individualities, that aesthetic medicine is not a perfect science, and the overwhelming majority of patients’ expectations are met or surpassed. Alone and divided we are weak, but in the aggregate educating and advocating our voice has more impact, influence and meaning.

The review sites are a form of free speech that serve a well-meaning purpose in our modern increasingly democratic society, but we as physician educators and providers have a critical role to play. We are bound by a Hippocratic mandate and a moral obligation to challenge the dangers of misleading unsubstantiated medical information and allegations. It is incumbent upon us as physicians to expose inappropriate actions and teach our communities how to objectively analyze and dismiss soiling internet information. However to be effective we must do it on the terms of a new generation in a language and manner that is understood and accepted. This is a challenge we cannot disregard, not only do our reputations depend on it but so too may the future and direction of health care. n

1. Luca, M and Zervas, G. Fake It Till You Make It: Reputation, Competition, and Yelp Review Fraud (November 26, 2014). Harvard Business School NOM Unit Working Paper No. 14-006. Available at SSRN:http://ssrn.com/abstract=2293164

2. http://www.pewinternet.org/2013/01/15/peer-to-peer-health-care/

3. http://venturebeat.com/2012/02/06/yelp-advertising-is-a-rip-off-for-small-advertisers/

4. http://www.latimes.com/business/la-fi-yelp-ratings-20140905-story.html

5. Picavet VA. Plast Reconstr Surg. 2011 Aug;128(2):509-17

6. Robinison Willis. Daily Mail.com 15:13;26 March 2015.