As if the challenges of “online professionalism” and Facebook “friending” don’t complicate doctor-patient relationships enough, there is the additional strain of online rating services, where patients rate their physicians along several service-related parameters and then, if they choose, append brief evaluative comments. The physician rating websites that first appeared in the late 1990s – HealthGrades.com, RateMDs.com, WebMD.com, Vitals.com, et al. – are another outgrowth of the patient rights movement of the 1970s. Indeed, taken together these sites are the apotheosis of the consumerist vision of healthcare: We are consumers, our doctors provide services, and we have every right to evaluate their performance in ways that matter to us and presumably to others “in the market” for medical services. And who is to say this is a bad thing? What is wrong with knowing that the wait time for one doctor is unacceptably long or that another spends most of an office visit making eye contact only with his laptop?
There is nothing at all wrong here, as long as we are content with a consumerist orientation toward health care. If doctors are merely the corporeal equivalents of home repair experts, then perusing their star gradings, reading their consumer feedback, and noting if they are “Recognized Doctors” are good things entirely. The problem arises for those patients who persist in viewing their physicians as something more than body-maintenance tradesmen. For them, the rating websites, no less than Facebook and Twitter, have a downside.
For doctors, of course, ratings and comments can be damaging because – excepting only the review/scheduling service ZocDoc – they are not vetted. They encourage impulsiveness and verbal “acting out” on the part of individuals who may bear a grudge and may not even be patients of the doctor in question. Rare is the physician who cheerfully accepts rating websites because, “though virtually useless for meaningful evaluation of an individual physician,” they “make for refreshing reading” and, taken in the aggregate, may provide useful qualitative data on patients’ needs and preferences. One wonders how many physicians have the time and inclination to read and ponder patient ratings “in the aggregate” while remaining unconcerned with their own location on the totem pole of patient appraisal.
But my concern here is not for the doctor but for patients in search of more than body work. For them, the rating websites have an insidious long-term consequence, and this has to do with their impact on doctors’ emotional availability to patients and willingness to make this availability the lynchpin of the special friendships associated with medical caring. Never mind that, according to one 2012 study, online ratings of physicians are generally very positive, with rating variations deriving largely from evaluations of punctuality and staff. To the extent that doctors feel vulnerable – both professionally and financially – to the vagaries of patient feedback, they are forced to devalue that aspect of their professional identities that, in the pre-internet world, was integral to doctoring.
It is a matter, once more, of the caring aspect of care, which over time becomes embedded in meaningful human connections that resist decomposition into discrete units of bodily tune-up and repair, more or less conveniently rendered. This kind of personalized caring, with its procedurally driven, hands-on component, was integral to family medicine through the 1960s, and lives on among a dwindling minority of generalists, especially those who care for underserved, often rural, communities. But for the vast majority of physicians, including frontline primary care physicians, the rating sites have put them on the defensive and, in so doing, rendered mutual the consumerist orientation toward medical treatment (not care) that makes doctors plumbers of the body.
Some doctors who have felt the sting of negative feedback – whether “fake reviews” by fired employees, diatribes by angry patients denied medications they sought but didn’t need, or constructive comments on professional shortcomings – have gone on the offensive. Medical Justice, a member-based “medical identity management” firm launched in 2002, developed a contract to be signed by the patients of its client physicians. Via the contract, which came into use in 2007, patients assigned copyright to any subsequent online review of the physician to the physician being reviewed. In this manner, doctors who received less than flattering feedback could claim copyright infringement and have the offending patient review removed from the rating service. In exchange for the patient’s assignment of copyright, doctors agreed, by contract, not to share the patient’s medical data with marketers. Unsurprisingly, the contracts neglected to inform patients that by law doctors cannot share their confidential data with marketers without the patient’s prior authorization. The “privacy blackmail” contracts were jettisoned at the end of 2011, subsequent to a lawsuit and complaint filed with the Federal Trade Commission by the Center for Democracy and Technology.
Copyright law is no longer being misused to suppress patients’ rights to evaluate doctors, but physicians and their advocates remain inventively proactive in coping with the prospect of negative ratings. Rather than absorbing body blows to their professional selves, and having learned that courts provide no redress, they have embraced the growing role of physician ratings in medical practice and begun soliciting patient feedback through their own websites. Patients may be contacted by staff and invited to provide positive feedback on one or more of the rating websites. In a dramatic about face in 2012, Medical Justice began supplying client doctors with iPads to give to patients at the point of leaving the office. Patients are asked to write a review, and the firm makes sure that comments (presumably positive, possibly coerced) are posted on a review site. In the medical free market, there apparently is no defense like a good offense.
Even when preemptive strategies for garnering positive feedback fall short, there are things to do. In “Responding to Negative Online Comments,” the featured article in a recent issue of MCMS [Montgomery County Medical Society] Physician, a risk management specialist takes physicians down the list. “Don’t panic,” he tells them, and don’t respond immediately or impulsively to negative feedback. “Not all negative comments are worthy of your time to respond,” he continues. “A response may start a chain reaction of negative slurs and comments, potentially leading to litigation.” Clearly false or inflammatory feedback warrants contact with the website administrator in the hope that the site’s content guidelines will effect removal of the offensive posting. But suing a reviewer, he cautions, is a problematic affair, and physicians contemplating such action shuld consult with their attorneys as soon as possible. And there is the otherwise proactive strategy given here as a postscript to negative feedback: “Follow up with positive information about your practice,” but never, he warns, resort to posting fake consumer reviews.
What’s wrong with this picture? The physician rating websites provide the kind of transparency in health care long urged by consumer groups and the federal government, especially through the Centers for Medicare and Medicaid Services. Such transparency, it is held, will improve the quality and costs of care. But what is the nature of this transparency, and what exactly does it allow us to see? For the vast majority of doctors, those who receive a rating or two or none at all, we see very little. We do not see these men and women as human caregivers bound by professional ethics to reach out to other humans who come to them as needy “petitioners” hopeful that the doctor’s care will restore their damaged humanity. Less grandiloquently, we do not see how willingly these men and women embrace – or fail to embrace – the relational matrix in which care and caregiving traditionally came together. The ratings provide only a black-and-white, two-dimensional x-ray, often tendentiously rendered, of the “bones” that frame a doctor’s activities: office appearance; wait times; staff friendliness; time spent with a particular patient; and the like. And the energy spent soliciting, monitoring, and worrying about patient ratings is energy that might otherwise be deployed caring for patients in conflict-free ways far removed from the commercial world of consumer feedback.
So here, finally, is the payoff: between the Scylla of eviscerated Facebook “friending” and the Charybdis of skeletal patient ratings, physicians, especially general physicians who provide continuing care, are increasingly pulled away from a relational model of caregiving, a trend that all the patient-centered training and empathy workshops in the world cannot reverse. The fact is that the vast majority of physicians today have less energy and/or inclination to give patients in search of something more than body maintenance what physicians have traditionally offered them: a special kind of friendship.
 ZocDoc, founded in 2007, differs from other rating services. It requires registration by patients and physicians alike, and provides online scheduling of appointments along with physician reviews. But Zocdoc, unlike HealthGrades, et al., only allows reviews from patients who have actually seen a physician through Zocdoc. As such, it is a “closed loop” review system. See O. Kharraz, “Providers should think seriously about leveraging online reviews,” March 12, 2013 (http://www.thedoctorblog.com/providers-should-think-seriously-about-leveraging-online-/reviews/).
 S. Jain, “Googling ourselves – what physicians can learn from online rating sites,” N. Engl. J. Med., 362:6-7, 2010.
 G. Gao, 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., 14:e38, 2012.
 R. Reitman, “Medical justice: Stifling speech of patients with a touch of ‘privacy blackmail’,” May 4, 2011 (https://www.eff.org/deeplinks/2011/05/medical-justice-stifling-speech-patients-touch); E. Goldman, “Medical justice capitulates by ‘retiring’ its anti-patient review contracts,” December 1, 2011 (http://blog.ericgoldman.org/archives/2011/12/medical_justice.htm); R. Lieber, “The web Is awash in reviews, but not for doctors. Here’s why,” New York Times, March 9, 2012 (http://www.nytimes.com/2012/03/10/your-money/why-the-web-lacks-authoritative-reviews-of-doctors.html?_r=0&pagewanted=print).
 S. Reddy, “Doctors check online ratings from patients and make change,” Wall Street Journal, May 14, 2014. Cf. C. Ellimootil, et al., “Online reviews of 500 urologists, J. Urology, 189:2269-2273, 2013 and D. B. Bumpass & J. B. Samora, “Understanding online physician ratings,” AAOS Now [American Academy of Orthopedic Surgeons], September, 2013 (http://www.aaos.org/news/aaosnow/sep13/advocacy4.asp).
 Lieber, “Web awash in reviews,” op. cit.
 J. Hyatt, “Responding to negative online comments,” MCMS Physician (Official Publication of the Montgomery County Medical Society of Pennsylvania), Summer, 2014, 6-8.
 This is the language of the influential bioethicist Edmund Pellegrino, for example in Humanism and the Physician (Knoxville: University of Tennessee Press, 1979), 124, 146, 184, and passim.