Monday, March 9, 2009

Up with Zagat! Down with Patient Waivers!

I recently discussed the collaboration between Wellpoint and Zagat for rating physicians and concluded that the benefits of web-based rating systems outweigh the risks. Since writing that post I have come upon (a) a very informative report about physician-rating websites by Ruth Given and (b) a seven year old physician protection enterprise called "Medical Justice."

Ruth Given's survey of 40 physician-rating sites indicates that they are not ready for prime time in statistical validity. Medical Justice raises the spectre of malicious anonymous comments from disgruntled patients, competitors, ex-spouses and former employees ruining a physician's practice. It offers (for a not insignificant fee) a "mutual privacy contract" under which patients agree not to use the Internet sites and "are granted additional privacy protections by the doctor above and beyond those mandated by law."

I empathize with physicians' concern about being slandered. Several decades ago a patient of mine who suffered from a serious psychiatric ailment went to a series of emergency rooms all around Boston complaining about me. I received some polite and some not-so-polite inquiries about what I was up to and why I was treating my patient so badly. When that phase of the ailment lifted the ER visits stopped and the treatment continued successfully. Anonymous Internet slander would be much worse - at least I had the opportunity to continue working with my patient.

But the idea of asking new patients to sign a contract eschewing physician-rating sites and sweetening the deal with "additional privacy protections" is unseemly. Meaningful privacy protections are fundamental moral obligations - they're not chits to use as enticements for patients to sign a contract. If a physician greeted me by asking me to sign such a contract I'd be out of the office in an instant and badmouthing the physician shortly thereafter.

Still, the potential harm from anonymous slander is real. Medical Justice warns its potential customers about Section 230 of the "Communications Decency Act," which gives strong endorsement to free speech on the web:
The Congress finds the following:

(1) The rapidly developing array of Internet and other interactive computer services available to individual Americans represent an extraordinary advance in the availability of educational and informational resources to our citizens.
(2) These services offer users a great degree of control over the information that they receive, as well as the potential for even greater control in the future as technology develops.
(3) The Internet and other interactive computer services offer a forum for a true diversity of political discourse, unique opportunities for cultural development, and myriad avenues for intellectual activity.
(4) The Internet and other interactive computer services have flourished, to the benefit of all Americans, with a minimum of government regulation.
(5) Increasingly Americans are relying on interactive media for a variety of political, educational, cultural, and entertainment services.

It is the policy of the United States—

(1) to promote the continued development of the Internet and other interactive computer services and other interactive media;
(2) to preserve the vibrant and competitive free market that presently exists for the Internet and other interactive computer services, unfettered by Federal or State regulation...


No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider...
If we wait until statistically reliable well validated rating systems are developed before going ahead we'll still be waiting long after the cows have come home. There is definitely a danger to physicians from maliciously intended anonymous postings. But that danger is outweighed by the potential for the web to provide patients with a better level of guidance about the humanistic dimensions of how we physicians comport ourselves than is currently available. And asking patients to forswear the web will sully the medical profession without deterring maliciously intended behavior.


eric said...

Jim--you have assiduously developed a process for the public to follow to choose tests and treatments that it deems worthwhile. However, the service ratings systems that you refer to may not have been so carefully developed. Certainly Nielsen and Gallup are quite sophisticated in their methods of assessment. Zagat and Press-Ganey are similar in their sophistication. Mr. Press wrote an excellent book on customer service. But, the doctors who object have a valid point: garbage in=garbage out. For instance, the Press-Ganey questionnaire has a section on "your doctor" for post-hospital patients. In reality, "your doctor" is usually seven different individuals who see you during your hospitalization: the emergency department physician, the hospitalist who admits you, the hospitalist who sees you daily, the hospitalist who sees you at night, the primary care physician, the two specialists. I and my hospitalist group got scores consistently below "benchmark." This affected our pay and led to the hospital cancelling our contract. --Eric

Jim Sabin said...

Hi Eric -

As always, you make excellent points.

You're right that current systems for culling patient "reviews" of their medical care are primitive. That means that reporting systems can do harm, as your group experienced. But not bringing patient voice into public discourse is also a source of harm.

I regard the position I've taken as a judgment call. It involves weighing the harm of inaction against the harm of action. The "right" answer isn't obvious. My fear is that if we choose to wait for the Zagat-like systems to improve, the improvement simply won't happen. There's a learning curve for new systems just as there's a learning curve for new medical and surgical procedures, and there's no doubt that some bad things will happen as that learning occurs.



eric said...

Indeed, hospitals ignore the most valuable source of suggestions for improvement, the patients themselves. Going out of your way to learn the details of a patient's experience in the hospital is rewarding. And if you have a vice president who will listen to you, you can effect simple improvements with a minimum of fuss. However, the Zagats and Press-Ganeys are blunt instruments that don't give doctors and hospitals the practical details that they need to make improvements.

Jim Sabin said...

Hi Eric -

I agree that the best QI system is sincere, skillfully done inquiry with patients. I think that if we physicians had made a practice of doing this kind of common sense QI regularly the whole apparatus of third party check review would not have been seen as necessary.

Years ago a colleague trained his assistants to ask each patient leaving an appointment - "did you get what you needed today?" If the answer was "no" the assistant was instructed to tell the physician before the patient left so that the problem could be remedied. That's real time QI.

I try to remember to do this at the end of every class I teach - "what worked well and what could be improved?" Sometimes the feedback is subtle - "find ways of drawing students who aren't speaking into the discussion." Sometimes it is rather simple - "we need a bathroom break in the middle of this two hour class."

As always, thank you for the thoughtful comment!