Distraught over the results of cosmetic surgery on her nose, Katherine Chen did what many people do when they're unhappy with a doctor. She consulted a malpractice lawyer and filed a complaint with the Medical Board of California.
But the 22-year-old college student didn't stop there. Chen logged onto her home computer and wrote a tearful review about her experience, posting it to a website that encourages consumers to rate their healthcare providers. "I wasn't nasty about it," the West Covina resident says. "But I posted a comment about what I went through. These websites are useful. Doctors still have a lot of power."
Chen and thousands of other consumers are trying to rein in that power. They're saying what they think about the current state of healthcare and, more specifically, the doctors who provide it. Dozens of websites that permit people to rate, review, spin or flame their doctors have sprung up in the last year, operating in much the same way as online services that help people find the best hotels or avoid plumbers who overcharge.
Patients and site operators say the trend is good for consumers and good for healthcare. Thoughtful doctors, they say, will provide better customer service because of the feedback, and the bad ones will no longer be able to hide. And, they add, why should doctors be immune from the trend toward better customer service?
Physicians aren't so sure of such reasoning. Many say the reviews on RateMDs.com, Vitals.com, DrScore.com and other sites are skewed by disgruntled patients and are thus unfair, pushing some doctors to near-ruin after a single post.
"These sites don't yield enough power yet to get bad doctors to change. And in the meantime, they may hurt good doctors," says Dr. Phyllis Hollenbeck, a Washington, D.C., family physician and author of "Sacred Trust: The Ten Rules of Life, Death and Medicine," a new book promoting patient empowerment. "It only takes one or two scathing comments and a doctor is put in a terrible position."
The sites, more than two dozen of them, vary in how they operate, their scope of information provided and their efforts to be fair. But the trend is toward free, anonymous, no-holds-barred forums. Some sites have grown out of existing ratings services. Five years after he started the hugely popular RateMyProfessors.com, John Swapceinski and his business partner turned to medicine, launching RateMDs in 2004.
"You can find ratings on cars and flat-screen TVs, but it's hard to rate professional services," he says. "I think that's overlooked."
Angie's List, a membership-based service that allows consumers to rate dozens of types of local service providers -- painters, piano movers -- and then access those ratings, added healthcare services to its roster in March.
The operators of Vitals.com, which launched nationally in January, say their goal is to provide people with free, fair and balanced information to help them select a doctor.
"We think of it as something closer to Match.com, in which we want to match up patients with doctors who are right for them," says Mitchel Rothschild, chief executive of the Lyndhurst, N.J., company.
The restaurant survey company Zagat has even gotten into the act, teaming up with the national health benefits company Wellpoint Inc., parent company of Anthem Blue Cross, to provide some Blue Cross members with an online tool to evaluate their doctors. The service started in January and allows members to issue scores on a health professional based on specific criteria: trust, communication, availability and environment.
"Consumers can pretty much go on the Web and get information on anything, from what is a better shampoo to what is a better airline," says Dr. Zeinab Dabbah, chief medical officer of Anthem Blue Cross. "We're offering this to meet all of the expectations that consumers have about the marketplace."
An empowering tool
The ease of sharing information on the Web has given consumers a powerful hammer.
"The Internet is such a great tool for transparency," Swapceinski says. "In every profession there are some bad apples. In the medical profession, in particular, you really want to avoid them."
But viewing a doctor in the same manner as any service provider or product represents a dramatic shift in Americans' perception of healthcare. Once reverential of doctors, consumers today are more comfortable criticizing their physicians, says Dr. Kevin Weiss, president of the American Board of Medical Specialties, an organization that sets performance standards and certifies doctors.
"There is a lot of pent-up frustration," he says. "Costs are going up, and people are paying more out of pocket. Plus, there is a lot of data now on how the healthcare system needs to do better in terms of quality and safety."
The tradition of doctors monitoring their own conduct through state medical boards and peer organizations is failing, Swapceinski says. "There is a lot of protection for doctors," he says. "Even with the state medical boards there is recognition that doctors policing doctors is not the best way to handle things. Most complaints about doctors are never made public."
Chen says she did her homework -- checking the doctor's credentials and history of malpractice lawsuits and studying his website -- before the surgery last year to shorten her nose. "It was minor," she says, ruefully, of her dissatisfaction with her long nose. "I actually shouldn't have done anything, but I wanted to be perfect."
She found no red flags in the surgeon's background. The results of the operation, however, horrified her. After removing the bandage on her face, she says, "I started crying. I didn't recognize myself . . . . I spent the next nine months at home. I was embarrassed to go out. I quit my job and dropped out of school."
Chen says her nose was crooked and much too short, and that she was left with breathing problems and nose bleeds. She filed a complaint with the Medical Board of California, a process she later abandoned, and consulted a lawyer who discouraged her from filing a lawsuit because of the up-front costs involved. At the time, she was also facing the cost of surgery to correct her nose. Ultimately, Chen says, she felt exposing the doctor on the Internet was her only recourse.
Later, pleased with her revision surgery, Chen also used a ratings website to write favorably about the doctor who performed it. "I wanted people to know about my experience with him because he didn't really have any feedback on the site," she says.
Some state medical boards provide consumers with limited information on doctors, such as any disciplinary actions recorded and whether their licenses are current. Moreover, state governments, insurance companies and private organizations have attempted in recent years to gather data on physician performance that can be compiled into "report cards" to help consumers choose doctors wisely. Such measures have been shown to improve healthcare quality, according to the Agency for Healthcare Research and Quality. But those tools are in their early stages and are rarely consumer-friendly or easy to locate.
Gail Weiss, 30, of Los Angeles (no relation to Dr. Kevin Weiss) recently did a Google search to check out a new doctor who had joined the pediatric practice where she takes her three children. The search led her to a doctors' ratings website that, she says, was so interesting and easy to use that she ended up trolling for information on all of the family's doctors. She then posted an evaluation of her own doctor, whom she "loves," and Weiss' husband posted a positive rating of the family's former pediatrician.
"I wanted to know the doctor's credentials and the school she went to," Weiss says. "But the comments from other patients also made an impression on me. They said things like, 'the office staff isn't that courteous but the doctor is good.' I think these sites empower consumers."
Reputation on the line
That's the goal, say the site operators: help the consumer find a suitable doctor. Many doctors scoff at that description, however, saying the sites mislead potential patients and are unfair.
Dr. Richard Fischel, a thoracic surgeon in Orange, says his life was turned upside-down after a patient began posting vicious remarks online regarding a surgery Fischel performed. Fischel says the surgery was an elective procedure, that he and the patient discussed the pros and cons, and that the patient signed a consent form acknowledging that discussion.
The operation went well, Fischel says. But after the surgery, the patient complained bitterly about a previously discussed side effect that can sometimes occur as a result of the surgery, Fischel says.
"He decided his life was ruined and destroyed," says Fischel, who graduated from UCLA medical school in 1984 and is now director of thoracic oncology at Hoag Hospital in Newport Beach. Online, Fischel says, the patient posted "slanderous rants and raves."
Fischel, who says he can't reveal further details of the case because of a legal agreement he has since reached with the patient, soon discovered the pervasive power of the Internet. He says that his business was severely affected and that he suffered significant monetary and emotional costs because of the patient's postings. Fischel hired a lawyer to try to make the patient stop writing about him and became so depressed he considered leaving medicine.
"Doctors, in general, are sitting ducks," Fischel says. "It's impossible to fight back. The courts make it so you have almost no options."
Federal laws protect patient privacy and prohibit doctors from discussing an individual's healthcare in public. But the right of patients to criticize their doctors online has been established. Federal law asserts that the hosts of websites on which consumers post anonymous opinions are immune from charges of defamation.
The courts have also ruled on specific cases in which the identity of the patient is known. Last year, the 3rd District Court of Appeal ruled that a UC Davis plastic surgeon could not stop a patient from making negative public comments about him on the Internet because he was a "limited purpose public figure." The court noted that the doctor advertised his practice and had appeared on local television shows.
The case unfolded in 2003 when a Sacramento-area woman, Georgette Gilbert, filed a malpractice lawsuit against Dr. Jonathan Sykes, saying the brow lift he did had left her unable to close one eye fully and with one eyebrow higher than the other, creating a "permanently surprised look" on her face. Gilbert also took her dissatisfaction public -- creating a website detailing her experience.
Sykes said the results of the surgery were satisfactory and filed a defamation counterclaim, which the 3rd District Court ultimately rejected.
"There is a lot of power in the Internet and, in a way, certain doctors have used it to become famous," says Sykes, who is vice president of education for the American Academy of Facial Plastic and Reconstructive Surgery and director of facial, plastic and reconstructive surgery at UC Davis. "But it works in both directions. The Internet has a long voice. Something negative gets perpetuated because the website stays up. Good reputations can be tarnished by a sinister person."
Doctors shouldn't be rated like any other product or service provider, such as a car or car mechanic, says Dr. Kevin Weiss. Medicine involves highly individual and personalized interactions, he says, and each medical case and doctor-patient relationship is unique.
"With TVs and cars, people can subjectively talk about their experience because you have a consistent product," he says. "But with healthcare there is so much blended into the experience, it's hard to do an evaluation. You want a doctor who is both technically competent but also one who can communicate and understand the human dimensions beyond the technical aspect of good care."
Case for transparency
Operators of the websites say that consumer feedback can improve relations between doctors and patients.
The operators of RateMds.com read every comment and delete ones that are "blatantly libelous," Swapceinski says. About 5% of the posts are taken down. Still, he admits, he gets threats from doctors' lawyers "on almost a weekly basis."
Some sites, such as Wellpoint's Zagat tool, will not post doctor ratings until at least 10 consumers have weighed in. DrScore.com, which was founded by a doctor, allows only numerical doctor ratings to be posted online -- no anonymous comments.
However, Swapceinski says his experience running RateMyProfessors.com convinced him that even a handful of rankings and comments typically bears the ring of truth.
"It's hard to prove it scientifically, but I truly believe that the averages are a reflection of what people think," he says. RateMDs.com attracts about 450,000 visitors a month and has 600 to 1,000 new posts a day.
But many doctors think most of the sites are of limited value and that consumers could be as easily led astray as informed by them.
"I wish I could say that this kind of forum will motivate the doctors who are jerks to change," Hollenbeck says. "But what you see is an awful lot of baloney on these sites, a lot of unedited venting. Feedback would be more useful when it tries to say what works and what doesn't work."
Physician organizations support evaluating doctors with empirical measures and making the information public -- as long as it's fair, says Dr. Nancy H. Nielsen, president-elect of the American Medical Assn. In January, the AMA released a statement urging consumers to ignore anonymous doctor rating sites, saying they "have many shortcomings."
"We are very concerned with how we serve patients," Nielsen says. "Many doctors use patient satisfaction surveys. Many insurance companies use surveys too. Doctors are comfortable with that. But we would like to see a turning away from the pointing fingers, laying blame, 'gotcha' approach."
To protect himself, Fischel recently signed up for services with Medical Justice, a Greensboro, N.C., company that provides doctors with contracts and services to guard against frivolous malpractice lawsuits. Last year, the company designed a contract doctors can use asking their patients to "respect their physician's privacy on the Internet" by not participating in online ratings.
If a contract is in place beforehand, a doctor can force a website to take down the offending material, says Dr. Jeffrey Segal, a physician who runs the company.
To a doctor, reputation is everything, Segal says, adding that doctors shouldn't bear the brunt of dissatisfaction with the faltering healthcare system.
"All stakeholders -- consumers, doctors and payers -- are frustrated right now," Segal says. "Because of that there is a lot of finger-pointing and a lot of anger, some of which is unproductive."