Waivers as a Prescription for ‘online ratings’

On March 4th, 2009 the Indianapolis Star had a front page article titled ‘Docs try waiver as Rx for online ratings‘.  In another article on March 9th, 2009 there was an editorial from Angie Hicks of Angie’s List fame explaining her online rating system. With the appearance of opportunities to rate services, there has been concern that negative ratings may have a significant impact. The internet has made it very easy to post opinions and people are always looking for more information to make decisions regarding goods and services. Now the medical profession has become fair game for online commentary.

Let’s step back and look at the issue. Some physician offices are requiring a waiver signed by the patient agreeing that they will not criticize the physician through an online rating service. If the waiver is not signed, the patient could be turned away. The rationale for this is the threat to the physician’s reputation and practice through possible negative reviews.

The other side of the issue is that of our constitutional right to free speech and to express our opinions. This is a new and very interesting area of conflict. I wonder how other professions handle this? Clearly it is not only the medical profession that may sustain a negative or harmful impact.

This whole idea took me aback. I have always tried to place myself on the other side of the argument (since I too am a physician and have a wonderful practice), how would I react as a patient if asked to sign such a document? My instantaneous answer was that I would be out of that office so fast that the door would not have had a chance to hit me on the backside on my way out. I would certainly wonder what prompted this, why be so protective, so defensive? Is there a past history here? Is it a single occurrence or a well established pattern? No, I would not sign such a thing and in turn, I would not ask my patients to sign anything like this. What profession, what practice, is not subject to comment and critique? Can we not learn from commentary and critique to help the next patient? But criticism should be done correctly, without malice, and with the opportunity for the counter argument or case. I would also expect the critic to properly sign their work,  take responsibility and ownership and not be a sniper.

This also caused me to wonder about what could be going on in my own practice.

Many times the clinical experience is not entirely related to the doctor. Think about all the layers that exist in the clinical interaction. There is the health care delivery system that has individuals who make appointments, secretaries who may be looking for referrals, receptionists who are asking for insurance information, technicians who take a variety of measures, the physician, a medical student, possibly a resident, the nurse, the respiratory therapists, and even the phlebotomists in the laboratory. Then after the visit you have the cashiers, the pharmacy, and the insurance people to deal with. That single clinical encounter can result in interactions with up to 13 individuals. Now blend this array of personnel with a patient or family who have their own health belief model and expectations. So with all the possibilities for things to go wrong, it is most fortunate that at least here, they mostly go right.

In my experience over the past 24 years, there are situations that I have come across where things may not go as expected despite everyone’s good intentions. I call these ‘appointments that are doomed to failure’. I try my best to avoid these, but they still happen.

Interactions doomed to failure.

What is all this about? I work with allergy. This is a condition that is relatively common with perhaps up to 30% of the population in this country struggling with some variation of allergy. As noted in the page on allergy, allergy is a specific immune reaction. Sometimes others may state that a condition, an illness, a set of abnormal laboratory values was due to allergy and send the patient on to an allergist. Sometimes the history does not support an allergic reaction and sometimes no allergy is found. A family who has high expectations and firmly believed the illness was due to allergy leaves disappointed. They think that the evaluation failed and the physician was incompetent in not finding anything. An established belief was found to be wrong. An answer for the problem still must be there. The investigation needs to start all over again. The perception could be that the physician failed the patient in not finding anything. This is frustrating for all. There are others things that can make the encounter difficult.

Reasons for a doomed visit-

  1. Expectations not met- nothing was found
  2. Condition was not allergy as they were told in the past
  3. The child may not have been old enough to be sensitized – not knowing the time sequence for the development of allergy
  4. Communication gone bad
  5. Chemistry – the doctor-patient relationship did not materialize
  6. Respect was absent- the doctor for the patient’s time and the patient for the doctor’s time
  7. Past experiences with a specialty
  8. Conflicts with the art of medicine and the science of medicine- Hippocrates “above all do no harm”
  9. Dealing with evidence-based medicine
  10. An agenda not met
  11. Bad news- not allergy as was expected, if it was allergy it may be a life-long condition, dealing with pets and stuffed animals- parents and kids cry about being sensitive to the family dog or cat and the evil eye was given to me by children who have to consider less soft options because they have to retire their stuffed animals or place them in the freezer for a while
  12. Seeking cures vs. control- a considerable amount of allergy is chronic and not one-time fixes, with allergy you are in the game for the long haul
  13. Insurance restrictions- a never ending fight with limited choices or sacrifices that need to be made to cover visits, treatments, and medications

Remedies for doomed visits?

I wish that everyone who came to the office had allergy, but they often do not. How can I help avoid a doomed visit? A few things have worked. I think being cheerful and happy with what I do is helpful. I know the limitations of my specialty, and I hope that I am good at listening and establishing a rapport.

  1. If I sense that there is someone on my schedule with a condition that allergy care cannot help, we try to talk with both the family and the referring physician to see what is going on and then decide if we can meet their expectations and offer the appropriate service before they take off work, take the child out of school, and take the time to come for the visit. I want to be sure there is value for the visit on behalf of the family.
  2. If a family arrives with something that does not fit allergy, I explain things and I void the shortened visit for them.
  3. I have learned to ask  ‘ what do you want to know when you leave the office’ – this helps me address the family’s agenda. Sometimes the reason for a consultation is different from what the family wants to get out of the visit.
  4. I know what I can do and what I cannot do and I share that with the family. I do not try to extend the bounds of my expertise and specialty, that is being plain honest about things.

Is it always the doctor’s fault?

Good grief, I certainly hope not. Consider all the levels of interaction within the health care system, problems lurk potentially at every level.

  1. The physician
  2. The system
  3. The third party payer (health insurance)

How to make it work?

Physicians need to be caring, to be comforting, to be courteous, to be communicative and of course be competent. Patients/Families are seeking consultation for a problem or a set of symptoms and signs that may or may not be due to allergy.  Patients should be open minded when they arrive. They are asking for an opinion in a consultation. The opinion may or may not be acted upon based on the health beliefs of the patient/family.

Critiquing the critiques

I would advise extreme care with internet resources- not all sites are good. There is no sanctioning of information prior to online publication. Be careful of  what you read. Consider the source, is the author credentialed in the topic area? Where did the expertise come from? Are they trained or self-ordained? Is anything used as a point of reference for the argument or advice? Where did they get the facts or is it opinion? You have to be critical. In my post regarding my letter to the editor of the ‘Bottom Line Personal I looked up the author of the book. There were no publications to show any work in the areas that were commented on. So it was opinion, and not evidence-based.

Also, in regards to complaints – look to see if the author owed up to their comments by leaving their name. If no name is offered, then I would question the sincerity of the comments- the author did not have the intestinal fortitude (guts) to sign their work. No credible signature- no validity.

The individual who was the recipient of the complaint should also have a chance to respond. Angie’s List does this and I applaud her for that. If a complaint/critique is offered the physician is made aware of it and has a chance to respond. I do not know who makes the final judgment on this prior to publication (it would be interesting if a panel of 3 non-medical types, 3 physicians, and a minister/priest would decide the value/virtue of the commentary and majority vote for listing).

People (professionals) like to hear good things too, but all too often it is the negatives that make the headlines. If you ever see a story titled ‘Allergist controls runny nose’ let me know.  If I have had an interaction that I felt went badly, I have called people after the visit to go back over things.

So, online ratings- they were bound to happen sooner or later. No, I will take my chances and you will not have to sign any waivers here. I will just keep on going, learning from miscues when they happen in hopes to make me better at what I do.

Fred Leickly

March 15, 2009 · fleickly · 2 Comments
Posted in: The Pracitice of Medicine

2 Responses

  1. Rebecca Cooley - September 30, 2009

    I would have to agree with your stance on online ratings. I would rather make my decision about a doctor based upon the opinion of someone I know (such as the referring doctor, a family member, or friend) rather than someone I don’t know, whose opinion is on the internet.

  2. Fred Leickly - September 30, 2009

    Thank you for the comment. I was discussing this very issue with one of the new pediatric residents at Riley. She had never heard of this rating of physicians and how some are responding. We had quite a discussion on the topic.
    The health care provider business is like many others- people ask for opinions. Hopefully there is a chemistry and things work out. Now on to the other page to answer you first question.
    Fred Leickly