Why We're Still Waiting on the 'Yelpification' of Health Care

Reviewing doctors -- what seems like a simple, effective way to empower and inform patients -- isn't so straightforward.

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I found my new favorite restaurant shortly after moving to D.C. by reading online reviews from locals who promised it was great for vegetarians. They even called its food "slap yo mama good." Next up on my to-do list for settling down in a new city? Finding a doctor. And I had no idea where to begin.

"The web has been amazing in terms of collecting information and user experience to put power in the hands of the buyer instead of just the seller," said Mitch Rothschild, the founder and CEO of Vitals.com. The site, which allows patients to anonymously review their doctors, claims to be the largest of its kind and has, according to Rothschild, collected close to a million reviews of health care professionals.

When I spoke with Dr. Marty Makary about his call for increased transparency in the health care industry, he cited spaces like Vitals.com as an important step toward empowering patients with relevant information. Added Rothschild, "We have been kept very ignorant in a way we wouldn't accept in other areas" where we demand to know as much as possible before handing over our money.

While power has indeed shifted into the hands of the consumer when it comes to buying a car or choosing a restaurant, this revolution -- what Rothschild terms "Yelpification" -- hasn't, well, revolutionized health care.

Writing in the New York Times, Ron Lieber attributed the lack of authoritative doctor reviews to patients' unwillingness to do the actual reviewing. The problem, he said, is one of basic supply and demand: "Many people want this information, and more consumers would trust it if the sites had more robust offerings." While Vitals.com is accruing the numbers, it has yet to make the impact that its model, Yelp, has. Other sites, like Healthgrades and RateMDs remain similarly under the radar. And while Yelp itself, along with its paid counterpart, Angie's List, feature reviews of doctors and clinics, questions over just how reliable the information they provide is takes on greater significance when applied to something as important, and personal, as health care.

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If patients' alternating fear or idolization of their doctors does, as Lieber contends, prevent them from wanting to voice their opinions online, then Vitals' granting of anonymity to reviewers should help them to be as open as they want in composing their reviews. Part of the problem, suggests Rothschild, is that we don't tend to think of the patient-doctor relationship in terms of buyers and sellers. With the subtly incendiary tagline, "Where doctors are examined," Vitals attempts to reconfigure the power balance in favor of the "buyer" -- in this case, the patient.

But the redistribution of power to patients has understandably been met with some trepidation -- in the wrong hands, it can be wielded to defame and potentially destroy the career of doctor, who has little recourse against slanderous accusations.

"Doctors are a little bit helpless," said Ericka Adler, a lawyer who represents physicians. While there are ways of extracting an anonymous poster's identity, such as through a Doe subpoena, this can only be done if the comments rise to the level of defamation. Adler says she only advises her clients to pursue a lawsuit if the comments are truly terrible -- like, "This man is a Nazi" terrible. Some of the sites recommend that disgruntled physicians respond to their detractors, but Adler warns that this can only make things worse. A doctor who recognizes the specifics of a reviewer's case and attempts to set the record straight is in danger of violating confidentiality laws, and "could open some kind of conversation that shouldn't be opened."

When things do go wrong, they do so spectacularly: earlier this year, a patient was ordered to pay $12 million in damages for the all-out war she launched against her plastic surgeon. But while this woman was able to single-handedly destroy her doctor's career, not to mention his life, her actions went beyond physician-review pages, which are usually moderated. According to court records, she created her own website and harassed the doctor's other patients with allegations that he wasn't board certified, among other accusations.

But lawsuits are few and far between. This may be because they're so difficult to carry out, or it may just be because there isn't too much incendiary material being posted. A study in the Journal of Internet Medical Research looked through five years of ratings on RateMDs and found that four out of five reviews were positive. And Adler, whose firm represents over ten thousand physicians, says she's only approached with complaints about online reviews about once a month or so.

It could very well be that patients are just generally satisfied with their doctors. Or it could be that most don't have the insight to know when they have truly received substandard care. Considering the subjective nature of medicine, a patient may have heard what they wanted to hear without having actually been treated in their best interest, and on the flip side, a patient who claims they were misdiagnosed would have a hard time backing this up.

The most reliable information that patients can share with one another are what Rothschild terms "patient subjective intelligent responses" -- reviews that speak to a doctor's interpersonal skills or the overall office environment. These are important metrics, especially when considering a primary care physician, but they can't guarantee that a doctor who seems nice and helpful is objectively better at what she does than a doctor who is curt, or who keeps patients waiting for longer periods of time.

What's also needed, to intelligently select both a doctor and a hospital, is objective measures, what Makary identified as "complications, readmissions, bounce backs, patient satisfaction, safety and culture survey scores," among others. Physician review sites do try to compile as much of this information as they can, but much of it remains unavailable to the public. Rothschild spoke, for example, of filing a Freedom of Information request to make public the doctors who receive PQRI money through Medicare as a reward for providing quality care. After two years of battling privacy advocates and the medical establishment, he said, he was forced to give up.

In an Atlantic article about Todd Park's efforts to make government data more accessible as chief technology officer at Health and Human Services, O'Reilly Media's Alex Howard said: "We're seeing people not being able to make informed decisions based upon really good data ... The existing privacy laws are there for good reason, but they make it difficult for organizations to draw the kind of insights from them that they need." Both Rothschild and Makary have expressed hope that, aided by people like Park, more data will be public in the future. Once review sites are able to tell us more than whether a doctor is board certified or has won any awards, they might become more appealing.

In my own search, I ended up deciding that the most important concern was finding a doctor who takes my health insurance. Not knowing what the cost of an appointment is going to be upfront is another factor working against the would-be informed consumer, and Vitals is working on creating personalized cost estimators that they hope will appear on the site in the coming years. In this case, it won't matter that the contract between health plans and their doctors is private because, as Rothschild said, "All the consumer wants to know is how much is the check they're going to have to write." For now, cost is perhaps the most salient metric by which crowd-sourcing information fails tell you anything about how your own experience is going to be.

Maybe the simple answer is that doctors aren't restaurants -- there's too much going on for these sites to give us a clear image of what we want and need to know. It's not that they're useless: "At the end of the day, you want to avoid the bottom 20 percent, and if you've got something serious you definitely go to the top 20 percent, and then in that middle 60 percent, a lot of these other things do kick in," said Rothschild. Within that middle 60 percent, reviews are already empowering patients to be more informed about their health care decisions, and the potential for this to become more prominent is huge.