Doctor's (Gag) Orders

ALISON STEWART, host:

You can find Web reviews on just about anything nowadays. And while they might warn you away from a lousy meal or a tragic haircut, what about your medical care? Sites that host reviews of doctors are easy to find or broadcast, opinions and complaints. But if you're a doctor who has been called rude or brusque or unprofessional? Or worse, your medical skills have been questioned? Some physicians are asking patients to sign a legal document, waiving their right to post an unauthorized online review.

Dr. Jeffery Segal will join us in a moment. He is CEO and founder of Medical Justice, an organization behind waivers like the one I mentioned.

But first, we want to hear from you, those of you with a connection to doctor rating sites, medical providers who maybe you've been reviewed, or perhaps you're a patient who has posted, or maybe you've consulted one of these sites to get a review. Do they meet your needs? Do they need reform? Is it important to keep them the way they are? We'd love to know your thoughts. Our number here in Washington is 800-989-8255. The email address is talk@npr.org. And you can always join the conversation at our Web site. Go to npr.org and click on TALK OF THE NATION.

Now Dr. Jeffrey Segal is with us now from member station WFDD in Winston-Salem. Welcome to the program.

Dr. JEFFREY SEGAL (CEO, Medical Justice): Hi, Alison. Thanks for inviting me.

STEWART: All right. So let me ask the baseline question: What's wrong with letting people rate their doctors online?

Dr. SEGAL: We actually believe that rating doctors is a good thing. We just think it can be done better - indeed, much better.

STEWART: And what would make it better? What's a better way to rate doctors online than the way it's being handled right now?

Dr. SEGAL: There are number of existing problems. First and foremost, there are about 40-plus mostly anonymous ratings sites. So there, you don't even know if the person posting is even a patient. It could be a disgruntled employee, an ex-spouse, a competitor. Number two, although on most other sites, it's a noisy conversation where every party can participate, doctors are forbidden from participating. That is, because of state and federal privacy laws, they can't even comment that the poster was indeed a patient.

And then many of the sites only have, you know, one to two or maybe three posts. It's very anecdotal. Argument is that if there's a wisdom of the crowd, there's no crowd. So we think it can be done better, and I think it's very important to try and figure out what is good quality of care and how we can figure out and get this information to patients.

STEWART: And just so I'm clear, and I hope you don't mind the analogy, you know, when you go on TripAdvisor and a hotel, and someone writes a bad review, the hotel management can get online and say, we're really sorry you had this experience, or we did everything we could to accommodate this person. Doctors can't do that, right?

Dr. SEGAL: Doctors are forbidden by federal law, something called HIPAA. And then there are 50 state privacy laws, and then if that weren't enough, there are also medical ethics that prevent physicians from participating in this discussion. There have been some doctors who were unaware of some of these challenges. They went either online or to an organization and told their side of the story. They were promptly fined anywhere from $5,000 to $10,000.

STEWART: Now, do the Web sites have any sort of responsibility in this to weed out people who are clearly maligning someone or have written something that is particularly horrible?

Dr. SEGAL: I think that's been our argument. To the extent the site's self-policed, we probably wouldn't have a problem with them. So our goal is to provoke a national discussion and see if of those 40 sites that are out there, one, two, maybe three will take the lead and self-police, my guess is we'll get to a critical mass of really good rating sites.

STEWART: Well, it's interesting this whole subject - I'll be honest, I typed in my doctor's name, I needed to find her phone number, and I saw a review of her actually come up on Yelp, which is usually about restaurants and movies and reviews and theaters reviews. And she got great ratings from two people but there's one really long, nasty rating about her. I'll just read the last line - this is actually true: Extremely unprofessional. Did not answer any of my questions properly. Had a very bad attitude throughout. Made me feel unwelcome. And at some point, I just wanted to get up and leave. I will not waste any more time writing about this woman. But my advice is do not make the mistake to go there. Find someone who is and behaves like a real doctor.

DR. SEGAL: I find that interesting because you apparently know this doctor, I assumed that you have continued to go to this doctor because you trust him or her. What do you think about that?

STEWART: Well, I think it's sort of interesting reading this review and several other reviews that much of the criticism is really about bedside manner and about the front office.

DR. SEGAL: Right. And I think bedside manner is important. As physicians, we are not trained well in terms of communicating with a patient. And I think it's clearly important if we want patients to do well, we need to figure out how to get a message to him or her so they follow instructions. And, we view medicine as a partnership between the doctor and the patient.

One of the problems I have with the sites is that the sites often make no distinction between outcomes and quality of care as well as customer service. And with customer service, I'm talking about things like availability, trust, communication, what does the office look like and parking. I think if we're just limited it to those subjective impressions that a patient is expert at opining on, we think that would be quite good. When you start talking about quality of care and outcome, that's a very, very complicated subject and makes it much different than talking about roofing and plumbing.

STEWART: Let's talk about this legal waiver that some physicians - and your organization is saying, you know what we should get patients to sign this. This waiver, it's a non-disclosure agreement basically.

DR. SEGAL: It's kind of a low disclosure statement. What it states is that the doctor will give the patient additional privacy protections above and beyond that mandated by law. In exchange, the patient agrees not to post online, good or bad, without the doctor's assent. And we can well imagine any number of minimum thresholds where the doctor would be only too happy to give his assent.

Now, the patient is also free to speak in any number of venues including with friends, family, other doctors, lawyers, peer review committees, medical licensing boards and they can go to court. So there's still plenty of venues to get their message out. We just think that unless and until some Web sites take the lead and self-police that it's a very dangerous venue for both doctors and patients.

STEWART: But why would I as a patient sign a legal document that takes away my ability to do something?

DR. SEGAL: It turns out you get something in return, that's the first point. Number two, these agreements have made news recently but the program launched approximately two years ago. We have about 2,000 physicians, plan members in the organization, each of whom see anywhere between one and 3,000 patients a year. I don't know exactly how many physicians are using the agreement but I can tell you that probably hundreds of thousands of patients have signed this and most haven't seemed to find any problem with it. In fact, when I say most, I mean, the vast majority.

STEWART: Let's go to some of our listeners who want to weigh in. Angela(ph) is joining us from South Bend, Indiana. Hi, Angela. You've had a tough experience with a doctor?

ANGELA (Caller): Yes. And actually, it was (unintelligible) it wasn't through my care. I had a medical emergency with a relative. And I rushed to their side - it was my grandmother. The doctor was impersonal. He was short. He was brusque. He didn't really explain things thoroughly. And I mean my grandmother is not senile by any means, but when you have an older patient, you know, who may not be able to jut grasp what you say as you spit it out at them at 20 words a second. You know, and it's something that's important, that they need to catch, you know, this is your medication. This is how you should take it. Come back and see me, et cetera, et cetera. It was just really - it was awful. I felt like he didn't care. And then I've also had friends that have had the same - I actually had a friend recently who had the same experience.

STEWART: So did you post online? Did you…

ANGELA: I didn't post online. I decided not to because - for the same reason that I felt kind of weird, like, you can go to Web site and get reviews about a restaurant or a plumber or, you know, something that's a service. And then post about a doctor - I just, I didn't equate it like - he did his job. There was no, you know, misdiagnosis. I think that in some level there could have been some trouble with, you know, treatment if maybe my grandmother and I didn't hear him correctly and maybe she didn't pick the right doses of medicine, something like that.

But in general, I mean, he did his job. He wasn't singing a song while he was doing it. He didn't…

(Soundbite of laughter)

ANGELA: …welcome. But he's a doctor.

STEWART: Right.

ANGELA: And, you know, he treated the problem. He treated it correctly. And we were in and we were out.

STEWART: But you didn't - you decided not to post because you felt odd about it.

ANGELA: I felt odd about it. I mean, even though, you know, he was jerk. He was a jerk.

(Soundbite of laughter)

ANGELA: Now, we're going to - you know what I mean?

STEWART: I do.

ANGELA: But doctors don't, I mean, necessarily - you're supposed to go to a doctor to get the best medical care. You know, if you want really great service, then go to Applebee's.

STEWART: Angela, I'm going to leave it there, so we can get in a couple of other callers. Thank you so much for calling in.

ANGELA: Okay.

STEWART: Let's go to Carol(ph) who's calling us from Delaware. Hi, Carol, what are your thoughts?

CAROL (Caller): Hi. How are you?

STEWART: Good. Thank you.

CAROL: I think that Dr. Segal's idea would be a valid one if the doctor would also sign a reciprocal agreement agreeing to answer the patient's questions and to be upfront with them and to explain to them to their understanding what's happening or going to happen or why he or she is doing what he or she is doing. And especially since up to this point, traditionally, doctors have only been rating themselves through the AMA. There's been no attention to what patients' comments are. And there is now a site also hospitalcompare.gov and nursingcompare.gov, but I've looked into that and it's not available to the individual patient. The states are invited to report to them but - the states' Medicaid and Medicare personnel are invited to report to them - but individual patients have no other way.

STEWART: Let's Dr. Segal address this. Thank you, Carol.

What I'm hearing from people, Dr. Segal, is that they want some control over something so very personal as their healthcare.

DR. SEGAL: Yeah. I think the caller is on to something. I think that we as physicians could do a better job listening. I think for many years doctors viewed the delivery of medicine in a paternalistic way, that is, they said this is what the diagnosis is. This is what you need to do. Listen to me and don't ask any questions. I think we've learned over time that healthcare is a lot more complicated than that. The best doctors will actually listen to try and figure out what are the patient's goals and what are the options that the doctor can deliver to the patient, so the patient can achieve his or her goals.

For example, over this past weekend, I listened to a patient advocate talk about her story. She was a 34-year-old woman, three weeks pregnant, received a diagnosis of breast cancer. She went to eight physicians and said she had two goals: first, that she keeps her baby, number two that she live. And six of the eight doctors said look, if you really want to maximize your chance for survival, you need to terminate your pregnancy. She said I don't think you're listening to me and said I really want both of those. And she finally found a physician who essentially said look, I think we can do both but you need to accept some of the risk in a shared way so that you understand what the consequences are. And should it not turn out to be a good result, you'll understand that we really tried our best.

And I think that's actually a quality relationship. You have an informed patient who understands the options and based on those options can make a decision regardless of the difference in consequences.

STEWART: Let's talk to Zach(ph) who's calling us from San Francisco. And Zach, this is something you might have to deal with one day. You likely will because the Internet's not going away and you're gonna graduate from medical school at some point.

ZACH (Caller): Well, hopefully.

(Soundbite of laughter)

ZACH: I do believe that feedback, be it positive or negative, is something that can help a doctor, a physician, improve what something -whether they're doing something well and make it better or something that their patient feels they could seriously improve and take sharp notice to.

STEWART: All right. Zach, thanks a lot. Let's talk to Tom(ph) in Long Island. Hi, Tom.

TOM (Caller): Hi. Thanks. I just wanted to say that as an avid blogger myself, I believe we should be able to post our opinions no matter they are, you know? I watch a lot of movies that - you know, I'll read a horrible opinion online for and I end up loving them. And I just - you know, how can they take that right away and if they start there, what's coming next?

STEWART: Tom, thanks for the point of view. That's a question that Tom brings up. Does this stifle consumer discussion about doctors? Where are people to go to get information about their doctors?

Dr. SEGAL: Right. So, this is what we're doing. We decided that if the world can't do it, we'll try it ourselves. And so, what we have - what we've defined are minimum thresholds in terms of making this useful for both doctors and patients. And number one would be verify that the patient who is posting is indeed a patient, and that's actually a pretty simple to do thing. Number two is to collect a minimum number of comments - my number would be 30, but I can certainly see it being as low as 10, like the Zagat guide, before the postings are made public. And number three I think we should limit the commentary to subjective impressions and avoid technical details. The only reason that technical details should be avoided is because oftentimes there are two sides to the story.

If for example, a patient says I had surgery, two days later, the wound opened up. Your conclusion, your rational conclusion, is that the doctor did a very poor job. But if you now know that the patient was told to stay off of work for six weeks and not engage in heavy lifting and two days later, he went back to work as a ditch digger, your opinion changes.

So, I think it's really important to understand this in a context. I want to just clarify that our goal is not to stifle communication, indeed it's to make the quality of the information better. The waivers suggest that if these minimum thresholds are met, we'd actually be excited about some of the rating sites.

STEWART: Let's talk to Barbara(ph) in Chicago. Barbara, you think you have a better solution?

BARBARA (Caller): Well, I think that the necessity of these sites wouldn't exist if the AMA were more transparent about their doctors, their members and their records.

STEWART: All right. Barbara, thank you so much. Does Barbara have - does she hit on a point?

DR. SEGAL: I think Barbara's point is that it's been somewhat difficult to actually determine quality of care. And I think the government is spending billions - that's billions with a B - in dollars in terms of trying to figure out who is a good doctor and what type of treatments are effective. We clearly can do it for plumbing, for example. I think if someone comes to my house and they fix my hot water heater, I can tell pretty quickly did it work or did it not. But there are number of differences between healthcare and plumbing.

So, first, medicine is not a spectator sport. The patients are active participants. The patient needs to comply with taking medication and there's post-operative care. So by and large, two must tango. Number two is that medicine is not usually delivered by one person. It's usually delivered by a team. And what's sad is that many patients in a hospital, when care is delivered by 10 or 12 patients, can't even name one doctor. That's a problem. It must change. Number three is that results are often knowable only over a period of time.

STEWART: Sure.

DR. SEGAL: The plumbing, I can tell you that the hot water works or doesn't work. But whether my cancer is in remission or not, I often have to wait five years.

STEWART: All right. Dr. Jeffrey Segal is a neurosurgeon - the founder of Medical Justice Organization that provides doctors with resources to prevent and challenge lawsuits. He joined us from member station WFDD in Winston-Salem. Thank you so much.

DR. SEGAL: Thank you very much.

STEWART: On tomorrow's show, as baby boomers age, Alzheimer's cases increase. Tomorrow, we're going to talk with former Supreme Court Justice Sandra Day O'Connor, Newt Gingrich and Dr. David Satur(ph) about solutions. Please do join us.

And on Thursday, the economic crisis has spilled way beyond our borders. We invite you in our international listeners to be part of the global conversation. Join Neal Conan this Thursday for Talk Of The World.

This is TALK OF THE NATION from NPR News. I'm Alison Stewart in Washington.

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