Are you familiar with epinions.com? This user-driven site features product reviews. Cars, washing machines, computers, books, CD’s, and toys are all reviewed by interested parties. The site represents a marvelous use of the Internet: an international community discussion about products. Here you can find information to help you determine whether to purchase a new album from a favorite group, where the best price can be found for the refrigerator you’d like to buy, or the ease of obtaining repair for a new Dell computer.

Imagine such a site for services instead of products. Some years ago, I needed to obtain bodywork for my old Ford. I found a site, now long gone, which featured discussion about auto repair shops in the Boston area. People spoke of the important things: did the shops deliver services in a reasonable time, with reasonable quality, at the promised cost? Some were more expensive than others but delivered better quality. Based on the discussion, I was able to make an educated selection with the price:quality ratio that I desired. The repairs worked out well. More recently, I needed to find a mason to do some chimney work. After failing to find a discussion site online, I relied instead on advice from neighbors and friends. A few masons showed up to look at my chimneys. Two offered price quotes. None actually bothered to take on the job. Perhaps it is too difficult, or too small a job. I haven’t figured that out yet.

What if healthcare professionals worked this way? “Ahh, yes, you have alcoholism, but you’ve relapsed five times and have failed several attempts at rehabilitation. I’ll put you on the list and call when I have the time.” But of course we all know some doctors who still subscribe to the belief that patients who have relapsed while under their care should be discharged from that care. For some reason, that belief is still present in our field even though it doesn’t exist for diabetes, hypertension, or cancer.

So what if there were a Web site that allowed patients to choose their physician based on patient experiences? Let’s first think about how people choose doctors. It used to be that people chose their doctor based on convenience or personal recommendations. The doctor they picked worked in the evening, after work hours, or in a nearby town. Or perhaps the next-door neighbor spoke over dinner one night about the wonderful care his wife had received during a time of need at the hands of a certain physician. Sometimes that method worked about as well as it did during my mason search. There was no way to know whether the problem I suffered from was so different from that of my neighbor that the care given would be equally different.

But over the past decade or so, choosing a physician has been largely taken out of the hands of patients unwilling to pay out of pocket for what they assume their insurance should cover. Now they simply go to the specialist to whom they’re referred by their primary care physician. Or they pick from a list in a thick paperback tome provided by their carrier at the start of each year, knowing little more than the doctor’s address and phone number. Wouldn’t it make an enormous difference if patients had access to an epinions-like site for doctors and other healthcare professionals? Wouldn’t they begin to demand access to the physicians with the highest user-satisfaction ratings?

Some have developed the rationale that doctors should be compared based upon outcomes under the false belief that the best doctors have the best outcomes. I suspect that the best doctors end up with the toughest patients to treat and therefore might even have the worst outcome data.
I was recently told by a state government operated regulatory commission representative that they rate outcomes based upon length of stay; for example, if outpatients being treated for addictive disease remained in treatment for longer with Dr. Smith than with Dr. Jones, it was obvious that Dr. Jones was doing a better job. The commission is considering making such ratings available to the public. How ridiculous. Perhaps Dr. Smith is more dedicated, or perhaps he has more difficult patients, or perhaps he simply is knowledgable about the field of addictive disease and believes patients with this illness need to be seen at least occasionally indefinitely, as they would if they had any other chronic illness. Or maybe Dr. Jones really is better. Outcome data unfortunately don’t define physician skills, even when they are balanced by data describing each physician’s patient population, unless the correct outcomes are chosen for inspection.

By the same token, if we were to look at a Web site that provided “customer feedback,” a site very much like epinions, we would have to be smart consumers. We would have to know that Dr. Smith’s being a kind, gentle-hearted physician doesn’t necessarily mean she’s a good physician. We would have to understand that Dr. Jones’s uncomfortable waiting room and cold front desk crew doesn’t tell us anything particularly useful. But we are indeed that smart, aren’t we?

Just as I can determine whether the shiny white finish on the new oven I’m considering is less important than whether it actually heats food, I can probably read something into the description of a clinician provided by a patient. Of course, as a layperson, I might not understand that patients would speak highly of the rapidity with which they felt better upon being given Valium by their doctor, or with disdain about the resistance they met from another physician about the same medication.

Think about how you would approach the problem. If it were up to you to set up the specifications for a Web site that allowed consumer-patients to post comments of their experiences with healthcare professionals, perhaps allowing for the addition of specific data about each clinician, how would you configure the site? What would it include? What would it specifically exclude? Next time, we’ll look at some of the sites that have attempted to address this issue.

Stuart Gitlow, MD, is a member-at-large of the American Society of Addiction Medicine’s Board of Directors. This column represents his personal opinion and does not imply any position or policy taken by ASAM.

This article is published in Counselor,The Magazine for Addiction Professionals, February 2005, v.6, n.1, pp.66-67

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