Discussion: Gbolabo Sokunbi, MD, FAAOS

Over the last few decades, there has been an exponential increase in the speed and manner in which information exchange occurs. Today the average consumer possesses immediate digital access to most commodities (including healthcare services) with an equally impressive ability to deliver instantaneous feedback. In the current digital age, all US-practicing physicians are subject to varying degrees of online feedback, some unsolicited, and some sometimes perceived as negative. While there may be creative ways to manipulate ones’ digital/online presence or reputation, the process remains largely unregulated and, may have deleterious effects on healthcare delivery and possibly even outcomes. Within the field of spine health/spine surgery, a healthy patient-doctor relationship is a key component to optimizing outcomes. Moreover, communication is the key to a healthy relationship. Several factors can affect communication between doctors and patients. Factors range from the urgency of the medical encounter, complexity of the pathology, social determinants of health and perhaps most important, the manner in which healthcare is marketed and delivered and currently utilized. A breakdown in the complex communication chain at any point between physician and patient often drives patient dissatisfaction, sometimes culminating in a negative review, often via an online platform. The anonymity available in many review processes may magnify both positive and negative aspects of the feedback process. Speed et al reported on the anonymity paradox in patient engagement. They concluded that while anonymity makes service users feel less vulnerable, it could have the opposite effect on managers and clinicians. They felt that this raised important implications for the use and utility of internet-based methods of collecting patient feedback.1 While the feedback process is designed to promote an honest exchange between purveyor (physician) and patient to address opportunities for improvement, the reality is that negative reviews sometimes carry more serious implications. Patient-engagement via online review processes can ultimately affect physician and hospital reputation, local/national rankings and in some cases may be indirectly associated with market share revenue and reimbursement models. Due to the limitations of reporting systems, the party on the receiving end of a negative review frequently may have little to no recourse to address inaccuracies in the reporting or the issues that were raised. Within the context of a non-emergent/urgent doctor-patient relationship model, we posed to our readers the following question: Should you feel obligated to continue to take care of a patient who has left negative feedback via a review process online? Our heterogenous poll results highlight the nuance of a ubiquitous review process within the context of a complex health-care delivery scenario of a patient. 30% of responders indicated a reluctance to continue providing care. This may not come as a surprise if said clinicians provide services in models/regions where reimbursement is tied to related metrics of patient satisfaction. Some may also feel that such reviews could be precursors to litigation. It is commonly reported that a significant proportion of medical lawsuits stem from a breakdown in communication. The poll results may imply that a proportion of physicians believe that such review processes, often applied to more benign activities like eating at restaurant, should not be compared to the more complex environments of doctor-patient relationships in healthcare. The reality is that the variability in responses is vastly more complex. First, one might assume that a negative review implies that the patient actually does not like their provider, in which case begs the question of why continue receiving treatment from a doctor not held in high regard? In contrast, while clinicians often deal with “challenging patients” it would be considered unethical to deny care based on “not liking a patient.” Consider the following scenarios: 1. You are one of few or the only one providing a niche service in a certain geographical location. 2. You are treating a patient you have operated on previously. 3. You are managing a complication (yours) in a patient who may need additional procedures. 4. You receive negative feedback from the patient’s family member (parent) while actively managing a complex chronic issue. Any of the aforementioned scenarios may justifiably generate any of the four polled responses. While the majority of physician-patient interactions are generally positive, some physicians may feel that it only takes one negative review or comment (justified or not) to harm ones’ reputation.2 The feedback process via online review has several limitations. It is common that clinicians may not even be aware that a negative review is present. In addition, the infrastructure to address reviews in a timely fashion may not exist. Despite this, having a pulse on ones online/digital presence is important. While it may not be constructive to perseverate on every online report perceived as negative, it is essential to at least ensure that gross inaccuracies and slander are not dominating these reports. For example, I have been a victim of reviews directed to different providers with similar names, or misplaced anger towards the system of which I was a part. The poll results demonstrate 24% of responders had concerns surrounding the peri-operative period, seemingly directed to avoiding scenarios of patient abandonment. This issue is of particular importance as the physician-patient dynamic is unbalanced in this area. Patients generally have the ability to fire their physicians at any point. The reverse is not true. When the physician-patient relationship becomes untenable, physicians must ensure compliance with appropriate protocols guiding transition of care to mitigate any liability for patient abandonment.3 Patient-engagement/feedback via (online/digital) review processes is here to stay. Luckily, negative reviews are not common relative to the larger number of positive experiences that often go undocumented, but physicians should understand these processes and continue to leverage opportunities to improve patient experience and perhaps outcomes.