www.greenbranch.com | 800-933-3711 341MARKETING The world has changed. Patients, now euphemisti – cally called consumers , head to the Internet… [600932]

www.greenbranch.com | 800-933-3711 341MARKETING
The world has changed. Patients, now euphemisti –
cally called consumers , head to the Internet before
choosing their doctor. In 2012, there are more than
80 doctor rating sites inviting patients to post their
experiences. These posts, in aggregate, do have an effect on
business. Managing one’s reputation (particularly a doc –
tor’s online presence) has never been more critical.
The problems associated with doctor review sites are
well documented. First, most posts are anonymous, so it
is impossible to determine whether the post was authored
by a real patient or someone posing as a patient. Who
would pose as a patient? Someone with an axe to grind. A
disgruntled employee. A competitor. An ex-spouse. Even
an online reputation management company promising to
“fix” a problem for a fee—a problem that company created
as an excuse for your business.
Next, if there’s a wisdom of the crowds, there’s no
crowd. The average review site has zero to three reviews
for any given doctor. The average doctor sees anywhere
between 1000 to 2500 patients a year. This is a big gap. In
general, the sampling on sites is not representative of a
doctor’s practice.
A bad review is inevitable.
In the United States, the antidote to offensive speech is
more speech. But doctors cannot post the medical record
on a Web site to correct a misleading account. Doctors are
hampered in their ability to respond because of HIPAA and
state privacy laws.
Good medicine is not always popular. Patients some –
times request antibiotics for viral syndromes. They may ask
for more pain medication than the doctor believes is neces –
sary. The list of unrequited patient expectations is long. An unhappy patient with a mouse and broadband connection
can create significant reputational damage.
The Internet is a double-edged sword. The Internet can
also promote one’s practice—doctor reviews are weighted
heavily by the major search engines. Doctors who invite
their patients to post reviews—and have many reviews—can
control the “real estate” on page one of organic searches.
More on that shortly.
A BAD REVIEW. WHAT NOW?
It’s impossible to have perfect scores forever. A bad review
is inevitable. First, don’t over-react. Read that again. Give
it perspective.
You can’t make everyone happy. The public at large
knows that. A simple opinion about customer service is
not defamatory. If patients want to write about poor bed –
side manner, a gruff front office, rotten parking, or long
wait times in the waiting room, let them. That is fair game.
And often it is the only way to get reasonable feedback
on what your patients perceive and how to fix problems.
Here’s a documented review about a Ritz-Carlton hotel.
Ritz-Carlton hotels provide excellent service and have a
stellar reputation, and everyone knows that.
This hotel is a genuine piece of crap! I have
stayed at some bad hotels and while this is not
the worst I have ever seen it is pretty bad! This
has to be the worst Ritz-Carlton in existence. I
would suggest burning this hotel down before
staying at it. The rooms suck, there is no gym or
pool. … The wall paper was falling off the walls
in my room and my friends were staying in a
room where they received a breakfast menu
from housekeeping that had the pages stuck Managing Your Online Reputation
Jeffrey Segal, MD, JD*
Doctor review sites now populate the Internet. Such posts are often anony –
mous. Doctors cannot respond because of HIPAA. And the information rarely
addresses matters such as patient safety and clinical outcomes. Nonetheless, a
doctor’s online reputation can positively or negatively impact a doctor’s busi –
ness. By following a number of rules, a doctor can proactively manage his or her
reputation.
KEY WORDS: Online reputation; doctor review sites; doctor rating sites; defamation;
slander; libel.*Founder and CEO, Medical Justice
Services, Inc.; phone: 336-691-1286;
e-mail: jsegal@medicaljustice.com.
Copyright © 2012 by
Greenbranch Publishing LLC.

342 Medical Practice Management | May/June 2012
www.greenbranch.com | 800-933-3711
together by chewed bubble gum! … This place
is horrible, I would suggest one of the trendy
boutique hotels in Old Montreal!1
Ouch.
If your rating is, in general, positive, there is often little
reason for concern. Many believe that a collection of ex –
cellent ratings punctuated by a couple of bad ratings is
perceived as being more credible than uniformly good rat –
ings. In other words, a couple of negative ratings (among
many positive ratings) may actually have the unintended
consequence of increasing the positive perception of posi –
tive ratings.
Having a couple of bad ratings is
perceived as being more credible
than uniformly good ratings.
Next, if the review is entirely unfair or inappropriate,
determine if it violates the site’s Terms of Use. Many sites
have formulated rules constraining how reviewers should
behave. For example, on many sites, reference to drugs or
alcohol, or abusive, objectionable, or inflammatory lan –
guage is prohibited. If the posting violates the Terms of Use,
you can submit a respectful letter to the site, drawing its at –
tention to the language of the post. The site is not obligated
to take down the post, but might be persuaded to honor its
Terms of Use policy. Civil discourse in a respectful tone is
more likely than inflammatory threats to be effective. Some
sites will respond to a persuasive tome, others will not.
Each site is different.
If you have an idea who wrote the post, it might be
productive to reach out to that patient. Recently, a dentist
was graded an “F” by an ex-patient. The poster alleged the
dentist “over-diagnosed” the number of cavities; the impli –
cation being the dentist was concerned only about money.
This ex-patient went to another dentist—who might have
added gasoline to the then nascent fire. The original den –
tist looked at the chart to make sure he had not made any
diagnostic mistakes. He had not.
The dentist wrote the patient. Selected excerpts follow:
A patient brought to my attention a review
you recently wrote. We really want all of our
patients to have a positive experience with our
office and it’s clear you were not satisfied. I
respect everyone’s right to voice their opinion.
But, your review stung.
I reviewed your chart and saw that we diagnosed
four cavities and recommended treatment. From
the review, I see you went for a second opinion
and that dentist disagreed with my diagnosis.
No healthcare practitioner gets it right 100% of the time and I am no exception. That said, I
used your review as an opportunity to double
check the record to see if I missed anything. I
also had the record reviewed (confidentially)
by 2 peers. Each agreed with my diagnosis.
It was never my intention to disappoint you
and for that please accept my apology. Given
the information above, I would appreciate it
if you would amend or remove the review you
posted. It’s ultimately your decision and please
receive this as just a request. I would be happy
to speak with you directly about this. And if
there is something I can do to reverse your initial
impression of our office, I would welcome the
chance to do so.
The patient responded positively to this overture—and
did indeed update the online grade to an “A.”
PROACTIVELY MANAGING ONE’S
ONLINE REPUTATION
A negative review has impact if it’s the only review on a site.
But an isolated negative review mixed within a sea of posi –
tive ratings is diluted. The literature suggests most patients
are happy with their doctors.
Coaxing one’s patients to post
feedback is a challenge.
Tehrani et al. published an article summarizing find –
ings of validated online patient satisfaction surveys.2 They
concluded the great majority of patients reporting their
satisfaction online are highly satisfied with their outpatient
medical care. The overall patient satisfaction rating was
9.28 on a scale from 1 to 10. Of the 14,984 ratings, 10,510
(70.1%) were 10s, and another 2291 (15.3%) were 9s. By
deputizing one’s patients to post reviews, honest feedback
is obtained, customer service issues can be remedied, and
the inevitable negative review will generate less anxiety.
Coaxing one’s patients to post feedback is a challenge.
There are more than 80 doctor review sites. No matter how
well intended, patients often forget about the request when
they get home. Or if they post, they may post to sites that
have zero impact on your online reputation.
One service that addresses this dynamic is eMerit.
With this service, patients are provided an e-tablet device
(such as an iPad) in the office to anonymously provide
feedback via a survey. With patients’ permission, their
comments can be uploaded to various doctor rating sites.
The response rate is dramatically better than relying on
patients remembering to participate when they leave your
office. Further, the system can identify customer service

www.greenbranch.com | 800-933-3711Segal | Online Reputation 343
challenges, ideally solvable, before they mushroom into
visible reputational problems.
Other solutions touted by reputation management ser –
vice providers include creating Web pages with “compet –
ing” positive content to drive negative content to deeper
pages on search engine results and “bread and butter”
search engine optimization that makes a doctor’s Web site
more easily found when common key words are entered
into an online search.
WHAT NOT TO DO
Suing a Web site or patient for defamation should rarely,
if ever, be pursued. There are exceptions, of course. In
December 2011, an Arizona jury awarded a $12 million
judgment to two doctors after a local jazz singer posted
critical Internet reviews of their practice and aired multiple
complaints to the state Medical Board.3 But most doctors
who sue alleging online defamation do not win.
Web sites, for the most part, are immune from the tort
of defamation. Section 230 of the Communication Decency
Act, a federal law, provides review sites a safe harbor to
display posts. To prevail in a suit for defamation, one must
sue the actual poster. That poses more challenges. The vast
majority of posts are anonymous. One would need to ob –
tain a “John Doe” subpoena to identify the IP address of the
source of the post. That entails significant work, a healthy
amount of cash, and a lawsuit—alleging defamation—that
is likely to prevail on the merits .
Most online rants are
catalogued as “opinion.”
This qualifier, “likely to prevail on the merits,” is daunt –
ing. To prevail in such a lawsuit, the doctor must prove that
the poster uploaded a false statement that damaged his or
her reputation. Statements of opinion do not count. And
truth is a defense to a charge of defamation. If a patient
states, “The doctor communicated poorly and did not seem
to care about me one iota,” that is treated as opinion and
is not actionable. If a patient states that Dr. X is not even
board certified, and he is indeed board certified, that does
qualify as a false statement, and is arguably actionable.
Most online rants are catalogued as “opinion.”
A lawsuit might have the
unintended consequence of
publicizing a post even more.
While a given review might qualify as legal defamation,
a doctor should resist the urge to sue. A lawsuit will convert
an obscure item on a Google search into page one news. That is, a lawsuit might have the unintended consequence
of publicizing the post even more. Further, the legal pro –
cess moves slowly and is unpredictable. There are times
when a lawsuit is the only tool left to achieve a reasonable
long-term result; but it should be the exception, and not
the rule.
OTHER DETAILS
Rounding out odds and ends:
1. Don’t pay patients (or provide discounts) for reviews. If
you do, the patient must clearly disclose that he or she
received material consideration for the review. This rule
was memorialized in the Federal Trade Commission’s
“Guides Concerning the Use of Endorsements and Tes –
timonials in Advertising.”
2. Be careful about responding to reviews. Some mistak –
enly believe if a patient has posted, he or she has waived
any expectation of privacy. That is not true. You are still
bound by HIPAA and state privacy laws not to disclose
any protected health information. That said, many posts
are anonymous and related to customer service. Some –
times it is possible to respond without violating privacy
standards.
SUMMARY
Online reviews do impact a doctor’s business—for better
and for worse. In general, more reviews are better. Most
reviews are either positive or constructive. An isolated
negative review generally has limited impact, as long as it is
diluted by a sea of positive reviews. If a significant number
of reviews are negative, attention should be paid to analyze
the content of such criticism and to determine whether it
can be remedied. It often can. Y
REFERENCES
1. Virtual Tourist. The Ritz Carlton Montreal; www.virtualtourist.com/
hotels/North_America/Canada/Province_of_Quebec/Montreal
-906413/Hotels_and_Accommodations-Montreal-The_Ritz_Carlton
_Montreal-BR-1.html. Accessed January 16, 2012.
2. Tehrani A, Feldman S, Camacho F , Balkrishnan R. Patient satisfaction
with outpatient medical care in the United States. Health Outcomes
Research in Medicine . November 2011;2:e197-202.
3. Alltucker K. Scottsdale doctors awarded $12 million in defamation
case. Arizona Republic. December 16, 2011; www.azcentral.com/
community/scottsdale/articles/2011/12/16/20111216scottsdale-doc
tors-win-lawsuit.html. Accessed January 16, 2012.
SUGGESTED RESOURCES
eMerit: www.emerit.biz
Reputation.com: www.reputation.com
Reputation Management: http://reputationmanagementx.com/

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