Otolaryngology Doctor–Patient Interactions Are Increasingly Under the Microscope

What’s the difference between a four-star physician and a five-star physician? Between a three-star patient satisfaction rating and a five star satisfaction rating?

It may seem reasonable to assume that a five-star physician provides better care than a four-star physician, but that’s not necessarily the case. A 2019 systematic review found a high degree of correlation between patient online reviews of physicians and patient experience, but a low level of correlation between patient reviews and clinical outcomes (J Med Internet Res. 2019;21:e12521). Patient ratings of medical interactions can vary wildly as well, with one patient giving a five-star review for an “excellent doctor” and another patient leaving a three-star review for a physician they describe as “the most responsive doctor that we’ve ever seen.”

Yet increasing numbers of hospitals and healthcare organizations are now publicly sharing information from patient satisfaction surveys, in the name of being more transparent about the quality of patient care. Massachusetts General Hospital has collected, monitored, and shared patient feedback internally for years, said Benjamin Bleier, MD, associate professor of otolaryngology–head and neck surgery at Harvard Medical School and the Claire and John Bertucci Chair in Otolaryngology–Head and Neck Surgery at Massachusetts Eye and Ear in Boston. Later this year, the institution plans to publish patient reviews and commentary on their websites.

At first, the majority physician opinion was apprehension. I think physicians’ general concern is being judged and rated by patients when they don’t have control over many aspects of patients’ care or their response to treatment. —Benjamin Bleier, MD

“At first, the majority physician opinion was apprehension,” Dr. Bleier said. “I think physicians’ general concern is being judged and rated by patients when they don’t have control over many aspects of patients’ care or their response to treatment.”

Although research has found that patient satisfaction scores and physician reviews are generally positive—a 2021 national review of academic otolaryngology practices found that the mean patient satisfaction score was 4.74 of 5, with limited variability between scores—public disclosures can be unnerving (Laryngoscope. 2021;131:2204–2210). Publication of patient feedback also raises interesting questions about how institutions collect, filter, and share data, as well as how physicians and patients are affected by public-facing reviews.

All Patient Surveys and Review Sites Aren’t Equal

Some websites allow anyone to post a review of a physician, without verifying whether the reviewer has actually seen that provider. Some allow physicians or healthcare institutions to pay to promote their practice and remove negative content for a fee. “I think that is an awful, nefarious practice,” said Eric Gantwerker, MD, MSc, MS, a pediatric otolaryngologist with Northwell Health in New Hyde Park, N.Y.

While most physicians likely agree with him, there are other, less direct ways that doctors can use to influence content on third-party rating sites such as Healthgrades and Yelp. “Some physicians will try to steer patients to particular review sites,” said Martin J. Citardi, MD, professor and chair of the department otorhinolaryngology–head and neck surgery at McGovern Medical School at The University of Texas Health Science Center in Houston. “It’s a little bit manipulative because most people don’t realize that the sorting isn’t happening randomly, but preferentially based on the strategy of the physician.”

In contrast, most hospitals and healthcare organizations that share patient data send surveys to all patients who receive care, which means that providers can’t selectively ask patients for reviews and patients can’t rate physicians they haven’t seen. Patient review data may still be skewed by human nature, however.

“I think there’s a selection bias,” Dr. Bleier said. “An unhappy patient is probably much more likely to leave a negative review than a happy patient is to leave a good review.”

Hospitals and healthcare organizations are trying to boost transparency (and build trust) by sharing patient satisfaction scores and feedback, so many institutions now have a webpage that describes their ratings and data publication process. The Northwell Health website (www.northwell.edu), for instance, states, “Both positive and negative comments will appear in their entirety on doctor’s profiles. However, we do not post comments that are libelous, slanderous, and profane or those that risk the privacy of our patients.” Northwell Health also discloses the criteria and scale used to assess physician performance.

Whether it’s a broken rung on the ladder, a sludgy pipeline, or a glass ceiling, things need to change to welcome women and promote them accordingly within our specialty. —Kathleen Yaremchuk, MD

Massachusetts General (www.massgeneral.org/patient-experience/ratings-process) also includes information about its ratings process, clearly stating that patient comments won’t be posted until a provider has at least five comments from patients during the previous 12 months; physician ratings will not be publicly posted until a provider has ratings from at least 30 patients in the previous 12 months. That’s a smart move, according to Alan Micco, MD, a professor of otolaryngology–head and neck surgery, medical education, and neurological surgery at Northwestern Medicine in Chicago.

“My feeling is that reviews and ratings really shouldn’t be made public unless they reach a critical mass,” Dr. Micco said, “because if you have only five reviews and one person gives you a bad score, you’re going to fall below national means.”

Clearly, there isn’t universal agreement regarding how to best rate physicians or share patient satisfaction scores. The fact remains, though, that patients and families want to know about others’ experiences with physicians. As many as 70% of patients report that reviews influence their selection of providers (Laryngoscope. 2021;131:2204–2210).

The Problems with Patient Reviews

Understanding the limitations of patient reviews and satisfaction scores—and the unintended negative effects of publicly sharing patient feedback—may eventually lead to the creation of better measures of physician ability, affability, and availability, as well as improved processes for information sharing. Here are four common concerns:

Surveys may not accurately assess physician care. Early generation third-party patient satisfaction surveys often asked about things outside of the physicians’ purview, such as wait time. Newer surveys ask about how providers manage long wait times. That’s a step in the right direction, Dr. Citardi said. “The question now is, ‘Did someone tell you about your wait time?’” he said. “The questions have improved.”

A patient–doctor interaction is a contract, of sorts. How can my patient sign that contract if I don’t educate him or her well enough? —Alan Micco, MD

Yet, patients still comment on things like parking availability and facility conditions and may rate a provider poorly based on factors beyond physicians’ control. As chair of the department of otolaryngology at Henry Ford Health in Detroit, Kathleen Yaremchuk, MD, reviews the patient satisfaction scores and feedback for everyone in her department weekly and refers comments about non-physician concerns to the appropriate departments so they can be addressed.

Current surveys may not accurately reflect clinical performance, either. As noted in a 2022 Journal of the American Medical Association (JAMA) Viewpoint article, most survey instruments were initially “optimized to evaluate patient experience as a broad component of care quality” and “are not responsive to the performance of individual physicians or care teams” (2022;328:2209). Because most patients don’t have medical backgrounds or training, some institutions won’t publish patient comments about clinicians’ diagnoses or treatments.

“If a patient makes a comment like, ‘Dr. X didn’t give me the right medicine or diagnosis,’ our system may remove them,” Dr. Micco said.

At present, most surveys and published reviews also don’t include any information about physicians’ clinical competency. “Surgical complication rates, inappropriate use of antibiotics, inappropriate ordering of radiology—those would be additional data points that I think would be generally nice to have,” Dr. Bleier said, while noting that such information is currently difficult to collect, compare, and put into context for patients.

Implicit bias may also influence patient satisfaction scores and reviews. A cross-sectional analysis of patient satisfaction data collected after outpatient otolaryngology visits from 2017 to 2020 found that older, male, White patients typically reported higher levels of patient satisfaction, while a “significantly higher” percentage of patients who were younger or self-identified as female, Black, Hispanic, and Asian gave lower patient satisfaction scores (Otolaryngol Head Neck Surg. 2022;166:1055–1061). The authors note that it’s impossible to determine “whether these ratings are due to survey response patterns or differential care.”

Doctors cannot respond to patient feedback. Although patient satisfaction scores and reviews are anonymous, physicians can sometimes figure out who left a particular comment based upon the included details. And, sometimes, a doctor will learn that a patient was displeased with an interaction that the physician thought went well. “You think, ‘That wasn’t how I would have rated that experience. I wonder where the communication broke down during that visit?’” Dr. Bleier said.

But currently, there’s no system for physicians to follow up with patients and discuss experiences patients perceived negatively. “I think some reciprocity to the process would be very helpful. We’d like the opportunity to course correct and learn from negative interactions,” Dr. Bleier said.

Physicians would also like to let patients know that their concerns have been noted and addressed. “We’d like to say, ‘Thanks for your feedback. We took care of that, and we hope this doesn’t happen again,’” Dr. Yaremchuk added.

Some institutions give physicians the right to appeal comments. At Northwestern, doctors can review patient satisfaction scores and comments before they’re published. “We’re allowed to appeal one or two every year,” Dr. Micco said. “If I disagree with something—maybe a comment had nothing to do with the visit but was more about getting the appointment, or the comment assumes medical knowledge—I can appeal. Most of the time, they’ll give it to us.”

Increased physician stress. Public-facing ratings and comments can be detrimental to physician well-being. “I know clinicians who’ve gotten negative reviews, either through our Press-Ganey survey or on social media, and those reviews had a significant impact on their mental health,” Dr. Gantwerker said. “The personalization of that feedback can be extremely detrimental, and that’s on top of all the other pressures that people are experiencing. The rates of suicide and mental health problems amongst healthcare professionals are skyrocketing, and we need to understand the role that reviews play in increasing pressure.”

Gaming the system. Given that patient satisfaction scores and reviews affect physicians’ (and institutions’) reputations and income, there’s significant temptation to artificially inflate performance indicators. It’s easy to find artificial intelligence (AI) review generators online, which is likely why many product review sites now include reviews that sound startlingly similar. Dr. Gantwerker noted that the rapid advancement of AI tools “may change the entire landscape” of patient review sites.

“AI can write reviews in a second. Natural language models can even create personas and modify the language, so the reviews seem like they’re from new patients,” Dr. Gantwerker said. “Imagine you’re a facial plastic surgeon in a very competitive market. It may not be beyond people to take drastic measures to get referrals, and that’s a problem.”

Review sites may use AI detection tools to intercept and eliminate artificially generated comments and ratings, but Dr. Citardi predicted there will “be a bit of an arms race because as the AI gets better, the defenses against it will scale.”

Perhaps more damagingly, evidence suggests that providers who prioritize patient requests over evidence-based medicine may garner higher patient satisfaction scores, so physicians under pressure may be more likely to prescribe unnecessary but patient-requested antibiotics, for instance (Laryngoscope. 2021;131:2204–2210). In a 2022 JAMA article, Kevin Shulman, MD, professor of medicine at the Stanford University School of Medicine, noted that people may “engineer efforts to boost measured performance … often with exacting focus on factors wholly insignificant to physiologic health” when patient satisfaction scores are linked to pay (2022;328:2209).

The Positives of Patient Feedback

Of course, patient perceptions of clinical encounters are important, and evidence shows that interpretation of patient experience data is “extremely useful and practical on a systems level” (N Engl J Med. 2019;380:801–803). Sharing patient feedback has numerous benefits.

Identifies areas for improvement. Obsessing over patient satisfaction scores and feedback isn’t helpful, but periodically reviewing patient feedback can point out possible areas of improvement. “If you see a trend, then maybe there’s a problem,” Dr. Micco said. “Maybe I’ve been worried too much about getting through clinic, for instance, and not spending enough time with patients.”

At Henry Ford Health, providers who persistently receive low scores may get an opportunity to work with patient experience specialists who can help physicians improve their interactions. “They may deconstruct interactions with the physician,” Dr. Yaremchuk said. “Did you sit down when you were talking to the patient? Did you make eye contact or were you looking at the computer screen the whole time? Did you finish the visit by asking, ‘Is there anything else I can do for you today?’”

Physicians receive positive feedback. Physician–patient interactions are usually problem focused. Even patients who are doing well will “focus on the 5% of residual symptoms they have,” Dr. Bleier said, because visits are a time to address problems. Patient satisfaction surveys give patients a chance to express their appreciation and physicians an opportunity to enjoy positive recognition.

Striving for patient satisfaction may improve clinical care. “If you want patients to participate in their care, they have to believe that you’re trying to do the best for them,” Dr. Yaremchuk said. Taking the time to attentively engage patients is a crucial first step to improving their health.

Effective communication skills are integral to both excellent patient satisfaction scores and excellent clinical outcomes. “A patient–doctor interaction is a contract, of sorts. How can my patient sign that contract if I don’t educate him or her well enough?” Dr. Micco said. “So, my job is to sit there, let them know what’s going on, try to allay their fears, give them options that they understand, and answer their questions so they can make a decision. We need someone to evaluate us, and it’s the patients.” 

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Jennifer Fink is a freelance medical writer based in Wisconsin.