Doctors Dominate

We humans pretend to resist domination, but actually tend to submit, and are often consciously unaware of the contradiction. I recently posted on our relating this way to police. We also relate this way to doctors. For example, people are basically scared to post negative web reviews of doctors. No, they don’t consciously feel scared. They’ll talk about how busy they are or they don’t feel qualified to judge. Yet their usual arrogance lets them rate lots of other things they know little about. And they are scared for good reason: doctors do got out of their way to retaliate against negative reviews. Details:

The Web Is Awash in Reviews, but Not for Doctors. Here’s Why.

… It is puzzling that there is no such authoritative collection of reviews for physicians, the highest-stakes choice of service provider that most people make. Sure, various Web sites like HealthGrades and RateMDs have taken their shots, and Yelp and Angie’s List have made a go of it, too. But the listings are often sparse, with few contributors and little of substance. … Not enough people take the time to review their doctors. …

RateMDs now has reviews of more than 1,370,000 doctors in the United States and Canada. But getting in the faces of the previously untouchable professional class has inevitably led to legal threats. He says he gets about one each week over negative reviews and receives subpoenas every month or two for information that can help identify reviewers, who believe they are posting anonymously. …

Several years ago, a physician reputation management service called Medical Justice developed a sort of liability vaccine. Doctors would ask patients to sign an agreement promising not to post about the doctor online; in exchange, patients would get additional privacy protections…. Medical Justice has now turned 180 degrees and embraced the review sites. It helpfully supplies its client doctors with iPads that they can give to patients as they are leaving. Patients write a review, and Medical Justice makes sure that the comments are posted on a review site. Sound coercive? … p

Patients may be steering clear for a far more ordinary reason: if they live in a small town or are only one or two degrees of social separation from physicians or their family members, they may not want to create any awkwardness. … An Angie’s List customer who read my column about the service last week raised a related concern. She said she would never talk negatively about her doctors on the site because there were only two decent hospital systems where she lived and she didn’t want to end up blackballed by doctors at either. …

Others idolize their doctors … Insurance giant WellPoint, … has found that only roughly 20 percent of customers will switch to a generic drug or use a less expensive imaging center, even if there is no health risk. Why? Because their doctor told them so. It is exactly this sort of unquestioning mind-set that may cause such low participation (or disproportionately positive reviews) at many review sites. …

WellPoint tracks doctors’ communication skills, availability, office environment and trust, but it doesn’t yet provide information about medical outcomes. .. It pays many physicians more when they achieve better results. But it’s not ready to share all of its outcome data. .. “The unintended consequences would be if certain surgical specialists would not take on the most challenging, needy and difficult patients.” … the big health care law requires Medicare to share all sorts of such data about doctors starting Jan. 1, 2013, assuming legal challenges don’t get in the way. The A.M.A. has raised many concerns about “risk adjustments.” (more; HT Tyler)

Risk adjustment is an issue for most products, since most have variations in who uses them. Yet we let people rate other products and collect track records on experiences with them. But for docs, we allow risk adjustment as an excuse to avoid accountability. This is an old issue is health econ — the story has always been that of course giving consumers info is a good idea, but we’d have to wait to give patients info until we “solve” the risk adjustment problem, which never happens, and never will. Mark my words, we will long delay publication of doc track records.

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  • RobS

    Reviewing individuals is very different than reviewing products. If someone reviews your TV badly, you can make a better one. If someone reviews your company badly, you can blame it on your colleagues. But if the review is of you, it’s difficult to rationalise or to demonstrate improvement. It feels personal, so it’s not surprising doctors react.

    What other reviews of individuals take place? Here in the UK, reviews sites for teachers and lecturers have been tried, and they have also attracted controversy and legal action.

    Anyone know of any other examples?

  • There is a problem, most patients are not competent to evaluate the care they received from their health care provider. They mostly base their reviews on how they subjectively feel, and not on how well the health care provider objectively dealt with what ever health care problem they had.

    Snake-oil salesmen tend to get great reviews because they are good at lying and scamming people. A competent but non-charismatic doctor might not get great reviews even though there was nothing wrong or substandard with the care he/she provided.

    A health care provider that provided large supplies of opiates and stimulants might get great reviews because his/her patients were very pleased with the drugs which made them feel lots better, but such a health care provider would be committing malpractice.

    Telling people what they want to hear, even when it it a lie, often results in great reviews. That is standard operating practice for politicians, consultants and many others who peddle advice. That is also what leads to groupthink and disastrous policies.

    • Poelmo

      Yup. You don’t see many reviews of engineers or scientists either. It seems people do seem to understand, deep down, they’re just not qualified to judge, for better or worse. We could try to instate private boards of qualified investigators, or we could just stop being free market fundamentalists and accept that some sectors just don’t fit the free market that well.

    • The idea that doctors are serving some other interest than subjective well-being – some mysterious interest the average person doesn’t have access to – is a way in which doctors dominate. See “Hospitals Aren’t Hotels.”

      Catholic priests might make a similar argument against penitent reviews. The concept of “health” is similar to the concept of “soul.”

  • blink

    Why shouldn’t we see some sort of tipping point? After all, we are beginning to see records for public school teachers and they have mounted a coordinated political and legal attack to stop dissemination. I think that example justifies at least a little more optimism about doctors.

  • I wonder how dentists and doctors compare, both in openness to ratings and other aspects. Seems as if many dental treatments are pretty standardized, dentistry being sort of a hybrid of internist and plumber, so it might be easier to rate dentists than doctors. I know my dentist was rated on a site, and if I weren’t lazy I’d be comfortable rating him

  • Max Marty

    I’ve had a similar experience when posting reviews of attorney’s on “Avvo”. If you want to know who is litigious about negative reviews, it’s attorneys!

    I posted four total reviews. Two of them (the very negative and mildly negative) ones have since been deleted, with no explanation. The positive ones have stayed put.

    This renders sites like this essentially useless. Does anyone have good solutions given the reasoning expressed in the post?

  • Gulliver

    Why not start offshore sites to do the ratings? If The Pirate Bay can get away with something as illegitimate as outright theft, surely it should be possible to get away with something as legitimate as uncensored services reviews.

    The downside would be no filter on libel. But if we’ve reached the point where even honest negative reviews bring threats of lawsuits no one can afford to fight, that filter is clogged to the point of stopping the drain.

    Or we could institute tort reform so that the law can’t be used as a bludgeon to silence criticism, but I suspect that’s a much taller order.

    • Prakash

      You could do it on anonymized peer to peer networks, but not many normal people use those.

    • Poelmo

      Copying without permission from the right holders =/= stealing because the right holder does not lose the original. Retroactively removing features that were paid for (as Sony likes to do) = stealing.

      • Gulliver

        @ Poelmo

        Copying without permission from the right holders =/= stealing because the right holder does not lose the original.

        I won’t engage in a protracted discussion of why you think artists should provide you their wares for free (AKA private serfdom), or why I think the RIAA, MPAA, IIPA and their various counterparts worldwide are racketeering corporate trusts that use collective rights management as an excuse to maintain entertainment monopolies immune to fair use competition (AKA corporate serfdom). That is not even remotely on topic.

        My point is that there are laws against what The Pirate Bay facilitates, yet it persists. There are no laws (in the U.S. and several other countries) shielding people and organizations from honest criticism, yet the bankrupting tort damages awarded for lawsuits often decided on the basis of a convoluted system of (sometimes contradictory) precedents deriving from extremely broad interpretations of laws has fostered an environment where well-financed individuals and organizations are able to leverage the mere threat of a spurious lawsuit as a means to silence less well-heeled critics who cannot afford to risk speaking up and losing their livelihoods or even freedom.

        Retroactively removing features that were paid for (as Sony likes to do) = stealing.

        It’s fraud, which is a form of theft. On this we agree.

        Sony defrauding customers doesn’t justify others using corporate malfeasance as an excuse to entitle themselves to the fruits of artists’ labors without remuneration. You want to live on a commune, best of luck. Here in the real world, people have to earn a living to survive. In capitalism as in communism, you can’t have the take half without the give half. The just way to fight corporate feudalism – in addition to legal and political advocacy such as supporting the EFF and the ACLU – is to deny those corporations your business and support independent artists, labels and studios that don’t play monopoly. The just way to fight corporate feudalism is not to simply steal products because you don’t agree with their business model; that’s just petty theft.

      • Dremora

        why you think artists should provide you their wares for free (AKA private serfdom)

        If I understand it correctly, serfdom was a form of slavery. Irregardless of what is the best way to finance the creation of art, it is clear that no one advocated that people be forced to create art for free. Worst case scenario, creating art becomes unattractive as a profession, which would almost certainly create pressure to establish new forms of compensation.

        Similar exaggerations are sometimes used to attack taxation, by framing it as slavery. While not untrue for people who are existentially coerced to work for a living, it becomes more and more ridiculous when applied to folk so rich that they could comfortably live without raising another finger.

  • Isn’t risk adjustment also used as an excuse to not evaluate teachers?

    • Douglas Knight

      Schools are evaluated without risk adjustment and the distorting effects are quite visible.

    • I think there could be some correction mechanism for risky patients and risky students. I imagine doctors rating their patients, or teachers rating their students. Something like this:

      A teacher could give rating (for example A, B or C) to a student, basicly an estimate “it would be easy/hard to teach this student”. Now other teachers can agree or challenge this estimate. If a teacher challenges an estimate by saying “no, this student deserves a better rating”, then that teacher must teach that student.

      The teachers would be evaluated by their students’ result, per rating group. It would be like: “teacher X can teach A students to 95% of tests, B students to 78% of tests, C students to 43% of tests”.

      So there is no problem with teaching hard students or curing hard patients, as long as their rating is properly estimated. You don’t have to refuse the challenging patient — you just have to give them a bad rating, so the result won’t harm your statistics. On the other hand, if someone tries to cheat by giving their patients artificially low ratings, the competitors could take the patients by giving them better rating.

      Problem with this model is that patients and students either would have no choice of doctors and teachers, or they would see their own ratings (which could be psychologically damaging).

    • The motive behind “rating” teachers is to have teachers to blame for students doing poorly so that teachers’ wages can be cut when the real cause of students doing poorly is mostly socioeconomic status.

      Fixing socioeconomic status costs a lot more than lowering teachers’ wages. It is worth it because an educated population has greater innovation and greater economic growth. But there is a time lag, and the growth lifts all boats, not just the boats of the 1% who pay taxes they consider to be too high.

      Because the 1% already have a sufficiently materialistic lifestyle, what the 1% want more money for is more status. Since status is zero sum, more money only equals more status when growth does not lift all boats.

      • Poelmo

        I agree. Any honest review of a teacher requires in-depth knowledge about the subject as well as teaching itself and most importantly it would require parents to actually invest time in figuring out what their kids are doing all day, but if they did that than chances are most kids would do much better in school anyway, without any changes on the part of the teachers.

        In the United States about half of the reviews of science teachers would come from creationist bible thumping parents, so what could possibly go wrong?

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  • Gulliver

    @ Dremora

    serfdom was a form of slavery

    If a laborer, journeyman or skilled craftsperson is deprived of the right to do with the fruits of their labor as they see fit, they are a serf. Serfdom differs from conventional slavery in that the serf is free to walk away…but only from their entire profession. In the High Middle Ages, serfdom was used by landowners to deprive farmers and their families of most basic human rights as the cost of subsistence farming. Corporate trusts and monopolies have used serfdom to coerce workers into surrendering their leverage since the dawn of the charter company under landed nobility, and now through government lobbies and locked-in monopolies over marketing and distribution channels that lock-out smaller competitors.

    A thief who takes the fruits of a worker’s labor without compensating them may rationalize it by postulating that the Magic Market will find a way to compensate the worker, but rationalization is thin justification. If someone wants to create new avenues of compensation for content creators, they should actively support workers, organizations, labels and brands that put creators in a position of power over their content. Literally they should put their money where their mouth is. If they intend to take what a worker creates without regard for the worker’s wishes, they could at least spare everyone the hypocritical self-righteousness of the spoiled Western consumer. Those who take what they want because they can aren’t Robin Hood, they’re little robber barons.

    Similar exaggerations are sometimes used to attack taxation, by framing it as slavery.

    This is known as a strawman. Find an obtuse argument employing similar terminology and equate its absurdity to that of the original argument.

    If you think workers should not have the right to determine dispensation of the fruits of their labor, then I recommend applying to a major media company; you’ll fit right in. If you want to argue semantics, you can do that with someone else. This is totally off topic, so I am done with it. I wish you have a pleasant and fruitful week.

    • Poelmo

      If economics wants to do more than pretend to be a science it has to stop using the (often disproven) tenets of modern capitalism as axioms and act more as a science interested in studying ways to distribute resources efficiently and fair than as a religion devoted to defending modern capitalism. It would also be nice if people stopped making the fatal mistake of confusing the cold, hard, amoral workings of the free market with fairness, no matter how efficient that market may be. It was never meant to be fair, just less worse than other systems before it and its early advocates never pretended otherwise either. Economics sure could use some out of the box thinking. Right now there are too many people can solve the most complicated PDE yet don’t pause to think that maybe they’re wasting their time trying to prove 1+1=3.

      Anyway, what I’m trying to say is this: if I’m a carpenter then of course it’s fair for me to get a compensation for every chair I make, because every chair I make requires some of my work and resources. If I make twice as many chairs I have to work twice (or nearly twice) as hard for it and buy twice the raw materials. Now of course the exact price I can set for my chair depends on the amoral market, which is not really fair, but it is efficient and protects the consumer somewhat. When I’m an artist and upload my material to a server then I’ll have fixed expenditures of work and resources. If 2 billion people download my material I won’t have to work a minute longer than I would have if only 10 people downloaded my material. Still, I charge everyone money for their downloads, even if I make 1000s of % in profits I’ll keep charging and nobody can stop me or force me to lower my prices because copyright gives me a monopoly on my material. Basically I’ll make money off population size, not work. There is nothing fair about that and I seize being an artist and become a fraud. In fact, I can spend a tiny percentage of my profits to lobby politicians to keep extending the duration of my copyright (which makes me an artist again, because I’ve made fraud into an art form). Now, is downloading without payment stealing? If you would have otherwise paid money, then yes, part of the price was stolen (that small percentage of the price the artist needs to make ends meet), if you wouldn’t have bought the product then you haven’t stolen anything. We don’t consider buying a cheap car from manufacturer A as stealing from manufacturer B who builds cars with the same functionality but who sells them at a higher price, unpaid downloading of stuff you would otherwise not have bought is exactly the same.

      How can we fix this? Either get rid of copyright alltogether (but leave something like the GNU-license in place so true artists, the ones who are not in it to get rich, just to make art, still receive credit), or reform copyright and make it so that it is nullified once you’ve made, say 120% of your development costs. But that requires out of the box thinking and actual innovation, something today’s media empires lack.

      • John

        How about we get rid of copyright and artists start demanding payment up front, with the understanding that after a given piece of electronically-replicable art is complete it will inevitably be made available to the general public for some negligible marginal cost? If someone is unsatisfied with the art they have available, they can pay an artist to make more, and if an artist is unsatisfied with the money they’re making they can research what’s in demand, or try to attract more patrons of their personal style by doing spec work.

  • Poelmo

    To add to my previous post: I know people will tell me “but if there aren’t obscene amounts of money to be made no one will invest in progress, no medicines would be developed”. That is utter crap: we need the current system of IP-rights for progress like people in the 1930s needed to pay protection money to not get their legs broken by baseball bat in an alley.

    actual development costs could be strongly reduced if we would just give the scientists (who are not in it for the money, otherwise they wouldn’t work for corporations who don’t let them share in the profits today) control over their own research and cut all the useless middlemen making profits by selling papers, IP-based monopolies, crankinng up tuition every year and speculating with the resources the scientists need for their research. It is those middlemen who are running a racket and telling us we need to do certain things because that’s how the system, that they designed, works.

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