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Deborah Cohen: I want great care

25 Jul, 08 | by BMJ Group

Deborah Cohen We’re used to checking out the internet for the lowdown on our holiday destinations or theatre review, but what about finding yourself a good doc? Tapping into the government’s Choice agenda (see Michael Cross’ BMJ feature), the website www.iwantgreatcare.org is the brainchild of doctors.net founder and former hospital doctor, Dr Neil Bacon. According to Bacon, its aim is to empower: “patients to share their experience, knowledge and opinions [so] we can drive changes and improvements in the health service that will benefit all”.

It’s a slightly different beast to the NHS Choices website—rather less emphasis on objective “hard nosed” outcome measures, as the NHS’s medical director, Sir Bruce Keogh, might say—and offers an opportunity “for doctor’s patients, patients’ carers and relatives and colleagues” to rate doctors using “objective criteria derived from the evidence base for patient satisfaction”.

These measurements are sliding scales rating trust, listening ability and one measuring how highly the user recommends the doctor. There’s also a free text box asking the user to share their experience in as much detail as possible. It asks the user to mention what’s great about their doctor and what they could do to improve. So how do these objective criteria really measure up? Answers at the end of this blog, please.

Except for the sound of silence from government ranks and the odd plaudit from a political pundit, such as the Health Services Journal and Guardian columnist Michael White—“The British Medical Association was quick to condemn the idea—so it can’t be all bad”— its arrival amongst the pages of other ratings websites has been greeted with a hostile response.

The tables have been turned on Dr Bacon himself. Dr Rant has posted up a screengrab featuring Bacon with a 0% rating and another site ridiculing the concept has sprung up: www.iwantgreatbacon.com.

Harsh, perhaps. But with all the vitriol spewed out daily on doctors.net, what did he really expect? The site where the failed Glasgow bombers were called “beardy weirdies” and paediatricians list their favourite “chav baby names”. He was hardly going to get a mild rebuke from the 5% of doctors he claims are not behind the project.

Away from the specialist medical bloggers and press, Shinyred, which focuses on new media, points out, reviewing is slightly different with doctors—choosing your doctor is a longer term commitment and your health is pretty important to boot.

But another blogger on the same site is dismissive of the criticism. “People exercise human judgment on reviews shown, if a doctor has ridiculously flattering reviews from EVERYONE it would be pretty suspect,” he says. “Likewise with BAD reviews, we as human users can actually make a judgment. What happens in the real world? We listen to other opinions but we don’t just blindly follow them do we? So lets embrace these types of resources they can only make it better for us all in the long run.”

And why shouldn’t patients have the right to know who the failing or bad doctors are? And shouldn’t doctors be as accountable to the public as anyone else paid for by the national purse? This in itself is central to the Darzi mantra of openness and accountability.

But it’s doubtful if the website will provide any meaningful data and will drive up performance. The ferret fancier says: “Those like myself who work on the front line are already very accountable for our actions, it is remarkably easy for a patient to complain given the mechanisms in place, the argument that Iwantgreatcare will improve patient care is disingenuous”. The likelihood with a website such as this is it’ll attract those with a major crush on their doctor or those with an axe to grind – which will no doubt subsequently be removed when the doctor in question lodges a complaint or libel action.

Which is what has the BMA up in arms—doctors are bound by different codes of conduct. Other people or companies have the option to respond if they see fit. But doctors are bound by confidentiality and if they get a stinging review by a patient—and it’s unfounded—a doctor can’t respond. It’s much the same as already happens in the press—allegation from a patient, doctor can’t comment.

The BMA’s concern is that the site could leave doctors open to abuse, libel and even personal attack. One group of doctors has already sought legal advice to block it and Dr Crippen is keeping a blog of all defamatory comments made about doctors. The goal? Maybe one libel action will force the site to close.

What the end result will be remains to be seen. Whether this site will drive up standards is uncertain, but it will bolstering the coffers of media lawyers. If the glut of doctors rating sites in the US and Germany is anything to go by, it’ll be bad news for doctors and good news for lawyers. So what do you think? Will this affect your clinical practice? Or have you dismissed it as a money spinner for one former hospital doctor with an eye for a headline?

Deborah Cohen is Features Editori, BMJ

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  • Timothy Deegan

    I doubt I will be using this site to try and improve my performance as a doctor, for a start. Patients already have better and more direct ways of expressing their satisfaction or displeasure with my practice. I’m certainly not going to take any notice of anonymized comments for obvious reasons (unless so very defamatory as to give me a problem with the site owner) and I’m really not sure how I or anybody else is supposed to analyze a measure of satisfaction with me, left on a sliding scale. I’d like to see how well such tools have in fact been validated. In the meantime, assessing performance and improving on it has long been considered part of the job by all responsible doctors, me included. Nowadays there are many well designed tools and websites, including those attached to our yearly appraisal, to help us do this. Those not entering into the spirit of things already are unlikely to be swayed by iwantgreatcare.
    As far as my own health goes, some of the comments made so far have made such wildly unlikely claims about the supposed actions of the doctor in question as to make me doubt the reliability of any further reviews I read. Perhaps this will all change and the site will fill up with considered, objective comment attributable to named patients. But I’m not holding my breath.

  • Peter Ward

    When I was a houseman 12 years ago, my boss, an elderly surgeon nearing retirement were talking about a certain local GP that was highly thought of by patients but seemed to make some pretty dodgy medical decisions. He reflected “I don’t think patients can really tell if their doctors are any good”. I believe Harold Shipman was pretty highly rated by his patients.

    Now I’m a GP myself I think the elderly surgeon was right. Nice drs, emmollient ones who pump hands and say “you’re a great guy” and “It’s great to see you again” seem to get the favour of their patients more than the ones who practice what other drs perceive as good medicine.

  • http://www.shinyred.tv Laura Johnson

    Thanks for the mention Deborah, iwantgreathealthcare certainly seems to be stirring up quite a debate! It was interesting to read about if from your medical point of view – and I agree with you in that the end result remains to be seen and like Timothy, I am interested to see how the site shapes up once it gains more reviews – a ranting forum? A libel case waiting to happen? Accountability for doctors? Or a combination of them all?

  • Dr John Corish

    As someone who has been permanently banned from Dr Neil Bacon’s other prominent website, Doctors.net.uk, mainly – as far as I can establish – for expressing views critical of current UK abortion law, I regard Dr Bacon’s latest cyber adventure as professionally irresponsible. In no way can the views expressed (by either patients or colleauges) on such a website be regarded as an objective assessment of any doctor’s ability to provide “great care”.

    As a junior doctor training in Ireland over twenty-five years ago I worked with several consultants whose knowledge of clinical medicine seemed to me at least a couple of centuries out of date. Nonetheless, these individuals were held in the highest esteem by cohorts of long-standing patients who, had they been asked, would have undoubtedly replied that they had been in receipt of “great” care.

    Dr Bacon’s website quite clearly has the potential to destroy medical careers on the basis of hearsay and I strongly urge the GMC to insist that it be closed down immediately. Dr Bacon, of course, would probably denounce this as censorhip and an infringement of his right to free speech. In the event of such a scenario, I hope the GMC would gently point out to him that rights carry responsibilities and that this website fails to comply with the most basic standards of professional responsibility.

  • Tom

    The internet has painfully transformed many other industries, and it will transform healthcare regardless of what the doctors say or want.

    When I hear doctors railing against things like I Want Great Care, I think of all those in the music industry in the 1990s who railed against downloading. They railed but took little action to prepare for the new reality, and got hammered. Massive, disruptive change is coming whether you want it or not. Those doctors who embrace this and run with (my hunch it will be the younger docs) will thrive in the new environment. Those who refuse to adapt will sink.

    Learn the lessons painfully learned by other sectors about what Web 2.0 transparency does to professions, and start learning, growing, changing accordingly.

  • Dr John Corish

    Tom, you clearly aren’t a medic and as such do not understand the stringent regulations that govern our profession. According to our professional ethos, it is my understanding that it is quite improper for any doctor to set up the kind of website started by Dr Bacon whereby any member of the public can openly blow the professional reputation of another doctor to shreds with or without that doctor’s consent. As I’ve said above, this is a matter for our regulatory body, the GMC, to adjudicate and I shall be writing to them in the near future urging them to insist that Dr Bacon’s latest commercial enterprise be shut down.

    Your analogy with the copyright infringement (the unlawful reproduction of the work of another, often for the purpose of re-distribution and profit)which prevailed on the World Wide Web in the early ’90s but which has now, to a degree, been stamped out, has no great relevance whatsoever to this particular discussion.

  • Tom

    You’re right: I’m no medic. I’m a consultant who has worked in many different industries grappling with how to respond to the challenges digitisation and the internet present.

    And I understand why many UK doctors seem apoplectic. I probably would be, too, if I were you. Decades of training after a lifetime of performing well at school, all to have some upstart patient say you were rude and uncaring on some website. It’s challenging indeed.

    But there’s no way to stop it. So I guess what I’m saying is: it’s time for the medical industry (including the GMC) to figure out how it’s collectively going to deal with this new reality. Railing against it, suing it, trying to shut it down, etc., will not work. (Hence my music industry analogy.) Other strategies and approaches will be required, and some clinical leaders need to emerge to show the way, calm the debate, and lead the industry forward.

  • ben dean

    I am slightly baffled by the comment:

    “But with all the vitriol spewed out daily on doctors.net”

    Well, there is a small amount of vitriol, however the vast majority of what is written is not, most of it is actually well argued, humorous and/or intelligent. I actually remember last year how government cronies tried to write off the bulk of medical opinion as being just a little noise from a vocal minority.

    Neil Bacon’s infamous site is uniquely unpopular amongst the vast majority of doctors I have spoken to, whether they be close familiy or distant contacts on the web. Dr Bacon has plucked this 5% number from somewhere where the sun does not shine, it should not be accepted as fact without proper scrutiny.

    The website is just so poorly designed that it will burn itself out, why do I say this? Well legally any derogatory comments must be removed, thus the only comments remaining will be positive ones, this makes the website completely pointless.

    It is bad planning in the extreme that allows anyone who comments to do so completely anonymously, if there is no security or accountability then the comments are completely meaningless. A patient can pose as a doctor to post a comment as a ‘colleague’, this is just one example of how the badly designed site can be abused, thus making it’s output useless.

    Your comments about patients having a right to know about the relative skills of doctors do not make sense, as there is no way in the world that IWGC could possibly be used by a patient to reliably work out whether a doctor is good or not. The site is completely insecure and completely unreliable.

    I am amazed that so much time and effort has gone into something so very useless, so very badly thought out and so very badly designed. In fact it could have come straight from the creators of MTAS.

    Ironically doctors on the front line are very accountable for their work, there are already robust complaints procedures in place, in fact we should be encouraging patients to use the proper complaints procedures in place, not encouraging the use of an unreliable and insecure website that will benefit no one.

    I also find it strange at how no one is really considering what this means for doctors? Doctors already have one of the highest rates of mental illness and depression of any profession, and are already subject to numerous examinations and assessments, not forgetting robust complaints procedures. IWGC gives doctors no right of reply to comments that are made by anonymous individuals who have to provide no facts or evidence to back up their stories.

    The harm that this site will do to doctors is very real, while the benefits it will bring appear only to be in the GMC and Dr Bacon’s fruity imaginations.

    It is also strange that doctors on the front line who actually dare to practice clinically are so accountable by so many different means, while those that rule over the clinicians from the DH in Whitehall are completely unaccountable for their gross errors.

    As doctors we are taught to, first, do no harm. IWGC breaks this golden medical rule as it promises a lot of harm for no reward, perhaps Dr Bacon is being rewarded though, I see that this glaring conflict of interest has not really been much talked about in the media, strange that.

  • ML

    To some extent the key question about IWGC is simple: will patients benefit, individually or collectively? The proposed mechanism for such benefit is that IWGC will allow them to ‘choose’ great care, with the corollary that those doctors providing ‘poor care’ will lose patients, lose business and lose income…

    For this proposition to hold, IWGC would have to have a classy database, and generate reliable high quality information that could guide choice. And real choice would have to be available.

    It’s no good if the allegedly best GP in the UK works in Aberdeen if you the patient live in Andover. And it’s no good even if you live in Aberdeen if that ‘best’ GP is already fully employed, with no capacity to take on extra patients – as is likely if they really are that good.

    And it’s no good if the alleged best A and E consultant is in Wapping, and you fall and break your wrist in Winchester.

    Psychiatry is another ‘sectorised’ service with no real choice.

    And other services, such as the various medical and surgical departments of hospitals, are also restricted to limited choice (locality-based).

    Despite Tom’s brave new world hyperbole, [1] there is actually no real market in healthcare services in the NHS, which renders IWGC pointless.

    And both the IWGC database listings and the quality of data (to guide choice) on IWGC are embarassingly poor.

    These sorts of considerations have led many doctors to conclude that IWGC is both pointless, and potentially destructive. Note that it is potentially destructive of patients’ confidence in the care they receive.

    Question for Deborah: have you actually looked at the site yourself and explored and tested it?

    [1] Tom: Web 2.0 has transformed medicine and continues to do so. From your postings I’d guess you will be unaware of this. I think you should take care not to confuse opposition to a specific IT venture with a global failure to embrace necessary change.

  • http://drgumble.blogspot.com Dr Grumble

    Some of the worst doctors I have come across have been greatly loved by their patients. These are charming people who have an easy life by just chatting to their patients and giving them what they want. That could be reassurance or a pill. But the really caring doctor is always focussing on what questions need to be asked or what examination needs to be done to reach a diagnosis and make sure that any reassurance is justified. This leaves less time for the niceties. Patients don’t relish probing questions or intimate examinations. If you have the trust of the patient it is easy to reassure but it is no good doing that unless you are right – though much of the time you will get away with it even if you have not gone through all the hoops. It is easy to be a bad doctor and be loved.

    There are patient bloggers who have thought this issue through well. Their approach seems much better than Bacon’s. Few doctors seem to want this web site either and many seem prepared to use the British libel laws to protect themselves. If so Dr Bacon could have had his chips.

  • ML

    By the way, my posting above (which I am sure you will find acceptable) “is awaiting moderation”.

    Why? Why not just let me post what I like right there and then, no holds barred? Do you think I might post something disparaging or unwarranted – such as suggesting that your blog entry was frivolous and ill-considered? (Not that I would make any such suggestion, of course). And would it matter if I did? And even if something I posted was untrue, and misled your readers, or was defamatory, would that matter in the chatterbox world of Web 2.0?

    ML

    *** P.S. review postings (about doctors) to IWGC are NOT moderated before they appear on IWGC pages. IWGC removes allegedly offensive or abusive postings if and when it notices them, at a later date some time after the review has appeared on their pages.

  • Ruth Allen

    Interesting opinions;

    I feel that websites like I want great care – and those like them – are inherently flawed for a numbder of reasons.

    Firstly – like television chat shows, the people who post are likely to have a strong opinion one way or t’other or have been prompted to post by somebody reasonably sure of the outcome.

    Secondly – I suspect significantly bad reviews will be removed for fear (or actual threat) of litigation and this will bias the overall results.

    And thirdly – the site (as it stands) has no unique identifiers for any doctors – there are at least three registered doctors with my name – how does the reviewer or reviewed check that they are dealing with the correct person – not to mention the fact that deceased and retired doctors have been included in the database – hardly an advert for it being accurate and up to date

    Finally, the questions asked bear no relation to a doctors competence or probity – if you choose a doctor based on a website like this then more fool you.

  • Nicki

    I am concerned that my name has appeared but none of my colleagues.
    The reason this concerns me is that I wonder if my name has appeared because I have registered with doctors.net.
    Does anyone know why some names appear and not others?
    If there is a connection then who at doctors.net gave out the details?
    As a GP we have appraisals, patient questionaires etc etc.
    We are not against criticism or feedback but being a nice Dr and giving the patient what they want all the time does not mean that you are a good Dr.

  • http://bmj.com David Payne

    Dear ML,

    You raise a good point. We’re certainly looking into it. We’re not that new to the chatterbox world of Web 2:0, but we’ve only started posting blogs on a more regular basis in the last few months, and the last thing we want is to stifle debate. And the reality is that to date we’ve switched everything to live that’s come in. Anyway, this isn’t about I want great care, so I’ll bow out now. But thanks for raising.

  • http://ferretfancier.blogspot.com djdeeno1979

    http://www.pulsetoday.co.uk/story.asp?sectioncode=35&storycode=4120287&c=2

    Neil Bacon’s 5% claim is looking rather as if it came from the fresh air.

  • Dr John Corish

    Tom, my name is John Francis Corish, GMC registration no. 4049654. Now, in the interests of glasnost and perestroika (which you, like Dr Neil Bacon, seem to be championing for the medical profession) it would be helpful if you revealed your full identity. I will find these details necessary when I start my new website, Iwantgreatdigitisers.org.

    Furthermore, I declared any potential conflict of interest I might have with Dr Neil Bacon in the opening sentence of my first post. It would also be helpful if you did likewise. Specifically, are you now (or have you ever been) associated with Dr Bacon in a personal or professional capacity?

  • Martin Toal

    It is naive to think the intention behind IWGC is to improve patient care. If that was truly the case, the structure and operation of the site would allow the production of some useful and vlaid outputs. That is not currently the case and with the amount of resentment Bacon has intentionally stirred up, unlikely ever to be so.

    A properly thought out site would include at least some features which help identify meaningful measures of quality so as to help the reader know if they will get the great care in the name. As it stands it provides only gossip and innuendo in a “Was my doctor nice to me?” format. Perhaps iwantaniceoctorwhogivesmewhatiwant.org would be more accurate. The lack of substance allows a drug addict to rate a doctor 0% for not fuelling their addiction (or 100% for the opposite action), and thus could encourage bad and negligent care.

    It is also a basic principle of proper effective and validated feedback systems that they work only where feedback is wanted and accepted by the recipient and is validated. This is patently not the case for IWGC, and the problem extends to many doctors who do not practice clinical medicine any more are listed and have had requests for removal denied, although Dr Bacon appears to have the right to exempt himself from feedback, which was in actual fact pretty accurate prior to its censoring. Thus hypocrisy should be added to the list of charges laid against him.

    But the most damning problem is that the feedback is unverifiable. This makes it less than useless, because even if true, and we will never know, it cannot be properly interpreted or followed up, and thus exists only as gossip. If this is Web 2.0, we badly need Web 3.0.

  • Tom

    John: I have no connection to Bacon at all. Indeed, I have little connection to the UK, being an American here temporarily (3 year stay). I work as a consultant, and touch on healthcare from an information systems POV, but not a clinical POV.

    (Before knees jerk: I am a huge fan of the NHS, especially in comparison to the mess in the US.)

    I must have expressed myself poorly, as I sympathize hugely with what doctors are facing here and in the US with ratings. And I agree very much with Dr Grumble’s post.

    I’m merely trying to say that calling for IWGC to be shut down won’t work. These Web 2.0 tools must be engaged with by industry/clinical leaders to ensure they are rolled out transparently and implemented properly.

    For example: anonymous ratings and comments are garbage (yes I see the irony as I’m not posting my phone number) and consumers are smart enough to recognize them as such. IWGC won’t succeed if all it offers are anonymous stars and rants. Further, people have to be able to respond (as they do in blog comments like these). If doctors don’t have a voice versus rants, then that’s insane and unfair. Ways and means for this have to be sorted out, and the best way to do it is collaboratively between the industry (the doctors) and the service (IWGC and its competitors).

    I will now bow out and leave you the blog floor, as I see this topic is rather explosive.

  • ML

    Tom hi

    What do you think doctors should do if they have no confidence (at all) in a colloboration with a particular website or agency? Do you think the ‘open’ imperative of Web 2.0 means that we must deal with whoever is in the market, regardless of their conduct, and regardless of our confidence in them? I’m guessing you don’t think that – not least because you recognise that “anonymous ratings and comment are garbage” – but that’s what IWGC is.

    I’m sure you may appreciate now that your original disparagement of the opposition to IWGC (as fighting the tide of Internet history) was maybe a little misplaced. Comparing us to the dismal (and collapsing) record industry is a trifle heavy dude! – and unwarranted.

    In any event, best wishes, ML

  • Dr John Corish

    Tom, so you don’t have the courage to reveal your true identity? What’s sauce for the goose clearly isn’t sauce for the gander in this instance. QED. And, believe me, IWGC.org is living on borrowed time.

  • http://implementek.com Dr. Mary E Black

    I am a doctor, I live outside the UK and so my GMC registration is currently not valid, and I co-own an IT consulting company (as a very interesting sideline)

    I Want Great Doctors is a site that is poorly designed – badly thought out, visually boring, cannot identify between doctors of similar names. Given that very negative posts might be screened out for legal purposes it sort of removes the stated purpose of the site, which is to use debate to reward great care – and point to bad care. We can further note that the site offers a chance to report on perception of great care, but it actually is about communication and style and percieved care…. I could go on and previous posters have done so.

    Lets look at the results. There appear to be more posts on discussion forums about the site rather than posts on it. The comments that are posted on the site itself are pretty bland and boring – online readers go sites like this in the initial stages to see colour – different opinions, interesting posts, controversy. When such sites reach critical mass, in this case multiple posts about the majority of doctors in the country, then they also become useful and so people might then go there and search for a doctor they know to see what is said. Frankly I see no sign that this is likely to happen.

    As for me as a doctor, I have had patients yell at me, be rude to me, dislike me, try to kill me ( a patient with with febrile psychosis who wrapped his hands round my neck when I gave him his IV injections and was then forcibly restrained by a passing colleague). All practising doctors have similar tales. In future I should add to the list – be slagged off by anonymous patients online.

    Is it fair? No. Can it be stopped? In the world of Web 2.0, not entirely, only the worst excesses can, but the web allows wide dissemination of what would normally have got round as gossip, innuendo and passing comments. It also allows the most wonderful things – like online publication and debate!

    From my perspective as an IT developer, I surmise that the IWGC site is being built to

    a. collect as many emails as possible so they can be later sold on, used to build the next venture etc. 2 million is the minimum going rate now of users at which a social networking site becomes worth something in money terms.
    b. build a client base and generate attention and content so that advertisers might then find it worth their while paying to post ads or link services.
    c. Sell on later as a brand name if it ends up being a good and useful service.

    So all of this publicity and discussion is a boon to the developer – he gets increasing numbers of people registering, he captures content from all of us, he gets publicity and he builds his site up…..

    It is a business opportunity for him either way….

  • James

    Interesting comments here.

    It seems that doctors opposed to IWGC set up a simplistic dichotomy between the ‘nice doctor’ who gives his patients what they want and the ‘competent doctor’ who gives his patients what they want. It’s perfectly possible to be nice, compassionate, caring and attentive at the same time as denying your patients’ requests.

  • william

    get used to this happening alot. drop the shackles of power you have wrongly held for so long. maybe a business opportunity for him, but useful for patients who posess insight and sense. people make choices in alternative health already. although the vicious powers of government along with allopathic doctors tried to ban specific supplements before, however the case did not make it to law in the eu. i believe it was the eu supplements directive. i’m pleased as careful health aware people have access to a wide choice of suppplements which would have been terminated by the ban. i advocate alternative medicine and allopathic care together. whatever helps or cures your condition. by wise people, this rating system is a winner tbh. for example, what about a doctor who would not prescribe an opiate for a cosmetic treatment where a large ammount of topical anesthetic is used, therefore making it unsafe to use. an alternative type of analgesia needs to be used.

  • william

    ok james, what about the many iterations of a reasonable request by the patient, however through threat of higher powers can’t help as other patients screwed up with the medicine. what if the doctor knew the personality of the patient would pose no risks in treatment but her hands are tied?

  • http://www.aremi.me.uk/ Caspar

    Just a quick note – tried to visit iwantgreatbacon.com and it’s got a virus on the page. You may want to take off the link to that…

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