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• W4210271837 abstract "In recent years there has been an exponential rise in online feedback from patients reporting health experiences.1 While undoubtedly facilitated by increased availability of and access to the internet, a series of institutional changes within the UK’s National Health Service (NHS) has compounded the uptake. In 2004, NHS trusts were obliged to report service outcomes to the Healthcare Commission to be published online, allowing public access to information. In 2007, the launch of the NHS website provided a platform for patients to evaluate clinicians and hospitals online. Consequently, in 2016, NHS England implemented a strategy to incorporate technology into the future of the NHS, supporting digital transformation to revolutionise the way health care is provided. The emphasis on a patient-centred approach has facilitated the development of numerous physician feedback websites, including iWantGreatCare, Care Opinion and Doctoralia. Feedback is integral to improving standards across disciplines. In the travel and hospitality industries, online feedback is fundamental and has been estimated to influence at least £23 billion of consumer spending per year.2 In medicine, systematic patient feedback has been shown to help trainees identify areas of improvement, resulting in enhanced interpersonal skills.3 Institutionally, feedback can improve healthcare provision and quality of services. This is epitomised by the fact that clinical outcomes are associated with patient satisfaction,4 to an extent whereby hospitals rated poorly have higher mortality rates.5 However, evidence remains inconsistent regarding the association between online ratings and quality of care,6 and there are various ethical arguments that require consideration prior to increased implementation. The aim of this commentary is to discuss and summarise these considerations. The successful implementation of new healthcare initiatives depends on the attitudes of the stakeholders involved.7 It is therefore essential to consider healthcare professionals’ perceptions of online feedback. Despite the intention to improve health care, many healthcare professionals remain sceptical, with reluctance to embrace feedback websites.8 In a survey of 1000 doctors, 57% perceived that online feedback is generally negative.9 However, analysis of 228 113 online comments revealed a markedly higher frequency of positive evaluative words compared with negative (75% versus 25%),10 suggesting attitudes may be influenced by unrealistically negative misconceptions.1 Moreover, a number of studies have demonstrated the motivations for providing online feedback are often to praise a service, rather than to complain.11 The core drivers of online feedback are undoubtedly the doctor and patient, with a shared goal to assess healthcare standards and improve quality of care. Figure 1 illustrates a model of online feedback encompassing these drivers, in addition to a number of factors required by healthcare providers deemed integral to improving patient experience, as described by the NHS Trust Development Authority framework for enhancing patient experience.12 Model of online feedback Patients who give online feedback usually retain anonymity, which facilitates the expression of honest opinions,13 thereby enhancing autonomy and empowering them to leave negative or critical comments.1 Furthermore, social media platforms such as Facebook, Instagram and Twitter are bound by statutory rights including the freedom of speech.14 Therefore, members of the public are within their rights to post uncensored content in the absence of peer review. Many doctors perceive the ability to write unregulated comments as dangerous, exposing them to professional vulnerability and risk of online bullying or defamation.1 Although NHS Choices report regulations are in place to protect clinicians by removing inflammatory remarks, concerns remain regarding implementation in practice and the inability to respond prior to publication,6 resulting in many doctors demanding more formal regulation.1 Such professional vulnerability is compounded further by doctors’ duty of candour to maintain confidentiality, thus restricting their ability to contextualise comments or defend themselves. Professional bodies, including the Medical Defence Union, provide guidance for doctors receiving negative online feedback. This includes responding to feedback positively, addressing policies of the service provider publishing the comments, or requesting the right to be forgotten online – acknowledged by the Court of Justice of the European Union – through subtraction of search results from search engines including Google, Bing and Yahoo.15 Currently, there are a lack of distinctive considerations of law specific to medical professionals seeking action against defamation.16 However, doctors can take legal action if online comments are perceived to injure the reputation or discredit the individual in the estimation of peers within their society.16 Legal action does not guarantee a successful outcome and may take a number of months to resolve, associated with expensive costs. Publicity from pursuing legal action against libel may also draw further attention to the defamatory comment. Therefore, a number of doctors may be discouraged from pursuing legal action. The Defamation Act 2013 provides a number of defences that may also be difficult to challenge. Evidence from consumer markets demonstrates that online responses to negative feedback improve satisfaction among those complaining17 and improve perceptions of trustworthiness.18 This further highlights the disadvantages doctors face. As such, the initiative to respond to online feedback in a regulated and confidential manner may improve patient satisfaction and rebuild patient–doctor trust. While positive feedback can enhance reputation and potentiate career prospects, negative or malicious feedback in the public domain can conversely have a lasting negative impact on a clinician’s career. Significant psychological burden such as reduced confidence and self-esteem may arise, which in turn could impact clinical practice. Doctors who receive complaints are twice as likely to report suicidal thoughts, 77% more likely to suffer moderate to severe depression and have twice the risk of moderate to severe anxiety.19 Moreover, data from more than 10 000 doctors reported 45% of doctors felt powerless, 42% emotionally distressed and 21% unsupported when dealing with patient complaints.20 Reports of clinicians personally acquiring court orders to remove online reviews21 highlight similar issues that may arise as a consequence of negative online feedback. Obstetrics and gynaecology has one of the highest attrition rates of all specialties (30%).22 A study of more than 3000 obstetrics and gynaecology doctors in the UK identified that 36% fulfilled the criteria for burnout.23 The widespread implementation of online feedback may encourage comparison between peers, promoting competitive – rather than collaborative – working relationships, which may potentiate further the challenges of working in the specialty. It is therefore unsurprising that the British Medical Association (BMA) have raised concerns regarding slander and opposed clinician rating sites.24 For those working in private practice, there may also be significant financial implications for doctors exposed to poor reviews or suboptimal ratings. This is exemplified by data highlighting that patients who were exposed to a neighbour’s negative physician review were significantly less likely to choose the physician than those exposed to a positive recommendation only.25 Online feedback refers predominantly to interpersonal skills, rather than clinical care received.10 It could be argued that ratings focusing primarily on interpersonal skills do not correlate with professional competency, thereby bringing into question the validity of patient feedback.6 This is reaffirmed by the fact online ratings of doctors do not predict quality of care or peer assessment of clinical performance.26 Questions have been raised regarding how representative online feedback is of the entire population,27 as those who post online comments are predominantly younger in age.28 Furthermore, the use of clinician rating websites is reliant upon the cognitive capability of the user and as such may exacerbate inequality between educated and less educated patients, or indeed lower socioeconomic groups who do not have access to the internet. Following a complaint, clinical practice has been shown to be more defensive,23 including healthcare professionals performing more investigations, over referring or prescribing, avoiding performing procedures or not accepting high-risk patients.19 Doctors may make the correct clinical decision in the best interests of the patient, but if the patient does not agree, an inappropriately negative review may be left. For example, a woman with chronic pelvic pain expecting further investigation such as a diagnostic laparoscopy in the first instance, may not agree with the suggestion of a therapeutic trial of hormonal medication as first-line treatment. Following such scenarios, doctors may change their perfectly appropriate clinical practice to avoid future negative or malicious reviews. Obstetrics and gynaecology trainees are required to complete work-based assessments, including team observation forms from work colleagues, which anonymously assess clinical performance and nontechnical competencies such as professionalism and communication. As evidence suggests colleagues’ perceptions of a physician’s workplace behaviour correlate significantly with clinical performance,29 it could be argued that such assessments, which are completed by healthcare professionals governed by good clinical practice and regulated by educational supervisors, would be more appropriate in the public domain. Such a system would negate many of the limitations associated with patient feedback and may provide a more robust online presence for doctors. Alternatively, self-reported patient questionnaires can be considered a feasible feedback tool, although their usage is limited by a lack of validity and reliability.30 However, doctors interpersonal skills questionnaires (DISQs) are associated with high internal consistency that fulfils the criteria for various types of validity, and as such they can be considered as a feedback tool.31, 32 The efficacy of self-reported patient questionnaires is likely to be improved further, by collecting feedback immediately following the doctor encounter and including regular reassessment by new patients.30 There are multifactorial, varying and contrasting advantages and disadvantages of online feedback in obstetrics and gynaecology, as summarised in Box 1. Many doctors remain sceptical about its implementation, owing to fears of negative, unregulated comments. Moreover, as positive feedback does not necessarily constitute excellent clinical care, its role in the healthcare profession remains uncertain. However, feedback, whether positive or negative, remains essential for continued personal, professional and institutional improvement. With the continued uptake in online platforms and the ongoing plans to transform the NHS into a digitalised healthcare system, it may be an inevitable part of the future of being a doctor in obstetrics and gynaecology. An example of this is the COVID-19 pandemic, which has demanded widespread restructuring of NHS services and adaptation to the clinical care delivered within the specialty. Patients are increasingly encouraged to engage with technology and the internet, permitting a number of elective services to continue. We may therefore anticipate an escalation in the application and relevance of social media and online feedback during this pandemic, which may continue for the foreseeable future. In a specialty where less face-to-face interaction is expected from elective clinical work, online feedback will be paramount in aiding professional development. As such, continued debate and ethical reflection is vital, with a view to increasing regulation and enhancing protection for healthcare professionals. LSK wrote the article. SS, JBN, KJ, JY, RS and TB provided expertise and revised the final draft. BPJ conceived the manuscript, helped write the article and reviewed the final draft. There are no conflicts of interest." @default.
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• W4210271837 title "TOGadvisor: the role of online feedback in obstetrics and gynaecology" @default.
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