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A version of column was published in USA Today on September 14, 2014.

The public can rate and review most things today: books, hotels, and restaurants, to name a few. Even doctors. There are more options than ever where patients can rate their doctors online, and hospitals also routinely survey patients about how satisfied they are with their physicians. But while you’re pretty much assured a great meal at a 5-star restaurant, whether you receive excellent care from a 5-star doctor is less certain.

Doctor ratings generally focus on the patient experience, such as wait times, time spent with the doctor, and physician courtesy. Those are obviously important issues, but they paint an incomplete picture. Doctors with stellar interpersonal skills may not be the best at controlling patients’ blood pressures or managing their diabetes. High ratings may identify surgeons with great bedside manner, but mask high surgical infection rates.

The quest for ratings perfection influences medical decision making, as patient satisfaction increasingly affects doctors’ salaries. According to the management consulting firm Hay Group, more than two-thirds of physician pay incentives are based on patient satisfaction scores. And Medicare withholds as much as $850 million in payments to hospitals who fail to meet various quality metrics, with patient satisfaction being a significant component.

But doing what’s best for patients won’t necessarily make them happy. Denying antibiotics for viral infections or saying no to routine MRIs for patients with back pain are both sound medical decisions, but can anger patients; some vent their frustration by poorly rating their doctors. It’s no wonder that many physicians acquiesce to patient requests. In a survey by Emergency Physicians Monthly, 59% of emergency physicians said patient satisfaction surveys increased the amount of tests they ordered. In another survey by the South Carolina Medical Association, almost half of physicians said that pressure to improve patient satisfaction led them to inappropriately prescribe antibiotics or narcotics. In fact, Senators Dianne Feinstein (D-California) and Charles Grassley (R-Iowa) wrote a letter to Marilyn Tavenner, administrator of the Centers for Medicaid & Medicare Services, saying that “there is growing anecdotal evidence that these [patient satisfaction] surveys may be having the unintended effect of encouraging practitioners to prescribe opioid pain relievers (OPRs) unnecessarily and improperly, which can ultimately harm patients and further contribute to the United States’ prescription OPR epidemic.”

These extra tests and treatments are expensive and can hurt patients. A landmark study from JAMA Internal Medicine analyzed over 50,000 patient satisfaction surveys, and found that patients who were more satisfied with their doctors had higher health care costs, were hospitalized more frequently, and had higher death rates compared to less satisfied patients. That makes sense: Patients who receive more drugs and tests are exposed to their harmful side effects and complications.

Now, I’m not saying physicians shouldn’t be graded by patients. Subjective physician evaluations are valuable, but not by themselves. They need to be complemented with objective measures of medical care, like a surgeon’s operative complication rate, for instance. Until physician ratings evolve into a more holistic representation of doctors, they must not be financially tied to how physicians are paid.

And to patients: Don’t automatically choose doctors with the highest online ratings or perfect patient satisfaction scores, because they may be the ones who reflexively prescribe antibiotics or narcotic drugs to inflate their grade. It’s conceivable that those who have mixed reviews may actually provide better care. Because they could be the physicians who make the effort and take the time to occasionally say no to patients.

Kevin Pho is an internal medicine physician and co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is on the editorial board of contributors, USA Today, and is founder and editor, KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.

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