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zoom RSS 診察前に不満契約書にサインを/米国医療事情

<<   作成日時 : 2009/07/27 00:52   >>

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診察前に不満契約書にサインを
画像 最近5年間で40を越えるウェブサイトで医師のレビューがされ、患者が意志決定する際の情報を提供している(RateMDs.com, Angie's List, Yelp, DrScore and Vitals.comなど)。しかしインターネットの匿名性が、患者個人情報保護法で強制される医師の権利と相反する場合がある。
 防御手段として、医師によっては、「事前の同意なしでは」メディアへの流失やオンライン投稿・論評を禁止する包括的協定にサインすることを患者に要求している。多くの専門家は非倫理的で強制不可能だという。
 しかし、ますます多くの医師は、「私が私の人生においてこれまでに出会ったことがある最も悪い医師」「無作法、無関心、集中していない」など、真実でないようなコメントを許すサイトへの適切な反応とみなしている。
画像 RateMDsはGoogleから主として広告収益によってサポートされて、全国200,000人以上、メリーランドとバージニアの8,000人以上の医師の格付けを行い、1ヶ月で100万人以上のアクセスがある。規律上の履歴といくつかの州での不良治療支払いをチェックすることができる医学ボードへのリンクを含んでいる。「ほぼ毎週のように訴訟の脅威を受けている」という。24時間以内にスタッフがチェックし、不適切・疑わしい・中傷的であるものについて、約5%が削除されているという。
 治療の質を最も評価できないのが患者であり、結局人気取り競争に相当する。ぶっきらぼうなことが治療の質を相殺してしまう。
 医師は皿洗い人やゴミ圧縮機やミニバンではない。格付けサイトは、非常に小さなサンプルサイズであり科学ではないと、整形外科医ピーターラビンは言う。
 引退した脳外科医ジェフリーセガーは、Medical Justice 医学公正を設立し、495ドルからの料金で2000人の会員メンバーに対するオンラインコメントを監視している。協定があることで、医師がウェブサイトにたいして、プライバシー協定にサインした患者によるコメントを削除し、患者に対して訴訟を起こすように頼むことを可能にすると言う。医師は個人情報保護法で束縛されており、偽のオンライン情報から身を守ることが困難なため、自らの名望を守るために対策を講じる必要があると言う。
 ニューヨーク医療消費者センターのアーサーレビンとペンシルバニア大生命倫理アーサーキャプランは、違法で無分別だとして、こうした協定に強く反対している。しかし、格付けサイトの価値については同意していない。レビンは消費者が求める情報を提供できると言い、キャプランは最も重要な情報を明らかにしていないと言う。
 デンバーの形成外科医ニコラススレンコビッチは、事実誤認の格付けウェブサイトの上の「ごみ」から「自己防衛」するための棄権証書とみなしている。嫉妬した競争相手または不満な患者によってこき下ろされることについて悩まされている。自らの生計がかかっているが答える手段を持たない。これまでに、彼の患者の誰も、サインすることを断らなかったと言う。
 地域内科医のフォークは、違う種類のサイトをサポートするつもりであると言う。「患者について不満を言うことができるウェブサイトを持ちたい」と言い、「すべての医師はそう思っている」と。
----------------------------------------------------
Doctor's Orders
Want Treatment? Just Sign This No-Complaint Contract . . .
http://www.washingtonpost.com/wp-dyn/content/article/2009/07/20/AR2009072002335.html
By Sandra G. Boodman
Special to The Washington Post
Tuesday, July 21, 2009

Until recently, patients whose doctors kept them waiting for hours without explanation, brushed off their questions or seemed downright incompetent had little recourse, other than complaining to family, friends or, in egregious cases, the state medical board. That was before the Internet gave everyone with an e-mail address the ability to reach a vastly wider audience by posting -- often anonymously -- critiques of doctors, in much the same way travelers rate hotels on such Web sites as TripAdvisor.

In the past five years more than 40 Web sites, among them RateMDs.com, Angie's List, Yelp, DrScore and Vitals.com (motto: "where doctors are examined"), have begun reviewing physicians, providing information about one of the more difficult and important decisions consumers make routinely.

As these sites proliferate -- a reflection of the hunger for information about doctors in an era where patients are expected to make sophisticated decisions about their care -- questions about their usefulness, accuracy and fairness are intensifying. In some cases the freewheeling anonymity of the Internet has collided with the rights of physicians who are constrained by laws that protect patient privacy.

As a defensive measure, some physicians are requiring patients to sign broad agreements that prohibit online postings or commentary in any media outlet "without prior written consent."

Critics call the documents gag orders. Many experts say they are both unethical and unenforceable.
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But an increasing number of doctors view them as an appropriate response to sites that not only ask detailed questions about a doctor's punctuality, availability, communication skills, office staff and the effectiveness of treatment, but also permit comments that may be untrue. Some are scathing.

Case in point: A veteran District internist has attracted nearly 40 comments on one site, compared with the more typical one or two. Most are negative, focusing on his off-putting demeanor, dirty office and hostile staff.

"The worst doctor I have ever encountered in my life," one recent posting said. "Impolite, unengaged and unfocused." Said another: "Long wait, rude staff, never sent me a follow-up on my tests."

To Angie Hicks, founder of Angie's List, which last year added doctors to its reviews of plumbers and roofers, physician ratings are an extension of the contemporary zeitgeist.

"Consumers have been talking about their experiences with physicians forever," she said. "It's moved online, just as other parts of our communication with friends and family have.''

Unlike other sites that rate doctors, Angie's List does not allow anonymous postings (the site knows writers' identities, although the public does not) and its reviews are available only to members who pay a fee.

Many other sites are free and accessible to the public. John Swapceinski, a founder of RateMDs.com, one of the oldest and largest sites, said he was inspired by the success of the reviews on Amazon.com and thought consumer rankings could be applied to professors and physicians. After Swapceinski launched RateMyProfessors.com, he took RateMDs live in 2004.


Supported largely by ad revenue from Google, it contains ratings of more than 200,000 physicians across the country, more than 8,000 of them in the District, Maryland and Virginia. The site attracts a million unique visitors per month, Swapceinski said, as well as the ire of some doctors. RateMDs contains a link to the relevant medical board where patients can check disciplinary histories and, in some states, malpractice payments.

"We get threatened with lawsuits on a pretty much weekly basis," he said, adding that none has been filed. Nor, Swapceinski said, has he acceded to demands by doctors to remove comments he deems appropriate, although there is a mechanism by which doctors can respond.

All entries are reviewed by a staff member within 24 hours, Swapceinski said, and about 5 percent are deleted because they are irrelevant (the doctor is having an affair), suspicious (the doctor had an open bottle of vodka on his desk) or potentially libelous (the doctor touched me inappropriately).

"We're not just out to 'out' the bad ones, but to point out the good ones," he said. A "very positive or very negative rating opens the floodgates," eliciting additional reviews. Waiting time, he said, is a "huge issue" mentioned often, as are statements such as the doctor "never made eye contact and was out in 30 seconds."

But critics contend that such sites reveal little of importance.

"The people least capable of judging quality of care are patients," said District internist Nancy Falk, whose mostly positive ratings are offset by those calling her curt and intolerant of questions, descriptions she denies. "They don't know what we know." Falk regards doctor rating sites as just as dubious as "Best Doctors" compilations. In her view, both amount to popularity contests.
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Orthopedic surgeon Peter Lavine, president of the Medical Society of the District of Columbia, agrees. "Doctors aren't like dishwashers or trash compactors or minivans," he said. Ratings sites "are not scientific, have a very small sample size and often attract patients who have an axe to grind."

Some doctors advocate an aggressive response. Retired neurosurgeon Jeffrey Segal of Greensboro, N.C., is the founder of Medical Justice, a company that for a fee starting at $495 provides sample privacy agreements and monitors online comments for its 2,000 members. He said the agreements enable doctors to ask Web sites to remove comments by patients who have signed privacy agreements, and to take legal action against patients.

Doctors, Segal said, need to take steps to safeguard their reputations because of the Internet's "Wild West atmosphere" and because physicians are bound by privacy laws and can't defend themselves against spurious online allegations.

"We've learned how hard it is to protect and preserve doctors' reputations," Segal said. He cited a 2007 California appellate court decision that upheld the right of a patient to operate Myplasticsurgerynightmare.com, a Web site her surgeon tried to shut down.

"We're not opposed to free speech," Segal said. "We're trying to smooth out the extremes." Some sites have removed comments as a result of privacy agreements, Medical Justice officials say, but they did not provide specific examples.

Assessing Ambiance

Arthur Levin, director of New York's Center for Medical Consumers, a patient advocacy group, and Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, are strongly opposed to gag orders. Caplan echoes many legal experts, calling them "illegal, unenforceable and silly." But the two disagree about the value of ratings sites.

Levin said he believes they can provide information sought by consumers, such as whether others think a doctor communicates well. Caplan thinks they are merely "a measure of ambiance" and don't reveal the most important information: outcomes.

"One person's brusque is another's direct," Caplan said. "It's notorious that many doctors who would score well on ambiance are not good doctors, but manage to stay in practice." As a member of the New York state medical licensing board, "I saw again and again doctors who were well beyond the border of malpractice who kept going because patients loved them."

"Not only can't patients judge doctors, other doctors can't judge doctors," Caplan added. Without knowing a doctor's mortality, complication and infection rates, rankings reveal "just a piece" of the data consumers require.

Levin agrees that outcomes data are badly needed, but he thinks ratings sites can be useful. "What you need to look for is consistency and a certain number of ratings," he said. "It's one piece of a total picture

Beth Nash, an internist employed by Consumer Reports, advises that patients dump a doctor who demands a privacy waiver. "While we have all had bad days," she wrote on the group's health blog, "I find it hard to believe that a doctor with multiple negative reviews has just been unlucky enough to be judged on those occasional bad days."

Whose Privacy?

Northern Virginia OB-GYN Nicolae Filipescu has 35 reviews on RateMDs, far more than many of his peers. He also has one review on Angie's List and five on Yelp, both posted in the past six months. One Yelp poster described him as "competent and professional," while the other said he was rude, kept her waiting 90 minutes and offered to perform cosmetic surgery on her nose.
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The RateMD reviewers are similarly divided about Filipescu. One called him "the best" and said he delivered her three healthy children, while another advised, "Run as fast as you can." Several accused him of insensitivity and of telling patients, some of them pregnant, that they were getting fat. One said he ridiculed her when she told him she had fibromyalgia.

Filipescu, who has offices in Arlington and McLean, disputes the negative reviews. "I said, 'Please do not get fat,' " he said. Lengthy waits, he said, are not routine but may occur because of an emergency. And while he performs cosmetic surgery, Filipescu said he doesn't do nose jobs.

"You have to realize there are some people who are somewhat disturbed," he said. "I don't get complaints from the Medical Society of Virginia or the [state] medical board."

But Filipescu opposes privacy agreements. "It's a freedom-of-speech issue," he said. "Let them say what they want."

Denver plastic surgeon Nicholas Slenkovich couldn't disagree more. A member of Medical Justice, he regards the waivers as "self-preservation" from what he terms "garbage" on ratings Web sites that he says are riddled with factual errors.

"Perception is very important in my business," said Slenkovich, adding that he worries about being trashed by a jealous competitor or a disgruntled patient. "The Internet is out there and everyone's using it. This is my livelihood, and I have no ability to reply." So far, he said, none of his patients has refused to sign.

Although many doctors are unenthused about online ratings, Falk, the District internist, said she would support a different kind of site.

"I'd love to have a Web site where I could complain about patients," she said. "All doctors would."

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