Physicians and restaurant owners have at least one thing in common: They both know the exasperation of feeling they are at the mercy of online review sites and the anonymous folks who post judgments of them.

During an Instructional Course Lecture (ICL) on "Online Reputation Management" at the AAOS Annual Meeting, speakers provided tips and strategies for reckoning with the "transparent world" in which the public perception of a physician's competence can be shaped by the whims of nameless patients. The panel of speakers, including moderator Glenn B. Pfeffer, MD, of Cedars-Sinai in Los Angeles, offered perspectives from the side of the orthopaedic surgeon and that of a large online medical review site, Healthgrades.

According to Roger C. Holstein, vice chairman of Healthgrades and its former chief executive, the best way to deal with online reviews is to understand how the system works, how to minimize its unwanted effects, and how to maximize its potential for enhancing one's reputation and practice.

"The transparent world is good and it is bad," Mr. Holstein said. "If you embrace it, it can make a positive difference for you."

Own your reputation
Physicians and restaurants are two of the most often cited types of business and service providers for which "reputation" matters the most to the public in making choices, noted Basil R. Besh, MD, a hand, wrist, and elbow surgeon practicing in Fremont, Calif. Today, he explained, 80 percent of Americans read reviews online before selecting a physician.

Dr. Besh cited a definition of reputation management as "controlling what people see when they Google your name." He advocated a proactive approach to the process and described a "virtuous circle" of online reputation management in which patient reviews and feedback lead to improvements in the practice, which leads to increased patient satisfaction, which leads to better reviews and higher demand for services.

Reputation management begins in the office, Dr. Besh said. Training staff for customer service is an essential investment; how the staff deals with dissatisfied patients is a major factor in determining what patients write online.

"Don't ignore upset patients," he counseled. Patients should be offered an "easy pathway to communicate dissatisfaction," including an email link on the practice website, satisfaction surveys, and signage in the waiting room, including the message, "If you like us, tell your friends. If you don't like us, tell us so we can improve."

One thing physicians should not do is ignore online ratings. "Doctor, Google thyself!" Dr. Besh implored. "Read all the reviews, including the good ones. Look for red flags, and look for opportunities for improvement.

Opinions vary on whether to respond online to negative reviews. Dr. Besh said that if a practice does respond, the message should come from the doctor.

"Stay factual and polite," he said. "Don't get into an argument. Be sincere, transparent, and consistent, and above all, don't violate privacy rights."

In responding to a review, physicians should address the problem and seek to accentuate the positive. For instance, if a patient writes, "The doctor seemed rushed," a response might be, "As one of the few specialists in town, we pride ourselves in serving as many of our patients as possible."

One of the most effective strategies for managing an online reputation is to encourage satisfied patients to post positive reviews. According to Dr. Besh, positive reviews dilute negative reviews and push them down the list on websites. Common mistakes made in efforts to encourage positive reviews include having patients post reviews from an office computer, as the review sites will recognize repeat IP addresses and will delete the reviews. Patients should be encouraged to use mobile devices and home computers, with a link emailed to them.

He explained that sites use complex proprietary algorithms to prevent fake reviews. Sites will filter and hide reviews that are suspicious but "not egregious enough to remove completely." His practice will cut and paste positive reviews that have been filtered and post them to the practice website after receiving permission from the patient.

Rules of the ratings game
The influence of patient satisfaction has consequences for the allocation and cost of medical services globally and for government decisions.

"More tests and stronger drugs equals more satisfied patients, which equals more pay," said Dr. Besh. "The biggest loser is the patient."

Mr. Holstein explained that the "transparent world" has created enormous marketplaces characterized by accessible data, user profiles, user-generated content, and a disruptive effect. Health care is a vast marketplace but is one that is singularly opaque, he said, meaning that consumers cannot obtain objective evaluations of quality and value or compare prices, as they can in shopping for products like cars or appliances.

Mr. Holstein, who previously served as CEO of WebMD in the early days of the Internet, proposed four guiding principles for succeeding in a transparent world.

One, "data must be accurate." Physicians may find it worthwhile to contract with a reputation management firm, such as ReviewConcierge or Reputation.com, to monitor the more than 100 sites on which a doctor may be found and ensure that information is accurate and up to date.

The second principle is that "Everything that can be scored will be scored." Consumers are twice as likely to prefer doctors with experience, outcomes, and satisfaction information, Mr. Holstein said.

The third is "Personal information matters—a lot."

"Consumers and [referring] physicians want to know who you are," he said. "Physician websites should have photos and videos of the doctor, personal stories, and published articles and research." One online capability that many practices do not provide, he noted, is access to the physician's calendar and scheduling.

In addition, he noted that "information needs to be discoverable," meaning it must be easily found in a search.

Mr. Holstein concluded with the following "three things you can do to manage your reputation in a digital world:"

• At a minimum, make your data accurate.
• At a modicum, provide sites with objective and personal information.
• At a maximum, make your calendar accessible.

Dr. Besh added that a negative review could potentially have a positive result.

"Not all bad reviews are bad," he said. "Have faith in the consumer, or in the aggregate of the consumer. When people read, 'I wanted my pain medication and the doctor wouldn't give it to me, and therefore he doesn't care and I am going to give him only one star,' that's going to have the effect of keeping the pain-med seekers out of your office. People who want an MRI every time they have pain—do you really want them in your office? Stick to your principles. Practice ethical medicine."

Also speaking at the ICL was Clay Calvert, JD, PhD, a lawyer and professor at the University of Florida, who addressed legal issues and remedies regarding online reputation management.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Tips from the 2016 AAOS Now Forum
Dr. Besh offered more advice about how physicians can manage their online reputations during the AAOS Now-sponsored forum on risk stratification and quality of care reporting, held on Sunday, March 6, in Orlando, Fla.

"The effect of both positive and negative reviews on a patient's decision-making processes has been increasing over time, while the percentage of folks who either don't look at online reviews or who choose to ignore them is steadily decreasing," he said. It doesn't take many reviews to influence the average patient's decision about whether to seek treatment from a particular physician, he asserted.

"In our world of science, we would never base a treatment decision on a study with such a small sample size, and yet a patient may choose or not choose a physician based on fewer than five reviews," he said.

Dr. Besh outlined the following additional strategies for managing your online reputation:

• Give patients an alternative pathway to complain, either in the office or on your website, rather than heading to the Internet to flame you. Consider giving dissatisfied patients multiple avenues for reaching out to you, such as a number they can text, a suggestion box, feedback questionnaires, and/or a link to a feedback section on your website.
• Set up a Google alert for your name. It's free and easy. You will receive a Google alert whenever there is a change in your online presence, such as when a new review is posted.
• Consider outsourcing your online reputation monitoring. Some companies are dedicated to monitoring online reputation, while others include it as a service line in their broader marketing offerings.
• Analyze reviews carefully. Read all the reviews and look for worrisome trends. A patient may like you so much that they may be willing to overlook long wait times, but the next patient may not be so gracious. Always look for opportunities for improvement.

"Whatever you do," said Dr. Besh, "you cannot afford to bury your head in the sand."