Factors Affecting Orthopedic Sports Medicine Surgeons’ Online Reputation

Materials and Methods

This study did not require institutional review board approval because it only used publicly available web-accessible data sources. The American Orthopaedic Society for Sports Medicine (AOSSM)¹⁴ member directory was accessed from June 1, 2017, to July 30, 2017. A list was compiled of 2642 AOSSM physicians (MD or DO), noting their name and state of practice. Board certification and sports CAQ status were verified using the ABOS physician database.¹⁵ After application of the exclusion criteria, a total of 2099 surgeons was available for review (Figure 1). The authors excluded surgeons certified before 1986 without any board recertification because recertification was not required before 1986, thus preventing determination of current practice status.

Figure 1: Inclusion criteria. Abbreviation: AOSSM, American Orthopaedic Society for Sports Medicine.

Each surgeon was searched on Health-grades and Vitals because they are the 2 most visited PRWs.^5,12 The authors recorded the surgeon’s sex and the number of ratings. A combined Healthgrades and Vitals weighted rating, used for analysis, was tabulated with the following equation: Weighted Rating= ((HGnumber×HGrating)+(Vnumber× Vrating))/(HGnumber+Vnumber). In this equation, HGnumber is the number of Healthgrades ratings; HGrating is the Healthgrades rating; Vnumber is the number of Vitals ratings; and Vrating is the Vitals rating. This equation prevents the unequal influence of a single review when there is an unbalanced number of reviews between Healthgrades and Vitals.

Surgeons were divided into 4 categories based on years in practice measured from their initial board certification date. Group 1 had fewer than 10 years in practice. Group 2 had 10 to 20 years in practice. Group 3 had 21 to 30 years in practice. Group 4 had greater than 30 years in practice. Using the geographic data on the AOSSM directory, the authors divided surgeons into 9 regions of practice based on Medscape’s Orthopedist Compensation Report 2015.¹⁶

Statistical Analysis

A 2-tailed unpaired Student t test was used for comparisons of sex (male vs female) and sports CAQ status (with vs without sports CAQ). Analysis of variance was used for comparisons of years in practice (groups 1 to 4) and region of practice (Figure 2). Multivariable linear regression was used to identify factors contributing to PRW ratings, including the years in practice, sex, sports CAQ status, and number of ratings per surgeon. Type I error was set at alpha being .05, and statistical significance was defined as P<.05 for all analyses.

Figure 2: Map depicting the United States divided into 9 regions, with the number of board-certified orthopedic sports surgeons in each area. Note that the West region includes Hawaii, and the Northwest includes Alaska. [Adapted from Medscape (https://www.medscape.com). Peckham C. Medscape Orthopedist Compensation Report 2015. Published April 21, 2015. Online at: https://www.medscape.com/features/slideshow/compensation/2015/orthopedic. Accessed November 20, 2018.]

Results

Table 1 lists the general demographic data of physicians included in the study. The geographic distribution of the board-certified surgeons is provided in Figure 2. There were no statistical differences in mean PRW ratings for the different geographic regions. Of the surgeons who met inclusion criteria, 1981 were males and 118 were females. Mean PRW ratings were significantly higher (P=.014) for female orthopedic surgeons compared with their male counterparts; mean ratings were 4.32±0.46 and 4.21±0.51 for females and males, respectively. Mean years in practice was greater (P=.003) for males (12.8±9.0 years) compared with females (10.5±8.13 years). Multivariable analysis found sex to be an independent predictive variable when controlling for years in practice, number of ratings, and sports CAQ status (Table 2).

Table 1: General Demographics of Included Physicians

Table 2: Multivariate Linear Regression Results

Of the included surgeons, groups 1, 2, 3, and 4 had 981, 619, 434, and 65 surgeons, respectively, available for analysis. Mean weighted ratings were greater in group 1 than in groups 2, 3, and 4 (Table 3). A total of 1201 surgeons had a sports CAQ, and 898 surgeons did not have a sports CAQ; the PRW ratings showed no statistical difference between groups. Mean years in practice was higher (P<.001) for surgeons with a sports CAQ (14.4±8.4 years) compared with surgeons without a sports CAQ (10.3±9.2 years). After controlling for both CAQ and years in practice, CAQ was not found to be an independent predictive variable.

Table 3: Comparison of Physician Rating Website Ratings Between Groups

Discussion

The authors hypothesized that year in practice and CAQ status would correlate positively with better PRW ratings. Both of these hypotheses were disproven. In contrast, more years in orthopedic sports practice correlated with lower PRW ratings. The CAQ status had no effect on PRW rating.

Similar relationships were found by previous studies in other fields.^17–19 Gao et al¹⁸ found recent medical school graduates received higher average ratings. A few explanations for this apparent favorability of younger physicians include their focus on reputation when building a practice, technological savviness, and online presence of younger physicians as noted by Trehan et al⁴ and Calixto et al.¹⁹ Additionally, rating websites are more popular among younger patients,²⁰ and some patients may have a better personal connection with those of similar age,²¹ which would lead to higher PRW ratings.

Interestingly, sports CAQ did not affect the PRW rating, even when correcting for the years in practice. In the current study, surgeons with a sports CAQ had, on average, more years in practice (14.4±8.4 years) than surgeons without a CAQ (10.3±9.2 years) (P<.001). As the CAQ was not available when many surgeons started in practice, the surgeons who obtained sports CAQ did so after an average of 7.79±6.68 years in practice. This extra time also may be due to the additional time needed to fulfill the requirements to qualify for sports CAQ, which includes 1 year of Accreditation Council for Graduate Medical Education accredited fellowship, 1 year of at least 115 operative cases (75 of which must be arthroscopic), and non-operative cases.²² Additionally, the ABOS began issuing sports CAQs in 2007,²³ so board-certified orthopedic surgeons who began practicing before 2007 had to delay obtaining sports CAQ. Regardless, the results indicated that sports CAQ did not result in better or worse PRW ratings.

In contrast, specialty-specific certifications of other specialties have been correlated with positive patient outcomes.^24–27 Kao et al²⁴ found outcomes of percutaneous coronary intervention were more favorable if performed by board-certified interventional radiologists compared with non–board-certified interventional radiologists. Prystowsky et al²⁵ reported similar findings, whereby colorectal subspecialty board certification improved patient outcomes of colon resection. It is possible that sports CAQ results in better patient outcomes among orthopedic sports surgeons, but this does not necessarily result in better patient ratings. However, the authors did not examine patient outcomes in this study.

This study also found a positive correlation with physician rating and number of ratings, which was the only modifiable factor observed. This relationship may be due to self-promotion or the online presence of some physicians, which may elicit more positive reviews.¹ Physicians in their early years of practice have been found to have a higher rate of review acquisition,¹ which also plays into the fact that younger surgeons had higher PRW ratings. The importance of online marketing while building their practice may contribute to this increased rate.¹

Female sex had a positive impact on PRW ratings, even when accounting for the lower average years in practice for female orthopedic surgeons. This finding parallels a study by Nwachukwu et al.¹⁷ The discrepancy in patient satisfaction can be explained by Howick et al,^28,29 who used the consultation and relational empathy measure to conclude that female practitioners express empathy more effectively toward their patients compared with their male counterparts, which can improve patients’ satisfaction of their care. Furthermore, Meeuwesen et al³⁰ investigated physician sex preferences and found that patient-centered communication styles contributed to the preference for female physicians. Empathy and patient-centered communication in orthopedic sports medicine may play a role in the preference for female surgeons.

Several other factors have been found to impact patient satisfaction, including office environment, ease of scheduling, wait times, and many other variables that may be out of a physician’s control.¹² Variables that may play a role in patient satisfaction are the physician’s willingness to order diagnostic tests, prescribe medications, or respond to patient demands, all of which may not improve patient care.^3,31,32 Although deficiencies in these areas should be addressed, previous work suggests that surgeon ability does not necessarily contribute to better patient satisfaction^31,33,34 or physician online ratings.³⁵

Previous literature has indicated that better outcomes after knee and hip arthroplasty do not correlate with better online patient ratings.^35,36 The previous studies and the current study show that a physician’s online reputation consists of many factors, and most do not take into account the physician’s operative skills or knowledge. Taking these factors into account, physicians should consider modifying factors under their control that may improve their online reputation, which can help increase patient referrals. The modifiable factor that was found in this study was the number of reviews. Physician rating websites can be a helpful tool to amend the factors that affect patient satisfaction.

This study was limited by the survey bias of the actual PRWs themselves. The online reviews of a physician represent an incredibly small subset of the total number of patients evaluated by a given physician,^4,18 which can skew PRW ratings. The small sample represented by patients who review their physicians online may provide an image that is not indicative of a physician’s clinical or surgical abilities.

Additionally, specific populations are more likely to rate a physician online²⁰ and thus can be overrepresented on PRWs. Terlutter et al²⁰ reported that females are more likely to use PRWs. Previous studies have reported female patients may prefer female physicians, whereas male patients have less sex preference.³⁷ This could have skewed the current results in favor of female orthopedic sports surgeons. Furthermore, one cannot guarantee that the reviews on the PRWs were authentic. There was no way to determine whether there were coerced or falsified reports by patients or competing physicians.

Finally, despite their statistical significance, the correlation coefficients of the study were low, suggesting that although years in practice, female sex, and the number of reviews do impact PRW ratings, many other influencing factors were not measured in the study. These statistical differences may not be clinically significant.

Conclusion

It is difficult to separate all of the factors that impact patient satisfaction of orthopedic sports surgeons. In this study, the most substantial contributors to higher PRW ratings were female sex, fewer years in practice, and a larger number of reviews. However, their contribution to the overall rating was small. The number of reviews was the only modifiable factor seen that can lead to higher ratings. There was no significant difference between practicing locations and between surgeons with and without a sports CAQ. Patient satisfaction is complex, and PRWs only provide a glimpse of a physician’s patient satisfaction. Surgeons should consider all factors of patient satisfaction when improving their online reputation.